9.3 Cardiovascular Assessment
Open Resources for Nursing (Open RN)
A thorough assessment of the heart provides valuable information about the function of a patient’s cardiovascular system. Understanding how to properly assess the cardiovascular system and identifying both normal and abnormal assessment findings will allow the nurse to provide quality, safe care to the patient.
Before assessing a patient’s cardiovascular system, it is important to understand the various functions of the cardiovascular system. In addition to the information provided in the “Review of Cardiac Basics” section, the following images provide an overview of the cardiovascular system. Figure 9.1[1] provides an overview of the structure of the heart. Note the main cardiac structures are the atria, ventricles, and heart valves. Figure 9.2[2] demonstrates blood flow through the heart. Notice the flow of deoxygenated blood from the posterior and superior vena cava into the right atria and ventricle during diastole (indicated by blue coloring of these structures). The right ventricle then pumps deoxygenated blood to the lungs via the pulmonary artery during systole. At the same time, oxygenated blood from the lungs returns to the left atria and ventricle via the pulmonary veins during diastole (indicated by red coloring of these structures) and then is pumped out to the body via the aorta during systole. Figure 9.3[3] demonstrates the conduction system of the heart. This image depicts the conduction pathway through the heart as the tissue responds to electrical stimulation. Figure 9.4[4] illustrates the arteries of the circulatory system, and Figure 9.5[5] depicts the veins of the circulatory system. The purpose of these figures is to facilitate understanding of the electrical and mechanical function of the heart within the cardiovascular system.
Assessing the cardiovascular system includes performing several subjective and objective assessments. At times, assessment findings are modified according to life span considerations.
Subjective Assessment
The subjective assessment of the cardiovascular and peripheral vascular system is vital for uncovering signs of potential dysfunction. To complete the subjective cardiovascular assessment, the nurse begins with a focused interview. The focused interview explores past medical and family history, medications, cardiac risk factors, and reported symptoms. Symptoms related to the cardiovascular system include chest pain, peripheral edema, unexplained sudden weight gain, shortness of breath (dyspnea), irregular pulse rate or rhythm, dizziness, or poor peripheral circulation. Any new or worsening symptoms should be documented and reported to the health care provider.
Table 9.3a outlines questions used to assess symptoms related to the cardiovascular and peripheral vascular systems. Table 9.3b outlines questions used to assess medical history, medications, and risk factors related to the cardiovascular system. Information obtained from the interview process is used to tailor future patient education by the nurse.[6],[7],[8]
Table 9.3a Interview Questions for Cardiovascular and Peripheral Vascular Systems[9]
| Symptom | Question |
Follow-Up Safety Note: If findings indicate current severe symptoms suggestive of myocardial infarction or another critical condition, suspend the remaining cardiovascular assessment and obtain immediate assistance according to agency policy or call 911. |
|---|---|---|
| Chest Pain | Have you had any pain or pressure in your chest, neck, or arm? | Review how to assess a patient’s chief complaint using the PQRSTU method in the “Health History” chapter.
|
| Shortness of Breath
(Dyspnea) |
Do you ever feel short of breath with activity?
Do you ever feel short of breath while sleeping? Do you feel short of breath when lying flat? |
What level of activity elicits shortness of breath?
How long does it take you to recover? Have you ever woken up from sleeping feeling suddenly short of breath How many pillows do you need to sleep, or do you sleep in a chair (orthopnea)? Has this recently changed? |
| Edema | Have you noticed swelling of your feet or ankles?
Have you noticed your rings, shoes, or clothing feel tight at the end of the day? Have you noticed any unexplained, sudden weight gain? Have you noticed any new abdominal fullness? |
Has this feeling of swelling or restriction gotten worse?
Is there anything that makes the swelling better (e.g., sitting with your feet elevated)? How much weight have you gained? Over what time period have you gained this weight? |
| Palpitations | Have you ever noticed your heart feels as if it is racing or “fluttering” in your chest?

When did palpitations start? Have you previously been treated for palpitations? If so, what treatment did you receive? |
| Dizziness
(Syncope) |
Do you ever feel light-headed?
Do you ever feel dizzy? Have you ever fainted? |
Can you describe what happened?
Did you have any warning signs? Did this occur with position change? |
| Poor Peripheral Circulation | Do your hands or feet ever feel cold or look pale or bluish?
Do you have pain in your feet or lower legs when exercising? |
What, if anything, brings on these symptoms?
How much activity is needed to cause this pain? Is there anything, such as rest, that makes the pain better? |
| Calf Pain | Do you currently have any constant pain in your lower legs? | Can you point to the area of pain with one finger? |
Table 9.3b Interview Questions Exploring Cardiovascular Medical History, Medications, and Cardiac Risk Factors
| Topic | Questions |
|---|---|
| Medical History | Have you ever been diagnosed with any heart or circulation conditions, such as high blood pressure, coronary artery disease, peripheral vascular disease, high cholesterol, heart failure, or valve problems?
Have you had any procedures done to improve your heart function, such as ablation or stent placement? Have you ever had a heart attack or stroke? |
| Medications | Do you take any heart-related medications, herbs, or supplements to treat blood pressure, chest pain, high cholesterol, cardiac rhythm, fluid retention, or the prevention of clots? |
| Cardiac Risk Factors | Have your parents or siblings been diagnosed with any heart conditions?
Do you smoke or vape?
If you do not currently smoke, have you smoked in the past?
Are you physically active during the week?
What does a typical day look like in your diet?
Do you drink alcoholic drinks?
Would you say you experience stress in your life?
How many hours of sleep do you normally get each day?
|
Objective Assessment
The physical examination of the cardiovascular system involves the interpretation of vital signs, inspection, palpation, and auscultation of heart sounds as the nurse evaluates for sufficient perfusion and cardiac output.
Equipment needed for a cardiovascular assessment includes a stethoscope, penlight, centimeter ruler or tape measure, and sphygmomanometer.[10]
Evaluate Vital Signs and Level of Consciousness
Interpret the blood pressure and pulse readings to verify the patient is stable before proceeding with the physical exam. Assess the level of consciousness; the patient should be alert and cooperative.
Inspection
- Skin color to assess perfusion. Inspect the face, lips, and fingertips for cyanosis or pallor. Cyanosis is a bluish discoloration of the skin, lips, and nail beds and indicates decreased perfusion and oxygenation. Pallor is the loss of color, or paleness of the skin or mucous membranes, as a result of reduced blood flow, oxygenation, or decreased number of red blood cells. Patients with light skin tones should be pink in color. For those with darker skin tones, assess for pallor on the palms, conjunctiva, or inner aspect of the lower lip.
- Jugular Vein Distension (JVD). Inspect the neck for JVD that occurs when the increased pressure of the superior vena cava causes the jugular vein to bulge, making it most visible on the right side of a person’s neck. JVD should not be present in the upright position or when the head of bed is at 30-45 degrees.
- Precordium for abnormalities. Inspect the chest area over the heart (also called precordium) for deformities, scars, or any abnormal pulsations the underlying cardiac chambers and great vessels may produce.
- Extremities:
- Upper Extremities: Inspect the fingers, arms, and hands bilaterally noting Color, Warmth, Movement, Sensation (CWMS). Alterations or bilateral inconsistency in CWMS may indicate underlying conditions or injury. Assess capillary refill by compressing the nail bed until it blanches and record the time taken for the color to return to the nail bed. Normal capillary refill is less than 3 seconds.[11]
- Lower Extremities: Inspect the toes, feet, and legs bilaterally, noting CWMS, capillary refill, and the presence of peripheral edema, superficial distended veins, and hair distribution. Document the location and size of any skin ulcers.
- Edema: Note any presence of edema. Peripheral edema is swelling that can be caused by infection, thrombosis, or venous insufficiency due to an accumulation of fluid in the tissues. (See Figure 9.6[12] for an image of pedal edema.)[13]
- Deep Vein Thrombosis (DVT): A deep vein thrombosis (DVT) is a blood clot that forms in a vein deep in the body. DVT requires emergency notification of the health care provider and immediate follow-up because of the risk of developing a life-threatening pulmonary embolism.[14] Inspect the lower extremities bilaterally. Assess for size, color, temperature, and for presence of pain in the calves. Unilateral warmth, redness, tenderness, swelling in the calf, or sudden onset of intense, sharp muscle pain that increases with dorsiflexion of the foot is an indication of a deep vein thrombosis (DVT).[15] See Figure 9.7[16] for an image of a DVT in the patient’s right leg, indicated by unilateral redness and edema.
Auscultation
Heart Sounds
Auscultation is routinely performed over five specific areas of the heart to listen for corresponding valvular sounds. These auscultation sites are often referred to by the mnemonic “APE To Man,” referring to Aortic, Pulmonic, Erb’s point, Tricuspid, and Mitral areas (see Figure 9.8[17] for an illustration of cardiac auscultation areas). The aortic area is the second intercostal space to the right of the sternum. The pulmonary area is the second intercostal space to the left of the sternum. Erb’s point is directly below the aortic area and located at the third intercostal space to the left of the sternum. The tricuspid (or parasternal) area is at the fourth intercostal space to the left of the sternum. The mitral (also called apical or left ventricular area) is the fifth intercostal space at the midclavicular line.
