nursing exam

does not experience a definite end to fertility as female does

male

production declines after age 30 but continues very gradually so resulting physical changes are not evident until later in life

testosterone

in the absence of disease, withdrawal from sexual activity may be due to

- side effects of medication

- heavy alcohol use

circumcision

- lowers risk for certain STIs such as HPV, herpes simplex virus, genital ulcer disease in men

- decreased risk for bacterial vaginosis and trichomoniasis in females

- reduced risk for contracting HIV infection though heterosexual contact

chronic kidney disease (CKD)

- main causes are hypertension (HTN) and diabetes

- common in african-american, indian-american, hispanics

- can lead to end stage renal disease, gradual loss of kidney function

bladder cancer

- fourth most common cancer in men with ethnic differences

- smoking is the most common risk factor along with occupational exposure to chemicals

- painless hematuria

STIs

- inceasing #s each year

- many are asymptomatic

- use of counseling interventions

subjective data: genitourinary

- frequency (throughout the day)

- urgency (how bad can you hold it)

- nocturia (nighttime bedwetting)

- dysuria (pain and burning with urination)

- hesitancy and straining

- urine color

- past genitourinary history

- penis—pain, lesion, discharge

- scortum—selfcare behaviors, lump

- sexual activity and contraceptive use (blood clotting factors)

- sexually transmitted infection (STI) contact

penis inspection

- if uncircumcised, slide foreskin back to original position

- after using folly catheter, pull foreskin to insert but be sure to put it back in original position

scrotum

- perform transillumination if mass or swelling is detected

- skin might appear taut (tight) and pitting (fluid buildup)

- red glow is a sign of fluid buildup

hernia

- palpate inguinal canal

- palpate femoral area for a bulge

inguinal lymph nodes

- normal to palpate an isolated node on occasion

- enlarged, hard, matted, fixed nodes are abnormal findings

- when palpating a side, have the patient shift weight to the opposite side

urethritis

- urethral discharge and dysuria

renal calculi

- kidney stone

- abrupt sever flank pain into groin or abdomen, hematuria, obstruction of urinary flow, n/a (nausea and vomiting)

- symptoms are the same for men and women

acute urinary retention and urinary tract infection

- retention commonly caused by BPH

- retention can lead to UTIs

- can be caused by removal of folly catheter

urethral stricture

congenital (born with) or secondary to injury

urinary retention in women are most commonly caused by

UTIs

abnormal findings: penis, phimosis

- foreskin tight and fixed, unable to retract

- block urethral opening

- can cause urinary retention

- most likely to be surgically fixed

- can cause infection

abnormal findings: scrotum, testicular torsion

- twisting of the spermatic cord

- considered emergency

- common in children

- cut off blood circulation to scrotum

hydrocele

collection of serous fluid around testicle

scrotal hernia

- caused by indirect inguinal hernia

- intestine drop too low, pain in secretion

- pink or red glow when light is shown (transillumination)

inguinal and femoral hernias

- more common in men

- intestine goes through internal inguinal, pain with straining, swelling increase if pressure in abdomen increase

- goes through weak spots in abdominal cavity

- indirect inguinal hernia (most common)

- direct inguinal hernia

- femoral hernia (least common)

- reducible, physical pressure can cause hernia to go away

- incarcerated, valve can be reduced/returned, might need surgery to repair

- strangulated, blood supply to hernia is shut off

prostate cancer (PC)

- most frequently diagnosed cancer in men

- risk factors: increasing age, african ancestry, family history, inherited mutations BRCA1 and BRCA2

- screening recommendations: prostate specific antigen (PSA) blood test and digital rectal exam (DRE)

colorectal cancer (CRC)

- risk factors: age, inherited genetic syndromes (Lynch), family hx, inflammatory bowel disease, type 2 diabetes and general modifiable risk factors

