Health Assessment Lecture

BURI, JADE B.
HEALTH ASSESSMENT LECTURE FINALS
PHYSICAL
● (From the alveoli) converge into a single
lactiferous duct that leave each lobe and
conveys milk to the nipple.
ASSESSMENT ● The slight enlargement in each duct before it

reaches the nipple is called lactiferous sinus.
BREAST AND LYMPATHIC SYSTEM Fibrous tissue
External Breast Anatomy ● provides support for the glandular tissue

largely by way of bands called Cooper
● Skin of the breast smooth & varies in color ligaments (suspensory ligaments)
depending on the client`s skin tone.
● Nipple located at the center of the breast, Fatty tissue
contains the tiny openings of the lactiferous ● is the 3rd component of the breast. The
ducts through which milk passes. glandular tissue is embedded in the fatty
● Areola surrounds the nipple & contains tissue.
elevated sebaceous glands (Montgomery
glands) that secretes a protective lipid LYMPH NODES
substance during lactation. ● Major axillary lymph nodes consist of the
● Hair Follicles commonly appear around the - anterior (pectoral)
areola. - posterior (subscapular)
● Smooth muscle fibers in the areola cause the - lateral (brachial)
nipple to become more erectile during - central (mid-axillary) nodes
stimulation. ● The anterior nodes drain the anterior chest
● Nipple & areola have darker pigment than the wall and breasts.
surrounding breast. Their color ranges from ● The posterior chest wall & part of the arms
dark pink to dark brown, depending on the are drained by the posterior nodes.
person`s skin color. ● The lateral nodes drain most of the arms, &
⮚ The amount of pigmentation increases the central nodes received drainage from the
with pregnancy, then decreases after anterior, posterior and lateral lymph nodes.
lactation.
BREAST EXAMINATION
Internal Breast Anatomy
PALPATION (SITTING POSITION)
Female breast consists of 3 types of tissues:
Palpate the axillary, subclavicular &
- glandular
supraclavicular lymph nodes. Palpate the:
- fibrous
- fatty (adipose). ● Edge of the greater pectoral muscle (musculus
pectoralis major) along the anterior axillary
Glandular Tissue
line
● constitutes the functional part of the breast, ● Thoracic wall in the midaxillary area
allowing for milk production. ● Upper part of the humerus
● This tissue is arranged in 15 to 20 lobes that ● Anterior edge of the latissimus dorsi muscle
radiates in a circular fashion from the nipple. along the posterior axillary line
● Each lobe contains several lobules in which
Normal Findings:
the secreting alveoli (acini cells) are
embedded in grape- like clusters. - No tenderness, masses or nodules
Mammary ducts Deviations from Normal:
DR. ARLENE CORPUS2ND SEMESTERBSN 1-9
BURI, JADE B. HEALTH ASSESSMENT LECTURE FINALS
- Tenderness, masses or nodules - Concentric Circles Pattern
- Hands of the Clock/ Spokes on a wheel
Palpate the breast for masses, tenderness,
Pattern
discharge from the nipples.
- Vertical strips pattern
Normal Findings:
SELF BREAST EXAMINATION
- No tenderness, masses, nodules, nipple
discharge
Deviations from Normal:
- Tenderness, masses, nodules, nipple
discharge
● Palpate the breast for masses, tenderness &
any discharge from the nipples. Step 1:
● Do it in either of these patterns:
● Look at the breast in the mirror with
- Hands of the clock or spokes on a wheel
shoulders straight & your arms in your hips.
- Concentric circles
● Check the size, shape & color
- Vertical strips
● Notice if they are evenly shaped with no
● Palpate the areola & the nipples for masses.
distortion or swelling
Compress each nipple to determine the
presence of any discharge Deviations from Normal:
● Assess the discharge for amount, color,
- Dimpling, puckering or bulging of the skin
consistency & odor
- Inverted nipple (pushed inward instead of
When a lump is detected sticking outward)
- Redness, soreness, rash or swelling
a. Location: exact location relative to the
quadrants & axillary tail, distance from the Step 2:
nipple in centimeters
● Raise the arms and determine if the patient
b. Size: length, width, thickness of the mass
can see the same changes
in cm., determine the discrete edges
c. Shape: round, oval, lobulated, indistinct, Step 3:
irregular
● Look for any signs of fluid coming out of one
d. Consistency: hard to soft
or both nipples (e.g., watery, milky, yellow
e. Tenderness: whether palpation is painful
fluid or blood)
f. Mobility: if mass is movable or fixed
g. Skin over the lump: if reddened, dimpled, Step 4:
retracted
● Lie down with the arm behind the head.
h. Nipple: if displaced or retracted
● Use the 3 middle finger pads & move them in
PALPATION (SUPINE POSITION) a circular motion covering the entire breast
from top to bottom, side-to-side– from the
collar bone to the top of the abdomen & from
the armpit to the cleavage.
● The patient may also use an up-and-down
approach by moving the fingers up & down
vertically, in rows.
Breast Palpation Technique ● Use light pressure for the skin & tissue just
beneath; medium pressure for tissue in the
middle of the breast & firm pressure for the DIMPLING:
deep tissue in the back.
- The skin has a texture similar to an orange
Step 5: peel.
- Suggest malignancy
● Examine the breast when the skin is wet and
slippery during shower. PAGET DISEASE:
● Cover the entire breast using a circular motion
- Redness & flaking of the nipple
INSPECTION OF THE BREAST SIZE, SYMMETRY, - Tingling, itching, increased sensitivity,
CONTOUR burning, discharge & pain in the nipple are
the late signs of Paget disease.
Normal Findings:
- May occur in both breast but is rare.
- Females: rounded shape; slightly unequal
RETRACTED BREAST TISSUE:
in size; generally symmetric
- Males: breasts even with the chest wall; - Suggest malignancy
(obese) similar in shape to female breasts
RETRACTED NIPPLE:
- A nipple whose tip is pulled inward,
- Recent change in breast size suggest malignancy.
- Swelling
MASTITIS:
- Marked asymmetry
- Reddened, painful area on breast warm to
HEALTH ASSESSMENT
palpation.
Collection of the Subjective Data CANCEROUS TUMORS:
- History of present health illness - Irregular, firm, hard, not defined masses
- Personal health history that maybe fixed or mobile.
- Lifestyle & health practices - They are not usually tender & usually
Collection of the Objective Data occurred after the age of 50.
- Preparing the client FIBROADENOMAS:

- Equipment - These are lobular lesions, ovoid or round
- Physical Assessment - Firm, well-defined, seldom tender &
EQUIPMENTS usually singular & mobile
- They occur more commonly between
● Centimeter ruler puberty & menopause.
● Small pillow
● Gloves BENIGN BREAST DISEASE:
● Client handout for BSE (breast self- - Also called as fibrocystic breast disease
examination) - Marked by round, elastic, defined, tender
● Slide for specimen & mobile cysts
ABNORMAL FINDINGS - The condition is most common from age
30 to menopause, after which it
PEAU D`ORANGE: decreases.
- Resulting from edema, an orange peel HEART & NECK VESSEL
appearance of the breast is associated
with cancer. CARDIOVASCULAR SYSTEM
- Consists of the heart & central blood right ventricle produces a heave at or
vessels primarily the pulmonary, coronary near the sternum.
and neck arteries & veins ● Heart sounds can be heard by auscultation
- The HEART is usually assessed during ● The normal 1st two heart sounds (S1 & S2)
initial physical assessment; periodic are produced by closure of the valves of the
assessments may be necessary for heart.
long-term or clients with cardiac ⮚ S1- 1st heart sound
problems. - occurs when the atrioventricular (AV)
- Assessment: inspection, palpation & valves closed
auscultation - these valves closed when the ventricles
- Auscultation may be meaningful when have been sufficiently filled
other data will be obtained first. - is a dull, low-pitched sound described as
“lub”
HEART
● After the ventricles empty the blood into the
● (Average adult), heart lies behind & to the left aorta & pulmonary arteries, the semilunar
of the sternum valves close producing the 2nd heart sound
● Small portion (right atrium) extends to the “S2”
right sternum ⮚ S2 – described as “dub”, has higher pitch
● Both atria (upper portion of the heart) than S1 & shorter in duration
referred to as it`s BASE, lies towards the back - These 2 sounds S1 & S2 “lub-dub”
● Ventricles (lower portion of the heart) occur within one second or less,
referred to as its APEX, points anteriorly depending on the heart rate
● Apex of the left ventricle touches the chest - These 2 heart sounds are audible
wall at or medial to the left midclavicular line anywhere in the precordial area but
(MCL) & at or near the 5th left intercoastal are best heard over the aortic,
space (LICS) which is slightly below the left pulmonic, tricuspid & mitral areas
nipple. ● Associated with S1 & S2 sounds are systole &
● Point of Maximal Impulse (PMI), the point diastole
where the apex touches the anterior chest ⮚ Systole:
walls & heart movements are most easily - Period in which the ventricles contract
observed & palpated known as “emptying”
● Precordium, the area of the chest overlying - Begins with S1 & ends at S2
the heart is inspected & palpated for the - Normally shorter than diastole
presence of abnormal pulsations or lifts or ⮚ Diastole:
heaves. - Period in which the ventricles relax
⮚ LIFT/HEAVE: known as “filling”
- (Often used interchangeably) refers to - Starts with S2 & ends at the
a rising along the sternal border with subsequent S1
each heartbeat. ● However, nurses may perceive extra heart
- Occurs when cardiac action is very sounds (S3 & S4) during diastole.
forceful ● Both sounds are low in pitch & heard best at
- Should be confirmed by palpation with the apex using the bell of the stethoscope &
the palm of the hand the client is lying on the left side.
- Enlargement or activity of the left ⮚ S3 Sound:
ventricle produces a heave lateral to - Occurs early in diastole right after S2,
the apex, while enlargement of the sounds like “lub-dub-ee” (S1, S2, S3)
or “Kentuc-ky”
-Normal in children & young adults ● is an abnormal sound from the heart
-In older adults, may indicates “heart ● the sound is in synchronization with the
failure” heartbeat
⮚ S4 Sound: ● bruit that is normally heard over the carotid
- (Ventricular gallop) occurs near the artery is a sign that there are fats in the wall
very end of diastole, just before S1 of the vessel (fatty buildup
- Creates the sounds of “dee-lub-dub” ATHEROSCLEROSIS)
(S4, S1, S2) or “Ten-nessee”
Thrill
- May be heard in older clients & can be
a sign of hypertension Frequently accompanies a bruit, is a vibrating
● MURMURS: sensation like the purring of a cat or water
⮚ There are conditions that can create a running through a hose.
turbulent blood flow in which a swooshing
Jugular Veins
or blowing sound maybe auscultated over
the precordium. ● Drains blood from the head & neck directly
⮚ Such conditions are: into the superior vena cava & right side of the
- Increased blood velocity heart.
- Structural valve defects
- Valve malfunction ASSESSING THE HEART AND CENRAL VESSELS
- Abnormal chamber openings (e.g., ● Inspect & palpate the precordium for the
septal defect) presence of abnormal pulsations, lifts or
HEART EXAMINATION heaves.
Normal Findings:
● Heart sounds following the 4 auscultatory
area: - No pulsations; no lift or heaves
- Mitral area, tricuspid area for the first - No aortic pulsations
heart sound (S1)
- Pulmonic and Aortic area for the second
heart sound (S2) Compare the loudness, -Pulsations
intensity, rhythm -Diffuse lift or heave indicating enlarge
● Count apical rate per minute using the right ventricle
stethoscope - Bounding abdominal pulsations (aortic
aneurysm)
CENTRAL VESSELS
● Auscultate the heart in all 4 anatomic sites:
● Are the carotid arteries that supply aortic, pulmonic, tricuspid, & apical (mitral)
oxygenated blood to the head & neck.
Normal Findings:
● Since these arteries are the only source of
blood to the brain, prolonged occlusion of - S1 & S2 usually heard at all sites
these arteries can result in serious brain - Systole: silent interval; slightly shorter
damage. duration than diastole at normal heart
● The carotid pulses correlate with the central rate (60-90 BPM)
aortic pressure thus reflecting cardiac - Diastole: silent interval; slightly longer
function better than the peripheral pulses. duration than systole at normal heart rate
● The carotid is auscultated for a “bruit”.
Carotid Bruit

