Assessment Final

evaluate past and present health states of each body system; head-to-toe exam; note presence or absence of symptoms; subjective data only

• OPQRST
• onset, pain/palliation, quality, region/radiation, severity, time

rest, re-energize; ask pt. if they take naps, any insomnia, PND-paroxysmal nocturnal dyspnea, nocturia, SOB, light sleep

• ask every woman if she has been abused by husband/boyfriend. Abuse Assessment Screen (AAS)-routine questions to screen for violence
• 1- when you and partner argue are you afraid of them?
• 2- when you and paertner verbally arugye, do you think they try to emotionally hurt/abuse you?
• 3- does your partner try to control you?
• 4- has your partner or anyone else ever slapped you, pushed you, hit you, kicked your or otherwise physically hurt you?
• 5- since you have been pregnant, has your partner ever bit you, slapped you, pushed you, hit you, kicked you, or otherwise physically hurt you
• 6-has your partner ever forced you to have sex?

if yes, ask to share more.

• inspection is concentrated watching and ALWAYS comes FIRST
• use your sense
• close, careful scrutiny of the individual as a whole then of each body system
• inspection begins the moment you first meet the person
• a focused inspection takes time
• requries good lighting, adequate exposure, occasional use of instruments to enlarge view
• (inspection, palpation, percussion,auscultation)
• objective data

• cechetic/emaciated- very thin showing bone structures, as in cancer pts
• simple obesity- even fat distribution
• centipetal (truncal) obesity- fat in the neck, trunk and thin extremities (cushings syndrome)
• there is weight loss in acute disease- "unexplained weight loss with short term illness"
• remove shoes and heavy outer clothing to properly weigh pt
• when having to weigh every day, try to do it at the same time each day with same type of clothing
• measured in kilograms and pounds
• obesity is >120% of ideal body weight. may be due to endocrine disorder, drug therapy, mental depression

• <18.5 underweight
• 18.5-24.9 normal
• 25-29 overweight
• 30-39.9 obesity
• >40 extreme obesity

>35 in women and >40 in men= increase risk cardiovascular and metabolic diseases

• an amount of blood pumped by the heart with each beat
• ~70ml in the adult

CO=SVxR cardiac output= stroke volume x rate

• systolic- maximum pressure felt on artery during L ventricular contraction; systole
• diastolic- pressure the blood exerts constantly between contractions
• MAP-mean arterial pressure- pressure forcing blood into the tissues averaged over the cardiac cycle
• gradual rise through childhood and into adult years
• female adults have <BP than male adults
• Black pt BP usu. higher than white of same age
• <=120/80 normal
• 121-139/81-90 pre-hypertension
• 140-159/90-99 hypertension
• 160/100 severe hypertension
• causes of chaneges= diurnal rythm, weight, exercise, emotions,stress

• physical appearance- by 8th-9th decade body contour is sharper,more angular features, redistrubted body proportions
• posture-

• all pain is neurogenic
• SLIDTA:severity, location,intensity,duration,type,associated factors

• cutaneous :skin/scalp/teeth
• somatic: muscle/bone/ligament
• viscera: kidneys/pancreas/organs
• neuropathic:central and
• peripheral nervous system

• term used to
• describe how noxious stimuli are perceived as pain (4
• steps)
• 1-transduction: injured tissue releases chemicals that propagate pain message, action potential
• moves along an afferent fiber to the spinal cord
• 2-transmission:pain impulse moves from spinal cord to brain
• 3-perception of pain
• 4-modulation:neurons from brain stem release neurotransmitters that block the pain impulse
• neurotransmitters that propagate pain message: substance P, histamine, prostaglandins,
• serotonin, bradykinin
• pain is NOT normal in elderly; pain is indicative of a problem or disease

acute: short term, self limiting, follows predictable trajectory, dissipates after injury heals

• chronic: persistent, pain continues for 6 months or more, can be malignant or non-malignant; does not stop when injury heals
• -->malignant pain often parallels the pathology created by tumor cells; it is induced by tissue necrosis or stretching of an organ due to growing tumor