- screen: colonoscopy

- polyps, precursor lesions, abnormal growths of tissue that project from the lining of the colon

hemorrhoids

- abnormal finding

- engorged blood vessel, caused by increased lower pressure

- rectal bleeding, pain, blood when wiping

abscess

- rectal pain, fever, signs of inflammation/infection

- surgical drainage (pus) needed

BPH

- benign prostatic hyperplasia

- urinary frequency

- urgency

- hesitancy

- incomplete emptying

- nocturia

- straining to void

- intermittent stream

- common in older adult male

cervical cancer

- caused by human papilloma virus (HPV) infection

- fourth most common cancer in women worldwide

- Pap test for screening

- HPV vaccine, can prevent 90% of cervical cancers in women, can prevent oropharyngeal, anal, and penile cancers in men

subjective data: women

- menstrual history

- obstetric history

- menopause = women, night sweats, hot flashes

- acute pelvic pain

- urinary symptoms (continence)

- vaginal discharge

- past history

- sexual activity

- contraceptive use = assess smoking habit, increase risk of blood clotting or vascular issues, middle and young adult women

- sexually transmitted infection (STI) contact

urethritis and uti: women

- more common in women due to the shorter urethra opening/easier bacterial infection

- dysuria, frequency, flank or suprapubic pain

- older adults: confusion, communication problems, lethargy

cervical cancer

- bleeding between menstrual periods, after sex or menopause, unusual discharge

- dx (diagnosis) by Pap test and biopsy (doctor take tissue sample)

candidiasis

- pruitis, thick, whitish clumsy discharge, redness and swelling surrounding vulva

- can be caused by abx (antibiotic) use, oral contraceptives, diabetes

- yeast infection

assessing urinary function

- observe urine color/odor

- note pH and specific gravity (urinalysis)

- serum analysis of kidney function (blood tests), BUN/CR, GFR

- monitor rate of output

- if performing an exam, always have a chaperone present, or be the chaperone for the provider

spleen

- vascular

- laceration or injury is a risk to bleeding and pain in the left lower quadrant

developmental competence: pregnant woman

- n/v, morning sickness is a normal finding, may be due to hormone changes such as production of human chorionic gonadotropin (hCG)

- acid indigestion

- heart burn (pyrosis) cause by esophageal reflux

- burning sensation in upper abdomen

- constipation, due to backup in gi tract

- gastrointestinal motility decreases, which prolongs gastric emptying time, decreases absorption, and leads to constipation

development competence: aging adult

- changes of the gi system occur with aging

- salivation decreases, leading to a dry mouth and decreased sense of taste

- esophageal emptying and gastric acid secretion are delayed, which leads to decrease in vitaminb12 absorpition, which leads to pernicious anemia

- at older age secretion of gastric acid puts them at risk for pernicious anemia

occur with age

- gallstones

- liver size decrease, most liver function remain normal

- drug metabolism is impaired

- frequently report constipation

lactose intolerance

- decreased lactase

- have abdominal pain

- bloating

- flatulence when milks products are consumed

celiac disease

- autoimmune disorder

- intolerant of gluten

- gluten-free diet (GFD)

subjective data: abdomen

- appetite

- dysphagia

- food intolerance

- abdominal pain

- n/v

- bowel habits, , hard stools? diarrhea? how often? if they are experiencing diarrhea is it black tarry? is it normal for the patient? or is it new?

- past abdominal history

- medications, iron puts patient at risk for black stool

- nutritional assessment

objective data: abdomen

- adequate lighting

- expose abdomen so that it is fully visible; drape genitalia and female breasts

- position for comfort to enhance abdominal wall relation

- empty bladder prior to examination with specimen saved if needed

- lying on back with knees bent

- warm stethoscope and examine areas identified as painful last to prevent guarding

- auscultate prior to palpation and percussion

- (1)inspect, (2)auscultate, (3)percussion, (4)palpate

inspect abdomen

- bilateral, symmetric contour

- determine profile form rib margin to pubic bone; contour describes nutritional state and normally ranges from flat to rounded