Auscultation usually begins at the aortic area (upper right sternal edge). Use the diaphragm of the stethoscope to carefully identify the S1 and S2 sounds. They will make a “lub-dub” sound. Note that when listening over the area of the aortic and pulmonic valves, the “dub” (S2) will sound louder than the “lub” (S2). Move the stethoscope sequentially to the pulmonic area (upper left sternal edge), Erb’s point (left third intercostal space at the sternal border), and tricuspid area (fourth intercostal space. When assessing the mitral area for female patients, it is often helpful to ask them to lift up their breast tissue so the stethoscope can be placed directly on the chest wall. Repeat this process with the bell of the stethoscope. The apical pulse should be counted over a 60-second period. For an adult, the heart rate should be between 60 and 100 with a regular rhythm to be considered within normal range. The apical pulse is an important assessment to obtain before the administration of many cardiac medications.
The first heart sound (S1) identifies the onset of systole, when the atrioventricular (AV) valves (mitral and tricuspid) close and the ventricles contract and eject the blood out of the heart. The second heart sound (S2) identifies the end of systole and the onset of diastole when the semilunar valves close, the AV valves open, and the ventricles fill with blood. When auscultating, it is important to identify the S1 (“lub”) and S2 (“dub”) sounds, evaluate the rate and rhythm of the heart, and listen for any extra heart sounds.
Auscultating Heart Sounds
- To effectively auscultate heart sounds, patient repositioning may be required. Ask the patient to lean forward if able, or position them to lie on their left side.
- It is common to hear lung sounds when auscultating the heart sounds. It may be helpful to ask the patient to briefly hold their breath if lung sounds impede adequate heart auscultation. Limit the holding of breath to 10 seconds or as tolerated by the patient.
- Environmental noise can cause difficulty in auscultating heart sounds. Removing environmental noise by turning down the television volume or shutting the door may be required for an accurate assessment.
- Patients may try to talk to you as you are assessing their heart sounds. It is often helpful to explain the procedure such as, “I am going to take a few minutes to listen carefully to the sounds of blood flow going through your heart. Please try not to speak while I am listening, so I can hear the sounds better.”
Extra Heart Sounds
Extra heart sounds include clicks, murmurs, S3 and S4 sounds, and pleural friction rubs. These extra sounds can be difficult for a novice to distinguish, so if you notice any new or different sounds, consult an advanced practitioner or notify the provider. A midsystolic click, associated with mitral valve prolapse, may be heard with the diaphragm at the apex or left lower sternal border.
A click may be followed by a murmur. A murmur is a blowing or whooshing sound that signifies turbulent blood flow often caused by a valvular defect. New murmurs not previously recorded should be immediately communicated to the health care provider. In the aortic area, listen for possible murmurs of aortic stenosis and aortic regurgitation with the diaphragm of the stethoscope. In the pulmonic area, listen for potential murmurs of pulmonic stenosis and pulmonary and aortic regurgitation. In the tricuspid area, at the fourth and fifth intercostal spaces along the left sternal border, listen for the potential murmurs of tricuspid regurgitation, tricuspid stenosis, or ventricular septal defect.
S3 and S4 sounds, if present, are often heard best by asking the patient to lie on their left side and listening over the apex with the bell of the stethoscope. An S3 sound, also called a ventricular gallop, occurs with fluid overload or heart failure when the ventricles are filling. It occurs after the S2 and sounds like “lub-dub-dah,” or a sound similar to a horse galloping. The S4 sound, also called atrial gallop, occurs immediately before the S1 and sounds like “ta-lub-dub.” An S4 sound can occur with decreased ventricular compliance or coronary artery disease.[18]
A pleural friction rub is caused by inflammation of the pericardium and sounds like sandpaper being rubbed together. It is best heard at the apex or left lower sternal border with the diaphragm as the patient sits up, leans forward, and holds their breath.
Carotid Sounds
The carotid artery may be auscultated for bruits. Bruits are a swishing sound due to turbulence in the blood vessel and may be heard due to atherosclerotic changes.
Palpation
Palpation is used to evaluate peripheral pulses, capillary refill, and for the presence of edema. When palpating these areas, also pay attention to the temperature and moisture of the skin.
Pulses
Compare the rate, rhythm, and quality of arterial pulses bilaterally, including the carotid, radial, brachial, posterior tibialis, and dorsalis pedis pulses. Review additional information about obtaining pulses in the “General Survey” chapter. Bilateral comparison for all pulses (except the carotid) is important for determining subtle variations in pulse strength. Carotid pulses should be palpated on one side at a time to avoid decreasing perfusion of the brain. The posterior tibial artery is located just behind the medial malleolus. It can be palpated by scooping the patient’s heel in your hand and wrapping your fingers around so that the tips come to rest on the appropriate area just below the medial malleolus. The dorsalis pedis artery is located just lateral to the extensor tendon of the big toe and can be identified by asking the patient to flex their toe while you provide resistance to this movement. Gently place the tips of your second, third, and fourth fingers adjacent to the tendon, and try to feel the pulse.
The quality of the pulse is graded on a scale of 0 to 3, with 0 being absent pulses, 1 being decreased pulses, 2 is within normal range, and 3 being increased (also referred to as “bounding”). If unable to palpate a pulse, additional assessment is needed. First, determine if this is a new or chronic finding. Second, if available, use a doppler ultrasound to determine the presence or absence of the pulse. Many agencies use doppler ultrasound to document if a nonpalpable pulse is present. If the pulse is not found, this could be a sign of an emergent condition requiring immediate follow-up and provider notification. See Figures 9.9[19] and 9.10[20] for images of assessing pedal pulses.
Capillary Refill
The capillary refill test is performed on the nail beds to monitor perfusion, the amount of blood flow to tissue. Pressure is applied to a fingernail or toenail until it pales, indicating that the blood has been forced from the tissue under the nail. This paleness is called blanching. Once the tissue has blanched, pressure is removed. Capillary refill time is defined as the time it takes for the color to return after pressure is removed. If there is sufficient blood flow to the area, a pink color should return within 2 to 3 seconds after the pressure is removed.[21]
Edema
Edema occurs when one can visualize visible swelling caused by a buildup of fluid within the tissues. If edema is present on inspection, palpate the area to determine if the edema is pitting or nonpitting. Press on the skin to assess for indentation, ideally over a bony structure, such as the tibia. If no indentation occurs, it is referred to as nonpitting edema. If indentation occurs, it is referred to as pitting edema. See Figure 9.11[22] for images demonstrating pitting edema.
Note the depth of the indention and how long it takes for the skin to rebound back to its original position. The indentation and time required to rebound to the original position are graded on a scale from 1 to 4. Edema rated at 1+ indicates a barely detectable depression with immediate rebound, and 4+ indicates a deep depression with a time lapse of over 20 seconds required to rebound. See Figure 9.12[23] for an illustration of grading edema. Additionally, it is helpful to note edema may be difficult to observe in larger patients. It is also important to monitor for sudden changes in weight, which is considered a probable sign of fluid volume overload.
Heaves or Thrills
You may observe advanced practice nurses and other health care providers palpating the anterior chest wall to detect any abnormal pulsations the underlying cardiac chambers and great vessels may produce. Precordial movements should be evaluated at the apex (mitral area). It is best to examine the precordium with the patient supine because if the patient is turned on the left side, the apical region of the heart is displaced against the lateral chest wall, distorting the chest movements.[24] A heave or lift is a palpable lifting sensation under the sternum and anterior chest wall to the left of the sternum that suggests severe right ventricular hypertrophy. A thrill is a vibration felt on the skin of the precordium or over an area of turbulence, such as an arteriovenous fistula or graft.
Life Span Considerations
The cardiovascular assessment and expected findings should be modified according to common variations across the life span.
Infants and Children
A murmur may be heard in a newborn in the first few days of life until the ductus arteriosus closes.
When assessing the cardiovascular system in children, it is important to assess the apical pulse. Parameters for expected findings vary according to age group. After a child reaches adolescence, a radial pulse may be assessed. Table 9.3c outlines the expected apical pulse rate by age.
Table 9.3c Expected Apical Pulse by Age
| Age Group | Heart Rate |
|---|---|
| Preterm | 120-180 |
| Newborn (0 to 1 month) | 100-160 |
| Infant (1 to 12 months) | 80-140 |
| Toddler (1 to 3 years) | 80-130 |
| Preschool (3 to 5 years) | 80-110 |
| School Age (6 to 12 years) | 70-100 |
| Adolescents (13 to 18 years) | 60-90 |
Older Adults
In adults over age 65, irregular heart rhythms and extra sounds are more likely. An “irregularly irregular” rhythm suggests atrial fibrillation, and further investigation is required if this is a new finding. See the hyperlink in the box below for more information about atrial fibrillation.
Expected Versus Unexpected Findings
After completing a cardiovascular assessment, it is important for the nurse to use critical thinking to determine if any findings require follow-up. Depending on the urgency of the findings, follow-up can range from calling the health care provider to calling the rapid response team. Table 9.3d compares examples of expected findings, meaning those considered within normal limits, to unexpected findings, which require follow-up. Critical conditions are those that should be reported immediately and may require notification of a rapid response team.