- Increased/decreased intensity; varying - Bilateral measurements above 3-4cm are
intensity with different beats considered elevated (indicate right-sided
- Increased intensity at the aortic area & at heart failure)
pulmonic area - Unilateral distention (maybe caused by
- Sharp sounding ejection clicks local obstruction)
CAROTID ARTERIES AUSCULTATION OF THE HEART SOUND
● Palpate the carotid arteries using extreme Murmurs can be classified by seven different
caution. characteristics
Normal Findings: 1. Timing refers to whether the murmur is a
- Symmetric pulse volumes systolic or diastolic murmur.
- Full pulsations, thrusting quality 2. Shape refers to the intensity over time;
- Elastic arterial wall murmurs can be crescendo, decrescendo or
crescendo-decrescendo.
Deviations from Normal: 3. Radiation refers to where the sound of the
- Asymmetric volumes (possible stenosis or murmur radiates.
thrombosis) ⮚ The general rule of thumb is that the
- Decreased pulsations (indicate impaired sound radiates in the direction of the
left cardiac output) blood flow.
- Increased pulsations 4. Location refers to where the heart murmur is
- Thickened, hard, rigid, beaded, inelastic auscultated best. There are 6 places on the
walls (indicate arteriosclerosis) anterior chest to listen for heart murmurs;
● Auscultate the carotid artery a. 2nd right intercostal space
b. 2nd - 5th left intercostal spaces
Normal Findings: c. 5th mid-clavicular intercostal space
- No sounds heard on auscultation 5. Intensity refers to the loudness of the
murmur and is graded on a scale from 0-6/6.
Deviations from Normal: ✔ Grade I/VI: Barely audible
- Presence of bruit in one or both arteries ✔ Grade II/VI: Faint but easily audible
(suggest occlusive artery disease) ✔ Grade III/VI: Loud murmur without a
palpable thrill
JUGULAR VEINS ✔ Grade IV/VI: Loud murmur with a palpable
● Inspect the jugular veins for distention thrill
(semi-fowlers position) ✔ Grade V/VI: Very loud murmur heard with
stethoscope lightly on chest
Normal Findings: ✔ Grade VI/VI: Very loud murmur that can
- Veins not visible (indicating right side of be heard without a stethoscope
heart is functioning normally) 6. Pitch
Deviations from Normal: is low, medium or high and is determined by

whether it can be auscultated best with the bell
- Veins visibly distended (indicating or diaphragm of a stethoscope
advanced cardiopulmonary disease)
● If jugular distention is present, assess the 7. Quality
jugular venous pressure (JVP) a. blowing
Deviations from Normal: b. harsh

c. rumbling ● The anterior branch descends the top of the
d. musical foot, where it becomes the “dorsalis pedis
artery”. This can be palpated at the great-toe
PERIPHERAL VASCULAR SYSTEM
side of the top of the foot.
ARTERIES ● The posterior branch is called “posterior tibial
artery”. This can be palpated behind the
● Are blood vessels that carry oxygenated,
medial malleolus of the ankle.
nutrient-rich blood from the heart to the
capillaries. VEINS
● Each heartbeat forces to the arterial vessels
● Are blood vessels that carry deoxygenated ,
under high pressure creating a surge, & this
nutrient-depleted, waste-laden blood from
surge of blood is the “arterial pulse”.
the tissues back to the heart.
MAJOR ARTERIES OF THE ARM ● The veins of the heart, upper trunk, head &
neck carry blood to the superior vena cava,
Brachial Artery
where it passes into the right atrium.
● Is the major artery that supplies the arm ● Blood from the lower trunk & legs drains
● This can be palpated medial to the bicep's upward into the inferior vena cava.
tendon in & above the bend of the elbow ● The veins carry nearly 70% of the body`s
● The brachial artery divides near the elbow to blood volume, because blood in the veins is
become the radial artery (extending down the carried under much lower pressure than in
thumb side of the arm) and the ulnar artery the arteries, the vein walls are much thinner
(extending down to the little-finger side of the than the arteries.
arm). ● larger in diameter than arteries & can expand
if blood volume increases. This helps to
Radial Pulse
reduce workload in the heart.
● Can be palpated on the lateral aspect of the
TYPES OF VEINS
wrist
Deep Veins:
Ulnar Pulse
● The 2 deep veins in the leg are the femoral
● Located on the medial aspect of the wrist, is a
vein in the upper thigh & popliteal vein
deeper pulse & may not be easily palpated
located behind the knee
Femoral Artery ● These veins account about 90% of venous
return from the lower extremities
● Is the major supplier of blood to the legs
● Its pulse can be palpated just under the Superficial Veins:
inguinal ligament
● Are the great & small saphenous veins
● This artery travels down the front of the thigh
✔ Great Saphenous Vein is the longest of all
then crosses to the back of the thigh, where it
veins & extends from the medial dorsal
is termed as the “popliteal artery”.
aspect of the foot, crosses over the medial
Popliteal Pulse malleolus, continues across the thigh to
the medial aspect of the groin, that joins
● Can be palpated behind the knee
the femoral vein.
Popliteal Artery ✔ Small Saphenous Vein begins at the
lateral dorsal aspect of the foot, travels up
● Divides below the knee into anterior &
behind the lateral malleolus on the back
posterior branches.
of the leg, & joins the popliteal vein.
Perforator/Communicator Veins: Deviations from Normal:
● Connect the superficial veins with the deep - Swelling on one calf or leg; tenderness on
veins palpation
- Pain in calf muscles
PHYSICAL ASSESSMENT
- Warm & redness over vein
INSPECTION - Presence of phlebitis
PERIPHERAL PULSES: PERIPHERAL PERFUSION:
● Palpate the peripheral pulse on both sides of ● Inspect the skin of the hands & feet for color,
the client`s body temperature, edema & skin changes
Normal Findings: Normal Findings:
- Symmetric pulse volumes; full pulsations - Skin color is pink; skin temperature not
excessively warm or cold; no edema; skin
Deviations from Normal: texture resilient & moist
- Asymmetric volumes (indicate impaired Deviations from Normal:
circulation)
- Absence of pulsation (indicates arterial - Cyanotic (venous insufficiency)
spasm) - Pallor that increases with limb elevation
- Decreased, weak, thready pulsations - Dusky red color when limb is lowered
(indicate impaired cardiac output) (arterial insufficiency)
- Increased pulse volume (indicate - Brown pigmentation around ankles
hypertension, high cardiac output, (Arterial & chronic venous insufficiency
circulatory overload) CAPILLARY REFILL TEST:
PERIPHERAL VEINS: ● Press at least 1 nail on each hand between
● Inspect the peripheral veins in the arms & legs thumb & index finger about 5 seconds
for the presence or appearance of superficial ● Release the pressure & observe how quickly
veins. normal color returns (2 seconds)
Normal Findings: Normal Findings:
- Dependent position: presence of - Immediately return of color

distention & nodular bulges & calves Deviations from Normal:
- When limbs elevated: veins collapse (veins
may appear tortuous or distended in older - Delayed return of color (arterial
persons) insufficiency)
Deviations from Normal: OTHER ASSESSMENT:
- Distended veins in the thigh or lower leg ● Inspect the fingernails for changes indicative
or on posterolateral part or calf from knee of circulatory impairment
to ankle
● Assess the peripheral leg veins for the signs of
phlebitis
Normal Findings:
- Symmetric in size; limbs not tender
ASSESSMENT OF
2. Right Lumbar Region
- ascending colon
- lower half of the right kidney
THE ABDOMEN - part of the duodenum and jejunum

3. Right Iliac Region
- cecum
● Abdomen is bordered superiorly by the - Appendix
coastal margins, inferiorly by the symphysis - Lower end of the ileum
pubis & inguinal canals & laterally by the - right ureter
flanks - Right spermatic cord
● Important to understand the anatomic - Right ovary
divisions known as the “abdominal quadrants, 4. Epigastric Region
abdominal wall muscles & the internal - aorta
anatomy of the abdominal cavity” in order to - pyloric end of stomach
perform an adequate assessment of the - part of duodenum
abdomen - pancreas
FOUR ABDOMINAL QUADRANTS - part of liver
5. Umbilical Region
1. Right upper quadrant (RUQ) - Omentum
2. Right lower quadrant (RLQ) - mesentry
3. Left upper quadrant (LUQ) - lower part of duodenum
4. Left lower quadrant (LLQ) - Part of the jejunum and ileum
⮚ These quadrants are determined by an 6. Hypogastric Region
imaginary vertical line (midline) extending - Ileum
from the tip of the sternum through the - Bladder
umbilicus to the symphysis pubis. - Uterus
NINE ABDOMINAL REGIONS 7. Left Hypochondria Region
- stomach
- Spleen
- Tail of pancreas
- splenic flexure of colon
- Upper half of the left kidney
- Suprarenal gland
8. Left Lumbar Region
- Descending colon
- lower half of the left kidney
- part of the jejunum and ileum
9. Left Iliac Region
- sigmoid colon
1. Right Hypochondriac Region - left ureter
- Right lobe of liver - left spermatic cord
- Gallbladder - Left ovary
- part of the duodenum ABDOMINAL WALL MUSCLES
- hepatic flexure of the colon
- upper half of the right kidney ● Three layers of muscles extending from the
- suprarenal gland back, around the flanks, to the front.

1. External Abdominal Oblique – the Pancreas
outermost layer
- Located mostly behind the stomach, deep in
2. Internal Abdominal Oblique – middle
the upper abdomen, is normally not palpable.
layer
- Has 2 functions: endocrine gland & accessory
3. Transverse Abdominis – innermost layer
organ of digestion.
● Rectus Abdominis – a connective tissue from
these 3 muscles extends forward to encase a Spleen
vertical muscle of the abdominal wall.
- Located above the left kidney just below the
● Aponeuroses - fibers & connective tissue
diaphragm at the level of the ninth, tenth &
extensions of these muscles which provides
eleventh ribs.
strength to the abdominal wall.
- Posterior to the left mid-axillary line (MAL),
● Linea Alba – a white line that joined the
posterior & lateral to the stomach.
muscle fibers & aponeuroses at the midline of
- Functions: to filter the blood of cellular
the abdomen, extends vertically from the
debris, to digest microorganisms & to return
xyphoid process of the sternum to the
the breakdown products to the liver.
symphysis pubis.
⮚ The abdominal wall muscles protect the Kidneys
internal organs & allow normal
- Located high & deep under the diaphragm
compression during functional activities
- Primary function: filtration & elimination of
such as coughing, sneezing, urination,
metabolic waste products.
defecation & childbirth.
- Also play a role in blood pressure control &
INTERNAL ANATOMY maintenance of water, salt, & electrolyte
balances.
● Peritoneum a thin, shiny serous membrane
- They also function as endocrine glands by
lines the abdominal cavity (parietal
secreting hormones.
peritoneum) & provides covering for most of
the internal abdominal organs (viscera HOLLOW VISCERA
peritoneum).
● consist of structures that change shape
● Abdominal Viscera are the body systems like
depending on their contents. These includes
gastrointestinal, reproductive (female),
stomach, gallbladder, small intestine, colon &
lymphatic, and urinary.
bladder.
ABDOMINAL VISCERA IS DIVIDED INTO TWO
Abdominal Cavity
SOLID VISCERA
- Begins with the stomach
● are those organs that maintain their shape - Is distensible, flask-like organ located in the
consistently like liver, pancreas, spleen, LUQ just below the diaphragm, between the
adrenal glands, kidneys, ovaries & uterus liver & spleen
Liver Stomach
- Is the largest solid organ in the body located - Not usually palpable
below the diaphragm in the RUQ of the - Main function: to store, churn & digest food
abdomen.
Gallbladder
- Composed of 4 lobes that fill most of the RUQ
& extend to the left midclavicular line (MCL). - A muscular sac approximately 10 cm long,
- 4 Lobes: left lobe, right lobe, caudate & functions primarily to concentrate & store the
quadrate bile needed to digest fat.
- Located near the posterior surface of the liver ● Pulsations of the aorta are frequently visible
lateral to the MCL. & palpable midline in the upper abdomen
● The aorta branches into the right & left renal
Small Intestine
arteries, right & left iliac arteries just below
- The longest portion of the digestive tract but the umbilicus.
is named for its small diameter ● Pulsations of the right & left iliac arteries may
- 2 major functions: digestion & absorption of be felt in the RLQ and LLQ.
nutrients through millions of mucosal
HEALTH ASSESSMENT
projections lining its walls.
- Lies coiled in 4 quadrants of the abdomen, is Subjective data concerning the abdomen
not normally palpated.
● History of present illness/ current abdominal
Colon or Large Intestine pain
● Mechanisms & sources of abdominal pain
- Originates in RLQ, attaches to the small
● Personal health history
intestine at the ileocecal valve.
● Family history
- Composed of 3 major sections: ascending,
● Nutrition, bowel habits
transverse & descending
● Lifestyle & practices
o Ascending colon extends up along the
right side of the abdomen, at the junction Objective data (Comprehensive examination)
of the liver in the RUQ, it flexes at the
● Explore GI complaints
right angle & becomes the transverse
● Assess abdominal pain
colon.
● Presence of tenderness or masses
o Transverse colon runs across the upper
abdomen. In the LUQ near the spleen, the Equipment:
colon forms another right angle then
● Small pillow or rolled blanket
extends downward along the left side of
● Centimeter ruler/tape measure
the abdomen as the descending colon &
● Stethoscope
curves toward the midline to form the
● Marking pen
sigmoid colon in the LLQ.
- Sigmoid colon often felt as a firm structure on PHYSICAL ASSESSMENT
palpation, whereas the cecum & ascending
Preparing the Client
colon may feel softer.
- The colon functions primarily to secrete large ● Ask the client to empty the bladder before
amounts of alkaline mucus, to lubricate the starting the examination (to eliminate bladder
intestine & neutralize acids formed by the distention & interference with an accurate
intestinal bacteria. examination)
● Instruct the client to remove the clothes &
Urinary Bladder
put on the hospital gown
- Distensible muscular sac located behind the ● Position the client in “supine position” with
pubic bone in the midline of the abdomen arms folded across the chest or at the sides
- Functions as temporary receptacle for urine. ● Examination: inspection, auscultation,
percussion & palpation
VASCULAR STRUCTURES
Common Abnormal Findings:
Abdominal Organs
● Abdominal edema or swelling (ascites)
● Are supplied with arterial blood by the
● Abdominal masses (abnormal growth,
abdominal aorta & its major branches.
constipation)
● Unusual pulsation (aneurysm of the - Visible peristalsis in non-lean clients
abdominal aorta) (possible bowel obstruction)
● Pain associated with appendicitis - Marked aortic pulsations
● Observe vascular pattern
INSPECTION OF THE ABDOMEN
Normal Findings:
● Inspect for skin integrity
- No visible vascular pattern
Normal Findings:
- Unblemished skin color; uniform color
- Silver white striae/stretch marks or - Visible venous pattern (dilated veins)
surgical scars associated with liver cancer, ascites,
venocaval obstruction
AUSCULTATION OF THE ABDOMEN
- Presence of rash or lesions
- Tense, glistening skin (ascites, edema) ● Auscultate the abdomen for bowel sounds,
- Purple striae (Cushing`s Disease/rapid vascular sounds & peritoneal friction rubs
weight gain/loss) (flat disk diaphragm)
● Inspect the abdomen for contour &
Normal Findings:
symmetry
- Audible bowel sounds
Normal Findings:
- Flat, rounded (convex); scaphoid (concave)
- No evidence of enlargement of the - Hypoactive: extremely soft or infrequent
liver/spleen (one per minute)
- Symmetric contour - Hypoactive sounds (decreased motility,
inflammation, surgery, paralytic ileus, late
bowel obstruction)
- Distended - Hyperactive/increased/high-pitched, loud,
- Evidence of enlargement of the liver or rushing sounds known as borborygmi
spleen - Hyperactive sounds indicate intestinal
- Localized protrusion around umbilicus, motility with diarrhea, early bowel
inguinal ligaments or scars (hernia or obstruction, use of laxatives
tumor) ● Auscultate for vascular sounds (bell of the
● Observe for abdominal movements stethoscope) over the aorta, renal, iliac &
associated with respiration, peristalsis or femoral arteries. Listen for bruits.
aortic pulsations
Normal Findings:
Normal Findings:
- Absence of arterial bruits
- Symmetric movement caused by
respiration
- Visible peristalsis in very lean people - Loud bruits over the aorta (possible
- Aortic pulsations in thin people aneurysm)
- No visible vascular pattern - Bruits over the renal or iliac arteries
● Auscultate for peritoneal friction rubs
Normal Findings:
- Limited movement due to pain
- Absence of friction rubs
ND
DR. ARLENE CORPUS2 SEMESTERBSN 1-9
Deviations from Normal: - Obesity accounts for most uniformly
protuberant abdomens.
- Friction rub can be heard
- Abdominal wall is thick, & tympany is the
PERCUSSION OF THE ABDOMEN percussion tone elicited.
- Umbilicus appears sunken
● Percuss several areas in the 4 quadrants to
determine presence of tympany (sounds Feces
indicating gas in the stomach & intestines);
- Hard stools in the colon appears as a localized
dullness (decrease, absence or flatness or
distention
resonance over solid mass or fluid)
- Percussion over the area discloses dullness.
● Start in the RLQ, RUQ, LUQ, LLQ
Fibroids & other Masses
Normal Findings:
- A large ovaria cyst or fibroid tumor appears as
- Tympany over the stomach & gas-filled
generalized distention in the lower abdomen
bowels
- The mass displaces bowel, the percussion
- Dullness over the liver, spleen or full
tone over the distended area is dullness with
bladder
tympany at the periphery.
Deviations from Normal: - Umbilicus may be everted.
- Large dull areas (associated with presence Flatus
of fluid or a tumor)
- Abdomen with gas may appear as a
PALPATION OF THE ABDOMEN generalized protuberance or may appear
more localized.
● Perform light palpation 1st to detect areas of
- Tympany is the percussion tone over the area
tenderness or muscle guarding
Ascitic Fluid
Normal Findings:
- The fluid in the abdomen causes generalized
- No tenderness, relaxed abdomen with
protuberance, bulging flanks & an everted
smooth consistent tension
umbilicus.
Deviations from Normal: - Percussion reveals dullness over fluid (bottom
of abdomen & flanks) & tympany over
- Tenderness & hypersensitivity
intestines (top of abdomen)
- Superficial masses
- Localized areas of increased tension Enlarged Liver (Hepatomegaly)
● Palpate the bladder above the symphysis
- A span greater than 12cm at the midclavicular
pubis
line (MCL) and greater than 8cm at the
Normal Findings: midsternal line (MSL).
- An enlarged non-tender lover suggests
- not palpable
cirrhosis
Deviations from Normal: - An enlarged tender liver suggests congestive
heart failure, acute hepatitis or abscess
- Distended & palpable as smooth, round,
tense mass (urinary retention) Enlarged Nodular Liver
ABNORMAL FINDINGS (ABDOMINAL - Enlarged, firm, hard, Nodular liver suggests