• is an abnormal processing of pain message
• neuropathic pain will NEVER be in the brain because brain has NO pain receptors
• neuropathic pain is fro damage to peripheral nerves or central nerves
• neuropathic pain usu. found in diabetics
• it is a type of pain that does not adhere to typical and predictable phases of nociceptive pain
• the pain is perceived long after injury heals
• pain is sustained on a neurochemical layer and cannot be identified by x-ray,CT scan; nerve conduction studies are neededm

• (pain scales are intended to reflect pain intensity)
• used for children because they are incapable of self report, therfor the assessment is dependent on behavioral and physiological clues
• rating scales can be introduced at 4 or 5 y/o
• child is asked to choose the face that shows "how much hurt you have now?"
• coded as: 0-5 or 0-10 (couting in 2's)
• 0: no hurt
• 1 or 2: hurts a little bit
• 2 or 4:hurts a little more
• 3 or 6: hurts even more
• 4 or 8: hurts a whole lot
• 5 or 10: hurts worst

sufficient nutrients consumed to support day to daty body needs AND any increased metabolic demands due to growth, pregnancy or illness

when nutritional reserves are depleted and or when nutrient intake is inadequate to meet day to day needs or added metabolic demands

caused by the consumption of nutrients, especially calories, sodium and fat in excess of body needs

BMI greater or equal to 95th percentile based on age and gender specifics

BMI of 25 or more

BMI of 30 or more

BMI of 40 or more

babies cant feed themselves

aging adult may have socioeconomic issues and therefor a decline in nutrion

• poor dentition, decreased visual acuity, decreased salica production, slowed fastrointestinal mitility, decreased fastrointestinal absorption, diminished olfactory and taste sensitivity
• there is a decrease in nutritional requirements due to loss of lean body mass, the most metabolically active tissues and an increase in fat mass

• buddhism- no meat
• catholicism- ash wednesday, good friday and other holy days have restrictions
• hinduism-beef pork and some forms of fowl, alcohol, garlic and onions by some, red colored foods (tomatoes, etc)by some
• islam-all pork and pork products, meat not slaughtered according to ritual, alcoholic beverages and products (vanilla extract),coffee and tea, food and beferages before sunset during Ramadan
• mormon-alcoholic beverages, caffeinated beverages, medicines containing caffeine or stimulants or alcohol
• othodox judaism-all pork/pork products, meat not slaughtered according to ritual, all shellfish, dairy products and meat at same meal, leavened bread and cake during passover, food and beverages on yom kippur
• seventh day adventist- all pork/pork products, shellfish, meat/dairy products/eggs by some, alcoholic beverages, coffee and tea, highly seasoned foods

• 1- identify individuals who are amalnourisehed or are at risk of developing malnutrition
• 2- provide data for designing a nutrition plan of care that will prevent or minimize the development of malnutrition
• 3- establish baseline data for evaluating the efficacy of nutritional care

• may be completed in any setting, based on easily obtained data
• weight, weight history, conditions associated with increased nutritional risk, diet information and routine laboratory data

3 meals a day are not sufficient intake so snacks are good way to achieve enough intake

children 2 and under should NOT drink skim or low fat milk because calories and fatty acids are needed for proper growth and development of the central nervous system

dietary history and clinical information, physical examination for clinical signs, anthropometric measures and laboratory tests.

• easiest and most popular method for obtaining infomation about dietary intake
• errors may occur when pt or family does not remember intake, they alter truth, snacks and gravies may not be recorded, intake may be different than usual intake

• multiparous woman with pregnancies occurring less than one year apart has an increased risk of depleted nutritional reserves
• recommended weight gain of 25-30 lbs for normal weight; 28-35 for underweight and 15-25 for overweight

• <18.5 = underweight
• 18.5-24.9 = normal weight
• 25-29.9 = overweight
• 30-39.9 = obesity
• 40+ = severe obesity

>35 in women and >40 in men = increase risk of cardiovascular and metabolic diseases

