Health Assement

SCHOOL OF BACHELOR OF SCIENCE IN NURSING
General Luna Road, Baguio City Philippines 2600
Telefax No.: (074) 442-3071 loc 274 Website: www.ubaguio.edu E-mail Address: ste@ubaguio.edu
HEALTH ASSESSMENT
PERINEAL ASSESSMENT
I. Define the following terms:
1. Oliguria is the production of abnormally small amounts of urine by the kidney. Oliguria is
considered to be a urinary output of less than 400 milliliters of urine a day in an adult, which
is less than about 13.5 ounces over the course of 24 hours.The specific amounts for infants
and children are based on their weight (less than 1 milliliter per kilogram per hour
for infants, and less than 0.5 milliliters per kilogram per hour for children).
2. Polyuria is the production of large amounts of urine by the kidneys without an increased
fluid intake.
3. Nocturia is medical term for excessive urination at night or voiding two or more at night.
4. Fissure is deep grooves that occur as a result of dryness and cracking of the skin; a long,
narrow opening or line of breakage made by cracking or splitting
5. Fistula is an abnormal connection between two body parts, such as an organ or blood vessel
and another structure. Fistulas are usually the result of an injury or surgery. Infection or
inflammation can also cause a fistula to form; and an abnormal or surgically made passage
between a hollow or tubular organ and the body surface, or between two hollow or tubular
organs.
II. Differentiate “frequent urination” from “urgent urination”
Frequent urination means needing to urinate more often than usual. Frequent urination
describes the need to urinate more often than usual. However, there isn’t really a clear definition
of “frequent” when it comes to how often you urinate.The key to deciding if you have issues
with frequent urination is whether the need to urinate often is creating challenges in your life.
You may also consider whether you feel anxiety when you’re not near a restroom.
Urgent urination is a sudden, strong need to urinate. This causes a discomfort in your
bladder. Urgent urination makes it difficult to delay using the toilet. You may have urgent
urination issues if you sometimes can’t make it to the bathroom in time or if the urge to urinate
comes on very suddenly.
Frequent and urgent urination issues often occur together. You may feel the need to urinate
often, and the urge comes on suddenly. A frequent need to urinate at night is called nocturia.
Most people can sleep for 6 to 8 hours without having to urinate.
Causes
Common causes
• drin
king too much liquid
• drin
king caffeinated or alcoholic beverages
• Dia
betes
• pre
gnancy, especially in the third trimester, when there’s pressure on the bladder
• pro
state enlargement or infection
• anx
iety
• diur
etics
• Inte
rstitial cystitis chronic infection in the bladder
• ove
ractive bladder
vaginal infection
Less common causes include:

• Alc
ohol use
• An
xiety
• Bla
dder Cancer (not common)
• Spi
ne problems
• Dia
betes that is not well controlled
• Pre
gnancy
• Inst
ertisial Cystisis
• Me
dicines such as water pills (diuretics)
• Ove
ractive bladder syndrome
• Rad
iation therapy to the pelvis, which is used to treat certain cancers
• Str
oke and other brain or nervous system diseases
• Tu
mor or growth in the pelvis
III. What is testicular self-examination?
A testicular self-exam is an inspection of the appearance and feel of your testicles. You can do
a testicular exam yourself, typically standing in front of a mirror. Routine testicular self-exams
can give you a greater awareness of the condition of your testicles and help you detect changes.
Self-exams can also alert you to potential testicular problems.
Testicular self-exams help you learn how your testicles normally look and feel. Then you're
more likely to notice subtle changes.
Changes in your testicles could be a sign of a common benign condition, such as an infection or
a cyst, or a less common condition, such as testicular cancer.
VI. How do you do a testicular self-examination?
1. Exa
mine each testicle gently with both hands by rolling the testicle between the thumb and
forefingers.
1. Fin
d the epididymis, the soft tube-like structures behind the testicle that collects and carries
sperm. ...
2. Loo
k for any lumps or irregularities.
3. Loo
k for any changes in size, shape, or texture.
V. What is PAR Smear?
A Pap smear, also called a Pap test, is a screening procedure for cervical cancer. It tests for the
presence of precancerous or cancerous cells on your cervix. The cervix is the opening of the
uterus.
During the routine procedure, cells from your cervix are gently scraped away and examined for
abnormal growth. The procedure is done at your doctor’s office. It may be mildly uncomfortable,
but doesn’t usually cause any long-term pain. A Pap smear involves collecting cells from your
cervix — the lower, narrow end of your uterus that's at the top of your vagina. Detecting cervical
cancer early with a Pap smear gives you a greater chance at a cure. A Pap smear can also detect
changes in your cervical cells that suggest cancer may develop in the future. Detecting these
abnormal cells early with a Pap smear is your first step in halting the possible development of
cervical cancer.
VI. How is PAP Smear Done?
1. A Pap smear is performed in your doctor's office and takes only a few minutes.
You may be asked to undress completely or only from the waist down.
2. You'll lie down on your back on an exam table with your knees bent. Your heels
rest in supports called stirrups.
3. Your doctor will gently insert an instrument called a speculum into your vagina.
The speculum holds the walls of your vagina apart so that your doctor can easily
see your cervix. Inserting the speculum may cause a sensation of pressure in your
pelvic area.
4. Then your doctor will take samples of your cervical cells using a soft brush and a
flat scraping device called a spatula. This usually doesn't hurt.
After the Pap smear
After your Pap smear, you can go about your day without restrictions.
Depending on the type of Pap testing you're undergoing, your doctor transfers the cell
sample collected from your cervix into a container holding a special liquid to preserve
the sample (liquid-based Pap test) or onto a glass slide (conventional Pap smear).
The samples are transferred to a laboratory where they're examined under a
microscope to look for characteristics in the cells that indicate cancer or a
precancerous condition.
REFERENCES:
Kozier and Erb’s Fundamental of Nursing 10th ed. pg.615-620