Table 9.3d Expected Versus Unexpected Findings on Cardiac Assessment
| Assessment | Expected Findings | Unexpected Findings (Document and notify the provider if this is a new finding*) |
|---|---|---|
| Inspection | Apical impulse may or may not be visible | Scars not previously documented that could indicate prior cardiac surgeries
Heave or lift observed in the precordium Chest anatomy malformations |
| Palpation | Apical pulse felt over midclavicular fifth intercostal space | Apical pulse felt to the left of the midclavicular fifth intercostal space
Additional movements over precordium such as a heave, lift, or thrill |
| Auscultation | S1 and S2 heart sounds in a regular rhythm | New irregular heart rhythm
Extra heart sounds such as a murmur, S3, or S4 |
| *CRITICAL CONDITIONS to report immediately | Symptomatic tachycardia at rest (HR>100 bpm)
Symptomatic bradycardia (HR<60 bpm) New systolic blood pressure (<100 mmHg) Orthostatic blood pressure changes (see “Blood Pressure” chapter for more information) New irregular heart rhythm New extra heart sounds such as a murmur, S3, or S4 New abnormal cardiac rhythm changes Reported chest pain, calf pain, or worsening shortness of breath |
See Table 9.3e for a comparison of expected versus unexpected findings when assessing the peripheral vascular system.
Table 9.3e Expected Versus Unexpected Peripheral Vascular Assessment Findings
| Assessment | Expected Findings | Unexpected Findings (Document or notify provider if new finding*) |
|---|---|---|
| Inspection | Skin color uniform and appropriate for race bilaterally
Equal hair distribution on upper and lower extremities Absence of jugular vein distention (JVD) Absence of edema Sensation and movement of fingers and toes intact |
Cyanosis or pallor, indicating decreased perfusion
Decreased or unequal hair distribution Presence of jugular vein distention (JVD) in an upright position or when head of bed is 30-45 degrees New or worsening edema Rapid and unexplained weight gain Impaired movement or sensation of fingers and toes |
| Palpation | Skin warm and dry
Pulses present and equal bilaterally Absence of edema Capillary refill less than 2 seconds |
Skin cool, excessively warm, or diaphoretic
Absent, weak/thready, or bounding pulses New irregular pulse New or worsening edema Capillary refill greater than 2 seconds Unilateral warmth, redness, tenderness, or edema, indicating possible deep vein thrombosis (DVT) |
| Auscultation | Carotid pulse | Carotid bruit |
| *CRITICAL CONDITIONS to report immediately | Cyanosis
Absent pulse (and not heard using Doppler device) Capillary refill time greater than 3 seconds Unilateral redness, warmth, and edema, indicating a possible deep vein thrombosis (DVT) |
- “Diagram of the human heart” by Wapcaplet is licensed under CC BY-SA 3.0 ↵
- “Diagram of the human heart” by Wapcaplet is licensed under CC BY-SA 3.0 ↵
- “2018 Conduction System of Heart.jpg” by OpenStax is licensed under CC-BY-3.0. ↵
- “Arterial System en.svg” by LadyofHats, Mariana Ruiz Villarreal is in the Public Domain ↵
- “Venous system en.svg” by Lady of Hats Mariana Ruiz Vilarreal is in the Public Domain ↵
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology licensed under CC BY 4.0 ↵
- Felner, J. M. (1990). An overview of the cardiovascular system. In Walker, H. K., Hall, W. D., & Hurst, J. W. (Eds.), Clinical methods: The history, physical, and laboratory examinations (3rd ed., Chapter 7). Butterworths. https://www.ncbi.nlm.nih.gov/books/NBK393/ ↵
- Scott, C. & MacInnes, J. D. (2013, September 27). Cardiac patient assessment: putting the patient first. British Journal of Nursing, 15(9). https://doi.org/10.12968/bjon.2<IP_ADDRESS>91 ↵
- Scott, C. & MacInnes, J. D. (2013, September 27). Cardiac patient assessment: putting the patient first. British Journal of Nursing, 15(9). https://doi.org/10.12968/bjon.2<IP_ADDRESS>91 ↵
- Felner, J. M. (1990). An overview of the cardiovascular system. In Walker, H. K., Hall, W. D., & Hurst, J. W. (Eds.), Clinical methods: The history, physical, and laboratory examinations (3rd ed., Chapter 7). Butterworths. https://www.ncbi.nlm.nih.gov/books/NBK393/ ↵
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology licensed under CC BY 4.0 ↵
- “Swollen feet at Harefield Hospital edema.jpg” by Ryaninuk is licensed under CC BY-SA 4.0 ↵
- Simon, E. C. (2014). Leg edema assessment and management. MEDSURG Nursing, 23(1), 44-53. ↵
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology licensed under CC BY 4.0 ↵
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology licensed under CC BY 4.0 ↵
- “Deep vein thrombosis of the right leg.jpg” by James Heilman, MD is licensed under CC BY-SA 3.0 ↵
- “Cardiac Auscultation Areas” by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
- Felner, J. M. (1990). An overview of the cardiovascular system. In Walker, H. K., Hall, W. D., & Hurst, J. W. (Eds.), Clinical methods: The history, physical, and laboratory examinations (3rd ed., Chapter 7). Butterworths. https://www.ncbi.nlm.nih.gov/books/NBK393/ ↵
- “DSC_2277.jpg” by British Columbia Institute of Technology is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/clinicalskills/chapter/2-5-focussed-respiratory-assessment/ ↵
- “DSC_2314.jpg” by British Columbia Institute of Technology is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/clinicalskills/chapter/2-5-focussed-respiratory-assessment/ ↵
- A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2020. Capillary nail refill test; [updated 2020, Aug 9] https://medlineplus.gov/ency/article/003247.htm ↵
- “Combinpedal.jpg” by James Heilman, MD is licensed under CC BY-SA 3.0 ↵
- “Grading of Edema” by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
- Felner, J. M. (1990). An overview of the cardiovascular system. In Walker, H. K., Hall, W. D., & Hurst, J. W. (Eds.), Clinical methods: The history, physical, and laboratory examinations (3rd ed., Chapter 7). Butterworths. https://www.ncbi.nlm.nih.gov/books/NBK393/ ↵
A feeling of shortness of breath.
An attack of severe shortness of breath that generally occurs at night.
A feeling of shortness of breath when lying flat.
Swelling in tissues caused by fluid retention.
A temporary loss of consciousness usually related to insufficient blood flow to the brain.
An instrument for measuring blood pressure typically consisting of an inflatable rubber cuff.
A bluish discoloration of the skin, lips, and nail beds. It is an indication of decreased perfusion and oxygenation.
A reduced amount of oxyhemoglobin the skin or mucous membranes. Skin and mucous membranes present with a pale skin color.
Occurs when the increased pressure of the superior vena cava causes the jugular vein to bulge, making it most visible on the right side of a person's neck.
The region of the thorax in front of the heart.
Swelling due to an accumulation of fluid in tissues perfused by the peripheral vascular system.
A blood clot that forms in a vein deep in the body.
A blood clot that lodges in one of the arteries that go from the heart to the lung.
Clicking sound heard on auscultation of the precordium; often heard in patients with heart valve abnormalities.
A blowing or whooshing sound heard on auscultation of the precordium that signifies turbulent blood flow in the heart often caused by a valvular defect.
Uncommon heart sounds produced when the parietal and visceral pericardium become inflamed, generating a creaky-scratchy noise as they rub together.
A swishing sound when auscultating the carotid arteries. This indicates turbulence in the blood vessel due to atherosclerotic changes.
Capillary refill time is defined as the time taken for color to return after pressure is applied to an area to cause blanching.
The amount of blood flow to tissue.
The whiteness that occurs when pressure is placed on tissue or a nailbed, causing blood to leave the area.
An accumulation of fluid in tissue and causes an indentation when the area is pressed.
Palpable lifting sensation under the sternum and anterior chest wall to the left of the sternum; it suggests severe right ventricular hypertrophy.
A vibration felt with palpation of the precordium.
Shunt that connects the pulmonary artery and aorta in the developing fetus.
An irregular heartbeat that is often fast and increases the risk of heart attack or stroke.


Leadership Development Institute (LDI)
30th Leadership Development Institute
The LDI program began in 1992 and has been offered annually since that time (except in 2020-2021 when the pandemic occurred), making it a signature program of MC. The LDI promotes the philosophy that people lead from where they are and focuses on the participants’ self-awareness of personality, vision, influencing, building relationships, and interactions with others.
The cohort is open to all MC employees—faculty, staff, and administrators—and meets online for nine classes during the academic year. The program ends with participants presenting their projects that they self-selected and developed throughout the year and a graduation ceremony.
Since 1992, 638 employees have graduated from the LDI with increased self-awareness and self-confidence, an increased network of colleagues, and a sense of team bonding. The LDI always has been and continues to be a program that promotes a one-college view, enhancing employees’ abilities to contribute to student success. Be a part of the experience as the LDI begins another decade!
Note that full participation is expected as a requirement for completion. Only one absence is accepted. Additional absences require the participant to return the next year to make up the missed classes.
The application, available in Workday Learning, is due Thursday, September 14.
Classes meet online 8:45 a.m.-noon (*1:30-3 p.m.)
For more information, contact Cynthia Mauris, Training and Development Coordinator.
Professional Development


Wage and Hour Laws
In the U.S. we have employee wage laws at the city, state, and federal levels. Before we talk about the specifics of any one particular law, it’s important to note that an employee is entitled to follow whichever wage laws provide them the highest wage. For instance, where the state minimum wage is lower or higher than the FLSA wage requirement, the employee is entitled to the higher of the two.
