head to toe yoost Flashcards
what determines ski color and hue
pigment
what causes white pinkish skin
low melanin
absence of pigment is called
albinism
what is cyanosis
blue discoloration of the skin nail beds or mucous
what causes cyanosis
casoconstriction or deoxygenated hemoglobin in blood vessels newar skin
what is erythema
redness of skin
syoptoms of erythema
congestion or dialation of superficial vessels in skin,
what causes erythema
skin injury
sunburn
infection
fever
purpura is
bleeding underneath the skin
what does purpura indicate
vascular coagulation, platelet disorder
jaundice
yellow hue to skin, mucous membrain, eyes
causes of jaundice
excess bilirubin, liver failure
best site to check for jaundice
sclera, the hard palate, darker skinned people
pallor is
pale or lighetened skin tone
pallor causes
illness, emotional shock, stress, decreased exposure to sunlight, anemia, may be genetic
where is pallor observed
face, oral mucosa, nail beds, palms of hands, conjuctiva of eye
vitiligo is
loss of skin pigment
vitiligo causes
result of autoimmune response
skin lesions causes
benign, age related skin, skin tags, cherry angiomas, keratosis, warts, freckles
what is petechiae
tiny dark red spots
what does petechiae idicate
hemorrhage (blood) under skin
skin malignancies
a type of canser
taninng before age 35 increase the risk for
melanoma (deadliest skin canser)
skin lesion types
macule/ patch
papule/plaque
nodule
tumor
vesicle/bulla
pustule
wheal
burrow
cyst
Macule/Patch is
flat
>1cm
papule/plaque looks
solid, raised
>0.5cm
nodule looks like
raised with defined borders
0.5-2 cm
tumor looks like
solid mass
undefined bordes
>1-2cm
vesicle/bulla looks like
circumscribed
raised
<0.5
pustule
similar to vesicle, acne
wheal look like
hives, insect bites
burrow looks like
linear or circular
scabies mites
cyst look like
encapsulated fluid/ solid mass
cyst
Turgor
skin elasticity or ability to resist deformity after being displaced
edema is
swelling
edema cause
buildup of fluid in underlying tissue
trauma to an area
impairment of venous return
if you find hair on ___ etc it not normal
lips, palms, soles of feet, niples, labia minora, penis
types of skin cancer
basal cell carcinoma
squamous cell carcinoma
melanoma
basal cell carcinoma causes
sun exposure
fair complexions
family history
weakened immune system
radiation therapy
age
what causes squamous cell carcinoma
chronic sun exposure
rest as same for basal cell carcinoma
causes of melanoma
sun exposure
fair complexions
freckling
light hair
multiple moles
male gender
history of cancer in family or person
immune suppression
ABCDE when looking for malenoma
a= asymmetry
b=border
c=color
d=diameter
e=evolving
assymmetry of melanoma
one half of leasion do not match other half
border of malenoma
irregular/ uneven
color of malenoma
tan, brown, black, white, red, blue
diamertar of malenoma
6+ cm
evolving in malenoma
changes in shape color size
Documentation of Pitting Edema size
slight pit 2mm
depper pit 4mm
deep pit 6mm
very deep pit 8mm
when hair grow on lip its called
hirsutism
permanent or temprorary hair loss is called
alopecia
pruritus means
itching
nails are supposed to be
hard
Nail Shape abnormalietes
splinter hemorrhage
paronychia
clubbing
beaus lines
koilonychia
muehrcke
what does splinter hemorrhage look like and causes
red or purple
brown streak on nail bed
Minor trauma, trichinosis, subacute bacterial endocarditis
Paronychia what does look like and why
Inflammation of the skin at the base of the nail
causes:
Local infection
Acute: Staphylococcus aureus, herpes simplex virus
Chronic: Candida albicans, Pseudomonas spp.