- normally umbilicus's midline and inverted, no sign of discoloration, inflammation, or hernia

- normally skin surface is smooth and even, with homogenous color; assess skin turgor

- inspect for pigment change and presence of lesions or scars

- common pigment change -> striae (lines albicantes) & [igmented nevi (moles)

- pulsation from aorta in epigastric area is normal

auscultate: bowel and vascular

- percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds

- hold stethoscope lightly against skin; pushing too hard may stimulate more bowel sounds

- begin in RLQ at ielocecal valve area because bowel sounds are normally always present here

bowel sounds

- note character and frequency of bowel sounds

- bowel sound originate from movement of air and fluid through small intestine

- bowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute

- borborygmus is the sound of hyper peristalsis (stomach growling)

- perfectly "silent abdomen" is uncommon

- when auscultating abdomen start at right lower quadrant, right upper quadrant, left upper quadrant then left lower quadrant

abnormal bowel sounds

- hypoactive—decreased, can follow abdominal surgery or with inflammation

- hyperactive—loud, high-pitched signal increased motility

costovertebral angle tenderness (CVA tenderness)

- to assess kidney, place one hand over 12th rib at costovertebral angle on back

- thump hand with ulnar edge of your other fist

- a person normally feels thud but no pain

- positive finding for pain indicates inflammation of the kidney

mild tenderness

normally present when palpating sigmoid colon

palpation of spleen

- normally spleen is not palpable and must be enlarged three times its normal size to be felt

- to locate it, reach left hand over abdomen and behind left side at the 11th and 12th ribs

- lift up for support; place right hand obliquely on LUQ with fingers pointing towards ;eft axilla and just inferior to rib margin

- push your hand deeply down an under left costal margin, and ask the person to take deep breath

- you should feel nothing firm

- if you feel spleen, do not continue to palpate

- spleen enlargement can be caused by monoucleosis

enlargement of spleen can be seen with

mononucleosis, leukemia and lymphomas, portal HTN and HIV infection

palpation of aorta

- 2.5 to 4 cm wide in adult and pulsates in an anterior direction

widened in the presence of elf abdominal aortic aneurysm (triple a)

- using your opposing thumb and fingers, palpate aortic pulsation in upper abdomen slightly to left of midline

abnormal findings: abdominal distention

- obesity

- air or gas

- ascites, fluid in abdomen, protuberant belly

- ovarian cyst (large)

- pregnancy

- feces

- tumor

- constipation can cause this

palpate: murphys sign

- RUQ

- have patient take a deep breath cause pressure to be put against gall bladder

succussion splash

marked peristalsis + projectile vomiting in newborn = pyloric stenosis

infants and children

- growth plates close at 20 years old

- epiphyseal, cartilage that eventually fuses as we get older

pregnancy

- lordosis, normal finding for expecting women due to shift

- spine pushed anteriorly

aging adult

- osteoporosis—decreased bone density, caused by decreased estrogen, women are at more risk

- height decreases

- kyphosis, cervical, curvature of the neck, hump-back, signs of osteoporosis

- loss of muscle mass

patients with osteoporosis should be educated with

- physical activity

- maintain healthy body weight

- recommended dose of calcium and vitamin d

- diet

subjective data: musculoskeletal

- joints: pain, stiffness, swelling, heat, redness, limitation of movement

- knee joint (if injured) - due to heavy usage and loss of strength

- muscles: pain (cramps) or weakness

- bones: pain, deformity, trauma (fractures (if patient feel, sharp pain w/ movement, localized), sprains (throbbing aching pain, last longer), or dislocation)

- functional assessment (ADLs)

- patient-centered care

physical examination preparation: musculoskeletal

order: inspection, palpation, ROM (active to passive), strength

objective data: upper extremities (shoulder)

- pain can be from local cause or referred (ex. gall bladder can cause lower back issue)