Minimum Wage – FLSA
The FLSA became effective in 1938 during the Roosevelt administration. Its goal was to protect workers from exploitation prevalent in the industrial revolution. It provides basic pay standards for employees, such as minimum wage, overtime pay, and child labor standards. The Wage and Hour Division (“WHD”) of the Department of Labor administers and enforces the FLSA with respect to private employers. Employers are required to hang informational posters to educate employees about applicable wage laws. These posters, in several languages, are available on the DoL website for free. You should advise your client that they do not need to, and should not, purchase such posters.
The FLSA minimum wage is $7.25/hour (as of 1/29/22). We have seen bills introduced to amend the FLSA to increase the minimum wage, but they have not passed as of this writing.
Who is covered by the FLSA? Businesses can be subject to the FLSA in three different ways:
Enterprise Coverage: Gross annual revenues of at least $500,000 with at least two employees who handle goods in interstate commerce. This threshold pretty much guarantees that any business with at least two employees that meets the revenue threshold will be required to comply with FLSA because interstate commerce includes using anything that was made out-of-state, e.g. paper, pens, office furniture, etc. Note that if a business has several locations that do similar work (related activities, common control, common business purpose), then they will all be considered as part of the same enterprise for purposes of determining whether the business meets the $500,000 threshold. Organizing each location as a separate entity or with their own EINs does not change this aggregation. Well, what if a business owner has four businesses that meet the related activities, common control, and common business test but one of them only has $50,000 in annual revenue? If the aggregate meets the $500,000 threshold, then all employees at all of the businesses (including the smaller one), will be subject to the FLSA.
Individual coverage: If an employee’s work or job duties involve them in interstate commerce (work that crosses state lines). For example, sending an email that goes out of state or processing a credit card transaction. Individually covered employees are subject to FLSA protection; those that are not will not be.
Named enterprise coverage: There are certain businesses that the FLSA specifically lists to be subject to its requirements, regardless of the size of the business, e.g., hospitals, schools, government agencies.
If a business meets one of the above types of coverage, then it must compensate employees with at least the minimum wage, comply with the overtime rules, child labor rules, and posting of legal information and rights.
Note that the minimum wage for federal contractors increased to $15/hour (eff. Jan. 30, 2022) via the Raise the Wage Act. “[W]hile the $15 minimum wage will apply to construction workers, it will also apply to child care, health care, and building and other services workers employed on federal contracts. About 54% of the workers impacted by this minimum wage increase are women, and about 25% are workers of color. All of the workers who benefit from our minimum wage final rule will get an average raise of $5,228 per year” (Quote in the DoL’s blog, post by Jessica Looman). This new rule applies to not only new contracts but also to extensions or renewals of existing contracts and to the exercise of options within existing contracts. This means that the federal government could exercise an option in an existing contract to make it subject to the $15/hour rule. If you are interested in which contracts are covered and which were exempted/carved out, take a look at the rule. Lawsuits seeking exemption have already started. See, Amanda Pompuro, Judge refuses to exempt Colorado river guides from new $15 federal minimum wage, Missoula Current (Jan. 25, 2022).
Minimum Wage – States
Some states have more generous minimum wage laws; some states have no minimum wage laws showing deference to the FLSA. Look here at the State minimum wage rates as of January 1, 2022. While some states have scheduled incremental increases to reach a $15/hour minimum wage, California already has it for companies with 26 or more employees ($14 for companies with 25 or fewer employees).
Minimum Wage – Cities
New York City is a good example of a city that is proactive regarding those who work within city limits. The minimum wage for businesses in NYC, regardless of business size, is $15/hour.
Overtime – FLSA
Another part of the FLSA has to do with overtime pay. Overtime pay is 1.5 times regular pay and must be paid when an employee works more than 40 hours per week. An employer can set its pay week however it would like but it cannot switch it around. 💡Think about a certain type of business and whether it would make sense for them to deviate from a calendar week for its payroll/workweek.
There is no rule that says that you must pay people hourly, but unless the employee is exempt, you still must look at the number of hours they worked to see if they are working beyond 40 hours per week. For instance, a shuttle service was paying drivers a flat rate without regard to the number of hours they were actually working. Turns out that drivers were working 45-60 hour weeks. The company was ultimately found liable for $742,000 in back wages.
Another issue arises when employers do not count the hours of work properly. Here, an auto repair shop did not accurately calculate the hours worked and also did not include commissions earned when calculating whether overtime pay was due. The result was $79,505 in back wages for 72 workers.
AND if a company asks its workers to waive their right to overtime, and then does not pay them FLSA overtime pay, they will be in violation. “Investigators with the U.S. Department of Labor’s Wage and Hour Division found Alii Security Systems Inc. of Honolulu established a ‘voluntary program’ that offered guards more work hours if they waived their right to overtime and accepted straight-time pay for all hours worked. The division determined the company intentionally violated the Fair Labor Standards Act’s overtime laws, which requires that most employees be paid overtime pay when they work more than 40 hours in a workweek. The division identified $739,886 in back wages and an equal amount in liquidated damages owed to the workers, and assessed $60,000 in civil money penalties for the willful nature of violations.” See the news release.
Remember independent contractors are not protected by the FLSA and therefore not entitled to overtime pay. Therefore, if a company misclassifies its workers as independent contractors, it would be liable if it violated the overtime laws.
Surely there are exemptions from these overtime laws. What if the business pays the employee a salary? Many business owners and managers mistakenly believe that if an employee is salaried, they are automatically exempt from overtime pay. That thinking is over-inclusive and as attorneys, we need to pay attention to the intricacies of the overtime exemptions. So let’s look at the white-collar worker exemption which looks at any employee “employed in a bona fide executive, administrative, or professional capacity.” There are three tests that must be met for the employer to be able to exclude an employee from overtime pay:
- Salary Basis Test – The employee must be paid on a salary or fee basis (not hourly) and that salary cannot be reduceable due to variations in the quality or quantity (hours) of the work performed.
- Standard Salary Level Test – The employee must be paid a certain minimum level of salary (as of 2020 this level is $684/week or $35,568/year).
- Duties Test – The employee’s job duties must primarily involve executive, administrative, or professional duties.
There is also a special category that exempts “highly compensated employees” if their total annual compensation exceeds $107,432 and they customarily and regularly perform at least one of the exempt duties or responsibilities of an executive, administrative, or professional employee.
Computer (IT) professionals can be either paid a salary within the same amounts in #2 above or can be paid by the hour as long as it is at least $27.63/hour.
Sales employees are not required to have a minimum salary.
While our main goal is to advise clients, certainly we would like to know how we, as law professionals, fit within these rules right? 📖 Read 29 CFR § 541.304. Are we exempt from the overtime laws?
As practitioners, we will have to be knowledgeable in the state laws that apply to our clients as well. Sometimes the state aligns well with the FLSA, sometimes they are more generous.
Investigations – FLSA
If employees file complaints with the WHD of the Department of Labor, the WHD may choose to conduct an investigation looking into an employer’s compensation practices. The WHD also selects certain types of business or industries, specifically low-wage industries, to investigate compensation practices. A WHD investigator will review how employers pay their employees and ask to see records, such as payroll and time records. The purpose of these investigations is to determine whether employers have properly classified employees as exempt or non-exempt and whether minimum wage and overtime obligations are met.
Child Labor – FLSA
Often we think that child labor laws are not really being violated any more. We aren’t the same society that was hiring children to work in sewing factories, right? Well let’s see… how about some headlines:
Jordan Valinsky, CNN Business, Chipotle cited with 13,253 child labor law violations in Massachusetts.
[PA] Labor & Industry Helps Return $3.5 Million to Workers Wronged by Employers in 2021 (In 2021, the bureau issued fines to more than 100 entities and collected $3.1 million in child labor fines that were deposited into the general fund.)
Child labor laws were created to “protect the educational opportunities of youth and prohibit their employment in jobs that are detrimental to their health and safety.” It’s an important policy to protect young people and their well-being. Yet we see evidence that these laws are still being violated. Here is a poster for Illinois employers to display in a common area at their workplace that clearly outlines the state’s child labor law and other employment laws.
As you can see there are numerous rules that indeed are designed to limit the hours that children work so as not to interfere with their education and safety concerns.
Notably, Pennsylvania’s child labor laws remained unchanged from 1915 until 2012. In 2012, the Pennsylvania Child Labor Act was enacted, repealing the 1915 act. The law prohibits children under the age of 14 from working (with some exceptions). Anyone under age 18 must have a 30-minute break after 5 consecutive hours of work and they cannot work more than 6 consecutive days. A work permit is required and parental permission with an acknowledgment of duties and hours of employment is also required. PA also adopted the rule from the FLSA that children cannot work in hazardous occupations.
In PA, children who are 15 and under may not work before 7:00 am or after 7:00 pm, except that during school vacation periods they can work until 9:00 pm. They may not work more than 3 hours on a school day or more than 8 hours on a day when there is no school. They may not work more than 18 hours during a regular school week or more than 40 hours when school is not in session. There can be no “youth peddling,” which means they cannot engage in the sale of goods or services or hold signs or merchandise in order to attract potential customers unless the minors are stationed directly in front of the employer’s place of business (this is permissible as volunteers for non-profits).