DISTENTION) cancer
- Other cause maybe a late cirrhosis or syphilis
Fat
Enlarged Spleen (Splenomegaly)
- Defined by an area of dullness exceeding in
7cm
- When enlarged, the spleen progresses
downward & towards the midline
Aortic Aneurysm
- A prominent, laterally pulsating mass above
the umbilicus
- It is accompanied by bruit and a wide,
bounding pulse
Enlarged Kidney
- Maybe due to a cyst, tumor or
hydronephrosis.
- Maybe differentiated from an enlarged spleen
by its smooth rather than sharp edge, the
absence of a notch, & tympany on percussion
Enlarged Gallbladder
- An extremely tender, suggests acute
cholecystitis
- A positive finding is Murphy sign (sharp pain
that causes the client to hold the breath).

o Is an abnormal contraction of a bundle of
muscle fibers that appears as a twitch.
o Involuntary contraction or twitc hing of
groups of muscle fibers
MUSCULOSKELETAL SYSTEM
ASSESSMENT OF
● Is the supporting framework & collectively the
largest system in the body.
● It is the word of a 2 syllables: muscle +
THE skeletal
● Consist of:
MUSCULOSKELETA
1. Muscle accounts for approximately 50% of
the body weight
2. Bony structures & connective tissue
L SYSTEM accounts for approximately 25% of the

body weight.
● Encompasses the muscles, bones & joints SKELETAL MUSCLES

● The completeness on the assessment of this ● (Muscles) organs of the muscular system
system depends on the current needs & which are mostly attached by tendons to the
problems of the patient. bones of the skeleton
● Nurses assesses the musculoskeletal system ● Are the muscles that are connected to the
for muscles strength, tone, size, symmetry of bones & allows a person to perform a wide
muscle development & tremors. range of movements & functions
TREMOR 3 TYPES OF MUSCLES
● Is an involuntary trembling of a limb or body 1. Skeletal muscles (voluntary & striated)
part. 2. Cardiac muscles (involuntary & striated)
● May involve large group of muscle fibers or 3. Smooth/visceral muscles
small bundles of muscle fibers ● The musculoskeletal system is made up of 650
TYPES OF TREMOR skeletal (voluntary) muscles, which are under
the conscious control & are made up of long
1. Intention Tremor muscle fibers (fasciculi) arranged together in
- Involuntary rhythmic muscle contraction bundles & joined by connective tissue.
(oscillations) that may occur during a ● Skeletal muscles attached to the bones by way
purposeful, voluntary movement of the of a strong, fibrous cords called “tendons”.
affected body part ● These muscles assist with posture, produce
- Becomes more apparent when an individual body heat & allows the body to move.
attempts a voluntary movement such as
holding a cup of coffee, doing an activity like SKELETAL MUSCLE MOVEMENTS
eating a. Abduction moving away from the midline
2. Resting Tremor of the body
- Occurs when the muscle is relaxed such as the b. Adduction moving towards the midline of
hand is resting on the lap the body
- More apparent when the client is relaxed and c. Circumduction circular motion
diminishes with activity. d. Inversion moving inward
- Fasciculation e. Eversion moving outward
f. Extension straightening the extremity at 1. Movement of body parts: by isotonic &
the joint & increasing the angle of the isometric contractions
joint 2. Maintenance of posture
g. Hyperextension joint bends greater than 3. Production of body heat
180 degrees
SKELETAL SYSTEM
h. Flexion bending the extremity at the joint
& decreasing the angle of the joint Consists of the following:
i. Dorsiflexion toes draw upward to ankle
1. The skeleton (bones)
j. Plantar Flexion toes point away from
2. Articular system (joints)
ankle
3. Supportive connective tissues
k. Pronation turning or facing downward
l. Supination turning or facing upward SKELETON (BONES):
m. Protraction moving forward
● Mobility and weight-bearing capacity are
n. Retraction moving backward
directly related to the bone`s size and shape
o. Rotation turning of a bone on its own long
● Bones composed of cells, protein matrix and
axis
mineral deposits.
p. Internal rotation turning of bone towards
the center of the body TYPES OF BONES CELLS:
q. External rotation turning of a bone away
Osteoblast:
from the center of the body
● Large cell responsible for the synthesis &
SKELETAL MUSCLE CONTRACTIONS
mineralization of bone during both initial
● Is the tightening, shortening, or lengthening bone formation & later bone remodeling
of muscles when an individual do some ● Functions in bone formation by secreting
activity. bone matrix.
● Happened when a person hold or pick up
Osteocytes:
something or when a person stretch or
exercise with weights ● A cell that lies within a substance of a fully
formed bone
TYPES OF MUSCLE CONTRACTIONS
● Are mature bone cells involved in
1. Isometric Contraction bone-maintenance.
- The length of the muscle remains constant,
Osteoclasts:
but the force generated by the muscle is
increasing. ● A type of bone cell that breaks down bone
o Example: when one pushes against an tissue
immovable wall ● Involved in destroying, resorbing and
2. Isotonic Contraction remolding bone.
- is characterized by shortening of the muscle ● This function is critical in the maintenance,
with no increase in tension within the muscle. repair & remodeling of bones
o Example: flexion of the forearm
TYPES OF BONES:
⮚ Many muscle movements are a combination
of isometric & isotonic contraction. (E.g., Long bones
during walking, isotonic contraction results in
● Are hard, dense bones that provides strength,
shortening of the leg, & isometric contraction
structure & mobility
causes the stiff leg to push
FUNCTIONS OF MUSCLES
● Has shaft & two ends, some bones in the levels, inhibits bone reabsorption &
fingers are classified as long bones even increases the deposit of calcium in the
though they are short in length bone.
● Thigh bone (femur) is a long bone 5. Gerontologic Considerations: Aged persons
become prone to fracture (vertebrae, hips,
Short bones
wrist) due to weakness, fatigue or falls
● Are shaped roughly as a cube & contain
ANATOMY OF THE SKELETAL SYSTEM
mostly of spongy bones
● The outside surface is comprised of a thin BONES OF CRANIUM
layer of compact bone
● Located in the hands & feet
● The patella (kneecap) is considered as a short
bone
Flat bones
● Made up of a layer of spongy bone between
two thin layers of compact bone
● Have a flat shape & not rounded
● Examples: skull & rib bones
OSTEOGENESIS
Unpaired Bones
● Formation of bone
- 1 frontal bone
Ossification: - 2 ethmoid bones
- 3 sphenoid bones
● Is the process by which the bone matrix
- 4 occipital bones
(collagen fibers & ground substance) is
formed and hardening materials (e.g., calcium Paired Bones
salts) are deposited on the collagen fibers.
- 5 temporal bones
● The collagen fibers give tensile strength to the
- 6 parietal bones
bone & the calcium provides compressional
strength.
REGULATING FACTORS FOR BONE
MAINTENANCE
1. Local stress (Weight Bearing): acts to
stimulate bone formation & remodeling.
2. Vitamin D: promoting absorption of calcium
from the gastrointestinal tract. It also
facilitates mineralization of osteoid tissue.
3. Blood Supply: with diminished blood supply
or hyperemia (congestion), osteogenesis
(bone formation) and bone density decrease.
4. Parathyroid Hormone & Calcitonin
- Calcium homeostasis, demineralization of
bone and the formation of bone cyst.
- Calcitonin is secreted by the thyroid gland
in response to elevated blood calcium
BONES OF THE CRANIUM (IMMOVABLE

SUTURES)
BONES OF THE HAND
BONES OF THE APPENDICULAR SKELETON
BONES OF FOOT
JOINTS

● (or articulation) the point in which two or
more bones meet. The synotide membrane
lines the joints.
● It secretes synovial fluid that acts as a
lubricant so the joint can move smoothly.
Components:
✔ Synovial fluid JOINT MOTION PRODUCED BY MUSCLE
✔ cartilage CONTRACTION
✔ tendons
✔ Flexion
✔ ligaments
✔ Inversion
✔ bursae
✔ Extension
Bursae ✔ Eversion
✔ Dorsiflexion
● A disc shaped, fluid-filled synovial sacs that
✔ Internal rotation
develop at points of friction around joints,
✔ Plantar flexion
between tendons, cartilage & bone
✔ External rotation
● Decrease friction & promote ease of motion.
✔ Adduction
CLASSIFICATION OF JOINTS ✔ Pronation
✔ Abduction
1. Synarthroses or fibrous joints
✔ Supination
- Are joined by fibrous connective tissue &
are immovable 3 SUPPORTIVE CONNECTIVE TISSUE
- E.g., sutures between skull bones
1. Cartilage
2. Amphiarthroses or cartilaginous
● Cushioning tissue within a joint so that the
- Are joined by cartilage
bone ends do not rub together
- E.g., joints between vertebrae
● Hyaline cartilages: trachea, nose & articular
3. Diarthroses or synovial = movable joints
surface of the bones
- Contain a space between the bones that is
● Elastic cartilage: ear, epiglottis & larynx
filled with synovial fluid, a lubricant that
● Fibrous cartilage: between the vertebral
promotes a sliding movement of the ends
disks, between bones of the pelvic girdle,
of the bones.
knee & shoulder.
- E.g., shoulders, wrist, hips, knees, ankles
2. Ligaments
- Bones in synovial joints are joined by
● Is a small band of dense, white, fibrous elastic
ligaments, a strong dense bands of fibrous
tissue, connect bones to each other at the
connective tissue.
joint level to limit dislocation & provide
- Some synovial joints contains “bursae”, a
stability while permitting controlled
small sacs filled with synovial fluid that
movement at the joint.
serve to cushion the joint
● This also supports many internal organs
MOVABLE JOINTS including the uterus, bladder, liver,
diaphragm, & supporting the breasts.
3. Tendons
● Connect muscles to bones, and when muscles
contracts (shorten), tendons at each end of
the muscle will cause the bone to move.

