In this episode of Think Like a Nurse, we break down the most urgent, high-stakes assessment findings every nursing student must recognize instantly. These are the red flags that signal a rapidly deteriorating client—and the ones you must master to think critically, intervene early, and pass the NCLEX with confidence. We walk through the four levels of prevention so you can understand not just when to act, but why. You’ll learn the correct physical assessment sequence (and the crucial abdominal exception), how to interpret dangerous respiratory sounds like stridor, and how to spot a tension pneumothorax using tracheal deviation and unilateral absent breath sounds. We also break down postpartum hemorrhage priorities step-by-step, newborn hypoglycemia signs you can’t miss, bowel sound patterns that signal obstruction, and the most important screening timelines across the lifespan. This episode ties together high-yield frameworks—developmental stages, maternal immunizations, fall-risk strategies, Beers Criteria, ABCD screenings, and motivational interviewing tools—so you can connect textbook learning to real-world clinical judgment. By the end, you’ll know exactly what to look for, what it means, and the fast priorities that save lives.
Covers lifespan: preconception → newborn → pediatrics → adults → geriatrics.
Nurse’s role: proactive teaching, risk reduction, assessing needs, prevention, and early recognition of red-flag assessment findings.
Prevents risk factors from ever emerging.
Examples: community exercise programs, safe walking areas, school nutrition standards.
Prevents disease or injury before it occurs.
Examples: immunizations, seat belt teaching, smoking counseling, surgery pre-teaching.
Detects disease early in asymptomatic clients.
Screenings: colonoscopy, pap tests, mammograms, blood pressure checks.
Disease already exists — goal is to reduce complications and maximize functioning.
Examples: cardiac rehab, diabetes foot care teaching, chronic medication management.
Normal sequence: Inspection → Palpation → Percussion → Listening
Abdomen exception: Inspection → Listening → Percussion → Palpation
Why? Touching first can artificially change bowel sounds.
Stridor
High-pitched, harsh, inspiratory sound → airway emergency.
Immediate actions: call rapid response, prepare advanced airway, oxygen, suction.
Tracheal deviation + absent breath sounds on one side
Strongly suggests tension pneumothorax.
Prepare for needle decompression or chest tube.
High-pitched “tinkling” sounds → sudden silence
Possible obstruction or ileus → perforation risk.
Actions: notify provider, strict I/O, make NPO, prepare NG tube, assess for rebound tenderness.
Colorectal screening: Begins at age 45 for average risk.
Pap tests:
Age 21–29: every 3 years.
Age 30–65: Pap every 3 years OR Pap + HPV every 5 years.
Older adult: integrity vs. despair → use reminiscence, life review, validation.
Toddlers/young children: concrete, literal → simple language, medical play.
Teens: abstract thinkers → risk discussions, long-term consequences.
Tdap every pregnancy, regardless of prior doses.
Timing: 27–36 weeks → maximizes antibody transfer to baby.
No live vaccines during pregnancy (MMR, varicella).
Administer postpartum; avoid pregnancy for 28 days after MMR.
Fundal massage
Oxytocin
Rapid fluids
Call for help
Prepare for additional interventions (e.g., uterotonics)
Signs: jittery, tremors, irritability, lethargy, poor feeding.
Check glucose immediately; feed or give IV glucose per protocol.
Mild slowing is normal. Dementia is NOT normal aging.
Use Beers Criteria to identify unsafe medications.
High risk meds: sedatives, benzodiazepines, anticholinergics.
Fix environment first: lighting, footwear, remove rugs, grab bars.
A: A1C
B: Blood pressure
C: Colon cancer
D: DEXA (bone density)
O: Open-ended questions
A: Affirmations
R: Reflective listening
S: Summaries
Assess
Advise
Agree
Assist
Arrange
Clients with positive BRCA results are not obligated to inform family members.
Respect autonomy and confidentiality.
Welcome to Think Like a Nurse. This show is created by Brooke Wallace, who brings, you know, 20 years of experience as an ICU nurse, organ transplant coordinator, clinical instructor, and published author. Our mission here is simple. Take really complex nursing topics and just make them easier to understand. Help you get that knowledge quickly and uh thoroughly. Yeah. Because we know studying for these high stakes topics can sometimes feel like, well, drinking from a fire hose, right? So, today we're going to cut through some of that noise. We're diving deep into uh one of the most foundational really critical areas health promotion and maintenance or HPM.
right and this category is well it's huge it covers the whole lifespan you know from preconception and clear through to geriatric care and it really demands that you think proactively not just reactively. exactly so our focus today is going to be on synthesizing really three key things risk assessment anticipatory guidance and recognizing those critical physical assessment findings the ones that save lives. We really want to give you those nuggets, those sharp insights you need to truly think like a nurse at the bedside. So, okay, let's start right at the foundation of HPM. That's the nurse's strategic role. We're change agents, aren't we?