If children are 16 or 17 they have less stringent rules. They may not work more than 28 hours during a regular school week. They may not work before 6:00 am or after midnight except until 1:00 am on Fridays and Saturdays or on days preceding a vacation during a school year. During school vacation, they may work up to 10 hours in a single day and up to 48 hours per week. If the child is not enrolled in school, there is no hourly limitation.
There are some exceptions to the above, like for volunteer firefighters in training and newspaper delivery people.
The FLSA contains child labor provisions that many states refer to or base their laws on. If your client is in the agricultural business, the rules could be different. Children under 14 are limited as to what they can do and the FLSA provides a list. Some things on the list include: babysitting on a casual basis, delivering newspapers, acting, performing, working as “a homeworker gathering evergreens and making wreaths,” working for a business owned entirely by the child’s parents as long as it is not in mining, manufacturing or hazardous.
As you may expect, the FLSA outlines what is hazardous. Some occupations that are deemed hazardous are:
- Manufacturing or storing of explosives
- Driving a motor vehicle or working as an outside helper on a motor vehicle
- Mining
- Forest fire fighting and prevention
- Logging and sawmilling
- Using power-driven woodworking machines
- Exposure to radioactivity
- Using power-driven metal forming, punching, and shearing machines
- Using power-driven bakery machines
- Using balers, compactors, and power-driven paper products machines
- Manufacturing bricks, tile, and related products
- Using power-driven circular saws, band saws, etc.
- Working in wrecking, demo, and shipbreaking operations
- Roofing
- Trenching or excavating
Children 14-15 may work:
- 3 hours on a school day;
- 18 hours in a school week;
- 8 hours on a non-school day;
- 40 hours in a non-school week; and
- between 7 a.m. and 7 p.m., except from June 1 through Labor Day, when nighttime work hours are extended to 9 p.m.
Notably, the FLSA does not require work permits like Pennsylvania does. It also does not limit the number of hours or times of day that workers 16 years of age and older may legally work.
Jon Hyman, What Should You Do When the DOL Shows Up at Your Door?, Ohio Employer Law Blog (Dec. 7, 2022), https://www.ohioemployerlawblog.com/2022/12/what-should-you-do-when-dol-shows-up-at.html.
Fact Sheet #44: Visits to Employers, Wage and Hour Division: United States Department of Labor (Rev. Jan. 2015), https://www.dol.gov/agencies/whd/fact-sheets/44-flsa-visits-to-employers#:~:text=In%20addition%20to%20complaints%2C%20WHD,such%20as%20growth%20or%20decline.


10.9 Rheumatoid Arthritis
Rheumatoid arthritis (RA) causes symptoms such as bilateral joint pain, stiffness, and swelling. It is known for its pattern of remission and exacerbations, where symptoms might improve and worsen intermittently. Deformities may occur like a swan-like deformity of the hands (see Figure 10.37[1]) or boutonniere deformities, which are firm, observable lumps underneath the skin on or near the base of the joint (see Figure 10.38[2]).[3]
Several risk factors contribute to the development of RA. Women are more likely than men to develop RA, and it commonly begins between the ages of 20 and 50. Genetic predisposition also plays a significant role, so family history of RA can increase the likelihood of occurrence. Chronic stress has also been associated with RA because of its effect on the immune system.
Early diagnosis and appropriate management, including medications, physical therapy, and lifestyle modifications, aim to reduce inflammation, manage symptoms, and slow down joint damage progression in individuals with RA.[4]
Pathophysiology
RA is a chronic, systemic autoimmune disorder primarily affecting the synovial tissue (i.e., the lining of joints). The inflammatory process that occurs in RA is bilateral, meaning it affects both sides of the body, and often involves multiple joints simultaneously. The immune system’s attack on the synovial tissue causes chronic inflammation, which, if left untreated, can cause damage to the joint cartilage, bones, and other nearby structures.
Assessment
Physical assessment findings for rheumatoid arthritis vary based on early versus late stages of the disease. A summary of signs and symptoms of early and late stages of rheumatoid arthritis by body system is provided in Table 10.9.
Table 10.9. Manifestations of Early and Late Stages of Rheumatoid Arthritis[5],[6],[7]
| Body System | Early RA Physical Assessment Findings | Late RA Physical Assessment Findings |
|---|---|---|
| Musculoskeletal | Joint pain and tenderness; swelling, warmth, and erythema at affected joints; morning stiffness lasting greater than 30 minutes; symmetrical involvement of multiple joints (hands, wrists, etc.); muscle weakness; and fatigue | Severe joint deformities (e.g., swan-neck or boutonniere deformities), limited range of motion, joint contractures due to chronic inflammation, joint instability, and muscle wasting due to disuse |
| Cardiovascular | Pericardial friction rub may be heard in auscultation | Increased risk of cardiovascular diseases due to accelerated atherosclerosis |
| Respiratory | Mild pleuritic chest pain or dry cough | Pleurisy (inflammation of lung lining) or interstitial lung disease |
| Neurological | Numbness or tingling due to nerve compression or inflammation. Mild eye dryness or irritation | Peripheral neuropathy, scleritis (inflammation of the eye’s outer layers) |
Diagnostic Testing
Blood tests commonly ordered by health care providers to diagnosis RA include the following[8]:
- Rheumatoid Factor (RF) Antibody Assay: Detects atypical IgG and IgM antibodies commonly found in connective tissue disorders
- Antinuclear Antibody (ANA): Measures antibodies that target cell nuclei, contributing to tissue damage in autoimmune conditions
- Erythrocyte Sedimentation Rate (ESR): Confirms the presence of inflammation or infection throughout the body
- C-reactive Protein (CRP): Assists in gauging the level of inflammation present
Review normal reference ranges for common diagnostic tests in “Appendix A – Normal Reference Ranges.” Diagnostic testing may include X-rays, MRIs, and ultrasounds.
Nursing Diagnoses
For clients diagnosed with RA, nursing diagnoses often revolve around managing symptoms, promoting mobility, and providing support. Common nursing diagnoses for clients with RA include the following:
- Chronic Pain
- Impaired Mobility
- Fatigue
- Risk for Altered Skin Integrity
Outcome Identification
Outcome identification includes setting short- and long-term goals and creating expected outcome statements customized for the client’s specific needs. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions. Sample expected outcomes for a client diagnosed with RA include the following:
- The client will report a reduction in pain levels to 3/10 or less on the pain scale within two weeks.
- The client will accurately demonstrate prescribed exercises and mobility-enhancing techniques within two weeks.
- The client will verbalize a reduction in fatigue levels, reporting increased energy to perform daily activities within three weeks.
- The client will maintain intact skin over nodules utilizing moisturizing techniques.
Interventions
Medical Interventions
Medical interventions include medication therapy and physical/occupational therapy.
Medication Therapy
Medication therapy focuses on managing symptoms, reducing inflammation, and slowing disease progression and may include the following medications[9],[10]:
- Analgesics, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), and Opioids: Acetaminophen, ibuprofen, naproxen, or opioids may be prescribed to manage chronic pain.
- Antimalarial Medications: Antimalarial medications like hydroxychloroquine and chloroquine may be prescribed for their anti-inflammatory properties to manage joint pain and fatigue and to prevent flare-ups.
- Steroids: Prednisone is a corticosteroid that can swiftly reduce inflammation and provide rapid relief. It is often prescribed for acute flare-ups of RA or as a short-term bridge therapy. Intra-articular injections of corticosteroids directly into affected joints can provide targeted relief from pain and inflammation, particularly when specific joints are severely affected.
- Immunosuppressants: Immunosuppressants help to slow down the immune system’s response that causes joint inflammation and damage. Cyclophosphamide is a potent immunosuppressant that may be considered in severe cases of RA.
- Disease-Modifying Anti-Rheumatic Drugs (DMARDs): Medications like methotrexate and sulfasalazine aim to slow or alter the disease progression by modifying the immune response. Methotrexate is one of the most commonly used DMARDs due to its effectiveness in reducing inflammation and slowing joint damage. DMARDs have potentially distressing and life-threatening side effects such as drug reaction with eosinophilia and systemic symptoms (DRESS), erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, torsades de pointes, hepatotoxicity, or aplastic anemia.
- Biological Response Modifiers: Also known as biologics, these medications target specific components of the immune system to reduce inflammation.
- Tumor Necrosis Factor (TNF) Inhibitors: Medications like infliximab and adalimumab are biologics that target TNF, a protein involved in the inflammatory response. They can effectively reduce symptoms and slow joint damage. However, caution is necessary as these medications can suppress the immune system, increasing susceptibility to infections. Therefore, they might not be suitable for clients with serious infections.
Physical/Occupational Therapy
Structured exercise programs and physical therapy are integral for maintaining joint flexibility, strength, and function. Customized exercises help manage pain, prevent muscle atrophy, and improve mobility. Occupational therapists assist clients in adapting their daily routines and environments to reduce strain on joints. They provide guidance on adaptive equipment and techniques for tasks like dressing, cooking, and using tools.[11]
Assistive devices such as splints, braces, or orthotics may be recommended to support and protect affected joints, reducing strain and improving function.[12]

Skin and Joint Care
Nurses assist in joint protection by reinforcing the effective use of splints or braces. If these devices are used, nurses perform skin assessments on areas at risk for skin breakdown and educate clients on proper skin care to prevent pressure injuries.