Clubbing what does look like and why
Enlargement of the fingertips, softening of the nail bed, and flattening of the nail; angle between the nail plate and the nail often greater than 180 degrees
Nail injury, systemic injury, eczema, psoriasis, paronychia
Koilonychia what does look like and why
Concave curves of the nail, with thinning of the nail plate; also called “spoon nail”
Iron deficiency anemia, repeated chemical trauma, syphilis
Beau’s lines what does look like and why
Transverse ridging in nails due to a temporary halt in nail growth
Muehrcke lines what does look like and why
Double band of white lines (leukonychia)
Renal disease
Obtaining a health history begins with
patient interview
Physical examination requires
privacy
Equipment Used for Physical Examination
Patient gown
* Scale
* Height assessment tool
* Sphygmomanometer with cuff
* Stethoscope with bell and diaphragm
* Thermometer
* Wristwatch
* Pulse oximeter
* Disposable pads and/or examination table paper
* Bath blanket or sheet
* Gloves
* Cotton applicators and/or cotton balls
* Eye chart
* Flashlight or penlight
* Otoscope and ophthalmoscope
* Tuning fork
* Tongue depressor
* Reflex hammer
* Tape measure or ruler
* Specimen containers, as needed
The following should be done with all specimen containers
Handle with gloves.
* Wipe clean of debris.
* Mark or label with the patient’s identification information.
* Bag after collection before sending the specimen to the laboratory.
Patient’s emotional and physical responses often depend on their level of
comfort or anxiety
positions required for physical assessment depends on the patient’s level of
mobility, physical strength, and comorbid conditions
comorbid conditions is
two or more medical conditions existing simultaneously
chief complaint
presenting problem
clinical manifestations
signs and symptoms
Physical Examination Positions
Supine
Dorsal recumbent position
fowler
lithotomy
prone
left lateral recumbent
knee chest
supine position is to examine
To examine the head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen, extremities, and pulses
Dorsal recumbent is to examine
To examine the head and neck, anterior thorax and lungs, breasts, axillae, heart, and abdomen
fowler is to examine
To examine the head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen, lower extremities, and pulses
Lithotomy is to examine
To examine the female genitalia
Prone is to examine
To examine the back, spine, posterior aspect of the head, neck, thorax, buttocks, and lower extremities
Left lateral recumbent is to examine
To examine the rectal and perineal areas
Knee-chest is to examine
rectal area
accumulation of cerebrospinal fluid in the ventricles of the brain is called
hydrocephalus
crossed eyes is called
Strabismus
causes of strabismus
due to muscle weakness or paralysis
seeing double is called
diplopia
The eyes are positioned on each side of the nasal bone, approximately
1 to 2 inches apart from one inner canthus to the other
When abnormal drooping of the eyelid occurs, the condition is known as
ptosis
The sclera is examined to check its
color and ensure that it is intact, without lesions
the cornea refracts light and accounts for approximately ______ of the eye’s total optical power
two-thirds
Documentation of a normal pupillary reflex examination is recorded as
PERRLA
PERRLA stands for
pupils equal, round, reactive to light and accommodation
Movement of the eyes in all directions is controlled by the combined function of three cranial nerves which are
III, oculomotor; IV, trochlear; and VI, abducens
rapid, shaking, involuntary movement of the eyes is called
nystagmus
cranial nerve II control
patency and central vision
if a patient cant see far what nerve Is likely the cause
cranial nerve 2
Cataracts are
Opacity or clouding of the eye lens
cataracts causes
Increasing age, female gender
* Prolonged sun exposure
* Cigarette smoking, alcohol or steroid use
* Diet low in antioxidants
Glaucoma is
Optic neuropathy, usually associated with increased intraocular pressure
Glaucoma causes
Increased age, African or Hispanic ancestry
* Migraines, diabetes, low blood pressure
* Increased intraocular pressure
* Family history
* Eye injury
Macular Degeneration
- Deterioration of the macula, the area on the retina that is responsible for central vision, allowing for clear vision of fine details; Two types: dry and wet
Macular Degeneration causes
- Family history, white ancestry
- Overactive immune system causing inflammation
- Smoking, hypertension, hypercholesterolemia
Myopia is