ASSESSMENT OF THE MUSCULOSKELETAL ● PQRSTA: useful in gathering data about any
SYSTEM complaint/problem/symptoms
● Provocative or Palliative
AIMS OF MUSCULOSKELETAL ASSESSMENT: ✔ What causes the symptoms?
● For the patient presenting with a ✔ What makes it better or worse?
musculoskeletal problem, his primary ✔ What have you done to get relief?
complaint is likely to be that of pain or a SUBJECTIVE DATA: PQRSTA
decrease in functional ability.
● Thus, the aim of the musculoskeletal ● Severity
assessment is to determine the degree to ✔ How does the symptom rate on a severity
which the patient`s activities of daily living are scale of 1 to 10 with 10 being the most
affected through a systematic assessment. intense.
● Timing & Time
GENERAL ASPECTS OF MUSCULOSKELETAL ✔ Timing: When did the symptoms begin?
ASSESSMENT: ✔ How long does it last (identify 24-hour
● Two objective stages together: inspection & pattern of presenting complaint)
palpation rather than inspecting all joints & ✔ Time: How often does it occur? Is it
then returning to palpate. sudden or gradual?
● To discover you must uncover but ensure ● Quality or Quantity
privacy and dignity. ✔ What is the character of the symptoms
● Always ask whether the patient has any pain (e.g., pain: is it crushing, piercing, dull,
and if so, assess the pain- free side first. sharp?)
● Position for patient`s comfort ✔ How much of it are your experiencing
● Always compare each side now?
● Organize your examination of the bones, ● Region or Radiation
muscles & joints in a head-to- toe method of ✔ Where is the symptom?
assessment. This will help avoid omissions. ✔ Does it spread?
● Always start each part of the examination ● Associated Signs & Symptoms of the chief
from the neutral position complaint
✔ Most common chief complaint: pain,
PREPARING THE CLIENT: weakness, deformity, limitation of
● Explain the procedure to the client movement, stiffness, joint crepitating,
● Use firm support, gentle movement changes in sensation or in the size of the
● Have the patient in comfortable position muscle, discomfort, disturbed sleeping
● Make sure to have an adequate lighting pattern.
GATHERING OF SUBJECTIVE DATA GATHERING OF OBJECTIVE DATA:
● Demographic data ● Inspection & palpation for system & its

● Present history (musculoskeletal complaints) functions; ROM-limb measurement-
✔ Functional limitation bones-joints-muscles & diagnostic studies
✔ Symptoms in single vs multiple joints 1. Inspection
✔ Acute vs slowly progressive ● For comprehensive assessment,
✔ If injury – mechanism inspection should be carried out observing
✔ Prior problems with area from anterior, posterior & lateral views.
✔ Systemic symptoms ● Inspection should assess for:
✔ Shape: size, contour, symmetry (alike
both side)
✔ Structure: normal or deviated from ● Activity-Exercise Pattern,
normal (deformities, fracture) Nutritional-Metabolic Pattern, Elimination
✔ Muscle configuration: Pattern, Sleep Pattern, Role- Relationship
hypertrophy/atrophy (steroid use, Pattern
malnutrition)
PAST HEALTH HISTORY:
✔ Body build, posture & body alignment:
standing, sitting & recumbent 1. Certain illness can affect the musculoskeletal
✔ Structural relationships: system either directly or indirectly
- gait-involuntary movements – full - Tuberculosis, poliomyelitis, diabetes
ROM of all joints mellitus, parathyroid problems,
- shoulder level, scapulae level, iliac hemophilia, rickets, soft tissue infection &
crest level. neuromuscular disabilities
✔ Skin condition: - Arthritis & connective tissue disease (e.g.,
- swelling, edema (effusions, gout, psoriatic arthritis, systemic lupus
hematoma) erythematous)
- Discoloration (vascular 2. History of Trauma: surgery, period of
insufficiency, bruising) prolonged immobilization, alcohol use,
- Pressure sores, necrosis, scarring smoking, family history of osteoporosis.
scars indicating previous surgery 3. Diet: adequate amounts of vitamin C and D;
or trauma. calcium & protein are essential for a healthy,
2. Palpation intact musculoskeletal system.
● Palpate joints, bursal sites, bones & 4. Medications: for any possible side effects like
surrounding muscles antiseizure drugs (osteomalacia),
● Assess the patient for both verbal & corticosteroids (vascular necrosis, decrease
non-verbal cues of pain. bone & muscle mass) & potassium depleting
● Ask the patient “Does pain radiates diuretics (muscle cramps & weakness).
elsewhere from the initial region?” - A history of medication use & response to
pain medication aids in designing
OBJECTIVE DATA: PALPATION USING THE (TEC)2
medication management regimen.
T: increased temperature (use the back of your
MUSCULOSKELETAL SIDE EFFECTS OF
hand in palpating the temperature; compare the
MEDICATIONS/ SUBSTANCES
reading with the other side:
T: tenderness ● Amphetamines: muscle hyperactivity
● Anticoagulants: bleeding into the joints
E: edema/swelling ● Antipsychotics: dystonic movements, altered
E: enlargement (bone tumor) gait
● Caffeine: muscle hyperactivity
C: crepitus (osteoarthritis: listen for crepitus as ● Corticosteroids: necrosis of femur head
well as feeling) ● Diuretics: muscle weakness & cramping
C: consistency & tone of muscle ● Phenothiazines: gait disturbances
EFFECTS OF PRESENTING MUSCULOSKELETAL ASSESSMENT OF THE MUSCLES
COMPLAINTS: GENERAL VIEW OF THE MUSCLE:
● Activities of Daily Living: able to care for 1. Muscle Mass

himself (independently or with assistance or ✔ Atrophy
complete dependence ✔ Hypertrophy
✔ Normal ● Signs of inflammation, injury (swelling,
2. Muscle Measurement redness, warmth), deformity & compare with
✔ Muscle mass is measured the opposite side
circumferentially at the largest area of the ● Activity & Range of Motion: specific
muscle. limitations, discrete events (e.g., trauma),
✔ When recording measurements, mechanism of injury
document the exact location at which the ● Palpate Joint for temperature & tenderness
measurements were obtained (e.g., ● Strength, neurovascular assessment
quadriceps muscle is measured 15cm ● Pain or injury
above the patella)
Range of motion (ROM)
✔ This informs the next examiner of the
exact area to measure & ensures ● Assess (Type: active, passive, full, limited,
consistency during re-assessment. stiffness, contractures)
3. Muscle Strength ● If ROM is limited:
✔ Assess each group: strong & equal ✔ determine the cause like excess fluid or
✔ Compare each side any loose bodies in the joint (e.g.,
✔ Scale 0-5 cartilage, joint surface irregularity,
✔ It is considered a disability if the muscle osteoarthritis, contracture of muscle,
strength is less than grade 3. ligaments or capsule)
● ROM assessed by:
MUSCLE STRENGTH SCALE
✔ Goniometer: most accurate which
0- No detection of muscular contraction measures the angle of the joint
1- A barely detectable flicker or trace of ✔ Symmetry
contraction with observation
Limb Measurement
2- Active movement of body part with
elimination of gravity ● Limbs are in the neutral position
3- Active movement against gravity only and ● The patient is lying straight
not against resistance ● Full length of the upper limb: measure from
4- Active movement against gravity and the acromion process to the end of the
some resistance middle finger
5- Active movements against full resistance ● Full length lower limb: lower edge of the
without evident fatigue (normal muscle ileum to the tibial malleolus
strength)
Special Test
ASSESSMENT OF THE BONES
Phalen`s Test:
Examine for: - Ask the client to hold the wrist in acute
● Deformity flexion for 60 seconds.
● Tumors - Numbness or burning indicates carpal
● Pain: is the pain focal (fracture/trauma, tunnel syndrome.
infection, malignancy, Paget`s disease, osteoid Bulge Sign:
osteoma), or diffuse (malignancy, Paget`s
disease, osteomalacia, osteoporosis, - Assess for small amount of fluid on the
metabolic bone disease). knee
- Milk upward on the medial side of the
ASSESSMENT OF THE JOINTS knee then tap the lateral side of the
Assess for the: patella. It indicated a joint swelling.
DIAGNOSTIC STUDIES OF MUSCULOSKELETAL - Very sensitive test for nerve
SYSTEM impingement & can detect very subtle
lesions & injuries.
1. Radiological studies ● QUANTITATIVE ULTRASOUND:
● X-RAY - Evaluate density, elasticity & strength
- provide information about the bone of bone using an ultrasound rather
deformity, joint congruity, bone than a radiation
density & calcification in soft tissue - Common area assessed is calcaneus`s
- Fracture Diagnosis & Management are (heel)
the primary indications for x-ray ● DUAL ENERGY X-RAY ABSORPTLOMATRY:
- It is also useful in the evaluation of - Assesses bone density to diagnose
hereditary, developmental & infectious osteoporosis
● FLUOROSCOPY: - Uses LOW dose radiation to measure
- Real-time x-ray images with digital bone density
detectors - Painless procedure, non-invasive, no
- X-ray source is underneath the table & special preparation
detector above, thus shield needs to ● BONE SCAN:
be placed underneath the patient. - Imaging study with the use of a
● DISCOGRAM: contrast radioactive material
- X-ray of cervical or lumbar - Pre-test: painless procedure, IV
intervertebral disk is done after radioisotope is used, no special
injection of contrast media into preparation, pregnancy is
nucleus pulpous. contraindicated
- Permits visualization of intervertebral - Intra-test: IV injection, waiting period
disk abnormalities of 2 hours before x-ray, fluids are
● COMPUTED TOMOGRAPHY: allowed, supine position for scanning
- CT uses x-ray to produce cross - Post-test: increase fluid intake to flash
sectional images out radioactive material.
- X-ray beam is used with a computer to 2. Bone mineral density (BMD) measurements
provide a three-dimensional picture. 3. NUCLEAR studies
● MAGNETIC RESONANCE IMAGING (MRI): 4. Endoscopic studies: arthrocentesis,
- Radio waves & magnetic field are used arthroscopy
to view soft tissue. ● ARTHROSCOPY:
- Useful in the diagnosis of a vascular - A direct visualization of the joint cavity
necrosis, disk disease, tumors, - If general anesthesia is used, client is
ligament tears, and cartilage tears. NPO after midnight.
- Patient is placed inside the scanning - Following the procedure, assess for
chamber bleeding & swelling, apply ice to the
- Gadolinium may be injected IV to area if prescribed & teach client to
enhance visualization of structures avoid excessive use of the joint for 2-3
● E-MYELOGRAM WITH OR WITHOUT CT: days.
- Involves injecting a radiographic ● ARTHROCENTESIS:
contrast medium into the sac around - Done to obtain synovial fluid from a
the nerve roots joint for diagnosis such as
- CT scan may follow to show how the infections/hemorrhage or to remove
bone is affecting the nerve roots excess fluid.

- A needle is inserted through the joint
capsule & fluid is aspirated
● BONE BIOPSIES:
- In metabolic bone diseases
- In patients who are suspected of
having osteomalacia
5. SYNOVIAL fluid analysis
6. Muscle biopsy
● For myopathy & myositis
● Needle muscle biopsy of the quadriceps or
deltoid
● Preferred to open surgical biopsy because
it is a simple procedure which can be
repeated for serial monitoring of
treatment response
RELATED NURSING CARE
● Maintain privacy of the patient

● Ask the patient to remove some or all his
clothes & to wear a gown during the
examination
● May also ask the patient to remove jewelries,
removable dental appliances, eyeglasses &
any metal objects or clothing that might
interfere with the x-ray images
● If contrast medium is used, assess allergy to
shellfish, iodine, or contrast medium used
from previous tests. If allergy is present, tests
will not be performed.

● The electrical activity of the CNS is governed
by neurons located throughout the sensory &
motor pathways.
● CNS contains upper motor neurons that
influence lower motor neurons, located
mostly in the peripheral nervous system.
Brain
● Located in the cranial cavity
● Has 4 major divisions
✔ The Cerebrum divided into right & left
cerebral hemispheres, which are joined by
the corpus callosum.
- Corpus Callosum – a bundle of nerve
fibers responsible for communication
between the hemispheres.
- Each hemispheres sends & received
impulses from the opposite sides of
ASSESSMENT OF
the body & consist of 4 lobes (frontal,
parietal, temporal, occipital).
- Lobes – are composed of substance
THE NEUROLOGIC known as gray matter, which mediates

higher-level functions such as memory,
SYSTEM
perception, communication &
initiation of voluntary movements.
- Gray Matter rims the surfaces of
NEUROLOGIC SYSTEM cerebral hemispheres, forming the
cerebral cortex.
● The very complex neurologic system is ✔ The Diencephalon lies beneath the
responsible for coordinating and regulating all cerebral hemispheres & consists of the
body functions. thalamus, hypothalamus & epithalamus.
● This consists of two structural components: - Most sensory impulses travel through
CENTRAL NERVOUS SYSTEM the gray matter of the thalamus,
which is responsible for screening &
● Encompasses the brain & spinal cord, which directing the impulses to specific areas
are covered by meninges & three layers of in cerebral cortex.
connective tissues that protect & nourish the ⮚ Hypothalamus
CNS. - part of the autonomic nervous
Subarachnoid Space system, which is a part of the
peripheral nervous system
● Surrounds the brain & spinal cord - is responsible for regulating many
● Filled with cerebrospinal fluid (CSF), formed body functions including water
in the ventricles of the brain & flows through balance, appetite, vitals signs
the ventricles into the space. (temperature, BP, pulse &
● This fluid space cushions the brain & spinal respiratory rate), sleep cycles,
cords, nourishes the CNS & removes waste pain perception & emotional
materials. Peripheral nervous system status.
⮚ Epithalamus: - Stretch reflex (simplest type of reflex arc)
- posterior segment of – involves one sensory neuron (afferent);
diencephalon consist of one motor neuron (efferent), & one
habenular nuclei & their synapse.
interconnecting fibers,
Example of stretch reflex:
habenular commissure, the stria
medullaris & the pineal gland - Knee jerking – elicited by tapping the
✔ The Brain Stem patellar tendon.
⮚ Pons links the cerebellum to the
NEURAL PATHWAYS
cerebrum & the midbrain to the
medulla & is responsible for various ● Sensory impulses travels to the brain by way
reflex actions. of two ascending neural pathways
⮚ Medulla Oblongata contains the nuclei (spinothalamic tract & posterior columns)
for cranial nerves & has centers that ● Sensations of pain, temperature, crude & light
control & regulate respiratory function, touch travel by way of the spinothalamic
heart rate & force; and blood pressure. tract.
✔ The Cerebellum ● Sensations of position, vibration & fine touch
- Located behind the brain stem & travel by way of the posterior columns.
under the cerebrum & has 2 ● Motor impulses are conducted by two
hemispheres descending neural pathways; the pyramidal
- Does not initiate movement, its (corticospinal) tract & extrapyramidal tract.
primary functions include ● Pyramidal Tract – most of the neurons in this
coordination & smoothing of tract originate in the motor cortex & travel
voluntary down to the medulla, cross over to the
- movements, maintenance of opposite side & travel down to the spinal
equilibrium, & maintenance of cord, where they synapse with a lower motor
muscle tones. neuron in the anterior horn of then spinal
cord.
SPINAL CORD
● Extrapyramidal Tract – consist of motor
● Located in the vertebral canal & extends from neurons that originate in the motor cortex,
the medulla oblongata to the first lumbar basal ganglia, brain stem & spinal cord outside
vertebra the pyramidal tract.
● The inner part of the cord has an H-shaped ● Travels from the frontal lobe to the pons,
appearance & is made up of 2 pairs of cross over to the opposite side & down to the
columns (dorsal & ventral) consisting of gray spinal cord, connect with lower motor
matter. neurons that conduct impulses to the
● The outer part is made up of white matter & muscles.
surrounds the gray matter ● These neurons conduct impulses related to
● conducts sensory impulses up ascending maintenance of muscle tone & body control.
tracts to the brain, conducts motor impulses
PERIPHERAL NERVOUS SYSTEM
down descending tracts to neurons that
stimulate glands & muscles throughout the ● Carrying information to & from the CNS
body, is responsible for simple reflex activity. ● Consist of 12 pairs of cranial nerves & 31 pairs
● Reflex activity involves various neural of spinal nerves
structures ● These nerves are categorized into 2 types of
fibers:
Example:

- Somatic Fibers carry CNS impulses to SPINAL NERVES
voluntary skeletal muscles. Somatic
● 31 pairs of spinal nerves are named after the
Nervous System mediates conscious or
vertebrae, each one`s exit point along the
voluntary activities
spinal cord
- Autonomic Fibers carry CNS impulses to
● Comprising 8 cervical, 12 thoracic, 5 lumbar, 5
smooth, involuntary muscles (in the heart
sacral, & 1 coccygeal nerves
& glands). Autonomic Nervous System
● Each nerve is attached to the spinal cord by 2
mediates unconscious, or involuntary
nerve roots(posterior & anterior)
activities
● The sensory (afferent) fibers enters through
CRANIAL NERVES the dorsal (posterior) roots of the cord
● The motor (efferent) fibers exits through the
● Twelve pairs of cranial nerves evolve from the
ventral (anterior) roots of the cord
brain or brain stem & transmit motor or
● Dermatome – is an area of the skin where the
sensory messages.
sensory root of each spinal nerve innervates
● A useful mnemonic for 12 cranial nerve is “On
Old Olympus Towering Tops, A Finn & German AUTONOMIC NERVOUS SYSTEM
Viewed Some Hops”
● The impulses in this autonomic nervous
system are carried by both cranial & spinal
nerves
● These nerves are carried from the CNS to the
involuntary, smooth muscles that make up the
walls of the heart & glands.
● Maintains the homeostasis of the body,
incorporates the sympathetic &
parasympathetic nervous systems.
Sympathetic Nervous System
● The “fight or flight” system
● Is activated during stress & elicits responses
such as decreased gastric secretions,
● Another useful mnemonic is “Some Say Marry bronchiole dilatation, increased pulse rate &
Money, But My Brother Says Bad Business pupil dilatation.
Marries Money” ● These fibers arise from the thoracolumbar
Cranial Nerve Functions level (T1 to L2) of the spinal cord.
✔ Olfactory- sensory- some Parasympathetic Nervous System

✔ Optic- sensory-say ● Functions to restore & maintain normal body
✔ Oculomotor-motor-marry functioning (e.g., decreasing heart rate)
✔ Trochlear-motor-money ● Arise from the craniosacral regions (S1 to S4 &
✔ Abducens-motor-money cranial nerves III, VI, IX and X
✔ Facial-both-Brother
✔ Auditory-sensory-says ASSESSING THE NEUROLOGIC SYSTEM
✔ Glossopharyngeal-both-bad
✔ A thorough neurologic examination takes
✔ Vagus-both-business
up to 1 to 3 hours;
✔ Accessory-motor-marrying
✔ First, a routine screening tests are usually
✔ Hypoglossal-motor-money
done.
✔ If the results of these tests raise ✔ Aphasia - Any defects in or loss of the
questions, more extensive evaluations are power to express oneself by speech,
made. writing, or signs, or to comprehend
spoken or written language due to disease
Three major considerations to determine the
or injury of the cerebral cortex.
extent of a neurologic exam
✔ Aphasias can be categorized as:
1. The client’s chief complaints ● Sensory or receptive aphasia loss of the
2. The client’s physical condition (i.e., level of ability to comprehend written or spoken
consciousness and ability to ambulate) words. There are 2 types:
because many parts of the examination 1. Auditory (acoustic) auditory aphasia have
require movement and coordination of lost the ability to understand the symbolic
the extremities content associated with sounds
3. The client’s willingness to participate and 2. Visual aphasia have lost the ability to
cooperate understand printed of written figures
Examination of the neurologic system includes Motor aphasia (expressive aphasia) involves loss
assessment of the following: of the power to express oneself by writing,
making signs, or speaking
1. Mental status including level of
consciousness Clients may find that even though they can recall
2. The cranial nerves words, they have lost the ability to combine
3. Reflexes speech sounds into words
4. Motor function
ORIENTATION
5. Sensory function
✔ This aspect of the assessment
ASSESSING MENTAL STATUS & LEVEL OF
determines the following:
CONSCIOUSNESS
● Client’s ability to recognize other people
Mental Status (person)
● Awareness of when and where they presently
1. Intellectual (cognitive are (time and place)
2. As well as emotional (affective) functions ● And who they, themselves, are (self)
If problems with use of language, memory, 1. The terms disorientation and confusion
concentration, or thought processes are noted are often used synonymously although
during the nursing history, a more extensive there are differences. Is always preferable
examination is required during neurologic to describe the client’s actions or
assessment statements rather than to label them
Major areas of mental status assessment include: MEMORY
Language ● The nurse assesses the client’s recall of

information
Orientation ● Immediate recall presented seconds
Memory previously
● Recent memory events or information from
Attention span earlier in the day or examination
And calculation ● Remote or long-term memory knowledge
recalled from months or years ago.
LANGUAGE
ATTENTION SPAN AND CALCULATION
✔ This component determines client’s ability o Example of a neuro- observation chart.
to focus on a mental task that is expected (the first half of the entire form. To fill
to be able to be performed by individuals up the form is to plot a visible dot on
of normal intelligence the squares corresponding to the time
assessed, and to indicate the GCS total
LEVEL OF CONSCIOUSESS
score below.
✔ Level of consciousness (LOC) can lie
anywhere along a continuum from a state
of alertness to coma
✔ A fully alert client responds to questions
spontaneously; a comatose client may not
respond to verbal stimuli
GLASGOW COMA SCALE
● GCS was originally developed to predict
recovery from a head injury, however, it is
used by many professionals to assess LOC
(level of consciousness) ✔ To assess movements of the limbs,
● It tests in three major areas: indicate in the squares as to which limb is
● Eye response affected by writing “R” or “L”.
● Motor response ✔ To assess for pupillary reactions, indicate
● Verbal response in the corresponding squares R(upper box)
✔ As assessment totaling 15 points indicates & L (lower box), the following:
the client is alert and completely oriented ● “-” – normal
✔ A comatose client scores 7 or less ● “S” – sluggish
● “o” – if none
● “C” – if eye closed by sensing.
● Indicate the size of the pupil in the lowest box
provided
ASSESSING THE CRANIAL NERVES & MOTOR

FUNCTION
CRANIAL NERVES
● The nurse needs to be aware of specific nerve
functions and assessment methods for each
cranial nerve to detect abnormalities
● In some cases, each nerve is assessed; in
other cases, only selected nerve functions are
evaluated
● During a complete neurological exam, most of
these nerves are evaluated to help determine
the functioning of the brains
● GCS 13-15 – Mild Head Injury EVALUATION OF THE 12 CRANIAL NERVES
● GCS 9-12 – Moderate Head Injury
● GCS 3-8 – Severe Head Injury
✔ Suggests coma with need for intubation
● Cranial Nerve I (olfactory nerve) the nerve of side to side against mild resistance, or to
smell. The patient is asked to identify different shrug the shoulders
smells with his or her eyes closed ● Cranial Nerve XII (hypoglossal nerve) the final
● Cranial Nerve II (optic nerve) carries vision to cranial nerve is mainly responsible for
the brain. A visual test is given, and the movement of the tongue. The patient is
patient’s eye is examined with a pen light instructed to stick out his or her tongue and
● Cranial Nerve III (oculomotor) responsible for speak.
pupil size and certain movements of the eye.
ASSESSING THE CRANIAL NERVES
The pupil is examined with a lights and have
the patient follow the light in various Cranial nerves by the numbers.
directions
● Cranial Nerve IV (trochlear nerve) helps with ✔ To remember the locations and functions
the movement of the eyes of the cranial nerves, picture this drawing
● Cranial Nerve V (trigeminal nerve) allows for ✔ All the cranial nerves are represented,
many functions, including: though some may be a little harder to
● The ability to feel the face spot than others
● Feel inside the mouth ✔ Example, the shoulders are formed by the
● And move the muscles involved with chewing. number “11” because cranial nerve XI
✔ Assessment is done by touching the face controls neck and shoulder movement.
at different areas and watch the patient as ✔ Recognize that the sides of the face and
he or she bites down the top of the head are formed by the
● Cranial Nerve VI (abducens nerve) helps with number “7”
the movement of the eyes. The patient is ✔ You’re well on your way to using this
asked to follow a light a finger to move the memory device
eyes REFLEXES
● Cranial Nerve VII (facial nerve) responsible for
various functions, including: ● A reflex is an automatic response of the body
1. The movement of the face muscle and taste to a stimulus
2. The patient may be asked to identify different ● It is not voluntarily learned or conscious
tastes (sweet, sour, bitter) asked to smile, ● The deep tendon reflex (DTR) is activated
move the cheeks, or show the teeth when a tendon is stimulated (tapped) and its
● Cranial Nerve VIII (acoustic nerve) the nerve associated muscle contracts
of hearing. A hearing test is performed on the ● The quality of a reflex response varies among
patient. individuals and by age
● Cranial Nerve IX (glossopharyngeal nerve) ● As a person ages, reflex responses may
involved with taste and swallowing. The become less intense
patient is asked to identify different tastes on ● Reflexes are tested using a percussion
the back of the tongue. The gag reflex is also hammer
tested ● The response is described on a scale of 0 to 4
● Cranial Nerve X (vagus nerve) mainly ● Experience is necessary to determine
responsible for the ability to swallow, the gag appropriate scoring for an individual
reflex, some taste and part of speech. The ● Generalist nurses do not commonly assess
patient is asked to swallow, and a tongue each of the deep tendon reflexes except for
blade may be used to elicit the gag response possibly the plantar (Babinski) reflex,
● Cranial Nerve XI (accessory nerve) involved in indicative of possible spinal cord injury
the movement of the shoulders and neck. The
patient is asked to turn his or her head from
● Proprioceptors are sensory nerve terminals
that occur chiefly in the muscles, tendons,
joints and internal ear that give information
about movements and the position of the
body
● Stimuli from the proprioceptors travel
through the posterior columns of the spinal
cord
● Deficits of function of the posterior columns
REFLEXES COMMONLY TESTED IN NEWBORNS of the spinal cord result in impairment of
muscle and position sense
(Most of these reflexes disappear between 4 and ● Clients with such impairment often must
6 months of age) watch their own arm and leg movements to
● Rooting Reflex stroke the side of the face near ascertain the position of the limbs
mouth, infant opens mouth and turns to the The cerebellum helps to control posture, acts
side that is stroked with the cerebral cortex to make body
● Sucking reflex place nipple or finger 3 to 4 cm movements smooth and coordinated, and
(1.2 to 1.6 in) into mouth, infant sucks controls skeletal muscles to maintain equilibrium.
vigorously
● Tonic neck Reflex place infant supine, turn DIFFERENT NEUROLOGICAL TEST TO DETERMINE
head to one side; arm on side to which head MOTOR FUNCTIONS
is turned extends; on opposite side, arm curls 1. ROMBERG TEST
up (fencer’s pose) ● Accomplished by asking the client to stand
● Palmar Grasp Reflex place finger in infant’s with feet together and arms resting at the
palm and press; infant curls fingers around sides, first with eyes open, then closed.
● Stepping Reflex hold infant as if weight Assessor to Stand close during this test.
bearing on surface; infant steps along, one ✔ Negative Romberg: may sway slightly but
foot at a time is able to maintain upright posture and
● Moro Reflex present loud noise or foot stance.
unexpected movement; infant spreads arms ✔ Positive Romberg: cannot maintain foot
and legs, extends fingers, then flexes and stance; moves the feet apart to maintain
brings hands together; may cry stance
MOTOR FUNCTION - If client cannot maintain balance with
the eyes shut, client may have sensory
● Neurologic assessment of the motor system ataxia (lack of coordination of the
evaluates proprioception and cerebellar voluntary muscles)
function - If balance cannot be maintained
● Structures involved are the proprioceptors, whether the eyes are open or shut,
the posterior columns of the spinal cord, the client may have cerebellar ataxia
cerebellum and the vestibular apparatus
(which is innervated by cranial nerve VIII) in 2. STANDING ON ONE FOOT WITH EYES CLOSED
the labyrinth of the internal ear ● Accomplished by asking the client to close the
● Proprioception plays a big role in self- eyes and stand on one foot. Repeat on the
regulation, coordination, posture, body other foot. The assessor is to stand close to
awareness, the ability to attend and focus and the client during this test.
speech