Health Assessment in Nursing 5th ed. (Weber and Kelley) pg.582-600
ACTIVITY 2
MUSCULOSKELETAL ASSESSMENT
I. ANSWER THE FOLLOWING QUESTIONS:

The 12 cranial nerves can be easily remembered using this mnemonic: On Old Olympus
Tippy Top, A Fat Armed Green View A Hop: Enumerate the 12 Cranial nerves. (12 pts)
I. Olfactory nerve.
II. Optic nerve.

III. Oculomotor nerve.
IV. Trochlear nerve.
V. Trigeminal nerve. (Ophtalmic branch, Maxillary branch, Mandibular branch)
VI. Abducens nerve.
VII. Facial nerve.
VIII. Vestibulocochlear nerve.
IX. Glossopharengeal nerve (Auditory, Vestibular branch, Cochlear branch)
X. Vagus nerve
XI. Accessory nerve
XIl. Hypoglossal nerve
II. IDENTIFY THE CLASSIFICATION OF EACH CRANIAL NERVE:

(SENSORY OR MOTOR) AND WRITE ITS FUNCTION
Number Name of the Cranial Nerve Classification Function

1. Olfactory Nerve Sensory Smell
2. Optic Nerve Sensory Vision and visual fields

3. Oculomotor Nerve Motor Extraocular eye movement
(EOM); movement of sphincter
of pupil; movement of capillary
muscles of lens.
4. Trochlear Nerve Motor EOM; specifically, moves eyeball
downward and laterally
5. Trigeminal Nerve Motor and Sensory
 Ophthalmic branch  Sensation of cornea, skin of
face, and nasal mucosa
 Maxillary branch  Sensation of skin of face and
anterior oral cavity
(tongue and teeth)
 Mandibular branch  Muscles of mastication;
sensation of skin of face
6. Abducens Nerve Motor EOM; moves eyeball laterally

7. Facial Nerve Motor and Sensory Facial expression; taste (anterior
two thirds of tongue )
8. Acoustic Nerve Sensory
 Vestibular branch  Equilibrium
 Cochlear branch  Hearing
9. Glossopharyngeal Nerve Motor and Sensory Swallowing ability, tongue
movement, taste (posterior
tongue)
10. Vagus Nerve Motor and Sensory Sensation of pharynx and larynx;
swallowing; vocal cord movement
11. Spinal Accessory Nerve Motor Head movement; shrugging of
shoulders
12. Hypoglossal Nerve Motor Protrusion of tongue; moves
tongue up and down and side to
side
REFERENCES:
Kozier and Erb’s Fundamental of Nursing 10th ed. pg.603-605

Health Assessment in Nursing 5th ed. (Weber and Kelley) pg.507-537
ACTIVITY 3
NEUROLOGICAL EXAM
I. ANSWER THE FOLLOWING:

1. WHAT ARE THE AREAS THAT MAY BE TESTED AND EVALUATED DURING
NEUROLOGICAL EXAM? HOW ARE THESE AREAS EXAMINED?
During a neurological exam, the healthcare provider will test the functioning of the nervous
system. The nervous system is very complex and controls many parts of the body. The nervous
system consists of the brain, spinal cord, 12 nerves that come from the brain, and the nerves that
come from the spinal cord. The circulation to the brain, arising from the arteries in the neck, is
also frequently examined. In infants and younger children, a neurological exam includes the
measurement of the head circumference. The following is an overview of some of the areas that
may be tested and evaluated during a neurological exam:
Mental status. Mental status (the patient's level of awareness and interaction with the
environment) may be assessed by conversing with the patient and establishing his or her
awareness of person, place, and time. The person will also be observed for clear speech and
making sense while talking. This is usually done by the patient's healthcare provider just by
observing the patient during normal interactions.
Motor function and balance. This may be tested by having Gross and Motor Balance
Tests including the patient push and pull against the healthcare provider's hands with his or
her arms and legs. Balance may be checked by assessing how the person stands and walks
or having the patient stand with his or her eyes closed while being gently pushed to one side
or the other. The patient's joints may also be checked simply by passive (performed by the
healthcare provider) and active struments: dull needles, tuning forks, alcohol swabs, or
other objects. The healthcare provider may touch the patient's legs, arms, or other parts of
the body and have him or her identify the sensation (for example, hot or cold, sharp or dull).
•
Sensory exam. The patient's healthcare provider may also do a sensory test that checks
his or her ability to feel. This may be done by using different instruments: dull needles,
tuning forks, alcohol swabs, or other objects. The healthcare provider may touch the
patient's legs, arms, or other parts of the body and have him or her identify the sensation
(for example, hot or cold, sharp or dull).
Newborn and infant reflexes. There are different types of reflexes that may be tested.
In newborns and infants, reflexes called infant reflexes (or primitive reflexes) are evaluated.
Each of these reflexes disappears at a certain age as the infant grows. These reflexes
include:
•
Blinking. An infant will close his or her eyes in response to bright lights.
•
Babinski reflex. As the infant's foot is stroked, the toes will extend upward.
•
Crawling. If the infant is placed on his or her stomach, he or she will make crawling
motions.
Moro's reflex (or startle reflex). A quick change in the infant's position will cause the infant
to throw the arms outward, open the hands, and throw back the head.
•
Palmar and plantar grasp. The infant's fingers or toes will curl around a finger placed in the
area.
Reflexes in the older child and adult. These are usually examined with the use of a
reflex hammer. The reflex hammer is used at different points on the body to test numerous
reflexes, which are noted by the movement that the hammer causes.
Evaluation of the nerves of the brain. There are 12 main nerves of the brain, called
the cranial nerves. During a complete neurological exam, most of these nerves are evaluated
to help determine the functioning of the brain:
•
Cranial nerve I (olfactory nerve). This is the nerve of smell. The patient may be asked to
identify different smells with his or her eyes closed.
•
Cranial nerve II (optic nerve). This nerve carries vision to the brain. A visual test may be
given and the patient's eye may be examined with a special light.
•
Cranial nerve III (oculomotor). This nerve is responsible for pupil size and certain
movements of the eye. The patient's healthcare provider may examine the pupil (the black
part of the eye) with a light and have the patient follow the light in various directions.
•
Cranial nerve IV (trochlear nerve). This nerve also helps with the movement of the eyes.
•
Cranial nerve V (trigeminal nerve). This nerve allows for many functions, including the
ability to feel the face, inside the mouth, and move the muscles involved with chewing. The
patient's healthcare provider may touch the face at different areas and watch the patient as
he or she bites down.
•
Cranial nerve VI (abducens nerve). This nerve helps with the movement of the eyes. The
patient may be asked to follow a light or finger to move the eyes.
•
Cranial nerve VII (facial nerve). This nerve is responsible for various functions, including
the movement of the face muscle and taste. The patient may be asked to identify different
tastes (sweet, sour, bitter), asked to smile, move the cheeks, or show the teeth.
•
Cranial nerve VIII (acoustic nerve). This nerve is the nerve of hearing. A hearing test may
be performed on the patient.
•
Cranial nerve IX (glossopharyngeal nerve). This nerve is involved with taste and
swallowing. Once again, the patient may be asked to identify different tastes on the back of
the tongue. The gag reflex may be tested.
•
Cranial nerve X (vagus nerve). This nerve is mainly responsible for the ability to swallow,
the gag reflex, some taste, and part of speech. The patient may be asked to swallow and a
tongue blade may be used to elicit the gag response.
•
Cranial nerve XI (accessory nerve). This nerve is involved in the movement of the
shoulders and neck. The patient may be asked to turn his or her head from side to side
against mild resistance, or to shrug the shoulders.
•
Cranial nerve XII (hypoglossal nerve). The final cranial nerve is mainly responsible for
movement of the tongue. The patient may be instructed to stick out his or her tongue and
speak.
•
Coordination exam :
•
The
patient may be asked to walk normally or on a line on the floor.
•
The
patient may be instructed to tap his or her fingers or foot quickly or touch something, such
as his or her nose with eyes closed.
REFENCES:
Kozier and Erb’s Fundamental of Nursing 10th ed. pg. 606-616

https://www.hopkinsmedicine.org/health/conditions-and-diseases/neurological-
exam
Health Assessment in Nursing 5th ed. (Weber and Kelley) pg. 545-578

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SCHOOL OF BACHELOR OF SCIENCE IN NURSING

General Luna Road, Baguio City Philippines 2600

I. Define the following terms:

II. Differentiate “frequent urination” from “urgent urination”

Less common causes include:

III. What is testicular self-examination?

VI. How do you do a testicular self-examination?

V. What is PAR Smear?

VI. How is PAP Smear Done?

Kozier and Erb’s Fundamental of Nursing 10th ed. pg.615-620

I. ANSWER THE FOLLOWING QUESTIONS:

II. Optic nerve.

II. IDENTIFY THE CLASSIFICATION OF EACH CRANIAL NERVE:

Number Name of the Cranial Nerve Classification Function

2. Optic Nerve Sensory Vision and visual fields

6. Abducens Nerve Motor EOM; moves eyeball laterally

Kozier and Erb’s Fundamental of Nursing 10th ed. pg.603-605

I. ANSWER THE FOLLOWING:

Kozier and Erb’s Fundamental of Nursing 10th ed. pg. 606-616

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