Nearsightedness
myopia causes
Familial history
Hyperopia is
Farsightedness
Hyperopia causes
Familial history
Presbyopia is
age-related loss of near vision
Presbyopia causes
Age older than 40 years
Ophthalmoscope is used for
Examination of the internal structures of the eye
Physical examination of the ear begins with direct inspection and palpation of
outer ear
Inspect the external ear canal for
discharge or drainage
purulent means
containing pus
purulent can indicate
indicate infection or foreign body penetration of the middle ear
cerumen is
earwax
cerumen color should be
yellow to dark brown
Insert the speculum no more than 1 to
1.5 cm
tinnitus is ______ _______ ______ in the ears
ringing, buzzing, or roaring in the ears
tinntitus indicate
hearing loss, overuse of salicylates
symptomatic of diseases that cause vertigo
whats vertigo
disequilibrium, spinning sensation
vertigo causes
Ménière disease
Hearing loss may result from
trauma, aging, heredity, disease, medication, and prolonged exposure to high-decibel sound
three primary types of hearing loss are
sensorineural, conductive, and mixed
Sensorineural hearing loss is due to
inner ear damage
Conductive hearing loss occurs when
something interferes with the transmission of sound via vibration to the inner ear
most common causes of vibration interruption
Fluid in the middle ear and cerumen accumulation
Mixed hearing loss results from
middle-ear and nerve damage
Weber Test is conducted when
patient complains of hearing loss in one ear
what is weber test conducted with
tuning fork
Rinne Test compares ______and _______ conduction
bone, air
Air-conducted sound should be heard _______as long as bone-conducted sound
twice
Patients with inner ear disorders often experience a loss of
equilibrium and vertigo.
Romberg Test is conducted to assess the patient’s
equilibrium
Inability to stay balanced with eyes closed during romberg test may indicate
vestibular disease
The nose and sinuses are inspected and palpated with the patient
seated or standing?
seated
The skin on and around the nose should be
smooth, even, and consistent with the color of facial skin tones
excoriation means
abrasion due to rubbing or scratching
Ask the patient to breathe through one nostril at a time, while the opposite nostril is pressed closed with a fingertip to check for
if air passes freely through nostrils
epistaxis is
noesbleed
epistaxis causes
high blood pressure or diabetes.
Assessment of the mouth, throat, and neck provides the nurse with the opportunity to evaluate many aspects of the patient’s health status, including:
- Oral hygiene
- Condition of the teeth and gums
- Hydration status
- Airway patency
- Ability to meet nutrition needs
- Patency of cerebral blood flow
Dry, cracked lips are called
cheilitis
cheilitis causes
dehydration from limited oral intake or exposure to excessive heat (hyperthermia) or cold
To test cranial nerve VII (facial nerve) function, ask the patient to demonstrate
clenching the teeth and then smiling if they can do it that good It indicates its working normally
inspect the teeth for
color, irregular shape, cavities, and Loose or missing teeth
Using a _____ _______ and ________, inspect the buccal mucosa, teeth, gums, tongue, uvula, tonsils, and palate for color, texture, lesions, ulcers, bleeding, and patency
tongue blade, penlight
The superficial lymph nodes in the neck, are _______ ______ under normal circumstances
not palpable
lymph nodes becomes enlarged when
it receives drainage from a specific area of infection or disease
The jugular veins are observed for ________ and ________
distention, blood flow
JVD stand for
jugular vein distention
carotid arteries, which provide ______ supply to the _____, are assessed for _____of _____ _____
blood, head, patency, blood flow
bruit is
abnormal “swooshing” sound
Inspect the thyroid gland for ______and _______
position, enlargment
The thyroid gland is the _______ endocrine gland in the body
largest
Assessment of respiratory status begins with questioning the patient about
risks for pulmonary complications
Questions
Respiratory System
- How far can you walk on level ground?
- How many stairs are you able to climb without becoming short of breath?
- Do you have a cough? If so, when did it start?
- Do you cough up mucus or blood? If so, describe the color and consistency.
- Can you lie flat when sleeping?
- Do you snore?
- Do you use oxygen or breathing machines at home? If so, how often and at what setting?
- Do you ever experience shortness of breath either at rest or with exercise?