• estimate of body fat stores or the extent of obesity or undernutrition
• biceps, subcapsular, suprailiac skinfolds can be used but triceps skinfold (TSF) is most common
• values 10% above or below = under or overnutrition respectively

estimates skeletal muscle mass and fat stores

good indicator of lean body mass and skeletal protein reserves

measures bone density

measures body composition

elbow breadth = skeletal breadth and is most accurate method to measure to determine frame size

• used to determin iron deficiency anemia
• increased hemoglobin levels= polycethemia vera or dehydration
• decreased hemoglobin levels= anemia, recent hemorrhage, hemodilution by fluid retention

• measure of cell vloume, also indicator of iron status
• low value=low hemoglobin formation

• measured to evaluate fat metabolism and assess risk of heart disease
• normal= 120mg/dl-200mg/dl

• used to screen for hyperlipidemia and to determine risk of heart disease
• these are age related

• most common used test of immune function
• important indicator of visceral protein status

• to verify immunity to antigens
• test is positive if response is 5mm or greater-commonly candida, tetanus, diptheria,strep,tuberculin,proteus,trichophyton
• positive= malnutition, hepatic falure, infection and immunosuppressive drugs

• measurement of visceral protein status
• normal serum albumin in children older than 6 months and adults ranges from 3.5-5.5g/dl
• low levels= protein/calorie deficiency, dehydration, decreased liver function
• <2.8g/dl = severe depletion
• consider persons history if this number is off because it can easily be altered

• protein-calorie malnutrition, prolonged starvation
• anorexia, bowel obstruction, cancer cachexia, chronic illness lead to marasmus

• protein malnutrition
• diets that contain little or no protein
• decreased visceral protein levels depressed immune function
• appear well nourished/edematous

• severe starvation
• emaciated appearance
• muscle and fat wasting
• from major surgery, trauma, burns in combo with prolonged starvation
• high risk of mortality

riboflavin deficiency/vitamin b-complex

• 3 or more risk factors present
• 1- fasting plasma glucose >/= 110mg/dl
• 2-BP >/=130/85
• 3-waist circumference of >/= 40 for men and 35 for women
• 4-high density lipoprotein (HDL) cholesterol <40 in men and <50 in women
• 5-triglyceride levels>/=150mg/dl
• associated with increased risk for hearty disease, DM type 2, mortality
• 28% prevalence in adolescents and 22% in adults

• Change in mole regular size, irregular, pigmentation, lesions, asymmetry, more than 6
• cm, itching, burning, or bleeding
• ABCDE:
• Asymmetric
• Border
• Color
• Diameter
• Elevation and Enlargement

holds information on the bodys circulation, hydration, signs of systemic disease

majority are result from occupational or environmental agents

• ages the skin earlier, causes lesions (primarily skin cancer)
• those more at risk are light-skinned people and those over 40 and those regularly in the sun with no protection

• hair loss
• alopecia areata is hair loss in the form of small circular patches-can be anywhere on the body

mask of pregnancy

fine downy hair in newborns

increased pigmentation in the midline of the abdomen during pregnancy

bigger areolas, increased pigmentation in areolae, nipples and vulva, linea nigra, vascular spyders, palmar eythema, striae gravidum (stretch marks)

• outer layer, stratum corneum, thins an flattens allowing chemicals easier access into the body
• wrinkling occurs because the underlying dermis thins and flattens
• loss of elastin, collagen, subcutaneous fat, reduction in muscle tone
• skin more apt to tear, shear
• sweat and sebaceous glands decrease secretion
• wound healing is delayed

fradile skin where trauma may produce dark red discoloered areas

• protect
• prevent penetrations
• perceptions-sensory organ for touch, pain, temperature
• temperature regulation
• identigication- hair color, skin color, fingerprints
• largest organ of the body

• vellus- covers most of the body, fine
• terminal- coarser hair, grows on scalp, eyebrows, axilla, pubec area, face, chest