Health Teaching
Clients taking immune-suppression drugs must follow stringent infection control techniques to minimize the risk of infections. Nurses provide teaching on the following topics:
- Perform Good Hand and Personal Hygiene: Regular and thorough handwashing with soap and water or using alcohol-based hand sanitizers helps prevent the spread of infections. Maintaining good personal hygiene, including regular bathing and oral care, helps prevent the spread of bacteria and viruses.
- Avoid Individuals Who Are Ill: Clients should avoid close contact with individuals who are sick or showing possible signs of infection to reduce the risk of exposure.
- Stay Current on Vaccinations: Staying up-to-date on vaccinations, including flu shots and other recommended vaccines, can provide additional protection against preventable infections.
- Follow Safe Food Handling Practices: Ensuring that food is properly cooked and handling it with care help prevent foodborne illnesses.
- Avoid Crowded Places: Limiting exposure to crowded places, especially during flu seasons or outbreaks, can reduce the risk of coming into contact with infectious agents.
- Use Protective Equipment: Wear face masks, gloves, and other protective equipment in health care and crowded settings to provide an extra layer of protection.
- Maintain Environmental Hygiene: Keep living spaces clean. Regularly disinfect surfaces to help eliminate potential sources of infection.
- Monitor Symptoms: Monitor for signs of infection and seek prompt medical attention if symptoms arise.
- Communicate with Health Care Providers: Open communication with health care providers about symptoms, concerns, and any changes in health status is essential for proper management of RA.
Advocacy and Psychosocial Support
Nurses advocate for clients’ needs within the health care team, ensuring comprehensive care and addressing barriers to treatment. Nurses may collaborate with other health care professionals like physical therapists, occupational therapists, and rheumatologists to ensure a multidisciplinary approach to client care. Nurses promote optimal functioning and independence by providing health teaching on self-care and self-management of chronic illness, including joint protection, energy conservation, and the use of assistive devices to enhance independence.
Nurses also provide active listening and therapeutic communication while addressing the emotional impact of living with a chronic illness. Clients are encouraged to participate in support groups or other community resources to cope with chronic illness and maximize emotional well-being.
Evaluation
During the evaluation stage, nurses determine the effectiveness of nursing interventions for a specific client. The previously identified expected outcomes are reviewed to determine if they were met, partially met, or not met by the time frames indicated. If outcomes are not met or only partially met by the time frame indicated, the nursing care plan is revised. Evaluation should occur every time the nurse implements interventions with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with other members of the interprofessional team.
RN Recap: Rheumatoid Arthritis
View a brief YouTube video overview of rheumatoid arthritis[13]:
- “Rheumatoid_arthritis_--_Smart-Servier_(cropped).jpg” by Laboratoires Servier is licensed under CC BY-SA 3.0 ↵
- “RA_hand_deformity.JPG” by Prashanthns is licensed CC BY-SA 3.0. ↵
- National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2022, November). Rheumatoid arthritis. National Institutes of Health. https://www.niams.nih.gov/health-topics/rheumatoid-arthritis ↵
- Arthritis Foundation. (2021, October 15). Rheumatoid arthritis: Causes, symptoms, treatments and more. https://www.arthritis.org/diseases/rheumatoid-arthritis ↵
- Arthritis Foundation. (2021, October 15). Rheumatoid arthritis: Causes, symptoms, treatments and more. https://www.arthritis.org/diseases/rheumatoid-arthritis ↵
- National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2022, November). Rheumatoid arthritis. National Institutes of Health. https://www.niams.nih.gov/health-topics/rheumatoid-arthritis ↵
- A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2024. Rheumatoid arthritis; [reviewed 2023, Jan. 25; cited 2023, Dec. 15). https://medlineplus.gov/ency/article/000431.htm ↵
- Johns Hopkins Medicine. (n.d.). Diagnosing bone disorders. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/diagnosing-bone-disorders. ↵
- Arthritis Foundation. (2021, October 15). Rheumatoid arthritis: Causes, symptoms, treatments and more. https://www.arthritis.org/diseases/rheumatoid-arthritis ↵
- A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2024. Rheumatoid arthritis; [reviewed 2023, Jan. 25; cited 2023, Dec. 15). https://medlineplus.gov/ency/article/000431.htm ↵
- National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2022, November). Rheumatoid arthritis. National Institutes of Health. https://www.niams.nih.gov/health-topics/rheumatoid-arthritis ↵
- National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2022, November). Rheumatoid arthritis. National Institutes of Health. https://www.niams.nih.gov/health-topics/rheumatoid-arthritis ↵
- Open RN Project. (2024, June 23). Health Alterations - Chapter 10 - Rheumatoid arthritis [Video]. You Tube. CC BY-NC 4.0 https://youtu.be/Jd4KWLSMy9M?si=VJX_ZKbuX7Lm9vd3 ↵
A disease known for patterns of remission and exacerbation causing symptoms such as bilateral joint pain, stiffness, and swelling.
A bending in (flexion) of the base of the finger, a straightening out (extension) of the middle joint, and a bending in (flexion) of the outermost joint.
Observable lumps underneath the skin on or near the base of the joint.


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Chapter 24 Black Holes and Curved Spacetime
24.0 Thinking Ahead
For most of the twentieth century, black holes seemed the stuff of science fiction, portrayed either as monster vacuum cleaners consuming all the matter around them or as tunnels from one universe to another. But the truth about black holes is almost stranger than fiction. As we continue our voyage into the universe, we will discover that black holes are the key to explaining many mysterious and remarkable objects—including collapsed stars and the active centers of giant galaxies.


8 Institutional Priorities
Even the most effective online program is doomed if it is misaligned with institutional priorities.
Key Questions
What are your institutional priorities that relate to online education?
How do these institutional priorities connect to market needs?
Examples
EGYPT
American University in Cairo has identified Innovation and Digital Transformation as key pillars. AUC has also prioritised resources to take first small steps towards a digital presence in the region, with seven fully online professional certificates/diplomas with the AUC brand. Seven AUC EDRAAK MOOCs have been launched since 2015, albeit slowly to experiment with multiple modalities. The university committed resources to staff a digital education unit to design and develop programs in-house, up to 3 programs per year.
UNITED STATES
While each Idaho’s eight institutions have unique missions and priorities, Idaho’s colleges and universities all value access, affordability, and transparency. The development of a statewide digital campus is an example of how these eight institutions are working together to leverage online courses and programs to increase access, affordability, and transparency for all current and potential students.
INDIA
Digital transformation and digital pedagogy are of highest priority from the top in Global University Systems India. Some evidences are found in the media coverage of the CEO of GUS :


30 Chemical Formulas
Learning Objectives
By the end of this section, you will be able to:
- Symbolize the composition of molecules using molecular formulas and empirical formulas
- Represent the bonding arrangement of atoms within molecules using structural formulas
A molecular formula is a representation of a molecule that uses chemical symbols to indicate the types of atoms followed by subscripts to show the number of atoms of each type in the molecule. (A subscript is used only when more than one atom of a given type is present.) Molecular formulas are also used as abbreviations for the names of compounds.
The structural formula for a compound gives the same information as its molecular formula (the types and numbers of atoms in the molecule) but also shows how the atoms are connected in the molecule. The structural formula for methane contains symbols for one C atom and four H atoms, indicating the number of atoms in the molecule (Figure 1). The lines represent bonds that hold the atoms together. (A chemical bond is an attraction between atoms or ions that holds them together in a molecule or a crystal.) We will discuss chemical bonds and see how to predict the arrangement of atoms in a molecule later. For now, simply know that the lines are an indication of how the atoms are connected in a molecule. A ball-and-stick model shows the geometric arrangement of the atoms with atomic sizes not to scale, and a space-filling model shows the relative sizes of the atoms.
Although many elements consist of discrete, individual atoms, some exist as molecules made up of two or more atoms of the element chemically bonded together. For example, most samples of the elements hydrogen, oxygen, and nitrogen are composed of molecules that contain two atoms each (called diatomic molecules) and thus have the molecular formulas H2, O2, and N2, respectively. Other elements commonly found as diatomic molecules are fluorine (F2), chlorine (Cl2), bromine (Br2), and iodine (I2). The most common form of the element sulfur is composed of molecules that consist of eight atoms of sulfur; its molecular formula is S8 (Figure 2).
It is important to note that a subscript following a symbol and a number in front of a symbol do not represent the same thing; for example, H2 and 2H represent distinctly different species. H2 is a molecular formula; it represents a diatomic molecule of hydrogen, consisting of two atoms of the element that are chemically bonded together. The expression 2H, on the other hand, indicates two separate hydrogen atoms that are not combined as a unit. The expression 2H2 represents two molecules of diatomic hydrogen (Figure 3).
Compounds are formed when two or more elements chemically combine, resulting in the formation of bonds. For example, hydrogen and oxygen can react to form water, and sodium and chlorine can react to form table salt. We sometimes describe the composition of these compounds with an empirical formula, which indicates the types of atoms present and the simplest whole-number ratio of the number of atoms (or ions) in the compound. For example, titanium dioxide (used as pigment in white paint and in the thick, white, blocking type of sunscreen) has an empirical formula of TiO2. This identifies the elements titanium (Ti) and oxygen (O) as the constituents of titanium dioxide, and indicates the presence of twice as many atoms of the element oxygen as atoms of the element titanium (Figure 4).