- Do you have any pain with breathing?
- Is the pain associated with coughing, shortness of breath, trauma, nasal congestion, or sore throat?
- Does chest pain cause splinting, shallow breathing, or uneven chest expansion, or does it radiate to the back, neck, or arms?
- What relieves the chest pain associated with respiration?
- Do you have any recent history of trauma or infection?
- Do you have a history of chronic conditions that affect respiration, including allergies, emphysema, chronic obstructive pulmonary disease, tuberculosis, cystic fibrosis, or asthma?
- Do you have a history of tumors or lung cancer?
- Do you use tobacco or marijuana? If so, how many years and packs per day?
- Have you been exposed to dust, fumes, or smoke in the environment at work or home?
- Have you traveled out of the country recently?
Inspection of the anterior and posterior thorax for symmetry and shape includes inspecting the following
chest hair for color, thickness, and even distribution
Nipples should be centered on either side of the sternum
Observe the spine (normally is midline and straight)
Ribs should slope downward
scapulae lie flat on either side of the spine
anteroposterior (AP) measurement of the chestnormal ratios of 1:2 to 5:7.
Normal breathing patterns are _______, _______, and effortless
relaxed, automatic, effortless
normal respiratory rate
12 and 20 bpm
Chest pain, shortness of breath, coughing, or diaphoresis may occur when
pulmonary embolism (PE), deep vein thrombosis (DVT) is present
the two types of venous thromboembolism (VTE)
pulmonary embolism (PE)
deep vein thrombosis (DVT)
Tactile fremitus is decreased or absent in patients with conditions that obstruct lung tissue, such as
pneumothorax, tumors, pleural effusion, or COPD
Tactile fremitus can increase with _____
pneumonia or consolidation close to the chest wall.
atelectasis is
collapse of all or part of the lung
breath sounds may be decreased or absent because of _______
atelectasis
normal Breath Sound tracheal pitch quality amplitude and location
Pitch high
Quality harsh
Amplitude loud
Over the trachea
normal Breath Sound Bronchial pitch quality amplitude and location
Pitch high
Quality hollow
Amplitude loud
Over the main bronchi
normal Breath Sound Bronchovesicular pitch quality amplitude and location
Pitch medium
Quality mixed
Amplitude medium
Posterior between the scapulae; anterior around the upper sternum in the first two intercostal spaces
normal Breath Sound pitch quality amplitude and location: vesicular
Pitch low
Quality blowing
Amplitude soft
Over most of the lung fields
Assist the patient into a supine position or raise the head of the bed 45 degrees to inspect and palpate the ________
Cardiac function (heart)
Adventitious Breath Sounds
Crackles
Rhonchi
Wheezing
Stridor
Pleural friction rub
Crackles sounds like
Brief crackling, popping sounds
Rhonchi sounds like
Low-pitched, snoring sounds
Wheezing sounds like
High-pitched, whistling sound
Stridor sounds like
Intense, high-pitched, and continuous monophonic wheeze or crowing sound
Pleural friction rub sounds like
Low-pitched, grating, or creaking sound
Health Assessment Questions
Cardiovascular System
Are you experiencing chest pain? If so, describe the pain. When was its onset or when did the pain begin? What is its duration or how long have you had this pain? What are the characteristics of the pain (sharp, stabbing, aching, burning, viselike)? Where is the pain? Does the pain radiate? What relieves the pain? Are there any other symptoms associated with the pain?
* Do you have any palpitations or extreme fatigue?
* Do you have any difficulty breathing or difficulty lying flat when sleeping?
* Do you have any past medical history of cardiac surgery or hospitalizations for cardiac events or disorders?
* Have you ever had acute rheumatic fever, swollen or painful joints, or inflammatory rheumatism?
* Do you have any chronic illnesses such as hypertension, hyperlipidemia, diabetes, coronary artery disease, congenital heart defects, or bleeding disorders?
* Do you have a family history of diabetes, heart disease, hypertension, hyperlipidemia, obesity, congenital or acquired heart defects, or sudden death at a young age? If so, include age at the time of diagnosis and death of first-degree relatives.