• is vestigial-no longer needed for protection from cold or trauma
• they are threads of keratin
• shaft is visible protruding part
• hair growth is cyclical
• arrector pili-contract and make hair stand up

thin but tough, stratifies into several layers

• basal cell layer, forms new skin cells
• major ingredient is keratin
• melanocytes (give skin color-melanin) are found here

• outer horny cell layer of dead keratinized cells that are tinterwoven and closely packed
• constantly being shed
• epidermis is completely replaced every 4 weeks

• hard plates of keratin
• pink color is from underlying vasculature
• lunula is white opaque half moon that lies over the area that new cells are formed

fat tissue, provides insulation,cushion effect

contains sebacous glands, sweat glands, arrector pili, hair follicle

• Clubbing of nails occurs with congenital chronic cyanotic heart disease
• and with emphysema and chronic bronchitis, and is greater than 180 degrees.

happens with fever, local inflammation, emotional reactions

yellowing of the skin due to increased serum bilirubin from liver inflammation or hemolytic disease such as after severe burns or some infections

jaundice in the sclera of the eye

usually stars as a skin colored papule, with translucent top and overlyig telangiectasia. then develops rounded pearly borders with central red ulcer. looks like large open pore with central yellowing, most common form of skin cancer, slow but inexorable growth

• Squamous Cell Carcinoma is erythematous scaly patch with sharp margins, 1cm or more.
• Usually on hands or head, areas exposed to solar radiation. Less common than
• basil cell carcinoma but grows rapidly.

• forms from preexisting nevi; usually brown but can be any color, even mixed
• pigmentation; maybe scaling, flaking, oozing

• inflammation of the membranes (meninges) and cerebrospinal fluid surrounding your brain and spinal cord, usually due to the spread of an infection. The swelling associated with meningitis often triggers the "hallmark" symptoms of this condition, including headache, fever and a stiff neck. Most cases of meningitis are caused by a viral infection, but
• bacterial and fungal infections also can lead to meningitis. Depending on the cause of the infection, meningitis can resolve on its own in a couple of weeks— or it can be life-threatening

• The largest of the three pairs of salivary glands. It lies within the cheeks in the front of the ear extending from zygomatic arch down to the angle of the jaw. It secretes saliva from its duct, Stensen’s duct, which runs forward to open on the buccal mucosa opposite the second molar.
• IS KNOWN TO BE FOUND IN AIDS PTS

Occurs with accelerated or turbulent blood flow. In the thyroid gland, indicates hyperplasia of the thyroid (e.g.hyperthyroidism). In the vascular system p.540: a bruit occurs with partial occlusion. In the Carotid artery p. 498: bruit identified as swishing blowing sound and indicates turbulence due to a local vascular cause such as atherosclerotic narrowing. In the abdomen, p. 571, the presence of any vascular sounds must be checked, especially in people with hypertension.

• Auscultate for a presence of a bruit
• Usually not palpable; if they are enlarged usually palpable before swallowing, or too tender to palpate

• Q: A pt noticed a lump above her adams apple that seems to be getting bigger during
• the assessment the findings reassures the nurse that it may not be a cancerous
• thyroid nodule is that the lump is

A: Mobile and not hard

• Lymphadenopathy is an enlargement of the lymph nodes (greater than 1 cm) from infection, allergy, or neoplasm. Feels enlarged and tender.
• Check the area for the source of the problem. For example, those in the upper cervical or submandibular area often relate to inflammation or neoplasm in the head and neck. Follow up on or refer your findings. Enlarged lymph node,
• particularly when you cannot find the source of the problem, deserves attention.