As discussed previously, we can describe a compound with a molecular formula, in which the subscripts indicate the actual numbers of atoms of each element in a molecule of the compound. In many cases, the molecular formula of a substance is derived from experimental determination of both its empirical formula and its molecular mass (the sum of atomic masses for all atoms composing the molecule). For example, it can be determined experimentally that benzene contains two elements, carbon (C) and hydrogen (H), and that for every carbon atom in benzene, there is one hydrogen atom. Thus, the empirical formula is CH. An experimental determination of the molecular mass reveals that a molecule of benzene contains six carbon atoms and six hydrogen atoms, so the molecular formula for benzene is C6H6 (Figure 5).
If we know a compound’s formula, we can easily determine the empirical formula. (This is somewhat of an academic exercise; the reverse chronology is generally followed in actual practice.) For example, the molecular formula for acetic acid, the component that gives vinegar its sharp taste, is C2H4O2. This formula indicates that a molecule of acetic acid (Figure 6) contains two carbon atoms, four hydrogen atoms, and two oxygen atoms. The ratio of atoms is 2:4:2. Dividing by the lowest common denominator (2) gives the simplest, whole-number ratio of atoms, 1:2:1, so the empirical formula is CH2O. Note that a molecular formula is always a whole-number multiple of an empirical formula.
Example 1: Empirical and Molecular Formulas
Molecules of glucose (blood sugar) contain 6 carbon atoms, 12 hydrogen atoms, and 6 oxygen atoms. What are the molecular and empirical formulas of glucose?
Show Answer
The molecular formula is C6H12O6 because one molecule actually contains 6 C, 12 H, and 6 O atoms. The simplest whole-number ratio of C to H to O atoms in glucose is 1:2:1, so the empirical formula is CH2O.
Check Your Learning
A molecule of metaldehyde (a pesticide used for snails and slugs) contains 8 carbon atoms, 16 hydrogen atoms, and 4 oxygen atoms. What are the molecular and empirical formulas of metaldehyde?
Show Answer
Molecular formula, C8H16O4; empirical formula, C2H4O
Portrait of a Chemist: Lee Cronin
What is it that chemists do? According to Lee Cronin (Figure 7), chemists make very complicated molecules by “chopping up” small molecules and “reverse engineering” them. He wonders if we could “make a really cool universal chemistry set” by what he calls “app-ing” chemistry. Could we “app” chemistry?
In a 2012 TED talk, Lee describes one fascinating possibility: combining a collection of chemical “inks” with a 3D printer capable of fabricating a reaction apparatus (tiny test tubes, beakers, and the like) to fashion a “universal toolkit of chemistry.” This toolkit could be used to create custom-tailored drugs to fight a new superbug or to “print” medicine personally configured to your genetic makeup, environment, and health situation. Says Cronin, “What Apple did for music, I’d like to do for the discovery and distribution of prescription drugs.”[1] View his full talk from the TED website.
It is important to be aware that it may be possible for the same atoms to be arranged in different ways: Compounds with the same molecular formula may have different atom-to-atom bonding and therefore different structures. For example, could there be another compound with the same formula as acetic acid, C2H4O2? And if so, what would be the structure of its molecules?
If you predict that another compound with the formula C2H4O2 could exist, then you demonstrated good chemical insight and are correct. Two C atoms, four H atoms, and two O atoms can also be arranged to form a methyl formate, which is used in manufacturing, as an insecticide, and for quick-drying finishes. Methyl formate molecules have one of the oxygen atoms between the two carbon atoms, differing from the arrangement in acetic acid molecules. Acetic acid and methyl formate are examples of isomers—compounds with the same chemical formula but different molecular structures (Figure 8). Note that this small difference in the arrangement of the atoms has a major effect on their respective chemical properties. You would certainly not want to use a solution of methyl formate as a substitute for a solution of acetic acid (vinegar) when you make salad dressing.
Many types of isomers exist (Figure 9). Acetic acid and methyl formate are structural isomers, compounds in which the molecules differ in how the atoms are connected to each other. There are also various types of spatial isomers, in which the relative orientations of the atoms in space can be different. For example, the compound carvone (found in caraway seeds, spearmint, and mandarin orange peels) consists of two isomers that are mirror images of each other.
Key Concepts and Summary
A molecular formula uses chemical symbols and subscripts to indicate the exact numbers of different atoms in a molecule or compound. An empirical formula gives the simplest, whole-number ratio of atoms in a compound. A structural formula indicates the bonding arrangement of the atoms in the molecule. Ball-and-stick and space-filling models show the geometric arrangement of atoms in a molecule. Isomers are compounds with the same molecular formula but different arrangements of atoms.
Exercises
- Explain why the symbol for an atom of the element oxygen and the formula for a molecule of oxygen differ.
- Explain why the symbol for the element sulfur and the formula for a molecule of sulfur differ.
- Write the molecular and empirical formulas of the following compounds:
- Write the molecular and empirical formulas of the following compounds:
- Determine the empirical formulas for the following compounds:
- caffeine, C8H10N4O2
- fructose, C12H22O11
- hydrogen peroxide, H2O2
- glucose, C6H12O6
- ascorbic acid (vitamin C), C6H8O6
- Determine the empirical formulas for the following compounds:
- acetic acid, C2H4O2
- citric acid, C6H8O7
- hydrazine, N2H4
- nicotine, C10H14N2
- butane, C4H10
- Write the empirical formulas for the following compounds:
Show Selected Answers
1. The symbol for the element oxygen, O, represents both the element and one atom of oxygen. A molecule of oxygen, O2, contains two oxygen atoms; the subscript 2 in the formula must be used to distinguish the diatomic molecule from two single oxygen atoms.
3. (a) molecular CO2, empirical CO2; (b) molecular C2H2, empirical CH; (c) molecular C2H4, empirical CH2; (d) molecular H2SO4, empirical H2SO4
5. (a) C4H5N2O; (b) C12H22O11; (c) HO; (d) CH2O; (e) C3H4O3
7. (a) CH2O; (b) C2H4O
PhET Exercises
- Open the Build a Molecule simulation and select the “Larger Molecules” tab. Select an appropriate atoms “Kit” to build a molecule with two carbon and six hydrogen atoms. Drag atoms into the space above the “Kit” to make a molecule. A name will appear when you have made an actual molecule that exists (even if it is not the one you want). You can use the scissors tool to separate atoms if you would like to change the connections. Click on “3D” to see the molecule, and look at both the space-filling and ball-and-stick possibilities.
- Draw the structural formula of this molecule and state its name.
- Can you arrange these atoms in any way to make a different compound?
- Use the Build a Molecule simulation to repeat question 8, but build a molecule with two carbons, six hydrogens, and one oxygen.
- Draw the structural formula of this molecule and state its name.
- Can you arrange these atoms to make a different molecule? If so, draw its structural formula and state its name.
- How are the molecules drawn in (a) and (b) the same? How do they differ? What are they called (the type of relationship between these molecules, not their names).
- Use the Build a Molecule simulation to repeat question 8, but build a molecule with three carbons, seven hydrogens, and one chlorine.
- Draw the structural formula of this molecule and state its name.
- Can you arrange these atoms to make a different molecule? If so, draw its structural formula and state its name.
- How are the molecules drawn in (a) and (b) the same? How do they differ? What are they called (the type of relationship between these molecules, not their names)?
Show Answers to Question 2
- ethanol
- methoxymethane, more commonly known as dimethyl ether
- These molecules have the same chemical composition (types and number of atoms) but different chemical structures. They are structural isomers.
Glossary
empirical formula: formula showing the composition of a compound given as the simplest whole-number ratio of atoms
isomers: compounds with the same chemical formula but different structures
molecular formula: formula indicating the composition of a molecule of a compound and giving the actual number of atoms of each element in a molecule of the compound.
spatial isomers: compounds in which the relative orientations of the atoms in space differ
structural formula: shows the atoms in a molecule and how they are connected
- Lee Cronin, “Print Your Own Medicine,” Talk presented at TED Global 2012, Edinburgh, Scotland, June 2012. ↵


63 Shortcodes
Contents
Overview
A shortcode is code similar to HTML, but is Pressbooks-specific and allows you to easily insert formatting or content elements. Shortcodes are typically easier to use than HTML and can be used both in the Visual Editor and in the Text editor.
For most users, inserting content via the Visual Editor will be the easiest option. However, for users whose workflow involves importing Word documents into Pressbooks or copy/pasting from a manuscript written in a different editor, shortcodes are a convenient way to insert or format content elements that are Pressbooks-specific.
Most of these shortcodes support custom classes. For more information on applying custom classes, see the “Applying Custom Classes” section at the end of this chapter.
Available Shortcodes
Headings and subheadings
[heading]Top-level heading inside chapter (H1)[/heading]
[subheading]Second-level heading inside chapter (H2)[/subheading]
Description: Formats the text as a heading (h1) or subheading (h2). Note that the “heading” is not the chapter title, but the next level of headings.
Custom classes may be applied to this shortcode.
| Example Code | Example Output |
Code
[code]Text to be rendered in fixed-width font.[/code]
Description: Formats the text with fixed-width font. HTML tags can be displayed if they are entered in the visual editor (Pressbooks will automatically convert them to HTML character entities).
Custom classes may be applied to this shortcode.
| Example Code | Example Output |
| The code can also be a block. 4 spaces before the line here and here more code [/code]” width=”370″ height=”108″> |
Note: for the second example above, the text needs to be entered in the Text Editor, with no extra blank lines between lines of text, otherwise it will not display correctly.