* Are you on an anticoagulant? Do you have a coagulation disorder?
* Does your employment include physical demands, emotional stress, or environmental hazards such as chemicals, heat, sunlight, or dust?
* Do you use tobacco? If so, at what age did you start? How many packs per day? Have you stopped using it?
* How often do you use alcohol or recreational drugs? If used, what type of alcohol or recreational drugs do you prefer?
* What is your nutritional status? Have you lost or gained weight recently?
* What do you do to relax?
* Do you exercise? How much and how often?
* Do you have aching, cramping, or pain in the legs while walking or exercising? If so, when did it start, how long have you had it, and what are its characteristics? Does anything relieve the pain?
* Have you ever had loss of consciousness or transient syncope? If so, was the episode associated with any other symptoms?
* Does shortness of breath interfere with your activities of daily living?
* Do you have any tingling, numbness, or coldness in your hands or feet?
* Do you have edema or swelling in your hands, feet, or ankles? If so, what makes it worse? What reduces the edema?
* Have you had any recent change in hair loss or growth on your hands, feet, or ankles?
* Has anything restricted blood flow to your extremities (cast, surgery, trauma, tight clothing)?
two distinct ______ sounds, known as S1 (“lub”) and S2 (“dub”), are heard
heart
An entire S1 plus S2 (“lub-dub”) cycle constitutes _______ heartbeat
one
Failure of the heart to beat at regular successive intervals is called
dysrhythmia
pulse deficit is when
patient’s radial pulse rate is slower than the apical pulse rate
Cardiac murmurs are
blowing or swishing sounds heard in systole or diastole
Cardiac murmurs cause
increased or abnormal blood flow through the valves of the heart
a thrill is
an abnormal vibration felt on palpation
a thrill is detected with a _____
murmur
Murmurs are graded according to intensity
what are the 5 grades
Grade 1: Scarcely audible with a good stethoscope in a quiet room
Grade 2: Quiet but readily audible with a stethoscope
Grade 3: Easily heard with a stethoscope
Grade 4: A loud, obvious murmur with a palpable thrill
Grade 5: Very loud with a palpable thrill; heard over the pericardium and elsewhere in the body (radiates)
Grade 6: Heard with a stethoscope off the chest; thrill palpable and visible
A Doppler ultrasound unit may be used to assess weak
peripheral pulses
tortuosity meaning
bending and twisting
While assessing the patient’s Peripheral pulse, the nurse notes its
intensity, rate, and rhythm, existence of blood vessel tenderness, tortuosity, nodularity
Intensity or volume of peripheral pulses is graded on a scale of 0 to 3:
0 Absent pulse (unable to palpate)
1 Diminished (weaker than expected; difficult to palpate)
2 Normal (able to palpate with normal pressure)
3 Bounding (may be able to see pulsation; does not disappear with palpation)
Femoral pulses are best assessed with the patient in the ______ or ____ ______ position.
supine, low Fowler
Phlebitis is the
inflammation of a vein
the five Ps of circulation
pain, pallor, pulselessness, paresthesia (numbness or tingling), and paralysis
paresthesia is
numbness or tingling
Lordosis is
a condition that causes an increased lumbar curvature just above the buttocks area
Kyphosis is
an outward curvature of the thoracic spine
Scoliosis is
a sideways or S-shaped curvature of the spine and is always abnormal
Health Assessment Questions
Musculoskeletal System
- Do you have any pain or stiffness in your joints, muscles, or back? If so, when did it begin? Where is the pain or stiffness? What is its quality? Is the pain burning, aching, shooting, constant, or intermittent? Does anything aggravate or relieve the pain?
- Are you able to perform activities of daily living, such as dressing or preparing meals, without musculoskeletal discomfort?
- Can you climb stairs and walk without limping?
- Do you have numbness or tingling in your extremities?
- Are you able to engage in strenuous activity or exercise?
- Have you experienced any recent trauma to any of your bones, joints, soft tissue, or nerves?