- local pain is reproducible and more likely musculoskeletal, hurts when moved or palpated

objective data: upper extremities (elbow)

- palpate slightly flexed with support

- full extension can usually r/o (rule out) fracture

objective data: upper extremities (wrist and hand)

- swelling bilateral or unitlateral

- carpal tunnel syndrome (burning sensation) tests, phallen test 60 seconds, tinel = pressing medial nerve

objective data: lower extremities (hip)

gait smooth and even

objective data: lower extremities (knee)

- bulge sign, fluid in knee, shift of fluid when you move patella

- signs of osteoarthritis

- signs of ligament or meniscal injuries, tear in meniscus, which cushions knee joint

objective data: lower extremities (ankle and foot)

swelling, pain or inflammation

objective data: spine

- check ROM of spine, touch toes, will show if patient has scoliosis

- bend sideways and bakcwards

- twist to one side then the other

health promotion and patient teaching

- diet to protect and maintain healthy bones -> calcium and vitmain d

- smoking cessation

- alcohol intake pattern

- exercise promotion

- osteoporosis screening

- fall prevention

osteoarthritis

- pain with movement

- degenerative

- happens overtime, older adults

- bones rub against another

rheumatoid arthritis

- autoimmune

- can affect everyone

- better with movement

common musculoskeletal abnormalities

- dislocated should

- tear of rotator cuff

- olecranon bursitiis

- epicondylitis

- carpal tunnel syndrome

- gout

- developmental dysplasia of hip

dislocated shoulder

- out of joint socket/out of place

- can't move limb after trauma

tear of roatator cuff

can't extend/flex shoulder

olecranon bursitis

- elbow has circular lump

- elbow joint issue

epicondylitis

- inflammation of a tendon where it attaches to a bone

- tennis elbow

- generalized swelling in forearm

carpal tunnel syndrome

issues with wrist inflammation of nerves

gout

- often seen in big toe, red swelling pain

- draw blood based on uric acid level to detect any gout

developmental dysplasia of hip

- asymmetric of hip

- flip baby over, look at gluteal fold if uneven, sign of hip dysplasia in kids

coordination assessments

- rapid alternative movements (RAM)

- thumb-to-finger

- finger-nose-finger test

- heel-to-shin test

balance tests

- observe their gait

- heel-to-toe walk (tandem walking)

- romberg (eyes closed standing up without swaying)

- want patient to pass these tests

sensory assessment: pain

- hypoalgesia

- analgesia

- hyperalgesia

sensory assessment: light touch

- hypoesthesia

- anesthesia

- hyperesthesia

sensory assessments

- kinesthesia

- sterognosis

- graphesthesia

- extinction

kinesthesia

position, up/down

stereognosis

- tactile discrimination

- knowing what you are holding or touching

graphesthesia

"read: number on skin

extinction

- touch felt at same time

- sensation on both sides

deep tendon reflexes

- limb needs to be supported and muscles relaxed

- reflex response graded on 4-point scale

- 4 = very brisk, hyperactive with clonus, indicative of disease

- 3 = brisker than average, may indicate disease

- 2 = average, normal

- 1 = diminished, low normal, or occurs with reinforcement

- 0 = no repsonse

- biceps

- triceps

- brachioradialis

- quadriceps (knee jerk)

- achilles (ankle jerk)

positive "babinski" reflex

- normal in infants up to two years old

- abnormal finding in adults

- technique: stroke finger up lateral edge and across ball o foot, toes should "fan out"

abnormalities

- myoclonus

- chorea

- tremors

- seizure disorders

myoclonus

short series of jerks at regular rintervals

chorea

sudden, quick, jerky movement at irregular rintervals

tremors

rhythmic involuntary contractions, disappear while sleeping

seizure disorders

- epilepsy

- LOC

- tonic phase—muscle rigidity/fixed

- clonic phase—violent muscular contractions/involuntary

- postictal—after seizure, deep sleep, fatigue, confused