• Q: an Enlargement of the lymph nodes greater then 1cm from an infection, allergy, or
• neoplasm
• :Lymphadenopathy

Temporal artery is on bone between eye and top of ear, but it feels hardened, tortuous, and tender

• on old olympus tiny tops a finn and german viewed some hops
• some say marry money but my brother says boobs matter more
• I: olfactory- smell
• II: optic-vision, peripheral, accomodation, literacy
• III: oculomotor-pupil constriction, 6 cardinal gazes
• IV:trochlear- eyes down and in
• V: trigeminal- mouth
• VI: abducens- lateral movement of eye
• VII: facial-smile, puff cheecks, show teeth
• VIII: acoustic/vistibulocochlear- balance, whisper test, rinne/weber test
• IX:glossopharyngeal- throat, uvula, midline tongue
• X: vagus-pharynx, larynx, talking, swallowing
• XI:spinal accessory- shrug shoulders, face against hand
• XII:hypoglossal- stick tongue out and move side to side

• Glaucoma is increased intraocular pressure, which is abnormal
• Determined by a balance between the amount of aqueous produced and
• resistance to its outflow at the angle of the anterior chamber

• Corneal light reflex: Shining a penlight towards eyes in the same place to the other eye; have patient stare straight ahead; See bright white dots
• Confrontation test: Measures peripheral vision
• 6 Cardinal signs

• Glass-like quality decreases lens’ ability to change shape to accommodate for near vision” with aging
• When patient needs to move card (or whatever is needing to be read), farther away

• Common with myopia or after middle age as a result of condensed vitreous fibers
• Usually not significant but acute onset may occur with retinal detachment

• An opening in the ear that connects the middle ear with the nasopharynx and allows the passage of air
• Tube is normally closed but it opens with swallowing or yawning

• Conducts sound vibrations from outer ear to central hearing apparatus in the inner ear
• Protects the inner ear by reducing the amplitude of loud sounds
• Eustachian tube allows equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture (Ex: during altitude changes in an airplane)

• AC>BC
• Air conduction is most efficient Pathway: Sounds waves produce vibrations on the tympanic membrane and are carried by the ossicles in the middle ear, it travels up the coils of the cochlea; On the way it vibrated the basilar membrane to signify frequency; The fibers on the basilar membrane (organ of Corti) are bent from vibrations and turns into electric impulses, sending signal to brain; the function of the cortex interprets the meaning of sound and begins appropriate response.
• Vibrations transmitted directly to inner ear and cranial nerve VIII

• Signifies pathology of inner ear, cranial nerve VIII, or auditory areas of cerebral cortex
• Simple increase in amplitude may not enable patient to understand words
• May be caused by presbycusis, a gradual nerve degeneration that occurs with aging

• Nasal cavity lined with blanket of ciliated mucous membranes
• Filters inhaled air by sweeping out dust and bacteria
• Bronchi are lined with cilia which sweeps particles upwards where they can be swallowed or expelled

Frenulum is a midline fold of tissue that connects the connect to the floor of the mouth

• Parotid gland (the largest): lies within the cheeks in front of the ear extending from the zygomatic arch down to angle of jaw
• Submandibular gland (size of walnut): lies beneath the mandible at the angle of the jaw
• Sublingual (size of almond): under the tongue

• Tonsil Crypts are small pockets that form on the outside of your tonsils.
• Same color as surrounding mucous membranes, look more gradular
• These pockets or tonsil crypts collect debris, ike the mucus from nasal drip as well as food particles

Dry mouth”; side effect of many drugs like antidepressants, antihypertensive, bronchodilators

• Tail of Spence = cone-shaped breast tissue that projects up into the axilla, close to the pectoral group of axillary lymph nodes.
• The upper outer quadrant is the site of most breast tumors

• ·
• Adolescents- at puberty, estrogens stimulate the growth of cells in
• the reproductive tract and the development of secondary sex characteristics

• ·
• Aging female- Ovaries stop producing progesterone and estrogen.
• During menopause bring dramatic physical changes. Uterus shrinks; vagina becomes shorter, narrower and less elastic.
• Secretion of estrogen and progesterone decreases causing the breast glandular tissue atrophy

• ·
• Non-inflammatory enlargement of breast tissue in male
• Usually affect 1 breast and temporary at puberty
• Occurs with use of anabolic steroids, some medications, and some disease states
• Common in aging male due to hormonal changes, bilateral and may be tender
• occurs with hormone stimulations, Cushing’s syndrome, cirrhosis of liver, leukemia occasionally, sometimes with medication