- Do you have any chronic illnesses that may affect the musculoskeletal system, including cancer, osteoporosis, arthritis, and renal or neurologic disorders?
- Do you have any known skeletal deformities or a congenital history that may affect the musculoskeletal system?
- Do you have any family history of arthritis (rheumatoid, osteoarthritis, ankylosing spondylitis), back problems (scoliosis, spina bifida), or genetic disorders (osteogenesis imperfecta, rickets, dwarfing syndrome)?
- Does your diet include adequate calcium and vitamin D?
hypertonicity is
increase in muscle tone
hypotonicity is
decrease in muscle tone
Clonus is a _____ ______ ______ of the muscle
repetitive vibratory contraction
Clonus causes
muscle and tendon stretch
Reflex responses to deep tendon and cutaneous reflexes are documented using a subjective scale as follows:
4+ Very brisk, hyperactive with clonus
3+ Brisker than average, slightly hyperactive
2+ Average, normal
1+ Sluggish or diminished
0 No response
Reflex of muscle and normal response to Tendon Reflex Assessment: Biceps
Biceps contraction and flexion
Reflex of muscle and normal response to Tendon Reflex Assessment:
triceps
Extension of the forearm
Reflex of muscle and normal response to Tendon Reflex Assessment: Achilles ankle jerk
Plantar flexion of the foot
Reflex of muscle and normal response to Tendon Reflex Assessment: Quadriceps or patellar knee jerk
Extension of the leg
Reflex of muscle and normal response to Tendon Reflex Assessment: Plantar
Adults and children: Plantar flexion of the toes and forefoot
Infants: Dorsiflexion of the big toe and fanning out of the toes (positive Babinski sign)
Cranial Nerve Function and Assessment:
Cranial Nerve I: Olfactory (Sensory)
Transmits the sense of smell
After assessing patency of both nares, have the patient close the eyes, obstruct one naris, and inhale to identify a common scent.
Cranial Nerve Function and Assessment:
Cranial Nerve II: Optic (Sensory)
Transmits visual information to the brain; located in the optic canal
Check visual acuity (have the patient read newspaper print or use a Snellen chart), and test visual fields for each eye.
Cranial Nerve Function and Assessment: Cranial Nerve III: Oculomotor (Motor)
Innervates four of the six muscles that collectively execute most eye movements; responsible for pupillary constriction and dilation
Assess pupil size and light reflex; note direction of gaze.
Cranial Nerve Function and Assessment:
Cranial Nerve IV: Trochlear (Motor)
Innervates muscles responsible for downward and inward gaze of the eyes
Ask the patient to gaze downward, temporally, and nasally.
Cranial Nerve Function and Assessment:
Cranial Nerve V: Trigeminal (Sensory and Motor)
responsible for the corneal reflex; receives sensation from the face and innervates the muscles of mastication
Motor: Palpate jaws and temples while patient clenches teeth.
Sensory: With the patient’s eyes closed, gently touch a cotton ball to all areas of the face.
Cranial Nerve Function and Assessment:
Cranial Nerve VI: Abducens (Motor)
Innervates muscles responsible for outward gaze of the eyes
Assess directions of gaze.
Cranial Nerve Function and Assessment:
Cranial Nerve VII: Facial (Sensory and Motor)
Provides motor innervation to the muscles of facial expression; receives the sense of taste from the anterior two-thirds of the tongue; provides innervation to the salivary glands (except parotid) and the lacrimal gland
Motor: Check symmetry of the face by having the patient frown, close eyes, lift eyebrows, and puff cheeks.
Sensory: Assess the patient’s ability to recognize taste (sugar, salt, lemon juice).
Cranial Nerve Function and Assessment:
Cranial Nerve VIII: Vestibulocochlear or Auditory-Vestibular (Sensory)
Vestibular branch: Carries impulses for equilibrium
Cochlear branch: Carries impulses for hearing
Assess the patient’s ability to hear a spoken and whispered word.
Cranial Nerve Function and Assessment:
Cranial Nerve IX: Glossopharyngeal (Sensory and Motor)
Receives taste from the posterior third of the tongue; provides innervation to the parotid gland; and provides motor innervation for swallowing
Sensory: Assess the patient’s ability to taste sour or sweet on last two-thirds of tongue.