We absolutely are. And that role, it spans everything from, you know, individual teaching right at the bedside up to potentially influencing health policy. But the big question is when do we step in? How do we target our actions? Ah, that's the critical piece, isn't it? And that's exactly why we have to understand the levels of prevention. It determines the timing, the scope of what you do. If you mix these levels up, well, your priorities are going to be mixed up, too. And it's not just three levels people sometimes think about. There are actually four.
Exactly. Four. We start way upstream, the highest level, uh, primordial prevention. This is about preventing the risk factors from even emerging in the first place. Often this means targeting like social conditions or systemic issues. Okay. Primordial. Can you give us a really solid example because I think this is where it gets a bit fuzzy for some people. Sure. Think about things happening at the community level. Maybe uh a city council designing safer walking paths or maybe schools mandating daily exercise and good nutrition education. You're essentially creating a healthier environment before those risky behaviors even get a foothold.
Got it. So, it's about shaping the whole environment. Okay. So, moving down a level, the one most nurses think of first, primary prevention, right? Primary is all about preventing a disease or injury before it even happens in an individual person. This is, you know, classic prevention. Think immunizations, teaching about seat belt safety, uh, preop, teaching before surgery, that kind of thing. Okay. Now, here's a common point of confusion. What about screenings? Say a client getting a routine colonoscopy. Is that primary?
Nope. That's definitely secondary prevention. Secondary is all about early detection. The client feels fine, they're asymptomatic, but we're actively looking, screening for early signs of disease. So, mammograms, papsmears, routine blood pressure checks. Yeah. Colonoscopy. is those all fall under secondary. Okay, so primary prevents the event entirely. Secondary finds it super early. So what happens if the disease or condition is already there? Then we shift gears to tertiary prevention. The goal here changes completely. Now it's about minimizing complications, slowing things down, maximizing the person's recovery and function. Examples cardiac rehab, teaching someone with diabetes how to do daily foot checks, managing chronic meds.
Yeah. That's all tertiary. And you know before we move on from levels, just a crucial reminder here across all four levels, we absolutely have to be sensitive to cultural beliefs, spiritual needs, gender identity. It's non-negotiable. Oh, absolutely. If you're making a care plan, especially around something like childbearing or family planning, it has to align with what the client believes and needs. If it doesn't, well, you can pretty much guarantee they won't follow it. Okay. So, we've talked about when we intervene. Now, let's talk about how we figure out if intervention is needed through physical assessment. We all learn that standard sequence, right? IPA, inspection, palpation, percussion, then oscultation.
right? And we learn it in that order for a reason. It helps us gather data systematically. But, and this is a big butt, there's a critical exception. Super high yield for practice. Ah, the abdomen. Tell us why we break the rules though. Okay. So, for the abdomen, we flip it. We use apection first, then oscultation, then percussion, and finally palpation. And why the switch? Because if you start poking around, palpating or percussing the abdomen, you can actually stir things up mechanically in the gut.
Ah, so you could create bowel sounds that weren't really there or maybe make existing ones sound different. Exactly. You could artificially stimulate sounds and maybe miss something important like hypoactive sounds or you could cause pain, make the muscles tense up and then the rest of your exam isn't accurate. Bottom line, listen before you touch the belly. Makes perfect sense. Okay, knowing the sequence is step one, but interpreting what you find, that's what saves lives. Let's talk red flags. Critical findings needing immediate action. Respiratory system first.
Okay. Top of the list. If you hear stridor, that high-pitched harsh sound on inspiration. That's an emergency. Full stop. It screams impending airway obstruction. Usually upper airway. Think anaphilaxis, epiglotitis. The airway is closing fast. So, what's the absolute first thing a nurse does? Not a full assessment, right? No way. Your immediate priority is preparing for an advanced airway. Call for help. Rapid response. The provider get the intubation card. Oxygen suction ready. You need to anticipate needing to secure that airway now. Stridor isn't wait and see.
Okay. Stridor equals airway emergency. What about another scary respiratory finding? Something suggesting the chest mechanics are failing? That would be hearing absent breath sounds on one side, plus seeing the trachea deviated, pushed over to the other side. That combo strongly suggests a tension pneumothorax. Air's trapped, building pressure, squishing the heart and lungs. It's rapidly fatal if you don't intervene. Priority there has to be getting that pressure off right immediately. Prepare for needle decompression or chest tube insertion. You're anticipating the provider's need to relieve that pressure ASAP. It requires super fast recognition and action.