✔ Normal: Maintains stance for at least 5 ✔ Abnormal findings: Performs with
seconds slow, clumsy movements and irregular
✔ Abnormal: Cannot maintain stance for 5 timing; has difficulty alternating from
seconds supination to pronation
3. FINGER-TO-NOSE AND TO THE NURSE’S
3. HEEL-TOE WALKING
FINGER
● Accomplished by asking the client to walk a ● Ask the client to touch the nose and then
straight line, placing the heel of one foot your index finger, held at a distance of
directly in front of the toes of the other foot. about 45 cm (18 in.), at a rapid and
✔ Normal findings: Maintains heel-toe increasing rate
walking along a straight line. ✔ Normal Findings: Performs with
✔ Abnormal Findings: Assumes a wider foot coordination and rapidity
gait to stay upright ✔ Abnormal Findings: Misses the finger
and moves slowly
4. TOE OR HEEL WALKING
4. FINGERS-TO-FINGERS
● Accomplished by asking the client to walk ● Ask the client to spread the arms broadly
several steps on the toes and then on the shoulder height and then bring the fingers
heels. together at the midline, first with the eyes
✔ Normal findings: Able to walk several open and then closed, first slowly and
steps on toes or heels then rapidly
✔ Abnormal findings: Cannot maintain ✔ Normal Findings: Performs with
balance on toes and heels accuracy and rapidity
✔ Abnormal Findings: Moves slowly and
FINE MOTOR TESTS FOR THE UPPER
is unable to touch fingers consistently
EXTREMITIES
5. FINGERS-TO-THUMB (SAME HAND)
1. FINGER-TO-NOSE TEST ● Ask the client to touch each finger of one
● Accomplished by asking the client to hand to the thumb of the same hand as
abduct and extend the arms at shoulder rapidly as possible.
height and then rapidly touch the nose ✔ Normal Findings: Rapidly touches each
alternately with one index finger and then finger to thumb with each hand.
the other. The client repeats the test with ✔ Abnormal Findings: Cannot coordinate
the eyes closed if the test is performed this fine discrete movement with
easily. either one or both hands
✔ Normal findings: Repeatedly and
FINE MOTOR TESTS FOR THE LOWER
rhythmically touches the nose
EXTREMITIES
✔ Abnormal Findings: Misses the nose
or gives slow response Ask the client to lie supine and to perform these
2. ALTERNATING SUPINATION AND PRONATION tests.
OF HANDS-ON KNEES
1. HEEL DOWN OPPOSITE SHIN
● Ask the client to pat both knees with the
● Ask the client to place the heel of one foot
palms of both hands and then with the
just below the opposite knee and run the
backs of the hands alternately at an
heel down the shin to the foot. Repeat
ever-increasing rate.
with the other foot. The client may also
✔ Normal findings: Can alternately
use a sitting position for this test.
supinate and pronate hands at rapid
✔ Normal Findings: Demonstrates
pace.
bilateral equal coordination

✔ Abnormal Findings: Has tremors or is ✔ Abnormal Findings: Areas of reduced,
awkward; heel moves off shin heightened, or absent sensation (map
2. TOE OR BALL OF FOOT TO THE NURSE’S them out for recording purposes)
FINGER 3. Kinetic or position sensation
● Ask the client to touch your finger with ● Commonly, the middle fingers and the
the large toe of each foot. large toes are tested for the kinesthetic
✔ Normal Findings: Moves smoothly, sensation (sense of position).
with coordination ● The middle fingers and the large toes are
✔ Abnormal Findings: Misses your tested for the kinesthetic sensation (sense
finger; cannot coordinate movement of position).
✔ Normal Findings: Can readily
SENSORY FUNCTION
determine the position of fingers and
Sensory functions include touch, pain, toes
temperature, position, and tactile discrimination.
Abnormal Findings: Unable to determine the
The first three are routinely tested. position of one or more fingers or toes
1. Light touch sensation DOCUMENTING NEURO ASSESSMENT
● Compare the light-touch sensation of
symmetric areas of the body. ● Document findings in the client record using
● The client is asked to close the eyes and to printed or electronic forms or checklists
respond by saying “yes” or “no” whenever supplemented by narrative notes when
the client feels the cotton wisp touching appropriate.
the skin. ● Describe any abnormal findings in objective
✔ Rationale: terms, for example, “When asked to count
- The sensory nerve may be assumed backwards by threes, client made seven errors
to be intact if sensation is felt at its and completed the task in 4 minutes.”
most distal part. Documenting Normal Findings
- Sensitivity to touch varies among
different skin areas. Sample assessment summary documentation
● If areas of sensory dysfunction are found, “The patient is alert and oriented to person,
determine the boundaries of sensation by place, and time with normal speech. No motor
testing responses about every 2.5 cm (1 deficits are noted, with muscle strength 5/5
in.) in the area. Make a sketch of the bilaterally. Sensation is intact bilaterally. Reflexes
sensory loss area for recording purposes. are 2+ bilaterally. Cranial nerves are intact.
✔ Normal Findings: Light tickling or touch Cerebellar function is intact. Memory is normal
sensation and thought process is intact. No gait
✔ Abnormal Findings: Anesthesia, abnormalities are noted”.
hyperesthesia, hypoesthesia, or
paresthesia SAMPLE DETAILED NORMAL EXAM
2. Pain sensation DOCUMENTATION
● determines “sharp” or “dull” sensations.
Mental Status:
● assessed by asking the client to close the
eyes and to say “sharp,” “dull,” or “don’t ✔ Patient is alert and oriented to person,
know” when the sharp or dull end of a place, and time with normal speech.
safety pin is felt. Memory is normal and thought process is
✔ Normal Findings: Able to discriminate intact.
“sharp” and “dull” sensations
Cranial Nerves: ✔ Disoriented to (person, time, place,
situation)
✔ (II, III, IV, VI) - Visual acuity 20/20
✔ Memory impairment noted (acute or
bilaterally. Visual fields normal in all
chronic)
quadrants. Pupils are equally round,
✔ Decreased muscle strength or tone
reactive to light and accommodation
(flaccid, atrophy)
(PERRLA). Extraocular movements are
✔ Decreased sensation
intact without ptosis.
✔ Hypo or hyperactive reflexes
✔ (V) Facial sensation is intact to bilaterally
✔ Cranial nerve deficits
to dull, sharp, and light touch stimuli.
✔ Cerebellar deficits (coordination)
✔ (VIII) Hearing is normal bilaterally.
✔ Gait abnormalities (position, speed,
✔ (IX, X) Palate and uvula elevate
balance, heel walking, toe walking)
symmetrically, with intact gag reflex. Voice
is normal.
✔ (XI) Shoulder shrug strong, and equal
LIFESPAN CONSIDERATIONS:
bilaterally.
✔ (XII) Tongue protrudes midline and moves CHILDREN
symmetrically
● Present the procedures as games whenever
Reflexes: possible.
● Positive Babinski reflex is abnormal after the
✔ Biceps, brachioradialis, triceps, patellar,
child ambulates or at age 2.
and Achilles are 2/4 bilaterally. No clonus.
● Assess immediate recall or recent memory by
✔ Plantar reflex is downward bilaterally
using names of cartoon characters. Normal
Sensation: recall in children is one less than age in years.
● Assess for signs of hyperactivity or abnormally
✔ Sensation is intact bilaterally to pain and
short attention span.
light touch. Two-point discrimination is
● Children should be able to walk backward by
intact.
age 2, balance on one foot for 5 seconds by
Motor: age 4, heel-toe walk by age 5, and heel-toe
walk backward by age 6.
✔ Good muscle tone. Strength is 5/5
● Use of the Romberg test is appropriate for
bilaterally at the deltoid, biceps, triceps,
children ages 3 and older
quadriceps, and hamstrings
OLDER ADULTS
Cerebellar:
● Intelligence and learning ability are unaltered
✔ Finger-to-nose and heel-to-shin test
with age. Many factors, however, inhibit
normal bilaterally. Balances with eyes
learning (e.g., anxiety, illness, pain, cultural
closed (Romberg). Rapid alternating
barrier).
movements normal. Gait is steady with a
● Short-term memory is often less efficient.
normal base. Coordination is intact as
Long-term memory is usually unaltered.
measured by heel walk and toe walk.
● Because old age is often associated with loss
ABNORMAL FINDINGS IN THE NEURO of support persons, depression can occur.
ASSESSMENT CAN BE DESCRIBED AS: ● Mood changes, weight loss, anorexia,
constipation, and early morning awakening
✔ Confused, disoriented may be symptoms of depression.
✔ Somnolent, lethargic ● The stress of being in unfamiliar situations can
cause confusion in older adults
● As a person ages, reflex responses may
become less intense.
● Although there is a progressive decrease in
the number of functioning neurons in the
central nervous system and in the sense
organs, older adults usually function well
because of the abundant reserves in the
number of brain cells.
● Impulse transmission and reaction to stimuli
are slower.
● Many older adults have some impairment of
hearing, vision, smell, temperature and pain
sensation, memory, or mental endurance
● Coordination changes and includes slower
fine finger movements.
● Standing balance remains intact, and
Romberg’s test remains negative.
● Reflex responses may slightly increase or
decrease.
● Many show loss of Achilles reflex, and the
plantar reflex may be difficult to elicit.
● When testing sensory function, the nurse
needs to give older adults time to respond.
● Normally, older adults have unaltered
perception of light touch and superficial pain,
decreased perception of deep pain, and
decreased perception of temperature stimuli.
Many also reveal a decrease or absence of
position sense in the large toes.

● Functions as the protective covering for the
testes, epididymis & vas deferens; helps to
maintain the body temperature necessary for
production of sperm (less than37 ̊C).
● Can maintain a temperature control because
the cremaster muscle is sensitive to changes
in temperature.
INTERNAL GENITALIA
TESTES
● A pair of ovoid-shaped organs, similar to the
ovaries in the woman that are approximately
MALE & FEMALE 3.7 to 5 cm. long, 2.5 cm. wide & 2.5 cm deep.
● Each testis is covered by a serous membrane
GENITALIA ANUS &

called the tunica vaginalis, which separate the
testis from the scrotal wall.
● The tunica vaginalis is double layered &
RECTUM lubricated to protect the testes from injury.

● The function of the testis is to produce
spermatozoa & the male sex hormone
EXTERNAL GENITALIA testosterone.
● The external genitalia consist of the penis and SPERMATIC CORD
the scrotum
● Contains blood vessels, lymphatic vessels,
PENIS nerves & the vas deferens (ductus deferens),
● Is the male reproductive organ which transport spermatozoa away from the
● The shaft of the penis is composed of 3 testes/testis.
cylindrical masses of vascular erectile tissue ● The spermatic cord on the left side is usually
that are bound together by fibrous tissue: 2 longer, thus the left testes hangs lower than
corpora cavernosa on the dorsal side & the the right testes.
corpus spongiosum on the ventral side. ● The epididymis is a comma-shaped, coiled,
● Foreskin or prepuce is a hood-like fold of skin tubular structure that curves up over the
that covers the glans. upper & posterior surface of the testes.
● Urethra is located at the center of the corpus ● The vas deferens is a firm, muscular tube that
spongiosum which travels through the shaft & is continuous with the lower portion of the
opens as a slit at the tip of the glans as the epididymis.
urethral meatus called as the frenulum. ● The vas deferens provides the passage for
● Has a role in both reproduction & urination transporting sperm from the testes to the
urethra for ejaculation.
SCROTUM ● Secretions from the vas deferens, seminal
● Is a thin-walled sac that is suspended below vesicles, prostate gland & Cowper`s
the pubic bone, posterior to the penis. (bulbourethral) glands mix with the sperm &
● Contains sweat & sebaceous glands that form semen.
consists of folds of skin (rugae) & the INGUINAL AREA
cremaster muscle.