• Rust color = tuberculosis, pneumococcal pneumonia
• White/clear mucous = colds, bronchitis, viral infections
• Yellow/green = bacterial infections
• Pink/frothy = pulmonary edema

• Continuous throughout day = acute illness (respiratory infection)
• Afternoon/evening = may reflect exposure to irritants at work
• Early morning = chronic bronchial inflammation of smokers
• Night = postnasal drip, sinusitis
• Chronic bronchitis is characterized by a history of productive cough for 3 months of the year for two years in a row

• Q: A 40 yr old man has a recent weight loss of 20 lbs and keeps getting the cold and the flu. An additional to nutritional assessment the nurse would want to get what lab
• A: A total lymphocyte count

• Apices → supraclavicular areas down the 6th ribs
• Side-to-side as moving downward – 1 full respiration each location
• Don’t place directly over female breast
• Bronchial = high pitched, loud, inspiration < expiration
• Bronchovesicular = moderate, inspiration = expiration
• Vesicular = low, soft, inspiration > expiration
• Person is sitting, leaning forward slightly. Person should breath through the mouth, a bit deeper than usual, but to stop if he/she begins to feel dizzy. Listen to one full respiration in each location.
• Use flat diaphragm end piece of stethoscope and hold it firmly on person’s chest wall.

• Atelectatic crackles – sound like fine crackles but do not last and are not pathogenic. Disappear after the first few breaths.
• Only heard in periphery (axillae and bases), usually dependent portion of the lungs

• Unoxygenated blood (systemic veins) → Superior Vena Cava/Inferior
• Vena Cava R. atrium→ R. ventricle→ Tricuspid valve → Pulmonic valve → Lungs by
• pulmonary arteries→ pulmonary veins (Oxygenated blood) → L. atrium → Mitral
• valve → L. ventricle → Aortic valve → Systemic circulation

• ·
• 4 valve2 AV (atrioventricular) valves separate atria and ventricles: R =Tricuspid; L = Mitral
• 2 SL (semilunar) valves separate ventricles and arteries: R =
• Pulmonic; L=Aortic

• SA nodes (pacemaker) →AV node → Bundle of His →R&L bundle branches
• (Perkinje fibers

• Paroxysmal nocturnal dyspnea – awakening from sleep with SOB and
• needing to be upright to achieve comfort
• Relates to cardiac problems

• Q: A 65 yr old pt is awaken from sleep with SOB what would the nurse do?
• A: A test for PND or Paroxysmal nocturnal dyspnea

• Q: A 45 yr old man is going for a routine physical during the history the pt states he is having difficult breathing, sleeps fine, and then wakes up and cant catch his breath. The nurses best response would be
• A: Do you have any history of problems with your heart

• Sedentary lifestyle (physical inactivity)
• High blood pressure
• High cholesterol levels
• Obesity
• Diabetes
• Oral contraceptives and postmenopausal hormones
• Blacks → White→ Mexican-American
• Q: During a cardiac assessment on an adult pt in the hospital for chest pains the nurse finds the following jugular veins 4 cm above the sternal angle when elevated at 45 degrees, Bp of 98/60, HR 130, angle edema, difficult breathing when suspine, and a S3
• A: Heart failure

• S3
• (pg. 518) – ventricular filling sound.
• Occurs early diastole during rapid filling phase
• Heard best at apex or lower left sternal border; the split S2 at base (heard right after S2)
• Dull, soft sound, low pitched (lower than S2)
• May be physiologic (normal) = in children and young adults
• May be pathologic (abnormal) = in adults usually, S3 gallop, increase compliance of ventricles, (heartfailure), L/R ventricle, L-sided S3 at apex in left lateral position, R-sided S3 at LL sternal border and louder with inspiration