Okay, let's swing back to the abdomen. Now, those critical bowel sound patterns we mentioned, right? So, when you listen, if you first hear really high-pitched, almost tinkling, frantic sounds, that often means the bowel is working overtime, trying hard to push past some kind of blockage. But then, if those sounds suddenly disappear, or become really faint, really hypoactive. That's ominous. It suggests the bowel might have just given up. Could be a complete obstruction or a paralytic ileus. That sounds really serious. Perforation risk.
Huge risk. So besides telling the provider right away, you're immediately assessing for signs of perforation like a sudden fever, worsening pain, rebound tenderness, and you'll be keeping strict I & O's, probably making the client NPO, maybe getting an NG tube ready for decompression. Lots to do quickly. Okay, good. And just before we leave, Let's quickly circle back to secondary screening. Some key timelines clients ask about colorectal cancer screening starts routinely at age 45. Now that's a bit earlier than it used to be for average risk folks.
right? And cervical cancer, papsmears. Yeah, the timing depends on age. For ages 21 to 29, it's a pap test every 3 years. But then for women 30 to 65, they have options. They can continue pap every 3 years or do co- testing. That's a pap plus HPV test every 5 years, assuming their prior results were normal. Good clarifications. Okay, shifting gears now to lifespan transitions. If we want our teaching to actually stick, we need to tailor it, right? Developmental theory comes in handy. Absolutely. You can't talk to a toddler the same way you talk to a teen or an older adult. We use theorists like Erikson and Piaget to help guide how we communicate. Think about Erikson's stages. You connect the person's developmental stage to the kind of intervention or interaction they need.
So, give us an example. Maybe an older adult dealing with Erikson's integrity versus despair stage. How does Does that change how we interact or teach? Well, they often need validation, a sense of meaning from their life. So, things like therapeutic life review, encouraging reminiscence, that's huge for them. It's actually a mistake sometimes nurses make kind of dismissing their stories. But listening, helping them reflect that fulfills a key developmental need and boosts their overall well-being.
Okay. And with Piaget, it's more about cognitive development, right? Yeah. How complex can our teaching be? Exactly. Toddlers, early school age kids, they're in that Pre-operational stage thinking is very concrete, literal. So teaching them, you need models, medical play, simple direct language. Forget abstract concepts. Contrast that with adolescence. They've usually reached formal operations. They can handle abstract thought, risk-benefit analysis, long-term consequences. So you can have much more effective talks about things like addiction risks or managing chronic illness.
That makes sense. Let's apply that tailored approach now to some high stakes areas. Maternal and newborn care, specifically immunizations. during pregnancy. That's big for HPM. Tdap (tetanus, diphtheria, pertussis) is critical and it must must be given during every single pregnancy. Doesn't matter if they had it last year. And the timing is key. Ideally between 27 and 36 weeks gestation. Why that specific window 27 to 36 weeks? Because that timing maximizes the transfer of mom's antibodies across the placenta to the fetus. The main goal is protecting the newborn from pertussis (whooping cough) in those first few vulnerable months. before they can get their own shots.
Okay. Tdap every pregnancy. What about live virus vaccines then? Strictly avoided. Big contra indication. Live vaccines like MMR (measles, mumps, rubella), and Varicella (chickenpox) carry a theoretical risk to the fetus. So if a client isn't immune to say rubella, we wait. We give the MMR vaccine after delivery postpartum. And then we teach them to avoid getting pregnant again for at least 28 days after that shot.
Got it. Okay. Now switching to a major postpartum emergency. PPH, postpartum hemorrhage. You walk in. Uterus is boggy, heart rate's climbing, BP's dropping. What's the sequence? There's a non-negotiable life-saving sequence. Priority one, fundal massage. Get your hands on that uterus and massage firmly. Try to get it to contract. Priority two, administer oxytocin, usually IV. That helps the uterus contract chemically. Priority three, if those don't work quickly, rapid infusion of IV crystalloid fluids to combat shock and restore volume. And of course, calling for help and notifying the provider are happening simultaneously or immediately after massage start. Fundal massage, oxytocin, fluids. Got it.