Motor: Check for presence of the gag reflex by inserting a tongue blade two-thirds into the pharynx.
Cranial Nerve Function and Assessment:
Cranial Nerve X: Vagus (Sensory and Motor)
Supplies innervation to the larynx and soft palate responsible for speech and swallowing; provides parasympathetic fibers to nearly all thoracic and abdominal smooth muscles
Depress the tongue with a tongue blade and have the patient say “ah” or yawn. The uvula and soft palate should rise and be symmetric. Assess speech for hoarseness.
Cranial Nerve Function and Assessment:
Cranial Nerve XI: Spinal Accessory (Motor)
Cranial root: Works with vagus nerve to control the muscles of the soft palate, pharynx, and larynx
Spinal root: Innervates muscles of the neck and back
Have the patient rotate the head and shrug the shoulders against passive resistance.
Cranial Nerve Function and Assessment:
Cranial Nerve XII: Hypoglossal (Motor)
Provides motor innervation to muscles of the tongue not innervated by the vagus nerve and to other glossal muscles; is important for swallowing and speech articulation
Assess tongue control (e.g., have the patient stick out the tongue and move it from side to side).
Level of orientation and mental status are assessed by determining the patient’s ability to identify _____, _______,________,______
person, place, time, and situation
Glasgow Coma Scale
Eye opening:
Spontaneous 4
To verbal command 3
To pain 2
None 1
Verbal:
Oriented 5
Confused but able to answer questions 4
Inappropriate responses 3
Incomprehensible speech 2
None 1
Motor:
Obeys commands 6
Purposeful movement to painful stimulus 5
Withdraws from pain 4
Abnormal (spastic) flexion, decorticate posture 3
Extensor (rigid) response, decerebrate posture 2
None 1
Possible total score range 3–15
Health Assessment Questions
Abdomen (Gastrointestinal tract)
- Do you have any pain or difficulty with swallowing?
- Have you experienced difficulty eating, weight change, or lack of appetite?
- Do you have nausea, vomiting, regurgitation of food, frequent burping, heartburn, indigestion, or bloating? If so, what do you do to relieve the symptoms?
- Are you experiencing abdominal pain? If so, what are the characteristics of the pain? Are there any associated symptoms? Does anything relieve the pain?
- What is your typical 24-hour food intake?
- Have you experienced any changes in bowel habits: diarrhea, constipation, incontinence, or frequent passing of gas?
- Have you noticed any blood in your stool?
- Do you have problems with hemorrhoids?
- Have you ever had abdominal surgery?
- Do you or any family members have a history of abdominal illnesses such as gallbladder disease, cancer, or irritable bowel syndrome?
Health Assessment Questions urinary tract
- Are you experiencing any difficulty with urination: Frequency, urgency, or difficulty starting or stopping your stream of urine?
- Do you have a history of urinary tract or kidney infections or kidney stones?
- Is there pain or burning when you urinate?
- Have you noticed a change in your frequency of urination: Less often or more often than previously?
- Do you feel that you empty your bladder when you urinate?
- Do you have to get up at night to urinate? If so, how many times?
striae meaning
stretch marks resulting from pregnancy or from weight loss or gain
The nurse visually inspects the skin over the abdomen, noting
color, tone, scars, bruises, lesions, venous patterns, striae, drains, tubes, and stomas
peristalsis is
progressive wave action causing movement of contents through the gastrointestinal system
borborygmi is heard as
loud grumbling
stenosis means
narrowing
Assessment of the Male Genitalia
include
size and shape of the penis and testes
distribution of pubic hair across the perineal area (Before puberty, in preadolescents, pubic hair is absent in the groin area)
enlargement and darkening of the testicles, appearance of pubic hair, and lengthening of the penis
pubic area should be free of rashes, lesions, masses, and obvious deformity
Observe for smegma
smegma is
a whitish substance under the foreskin of penis
prostate cancer screening is recomended to start at age
45