<EMAIL_ADDRESS>OR
[email<EMAIL_ADDRESS>/]
OR
[email<EMAIL_ADDRESS>to be displayed[/email]
Description: Formats the email address into a proper email link. This shortcode has multiple variants.
Custom classes may be applied to this shortcode.
| Example Code | Example Output |
<EMAIL_ADDRESS>|
<EMAIL_ADDRESS>|
[email address=<EMAIL_ADDRESS>/] |
<EMAIL_ADDRESS>|
[email address=<EMAIL_ADDRESS>] Email us [/email] |
Email us |
Equations/Latex
[equation]latex code here[/equation]
OR
[latex]latex code here[/latex]
| Example Code | Example Output |
| [equation]e^{\i \pi} + 1 = 0[/equation] |
Blockquote
[blockquote]Text to be formatted as a blockquote[/blockquote]
Description: formats the content as a block quote.
Custom classes may be applied to this shortcode.
| Example Code | Example Output |
Footnotes
[footnote]Your footnote text here [/footnote]
Description: Formats text into a footnote.
In the visual editor, the footnote text, wrapped in the shortcode, should be placed where the footnote reference number should be located, and not at the end of the chapter or page.
| Example Code | Example Output |
| This leads to a footnote[footnote]This is the footnote content. [/footnote]. |
Anchor
[anchor id=anchorname /]
Description: Creates an anchor which can then be linked to via href=”#anchorname”.
The ID is required. It is recommended to only use letters, numbers, hyphens (-) and underscores (_) in the ID. Note that the ID is case-sensitive.
A custom class may be applied to this element.
| Example Code | Example Output |
Note: by default, the anchor is “invisible”; it is displayed without any visual element associated with it.
Textbox
[textbox]Your text here[/textbox]
OR
[textbox class=shaded]Your text here[/textbox]
Description: Wraps the text inside a box with an outline. Depending on the selected theme, the box may have a background color.
The preset “shaded” class or custom classes may be applied to the textbox shortcode in order to change the appearance upon display.
| Example Code | Example Output |
Columns
[columns]Your text here[/columns]
OR
[columns count=2]Your text will be displayed in 2 columns[/columns]
OR
[columns count=3]Your text will be displayed in 3 columns[/columns]
Description: Formats text in 2 or 3 columns. If the number of columns is not specified, or is a number other than 2 or 3, the text defaults to 2 columns.
A custom class may be applied to this element.
| Example Code | Example Output |
Media
[media src="URL_of_the_video" /]
OR
[media src="URL_of_the_video" caption="Your caption text goes here" /]
Description: Embeds media content (usually videos) in an iframe, with an optional caption. The video must be oEmbed-compatible.
Please note that videos do not support alt-text.
| Example Code | Example Output |
Captions
[caption width=""]<image> Caption text here[/caption]
Description: formats text as a caption. This is used usually with an image.
This is a WordPress built-in shortcode. For more information, please consult the WordPress documentation on the Caption shortcode. The caption shortcode requires the Width parameter to work. The width indicates the width of the caption in pixels.
| Example Code | Example Output |
Notes: The caption shortcode can be inserted via the Visual Editor, and will look like the image on the left. If you then switch to the Text Editor, and back to the Visual Editor, the content will be updated to look like the image on the right, even in the visual editor.
Image gallery
[gallery ids=""]
Description: This is a WordPress built-in shortcode that displays a series of images as tiles, in an image gallery. The shortcode only works with image IDs, which are only assigned after the images are uploaded into Pressbooks.
Unless otherwise specified, the images automatically link to the attachment page for each image.
For more information on the various options available with this shortcode, please consult the WordPress documentation on the Gallery shortcode.
Please note that the Pressbooks themes do not currently support image galleries, which means the design of the image gallery will be very basic and it may not work will all export formats.
| Example Code | Example Output |
| [gallery ids="68,34,264"] |
Embed
[embed]URL_of_the_video[/embed]
Description: This is a WordPress built-in shortcode that allows setting height and width parameters on embedded media content (videos, audio, and other interactive content). Note that media from some sources may have their height and width parameters overridden by Pressbooks to make the content responsive to screen size.
Note that all content supported by the embed shortcode can be embedded by directly pasting the URL into the visual editor. We recommend this method a) if you are adding width and height parameters, or b) if you are formatting your content on another platform and then importing it to Pressbooks.
For more information on usage and supported sources, see the WordPress documentation on the Embed shortcode and our user guide chapter on embedded content.
Please note that content not supported by the embedding feature will display as a regular link.
| Example Code | Example Output |
Appplying Custom Classes
If you are familiar with CSS, you may apply custom classes and use custom CSS to modify the appearance of some of the elements. Shortcodes that support custom classes are indicated in the descriptions above. Custom classes in the shortcodes work the same way as custom classes in HTML, by adding class=""
.
For example, adding a custom class to a textbox:
[textbox class=custom_class]Your text here[/textbox]
Nested Shortcodes
There are known issues with nesting shortcodes within other shortcodes. In general, we would recommend that you avoid using shortcodes within shortcodes in your book content and suggest that when possible you use another formatting method for one of the nested functions.
Almost every shortcode has an alternate styling method available from the visual editor toolbar. The only shortcode elements that do not have a non-shortcode alternative are:
- Footnotes
- Glossary terms
- Captions
- Image gallery
We cannot guarantee that all combinations of nested shortcodes will function correctly in webbooks and various exports, but the following have been tested and verified:
- [latex][/latex] shortcodes inside of [footnote] and [blockquote] shortcodes
- [media] shortcodes inside of [glossary] shortcodes
- [footnote] shortcodes inside of [textbox] shortcodes


Activity
Now that you’ve watched the video, go to Occupy Wall Street’s Facebook page and do a close reading of the page and select another post with active comments. Gather a list of as many patterns, key words, new words, or contrasts you can identify. You should also answer the following questions to gather observations about the medium of the Facebook page:
- What specific language is unique to the medium being used? How is your specific user using this language? (“Like,” “Shares,” “Group”)
- What mechanics are UNIQUE to the SPECIFIC central document – i.e. a word limit, a focus on photographs, the image disappears after a set amount of time etc.
- What numbers are present on the page? What actions of documents are the numbers related to? How large are the numbers?
- What is the most common action on this page? Posting text? Posting photos? Commenting?
- How active is this page? How frequent is user activity?


Skeletal muscle fibers can be characterized by their metabolic processes and corresponding physiological traits.
142 Types of Skeletal Muscle Fibers
Slow-twitch and fast-twitch skeletal muscle fibers can be characterized by their metabolic processes and corresponding physiological traits.
LEARNING OBJECTIVE
By the end of this section, you will be able to:
- Differentiate between the types of skeletal muscle fibers
KEY POINTS
- Oxidative fibers rely on aerobic respiration to fuel muscle contractions, and include slow-twitch fibers, which are characterized as muscles with long contraction duration, associated with endurance.
- Glycolytic fibers rely on glycolysis to fuel muscle contractions and include fast-twitch fibers, which are characterized by fast muscle contractions of short duration.
- The proportion of fast-twitch vs. slow-twitch muscles of an individual is partly genetic in nature. However, concentrated exercise that prioritizes one type of muscle fiber use over the other can improve an individual’s ability to perform related physical activities.
GLOSSARY
fast-twitch: Type II fibers which are characterized by fast muscle contractions of short duration.
slow-twitch: Type I fibers characterized as muscles with long contraction duration, associated with endurance.
glycolytic: Of, pertaining to or producing glycolysis, which is the metabolic pathway that converts glucose into pyruvate.
Oxidative fibers rely on aerobic respiration to fuel muscle contractions, and consist of slow-twitch (Type I) fibers, which are characterized as muscles with long contraction duration, associated with endurance. Slow-twitch fibers are used to maintain posture. They are usually found in red muscles, indicative of the large concentration of myoglobin providing a steady supply of oxygen to them. The red muscles use oxidative phosphorylation to obtain ATP. Oxidative phosphorylation occurs in the red muscles as the process requires a lot of oxygen, and the red muscles contain high amounts of myoglobin. The process is slower than glycolysis, but much more efficient, which is why slow-twitch muscles do not tire easily. Also, slow-twitch fibers contain less sarcoplasmic reticulum, facilitating a slower release of calcium, regulating muscle contraction at slower rates.
Glycolytic fibers rely on glycolysis to fuel muscle contractions and consist of fast-twitch (Type II) fibers, which are characterized by fast muscle contractions of short duration. Fast-twitch fibers are constituents of white muscles and have less myoglobin due to their primary reliance on glycolysis (anaerobic respiration) to fuel muscle contractions. Although glycolysis is very quick, it is also inefficient at producing ATP. Glycolysis produces lactic acid as a byproduct, which leads to fatigue. The use of the glycogen cycle is the reason why fast-twitch muscles tire out quickly.
There is some evidence that the proportion of fast-twitch versus slow-twitch muscles of an individual is partly genetic in nature. That is, we are born with a unique proportion of such muscles that suit us to particular types of physical activity. This is not without debate, however. Regardless, concentrated exercise that prioritizes one type of muscle fiber use over the other, can lead to muscle hypertrophy (increase in size), improving an individual’s ability to perform related physical activities.