● Is contained between the anterior superior ● Begins at the anal sphincter & ends at the
iliac spine laterally & the symphysis pubis anorectal junction (pectinate line,
medially. mucocutaneous junction, dentate line);
● Running diagonally between these 2 measures 2.5 to 4 cm. long.
landmarks, just above & parallel with the ● It is lined with skin that contains no hair or
inguinal ligament, is the inguinal canal. sebaceous glands but does contain many
● The inguinal canal is a tube-like structure somatic sensory nerves, making it susceptible
through which the vas deferens travels as it to painful stimuli.
passes through the lower abdomen. ● Anal opening (anal verge), is hairless & moist
● The internal inguinal ring is the internal appearance that extends interiorly, overlying
opening of the inguinal canal. the external anal sphincter.
● The external inguinal ring is the exterior
PROSTATE
opening of the inguinal canal, which can be
palpated above & lateral to the symphysis PROSTATE GLAND
pubis.
● Is approximately 2.5 to 4 cm. in diameter
● When assessing the male genitalia, the nurse
surrounding the neck of the bladder &
needs to be familiar with the structures of the
urethra; lies between these structures & the
inguinal or groin area because “hernias”
rectum in male clients
(protrusion of loops of bowel through week
● Consist of 2 lobes separated by a shallow
areas of musculature) are common in this
groove called the median sulcus.
location.
● Secretes a thin milky substance that promotes
ANUS & RECTUM sperm motility & neutralize female acidic
vaginal secretions.
● Within the anus are the 2 sphincters that
● This chestnut or heart-shaped organ can be
normally hold the canal closed except when
palpated through the anterior wall of the
passing gas & feces.
rectum.
✔ External sphincter: composed of skeletal
muscles & is under voluntary control of SEMINAL VESICLES
the somatic nervous system.
● Located in either side & above the prostate
✔ Internal sphincter: composed of smooth
gland
muscles & is under involuntary control by
● These are rabbit-ear-shaped structures that
the autonomic nervous system.
produce, ejaculate, nourishes & protects the
● Just above the internal sphincter is the
sperm.
anorectal junction, the dividing point of the
● They are not normally palpable
anal canal & the rectum.
● The rectum is the lowest portion of the large COWPER`S (BULBOURETHRAL) GLANDS
intestine & is approximately 12 cm. long,
● Are mucus-producing, pea-sized organs
extending from the end of the sigmoid colon
located posterior to the prostate gland.
to the anorectal junction.
● These glands surrounds & empty into the
● The peritoneum lines the upper two-thirds of
urethra
the anterior rectum & dips down enough so
● They are not normally palpable
that it may be palpated where it forms the
rectovesical pouch in men & rectouterine PHYSICAL ASSESSMENT
pouch in women.
PUBIC HAIR:
ANAL CANAL
● Is the final segment of the digestive tract.
● Inspect the distribution, amount & - Scrotal skin is darker than the rest of the
characteristics of pubic hair body
- Size varies with temperature changes
Normal Findings:
(dartos muscles contracts when the area is
- Triangular distribution, often spreading up cold & relax when the area is warm)
the abdomen - Scrotum appears asymmetric (left testis is
usually lower than the right testis)
- Scant amount or absence of hair
- Discoloration; tightening of skin (indicate
PENIS:
edema or mass)
● Inspect the penile shaft & glans penis for - Marked asymmetry in size
lesions, nodules, swelling & inflammation
INGUINAL AREA
● Inspect the urethral meatus for swelling,
inflammation & discharge ● Inspect both inguinal areas for bulges while
the client is standing
Normal Findings:
● 1st have the client remain at rest
- Penile skin intact ● Next, have the client hold his breath & strain
- Appears slightly wrinkled & varies in color or bear down through having a bowel
as widely as other body skin movement. Bearing down make the hernia
- Foreskin is easily retractable from the more visible.
glans penis
Normal Findings:
- Small amount of thick white smegma
between the glans & the foreskin - No swelling or bulges
- Pink & slitlike appearance positioned at
the tip of the penis
- Swelling or bulges (possible inguinal or
femoral hernia)
- Presence of lesions, nodules, swellings or
ANUS & RECTUM
inflammation
- Foreskin not retractable ● Inspect the perianal area. Spread the client`s
- Large amount, discolored, malodorous buttocks & inspect the anal opening &
substance surrounding area for the presence of lumps,
- Inflammation; discharge ulcers, lesions, rashes, redness, fissures,
- Variations in meatal locations (e.g., thickening of the epithelium
hypospadias on the underside of the ● Palpate the anus
penile shaft; epispadias on the upper side ● Palpate the rectum
of the penile shaft) ● Palpate the peritoneal cavity
SCROTUM Normal Findings:
● Inspect the scrotum for appearance, general - Anal opening is hairless, moist & tightly
size & symmetry. closed
● Inspect all skin surfaces by spreading the - Skin around the anal opening is coarser &
rugated surface skin & lifting the scrotum as more darkly pigmented
needed to observe posterior surfaces. - The surrounding should be free from
redness, lumps, ulcers, lesions & rashes.
Normal Findings:
- Client`s sphincter relaxes, permitting entry - GRADE 2: hemorrhoid protrudes through
- Examination finger enters the anus the anus during straining or evacuation
- The client can normally close the but returns spontaneously.
sphincter around the gloved finger - GRADE 3: hemorrhoid protrudes through
- Anus is normally smooth, non-tender & the anus during straining or evacuation
free of nodule & hardness but needs to be manually returned to the
position.
- The rectal mucosa is normally soft, - GRADE 4: hemorrhoid remains prolapse
smooth, non- tender & free of nodules outside the anus.
PROSTATE GLAND
- Normally smooth & non-tender
● Palpate the prostate gland on the anterior
surface of the rectum by the turning the hand
- Lesions may indicate cancer, STIs or fully counterclockwise so that the pad of your
hemorrhoids appears swollen fingers faces toward the client`s umbilicus.
- Itchy, painful & bleeds when the client
Normal Findings:
passes stool
- Painful mass that is hardened & reddened - Normally non-tender & rubbery
- Redness & excoriation may be from - The 2 lateral lobes are normally smooth &
scratching an area infected by fungi or heart-shaped
pinworms
- Sphincter tightens, making further - Swollen, tender prostate may indicate
examination unrealistic acute prostatitis
- Examination finger cannot enter the anus - Enlarged, smooth, firm, slightly elastic
- Poor sphincter tone maybe the result of a prostate suggest benign prostatic
spinal cord injury, previous surgery, hypertrophy (BPH)
trauma or a prolapsed rectum. - A hard area on the prostate, fixed,
- Tenderness may indicate hemorrhoids, irregular nodules on the prostate suggest
fistula or fissure cancer.
- Hardness & irregularities maybe from ABNORMALITIES OF THE PENIS

scarring or cancer. SYPHILITIC CHANCRE:
- Nodules may indicate polyps or cancer
● Initially a small, slivery-white papule that
- Peritoneal protrusion into the rectum develops a red, oval ulceration
called rectal shelf, may indicate cancerous ● Painless; a sign of primary syphilis (sexually
lesion or peritoneal metastasis. transmitted infection STI) that spontaneously
- Tenderness may indicate peritoneal regresses.
inflammation ● Maybe misdiagnosed as herpes
HEMORRHOIDS GRADING: HERPES PROGENITALIS:
- GRADE 1: hemorrhoid protrudes into the ● Clusters of pimple-like clear vesicles that
canal but does not prolapse outside the erupt & become ulcers; painful
anus. ● Initial lesions of this (STI)- typically caused by
HSV-1 or HSV-2-disappear, the infection
remains dormant for varying periods of time.
● Recurrences can be frequent or minimally ● Failure of one or both testicles to descend
episodic. into the scrotum
● Scrotum appears undeveloped & testis cannot
CANCER OF THE GLANS PENIS:
be palpated
● Appears as hardened nodule or ulcer on the ● Causes increased risk of testicular cancer
glans; painless
ORCHITIS:
● Occurs primarily in uncircumcised men
● Inflammation of the testes, associated
PHIMOSIS:
frequently with mumps
● With phimosis, the foreskin cannot be ● Client complaints of pain, heaviness & fever
retracted over the penis tip ● Scrotum appears enlarged & reddened
● Swollen, tender testis is palpated.
PARAPHIMOSIS:
● The examiner may find difficulty
● A foreskin that is left in a retracted position differentiating between testis & epididymis.
leads to venous congestion & edema of the
SMALL TESTES:
foreskin
● Small (less than 3.5cm long), soft testes
ABNORMALITIES OF THE SCROTUM
indicate atrophy.
HYDROCELE: ● Atrophy may result from cirrhosis,
hypopituitarism, estrogen administration,
● Collection of serous fluid in the scrotum, extended illness or the disorder may occur
outside the testes within the tunica vaginalis. after orchitis
● Appears as swelling in the scrotum & is ● Small (less than 2cm long), firm testes may
usually painless indicate Klinefelter syndrome.
● Usually, the examiner can get fingers above
this mass during palpation TORSION OF SPERMATIC CORD:
● Will transilluminate (if there is blood in the ● Very painful condition caused by twisting of
scrotum, it will not transilluminate, this is spermatic cord
called as hematocele) ● Scrotum appears enlarged & reddened
TESTICULAR TUMOR: ● Palpation reveals thickened cord & swollen,
tender testis that may be higher in scrotum
● Initially, a small, firm, non-tender nodule on than normal
the testis ● This condition requires immediate referral for
● As the tumor grows, the scrotum appears surgery because circulation is obstructed.
enlarged & the client complaints of heavy
feeling VARICOCELE:
SCROTAL HERNIA: ● Abnormal dilation of veins in the spermatic

cord
● A loop of bowel protrudes into the scrotum to ● Client may complain of discomfort & testicular
create what is known as an indirect inguinal heaviness
hernia ● Tortuous veins are palpable & feel like a soft,
● Hernia appears as swelling in the scrotum irregular mass or a “bag of worms” which
● Palpable as a soft mass & fingers cannot get collapses when the client is in supine
above the mass ● Infertility maybe associated with this
CRYPTORCHIDISM: condition.
SPERMATOCELE:
● Sperm-like cystic mass located in the PERIANAL ABSCESS:
epididymis
● Is a cavity of pus, caused by infection in the
● Palpable as small & non-tender, movable
skin around the anal opening.
above the testes
● It causes throbbing pain & is red, swollen,
● This mass will appear on transillumination
hard & tender.
INGUINAL & FEMORAL HERNIAS
ANAL FISSURE:
INDIRECT INGUINAL HERNIA:
● These splits in the tissue of the anal canal are
● Bowel herniates through internal inguinal ring caused by trauma.
& remains in the inguinal canal or travels ● A swollen skin tag (sentinel tag) is often
down into the scrotum (scrotal hernia) present below the fissure on the anal margin.
● This is the most common type of hernia ● Cause intense pain, itching and bleeding.
● It may occur in adults but is more frequent in
RECTAL PROLAPSE:
children
● Occurs when the mucosa of the rectum
DIRECT INGUINAL HERNIA:
protrudes out through the anal opening.
● Bowel herniates from behind & through the ● It may involve only the mucosa or the mucosa
external inguinal ring. It rarely travels down and the rectal wall.
into the scrotum ● It appears as a red, doughnut-like mass with
● This type of hernia is less common than an radiating folds.
indirect hernia.
RECTAL CANCER:
● It occurs mostly in adult men older than age
40. ● A rectal carcinoma is usually asymptomatic
until it is quite advanced
FEMORAL HERNIA:
● Thus, routine rectal palpation is essential
● Bowel herniates through the femoral ring & ● This may feel like a firm nodule, an ulcerated
canal. It never travels into the scrotum, & the nodule with rolled edges, or as it grows, a
inguinal canal is empty. large, irregularly shaped, fixed, hard nodule.
● This is the least common type of hernia ● Treatment: neoadjuvant chemoradiation
● It occurs mostly in women
RECTAL POLYPS:
ABNORMALITIES OF THE ANUS & RECTUM
● These soft structures are common & occur in
ANORECTAL FISTULA: varying sizes & numbers.
● 2 types: pedunculated (on a stalk) & sessile
● Evidenced by a small, round opening in the (on the mucosal surface)
skin at surrounds the anal opening. ● Technique of snare polypectomy: a) a polyp
● Suggests an inflammatory tract from the anus on a stalk is seen in the midsigmoid colon; b)
or rectum out to the skin. the snare encompasses the head of the polyp;
● A previous abscess may have preceded the an adjacent pedunculated polyp can be seen.
fistula
● With an anoscope inserted in the anal canal, ABNORMALITIES OF THE PROSTATE GLAND
an anal fissure can be seen in the posterior
ACUTE PROSTATITIS:
midline of the squamous epithelium of the
anal canal. ● A swollen prostate, tender, firm & warm to
● A sentinel skin tag can be seen on the distal the touch.
end of the fissure on the anal verge. ● Caused by a bacterial infection.

BENIGN PROSTATIC HYPERTROPHY: ● Is located at the anterior end of the labia
minora.
● Enlarged prostate, smooth, firm & slightly
● It is a small cylindrical mass of erectile tissue
elastic
& nerves with 3 parts: the glans, the corpus &
● The median sulcus may not be palpable
the crura.
● It is common in men older than 50 years old.
● Glans is the visible rounded portion of the
CANCER OF THE PROSTATE: clitoris.
● Corpus is the body
● A hard area on the prostate, fixed irregular
● Crura are the 2 bands of fibrous tissue that
nodules which suggest cancer.
attach the clitoris to the pelvic bone.
● The median sulcus may not be palpable.
● The clitoris is similar to the male penis &
ASSESSING
contains many blood vessels that become
engorged during sexual arousal.
● Vestibule: a boat-shaped area (fossa) in the
FEMALE skin folds of labia majora & labia minora, that

contains several openings.
● Urethral Meatus: located between the clitoris
GENITALIA ANUS & & the vaginal orifice
● Skene`s glands secretes mucus that lubricates
RECTUM & maintains a moist vaginal environment.