• S4:
• (pg. 519) – ventricular filling sound. Occurs when atria contract late in
• diastole
• Heard immediately before S1
• Very soft, very low pitched
• Heard best at apex, left lateral position
• Physiologic = adults >40/50 years old with no evidence of cardiovascular
• disease
• Pathologic = atrial gallop or S4 gallop, decreased compliance of ventricle & systolic overload (after load), outflow obstruction of ventricles (aortic stenosis), systemic HTN – L-sided
• R-sided S4 = less common, heard at LL sternal border and may increase with inspiration, occurs with pulmonary stenosis or pulmonary HTN

• PMI (pg. 501)– pulsation created as the left ventricle rotates against the chest wall during systole
• Location: 4th or 5th intercostals or medial to midclavicular line
• Size: 1 cm x 2 cm normally
• “exhale and hold”
• Short gentle tap, occupies only 1st ½ of systole
• Not palpable in half of adults especially those who are obese or with thick chest walls
• Bruits (pg. 498)– blowing swishing sound indicating turbulent blood flow, normally non present (through vascular
• narrowing)
• 1) angle of jaw, 2) midcervical area, 3) base of neck
• Have patient take breath, exhale, and hold while listening

• Q: When assessing an elderly pt with a carotid artery with cardio
• vascular disease the nurse would?

A:Listen with the bell of the stethoscope to listen for bruit

• Q: While listening to an apical pulse of a 16 yr old pt the nurse notices an irregular rhythm; his rate speeds up on inspiration and slows on expiration. Nurses response
• A: No further response is needed- Sinus Arrhythmia

• Any disease that affects heart muscle, diminishing cardiac performance
• Cardiac enlargement from increased ventricular volume or wall thickness can be due to cardiomyopathy

• Temporal artery (front of ear)
• Carotid artery (groove between sternomastoid muscle and trachea)
• Brachial artery (biceps-triceps furrow of upper arm and antecubital fossa in elbow)
• Radial and ulnar arteries (branched from brachial arteries)
• Femoral artery (passes under inguinal ligament)
• Popliteal artery (behind knee)
• Dorsalis pedis (anterior tibial artery travels down anteriorly towards dorsal side of foot)
• Posterior tibial artery (travels down behind medial malleolus and in foot forms the planter arteries)

• Q: During the assessment of a healthy adult where would the nurse expect to palpate the adult
• A: 5th L intercostals space at the midclavicular line

• RUQ –hepatic flexure of colon, part of ascending and transverse colon
• LUQ –splenic flexure of colon, part of transverse and descending colon
• LLQ – part of descending colon & sigmoid colon

• Scratch test = define liver border and distended abdomen
• Stethoscope over liver, with one fingernail, scratch short strokes over abdomen, start in RLQ up toward liver.
• When scratching sound becomes magnified, you will have crossed the border over a hollow organ to a solid one

• Muscle= 40-50% of body’s weight, produce movements, 3 types (skeletal,smooth, cardiac)
• Tendon= strong fibrous cord attaches muscles to bones
• Ligament= fibrous bands running directly from one bone to another bone that strengthen the joint and help prevent movement in undesirable directions
• Bone= specialized form of connective tissue, hard, rigid, and very dense,support body

• Osteoarthritis(pg. 643)
• -degenerative joint disease
• -non-inflammatory,localized, progressive disorder involves deterioration of articular
• cartilages and subchondral bone and formation of new bone (osteophytes) at joint surfaces
• -asymetric joint involvement commonly affects hands, knees, hips, & lumbar & cervical segments of spine
• -stiffness,swelling with hard, bony protuberances, pain with motion, & limitation of motion

• Rheumatoid arthritis ( pg. 643)
• chronic,systemic inflammatory disease of joints and surrounding connective tissue
• inflammation of synovial membrane leads to thickening →fibrosis (limiting motion) →bony ankylosis
• symmetrical & bilateral
• characterized by heat, redness, swelling, & painful motion of affected joints
• associated with fatique, weakness, anorexia, weight loss, low grade fever, & lymphadenopathy