Okay. And for the newborn, what's a critical condition we need to catch right away? Hypoglycemia, low blood sugar. Newborns are making a big metabolic transition and really low glucose like say under 40 or 45, but especially critical low like 25 can cause serious even permanent brain injury. The signs can be subtle sometimes, maybe just tremors, irritability, being lethargic, poor feeding, or that classic jitteriness. See that? Check the glucose immediately. Intervene with feeding. or IV dextrose per protocol. Don't wait.
Okay. Critical glucose check for jittery babies. Let's move to the other end of the lifespan. Now, geriatric health promotion. Focus here shifts a lot towards safety. Medications, right? And we need to start by busting a myth. While yeah, processing speed might slow down a bit, maybe memory retrieval takes a second longer, dementia, severe cognitive decline is not a normal part of aging. We screen for it, assess it, but we don't just assume it's inevitable. Good point. And probably the biggest clinical challenge we face with older adults is polypharmacy, right? So many medications.
It's a huge issue and the nurse's role here is vital. We use tools like the Beers Criteria. This list helps us identify potentially inappropriate medications or PIMS for older adults. Now, to scrutinize that medication list, are the doses right for potentially decreased kidney function? Are we watching closely for side effects like over sedation from benzodiazepines or opioids? And why is over sedation such a risk? because it leads directly to our next big geriatric priority. Falls. Falls are a massive cause of injury, hospitalization, loss of independence in this age group. So, primary prevention for falls is often about fixing the environment. Things like grab bars in the bathroom, good lighting throughout the house, removing rugs, ensuring proper footwear.
and we always try non-drug approaches first for things like confusion or agitation. Always. Always. If an older client is getting restless or confused, we try reorientation, therapeutic communication. Maybe establishing routines, addressing underlying causes like pain or infection before reaching for sedating meds. Those meds often just increase the fall risk. Makes sense. And hey, you mentioned pneumonics earlier. Is there one for key geriatric screenings? There is. It's a handy one. Just remember ABCD.
ABCD. Okay. Break it down for us. A is for A1C checking for diabetes. B is for blood pressure screening. C is for colon cancer screening. Remembering that now starts at 45. And D is for DEXA scan checking bone density to assess Osteoporosis risk. ABC D A1C blood pressure colon DXA. Nice. Okay, final segment. Let's talk behavior change because often the issue isn't that the client doesn't know what to do. It's that they lack motivation or confidence. Right. Non-adherence.
Exactly. Knowledge deficit isn't always the problem. This is where our communication skills become paramount. We often use techniques from motivational interviewing or MI. MI is all about drawing out the client's own motivation, their own reason. for change in building their confidence. There's a great pneummonic for the core skills or like rowing a boat. Okay. What does OARS stand for? O is for open-ended questions. Asking questions that invite more than a yes no answer. Exploring their thoughts. A is for affirmations. Recognizing their strengths, their past efforts, building them up. R is for reflective listening. Really listening and reflecting back what you hear to show understanding and let them hear their own thoughts. And S is for summaries, pulling together the conversation, reinforcing their change talk, confirming next steps. Open-ended questions, affirmations, reflections, summaries. Great tool. And for specific behaviors like quitting smoking.
For things like tobacco cessation, we often use another structured model, the five A's. The five A's. What are those? It's a sequence. Assess their use and readiness to quit. Advise them clearly and personally to quit. Agree on a quit plan collaboratively. Assist them with resources, counseling, maybe medications, and Arrange follow-up contact to support them. Assess, advise, agree, assist, arrange very systematic. Okay one last point touching on ethics. we talked about genetic risk earlier like BRCA testing for breast cancer risk. what's the key ethical piece there regarding family?
autonomy and confidentiality are paramount. while a positive BRCA result certainly informs our plan for that client's screening they are absolutely not obligated to tell their family members about that risk. our job is to educate them about the implications offer support maybe suggest resources for family communication, but ultimately the decision to disclose is theirs alone. We have to respect that.
crucial distinction. Wow. Okay. We've covered a ton of ground today. All the way from primordial prevention. Yeah. Through the four levels, hitting those critical assessment red flags like stridor, the sequence for the abdomen, the PPH priorities, newborn glucose, geriatric safety with Beers and ABCD, and then communication strategies like OARS and the 5 A's. It really connects the dots, doesn't it? From theory to those immediate bed site actions. That's the goal. We hit those key pneumonics, those priority sequences. These are the nuggets that really help you start to well think like a nurse. Absolutely. These details help connect that textbook knowledge right to the clinical judgment you need every day.
We hope this conversation helps clarify some of these complex HPM topics for you. Join us again next week for another deep dive. And then definitely don't forget to visit think likeurse.org. There are tons more resources, study guides, and support there specifically for nursing students and new grads. Thanks for tuning in.