● Vaginal orifice the external opening of the
vagina & has either a slit-like or irregular
EXTERNAL GENITALIA circular structure, depending on the
● The external genitalia are those structures configuration of a hymen.
that can be readily identified through ● Hymen is a fold of membranous tissue that
inspection. covers part of the vagina.
● The area is sometimes referred as the “vulva ● Bartholin`s gland are glands that secretes
or pudendum”; extends from the mons pubis mucus which lubricates the area during sexual
to the anal opening. intercourse.
● Mons pubis is the fat pad located over the ● Greater vestibular glands are small glands,
symphysis pubis. are not visible to the naked eye.
● It is covered with pubic hair in which INTERNAL GENITALIA
functions is to absorb force & protect the
symphysis pubis during coitus (sexual ● Functions as the female reproductive organs
intercourse). ● Includes the vagina, cervix, uterus, fallopian
● Labia majora are 2 folds of skin that extend tubes & ovaries.
posteriorly & inferiorly from the mons pubis VAGINA:
to the perineum.
● Labia minora is a thinner skin folds inside the ● a muscular, tubular organ, extends up &
labia majora. slightly back towards the rectum from the
● These folds join anteriorly at the clitoris & vaginal orifice (external opening) to the
form a prepuce or hood; posteriorly the 2 cervix.
folds join to form the frenulum. ● It lies between the rectum posteriorly, the
urethra & bladder anteriorly, & is
CLITORIS: approximately 10 cm. long.
Functions:
✔ Allows the passage of menstrual flow vaginal wall) & red, rough-looking columnar
✔ Receives the penis during sexual epithelium (lines the endocervical canal).
intercourse
Functions:
✔ Serves as the lower portion of the birth
canal during delivery ✔ Allows the entrance of sperm into the
uterus
Vaginal Wall comprises of 4 layers
✔ Allow the passage of menstrual flow
1. Outer layer composed of pink squamous ✔ Secretes mucus & prevents the entrance
epithelium & connective tissue of vaginal bacteria
✔ It is under the direct influence of the ● During birth, the cervix stretches (dilates) &
hormone estrogen & contains many allows the passage of the fetus.
mucus-producing cells.
UTERUS:
✔ This outer layer of epithelium lies in
transverse folds called rugae ● Is a pear-shaped muscular organ that has 2
✔ This transverse folds allows the vagina to components:
expand during intercourse; & facilitate 1. The corpus or body
vaginal delivery of a fetus 2. The cervix or neck
2. Second layer is the sub-mucosal layer ● The corpus is divided into fundus (upper
✔ It contains blood vessels, nerves & portion); body (central portion) & the isthmus
lymphatic channels (narrow lower portion).
● Usually situated in a forward position above
3. Third layer is composed of smooth muscle
the bladder at approximately a 45-degree
4. Fourth layer consists of connective tissue & the angle to the vagina when standing
vascular network (anteverted & anteflexed positions)
● The normal size uterus is approximately 7.5
✔ The normal vaginal environment is acidic
cm. long, 5 cm wide & 2.5 cm thick.
(pH of 3.8-4.2)
● It is movable.
✔ This environment is maintained because
the vaginal flora is composed of Doderlein 3 Layers of the Uterine Wall:
bacilli, & the bacilli acts on glycogen to
1. Endometrium
produce lactic acid.
2. Myometrium
✔ This acidic environment helps to prevent
3. Peritoneum
vaginal infection
ENDOMETRIUM:
CERVIX:
● Is the inner mucosal layer & is composed of
● (neck of the uterus) separates the upper end
epithelium, connective tissue & vascular
of the vagina from the isthmus of the uterus.
network.
● The junction of the isthmus & the cervix forms
● Estrogen & progesterone influence the
the internal os
thickness of this tissue
● The junction of the cervix & the vagina forms
● Uterine glands contained within the
the external os or ectocervix.
endometrium secrete an alkaline substance
● OS refers to the opening in the center of the
that keeps the uterine cavity moist
cervix. Is composed of smooth muscle, muscle
● A portion of the endometrium sheds during
fibers & connective tissue
menses & childbirth
● The external os or ectocervix is covered by
the pink squamous epithelium (lines the MYOMETRIUM:
● Is the middle layer of the uterus
ND
DR. ARLENE CORPUS2 SEMESTERBSN 1-9
● It is composed of 3 layers of smooth muscle ● It is lined with skin that contains no hair or
fibers that surround the blood vessels. sebaceous glands but does not contain many
● This layer functions to expel the products of somatic sensory nerves, making it susceptible
conception. to painful stimuli.
PERITONEUM: ANAL OPENING:
● Is the outer uterine layer that covers the ● Or anal verge, can be distinguished from the
uterus & separates it from the abdominal perianal skin by its hairless, moist appearance
cavity ● Extends interiorly, overlying the external anal
● This forms anterior & posterior pouches sphincter.
around the uterus
EXTERNAL SPHINCTER:
● The posterior pouch is called recto-uterine
pouch of the cul-de-sac of Douglas. ● Is composed of skeletal muscle & is under
voluntary control
OVARIES:
INTERNAL SPHINCTER:
● Are a pair of small, oval-shaped organs, each
of which is situated on the lateral aspect of ● Is composed of smooth muscle & is under
the pelvic cavity involuntary control by autonomic nervous
● Each is approximately 3cm long, 2cm wide & system
1cm deep
ANORECTAL JUNCTION:
● The ovaries are connected to the uterus by
the ovarian ligament ● Located just above the internal sphincter, is
● The ovum travels form the ovary to the uterus the dividing point of the anal canal & the
through the fallopian tubes. rectum
● These fallopian tube is 8-12 cm long begins ● Is not palpable but may visualized during
near the ovaries & enter the uterus just internal examination
beneath the fundus.
RECTUM:
● Fimbriae is a finger-like extensions connected
at the end of the tube near the ovary. ● Is lined with folds of mucosa known as
● Adnexa (Latin for appendages) are the columns of Morgagni
ovaries, fallopian tubes & the supporting ● Is the lowest portion of the large intestine,
ovarian ligaments. approximately 12 cm long, extending from the
end of the sigmoid colon to the anorectal
Functions:
junction.
● To develop & release ova ● It enlarges above the anorectal junction &
● To produce hormone such as estrogen, proceeds in a posterior direction towards the
progesterone & testosterone hollow of the sacrum & coccyx, forming the
rectal ampulla
ANUS & RECTUM
● The inside of the rectum contains 3 inward
ANAL CANAL: foldings called the “valve of Houston”.
● The functions of the valve of Houston is
● Is the final segment of the digestive system
unclear. The lowest valve may be felty, usually
● It begins at the anal sphincter & ends at the
on the client`s left side.
anorectal junction (pectinate line,
● The peritoneum lines the upper two-thirds of
mucocutaneous junction, dentate line)
the anterior rectum & dips down enough so
● It measures for 2.5 to 4cm long.
that it may be palpated where it forms the

rectovesical pouch in men & the rectouterine
pouch in women - No enlargement or tenderness
PHYSICAL ASSESSMENT Deviations from Normal:
PUBIC HAIR: - Lice, lesions, scars, fissures, swelling,

erythema, excoriations, varicosities
● Inspect the distribution, amount &
characteristics of pubic hair - Presence of lesions
Normal Findings:
- Presence of inflammation, swelling or
- Wide variations; generally kinky in the discharge
menstruating adult, thinner & straighter - Enlargement and tenderness
after menopause.
- Distributed in the shape of an inverse ABNORMALITIES OF THE EXTERNAL GENITALIA &
triangle VAGINAL OPENING
Deviations from Normal: SYPHILITIC CHANCRE:

- Scant pubic hair (may indicate hormonal ● Often 1st appear on the perianal area as
problem) silvery white papules that become superficial
- Hair growth should not extend over the red ulcers.
abdomen ● This are painless
● Usually transmitted & develop at the site of
PUBIC AREA:
initial contact with the infecting organism
● Inspect the skin of the pubic area for
GENITAL HERPES SIMPLEX:
parasites, inflammation, swelling & lesions.
● To assess the pubic skin adequately, separate ● The initial outbreak may have many small,
the labia majora & labia minora. painful ulcers with erythematous base.
● Recurrent herpes lesions are usually not as
● Inspect the clitoris, urethral orifice & vaginal extensive.
orifice when separating the labia minora
GENITAL WARTS:
● Palpate the inguinal lymph nodes ● Is caused by human papilloma virus (HPV)
● Use the pads of the fingers in a rotary motion, ● Are moist, fleshy lesions on the labia & within
noting any enlargement or tenderness the vestibule
● Painless & believed to be sexually transmitted
Normal Findings:
RECTOCELE:
- Pubic skin intact, no lesions
- Skin of vulva area slightly darker than the ● Is a bulging in the posterior vaginal wall
rest of the body caused by the weakening of the pelvic
- Labia round, full & relatively symmetric in musculature.
adult females ● Part of the rectum covered by the vaginal
mucosa protrudes into the vagina.
- Clitoris does not exceed 1cm in width &
CYSTOCELE:
2cm in length
- Urethral orifice appears as small slit & is ● A bulging in the anterior vaginal wall caused
the same color as surrounding tissues by thickening of the pelvic musculature
- No inflammation, swelling or discharge
● As a result, the bladder, covered by vaginal ● This condition produces a mucopurulent
mucosa prolapses into the vagina. yellowish discharge from the external os.
● It usually indicates infection with chlamydia or
UTERINE PROLAPSE:
gonorrhea
● Occurs when the uterus protrudes into the ● However, these STIs may also occur with no
vagina visible signs, although the discharge may
● It is graded according to how far it protrudes change the cervical pH.
into the vagina
MALFORMATIONS FROM EXPOSURE TO
● In the 1st degree prolapse, the cervix is seen
DIETHYLSTILBESTROL (DES):
at the opening
● In the second-degree prolapse the uterus ● DES, a drug used more than 50 years ago to
bulges outside of vaginal openings prevent spontaneous abortion & premature
● Third-degree prolapse the uterus bulges labor, was learned to be teratogenic (capable
completely out of the vagina of causing malformations in the fetus).
● Women exposed to this drug as fetuses may
ABNORMALITIES OF THE CERVIX
have cervical abnormalities that may progress
CYANOSIS OF THE CERVIX: to cancer.
● Some abnormalities associated with maternal
● The cervix normally appears bluish in the DES use includes:
client during 1st trimester of pregnancy ✔ Columnar epithelium that covers most or
● If the client is not pregnant, a bluish color of all of the ectocervix
the cervix indicates venous congestion or a ✔ Columnar epithelium that extends onto
diminished oxygen supply to the tissues. the vaginal wall
CERVICAL POLYP: ✔ A circular column of tissue that separates
the cervix from the vaginal wall
● A polyp typically develops in the endocervical ✔ Transverse ridge
canal & may protrude visibly at the cervical ✔ Enlarged upper ectocervical lip
os.
● It is soft, red & rather fragile. VAGINITIS
● Cervical polyps are benign
TRICHOMONAS VAGINITIS (TRICHOMONIASIS):
CANCER OF THE CERVIX:
● This type of vaginal infection is caused by a
● A hardened ulcer is usually the 1st indication protozoan organism & is usually sexually
but may not be visible on the ectocervix. transmitted.
● In later stages, the lesion may develop into a ● The discharge is typically yellow-green, frothy
large cauliflower-like growth. & foul smelling
● Pap smear is essential for the diagnosis ● The labia may appear swollen & red, rough &
covered with small red spots (petechiae).
CERVICAL EROSION:
● This infection causes itching & urinary
● This condition differs from cervical eversion in frequency in the client
that normal tissue around the external os is ● Upon testing, the pH of vaginal secretion will
inflamed & eroded, appearing reddened & be greater than 4.5 (usually 7.0 or more)
rough. ● If the sample of vaginal secretions is stirred
● Erosion usually occurs with mucopurulent into a potassium hydroxide solution (KOH
cervical discharge prep), a foul odor (known as a “+” amine) may
be noted.
MUCOPURULENT CERVICITIS:

ATROPHIC VAGINITIS: ● Irregular bleeding, bleeding between periods
or postmenopausal bleeding may be the 1st
● Occurs after menopause when estrogen
sign of the problem.
production is low
● The discharged produce may be blood-tinged UTERINE FIBROIDS (MYOMAS):
& is usually minimal
● Uterine fibroid tumors are common & benign
● The labia & vaginal mucosa appear atrophic
● They are irregular, firm nodules that are
● The vaginal mucosa is typically pale, dry &
continuous with the uterine surface
contains areas of abrasion that bleed easily
● They may occur as one or many & may grow
● Atrophic vaginitis causes itching, burning,
quite large
dryness & painful urination.
● The uterus will be irregularly enlarged, firm &
CANDIDAL VAGINITIS (MONILIASIS): mobile
● This infection is caused by the overgrowth of ENDOMETRIOSIS:
yeast in the vagina
● The uterus is fixed & tender
● It causes a thick, white, cheesy discharge
● Growths of endometrial tissue are usually
● The labia maybe inflamed & swollen
present throughout the pelvic area & may be
● The vaginal mucosa maybe reddened &
felt as firm, nodular masses.
typically contains patches of the discharge
● Pelvic pain & irregular bleeding are common
● This infection causes intense itching &
discomfort. ADNEXAL MASSES
BACTERIAL VAGINOSIS: PELVIC INFLAMMATORY DISEASE (PID):
● The cause is unknown (possibly anaerobic ● Typically caused by infection of the fallopian
bacteria) but it is thought to be sexually tubes (salpingitis) or fallopian tubes & ovaries
transmitted. (salpingo-oophoritis) with an STIs (e.g.,
● This discharge is thin & gray-white, has a gonorrhea, chlamydia).
positive amine (fishy smell) & coats the ● It causes extreme tender & painful bilateral
vaginal walls & ectocervix adnexal masses (positive Chandelier sign)
● The labia & vaginal walls usually appear
normal & pH is greater than 4.5 (5.5 to 6.0) OVARIAN CANCER:
● Masses that are cancerous, usually solid,
UTERINE ENLARGEMENT
irregular, non-tender & fixed
NORMAL ENLARGEMENT: PREGNANCY
OVARIAN CYST:
● The only uterine enlargement that is normal
● Are benign masses in the ovary
results from pregnancy & fetal growth.
● They are usually smooth, mobile, round,
● The isthmus feels soft (Hegar sign) on
compressible & non-tender
palpation, the fundus & isthmus are
compressible at between 10 & 12 weeks of ECTOPIC PREGNANCY:
pregnancy.
● Occurs when a fertilized eggs attaches to the
UTERINE CANCER (CANCER OF THE fallopian tube & begins developing instead of
ENDOMETRIUM): continuing its journey to the uterus for
development
● The uterus may be enlarged with a malignant
● A solid, mobile, tender & unilateral adnexal
mass
mass may be palpated if tenderness allows.

● The cervix & uterus will be softened &
movement of these structures will cause pain.
KUDOS !! WE MADE
IT <3

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BURI, JADE B.

HEALTH ASSESSMENT LECTURE FINALS

ASSESSMENT ● The slight enlargement in each duct before it

BREAST AND LYMPATHIC SYSTEM Fibrous tissue

External Breast Anatomy ● provides support for the glandular tissue

- Preparing the client FIBROADENOMAS:

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

Deviations from Normal: is low, medium or high and is determined by

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

PERIPHERAL PULSES: PERIPHERAL PERFUSION:

Normal Findings: Normal Findings:

Normal Findings: Normal Findings:

- Dependent position: presence of - Immediately return of color

Deviations from Normal: OTHER ASSESSMENT:

THE ABDOMEN - part of the duodenum and jejunum

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

ABNORMAL FINDINGS (ABDOMINAL - Enlarged, firm, hard, Nodular liver suggests

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

L SYSTEM accounts for approximately 25% of the

● Encompasses the muscles, bones & joints SKELETAL MUSCLES

BONES OF THE CRANIUM (IMMOVABLE

BONES OF THE HAND

BONES OF THE APPENDICULAR SKELETON

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

GATHERING OF SUBJECTIVE DATA GATHERING OF OBJECTIVE DATA:

● Demographic data ● Inspection & palpation for system & its

EFFECTS OF PRESENTING MUSCULOSKELETAL ASSESSMENT OF THE MUSCLES

COMPLAINTS: GENERAL VIEW OF THE MUSCLE:

● Activities of Daily Living: able to care for 1. Muscle Mass

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

RELATED NURSING CARE

● Maintain privacy of the patient

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

THE NEUROLOGIC known as gray matter, which mediates

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

✔ Olfactory- sensory- some Parasympathetic Nervous System

Major areas of mental status assessment include: MEMORY

Language ● The nurse assesses the client’s recall of

ASSESSING THE CRANIAL NERVES & MOTOR

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

GENITALIA ANUS &

RECTUM lubricated to protect the testes from injury.

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

- Hardness & irregularities maybe from ABNORMALITIES OF THE PENIS

HEMORRHOIDS GRADING: HERPES PROGENITALIS:

SCROTAL HERNIA: ● Abnormal dilation of veins in the spermatic

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

FEMALE skin folds of labia majora & labia minora, that

RECTUM & maintains a moist vaginal environment.

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

PHYSICAL ASSESSMENT Deviations from Normal:

PUBIC HAIR: - Lice, lesions, scars, fissures, swelling,

Deviations from Normal: SYPHILITIC CHANCRE:

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

DR. ARLENE CORPUS2ND SEMESTERBSN 1-9

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