• Edema:(pg. 542)
• 1+ = mild pitting, slight indentation, no perceptible swelling of leg
• 2+ = moderate pitting, indentation subsides quickly
• 3+ = deep pitting, indent remains for short time, leg looks swollen
• 4+ = very deep pitting, indent last long time, leg very swollen

• Muscle strengths (pg. 612)
• 5 = full ROM against gravity, full resistance, 100%, Normal
• 4 = full ROM against gravity, some resistance, 75%, Good
• 3 = full ROM with gravity, 50%, Fair
• 2 = full ROM with elim. Gravity (passive), 25%, Poor
• 1 = slight contraction, 10%, Trace
• 0 = no contraction, 0%, Zero

• Deep tendon reflexes ( pg. 660, 678)
• 5 components:

• 1) Intact sensory nerve (afferent)
• 2) Functional synapse in cord
• 3) Intact motor nerve fiber (efferent)
• 4) Neuromuscular junction
• 5)Competent muscle

• 4+ = very brisk, hyperactive with clonus, indicative of disease
• 3+ = brisker than average, may indicate disease
• 2+ = average, normal
• 1+ = diminished, low normal
• 0 = no response

• Acute:
• Metabolic disorder of disturbed purine metabolism (elevated serum uric acid)
• First in the metatarsophalangeal joint, redness, swelling, heat,extreme tenderness
• Primarily in men >40 years old
• Chronic:
• Extreme swelling and joint deformity
• Tophi-hard, painless nodule result in 1st toe, sometimes burst with chalky discharge

• Defect of extrapyramidal tracts in basal ganglia with loss of neurotransmitter dopamine
• Motor system dysfunction
• Tremor, rigidity, akinesia
• Slower monotonous speech and diminutive writing
• Immobile, flat facial expression, staring
• Excessive salivation
• Reduced eye blinking
• Stooped posture, trunk pitched forward
• Equilibrium impaired, loses balance easily, passive ROM

Male -Penis, scrotum (external), testis, epididymis, & vas deferens (internal)

Glandular structures accessory to genital organs: prostate,seminal vesicles, & bulbourethral glands

• External: vulva (pudendum), mon pubis, labia majora, labia minora,frenulum, clitoris, vestibule, urethral meatus,paraurethral gland (Skene’s gland), vaginal orifice, hymen, vestibular (Bartholin’s) glands
• TEST QUESTION: Can be seen in vestibular exam- Urethral meatus and vaginal orifice.
• Internal: vagina, (9cm), rugae, cervix (covered in smooth, pink,stratified squamous epithelium), os (covered with columnar epithelium),squamocolumnar junction, anterior/posterior fornix, retouterine pouch (cul-de-sac of Douglas), uterus, fallopian tubes, ovaries

Excessive fat in the stool as in malabsorption of fat

• Cessation of the menses, around age 45-51.
• Female hormones decrease rapidly
• Preceding 1-2 yrs of decline in ovarian function (irregular menses become father apart and lighter flow)
• Ovaries stop producing progesterone and estrogen (causing dramatic physical changes)
• Uterus shrinks due to ↓myometrium
• Ovaries atrophy to 1-2cm and not palpable
• Ovulation may still occur
• Sacral ligament relax and musculature weakens, uterus droops (may protrude prolapsed into vagina)
• Cervix shrinks and paler with thick, glistening epithelium
• Vagina shorter, narrower, and less elastic
• Without sexual activity, vagina atrophies half its former length and width
• Vaginal epithelium atrophies, becomes thinner, drier, and itchy
• Risk for bleeding and vaginitis (dry irritations and pain with sex– dyspareunia)
• pH more alkaline
• Mons pubis smaller
• labia and clitoris ↓ in size
• pubic hair thin and sparse
• Orgasms shorter, resolution more rapid, vaginal secretions andlubrication reduced

Q: A 30 yr old women with a history of MVP states she is very tired the nurse palpates a thrill and lift at the 5th intercostals space and midclavicular line and in the same area the nurse hears a blowing, swishing sound at S1. These findings are most consistent with

A: Mitral Regurgitation