Chapter 20-30

20, 21, 22, 23, 24, 25, 29, 30, 26, 27, 28

Anatomical Landmarks (GI):

Acscending colon: runs from right to transverse across epigastric area → L descending colon → sigmoid → rectum

Reference Lines:

Use either/or​

Most common is 4 quadrants​

Now where abdominal organs is in both 4 & 9!!

Diverticulitis

Inflammation of Diverticulum within colon

• Common Location: Left lower quadrant (LLQ) of abdomen.

• Key Symptoms:

  • Severe LLQ abdominal pain

  • Nausea and vomiting

  • Diminished bowel sounds

  • History of chronic constipation

  • Fevers/Chills

GU organs:

Auscultating lower aorta/iliac/femoral arteries → check for turbulent blood flow or plaque buildup

Spleen

• LUQ organ; very vascular

• Stores RBCs & platelets

• Produces RBCs & macrophages

• Activates B & T lymphocytes

• Trauma/MVA → rupture → hemorrhage

Abdominal Organs:

Kidneys: controls BP through renin​

• Erythropoietin -> RBC making​

​

Peritoneum: abdominal cavity; covers & holds organs​

• Parietal layers; serous membrane​

• Ex: parietal pleural, pericardium​

• Tumor can affect it -> a lot of fluid -> compresses organs​

• Causes ascites (liver cancer)/peritonitis​

​
Mesentery: fanlike structure; from dorsal aorta, supplies blood vessels & nerves to intestines

Ingestion & Digestion

• Mechanical digestion: chewing, peristalsis, churning

• Chemical digestion: breakdown via HCl, enzymes, hormones

• Begins in mouth – food + saliva → bolus

• Bolus → oropharynx → esophagus → stomach (peristalsis)

• In stomach: bolus + digestive juices + HCl → chyme

Absorption & Elimination

• Occurs mainly in small intestine

• Duodenum: receives bile + pancreatic juices

• Jejunum & ileum: villi absorb nutrients

Undigested food → large intestine

• Water & electrolytes absorbed

• Remaining waste → feces, excreted in ~48 hrs

Absorption problem with Older Adults:

• ↓ Saliva & stomach acid → trouble swallowing, digesting, absorbing

• ↓ Motility & peristalsis → bloating, distention, constipation

• Dental changes → painful chewing → diet shift (↓ protein, ↑ carbs)

• ↓ Muscle mass/tone → worsens constipation

• Less pain perception → vague, diffuse abdominal symptoms

  • Common w/appendicitis → vaguer type of pain

• Fat accumulation in lower abdomen → harder physical assessment

• Liver: smaller, ↓ function → slower med metabolism → lower dosage

• Kidneys: ↓ function → ↓ med elimination → lower dosage

• Combined ↓ liver/renal function → lower med effectiveness

• ↓ Thirst sensation → ↓ fluid intake → ↑ risk for UTIs & constipation

Cultural Variations with Abdominal issues:

• African Americans & Hispanic: ↑ sickle cell anemia, G6PD deficiency, lactose intolerance

  • Sickle cell → splenomegaly, jaundice, abdominal pain, vomiting

• Chronic liver disease: leading cause of death in African Americans & Hispanics

  • Linked to alcoholism, obesity, hepatitis B/C

    • Obesity (central): fat accumulates in liver -> compresses -> get rids of healthy cells -> take over -> cirrhosis

  • African Americans: highest hepatitis B rate & higher mortality from hepatitis B/C

Priority Urgent Assessment for Abdomen:

Acute abdominal pain may signal ruptured appendix or diverticula → emergency surgery​

• Ruptured appendix, rupture abdomen, ruptured fallopian/ ovarian cyst​

• Nauses, fever, vomiting, dehydrated​

• Can lead to severe bleeding -> hypovolemic shock​

​

Coffee Ground emesis: trauma, accident​

• Upper GI; digested blood​

• Careful with palpation​

Bright red blood: Upper GI​

• Watch out to not rupture spleen when palpating​

• Esophagus, ruptured ulcer​

​

Colon Bright red blood: → lower GI bleed or hemorrhoids​

​

Black Tarry stool: comes from above (partially digested blood) to -> rectum

Risk factors for Abdominal issues:

​s/s of Dehydration:

• Vomiting, nauses, no eating, tachycardic, low blood volume, low BP, fatigue, diaphoresis, syncope​

• Altered mental status, DIZZY

Unintentional Weight loss: never normal

• stress, difficulty with ingestion, socioeconomic issues, age-related issues, or dementia.

• Anorexia Nervosa

Chronic anti-inflammatories (Advil, Aleve, Ibuprofen): irritate GI tract → inhibit COX enzyme → erosion → gastric ulcers → may cause upper GI bleeding

.

Constipation:

• Change from expected pattern

• Often due to low fiber/fluid intake or medications (anticholinergics, narcotics)

• Assess for diet, meds, activity changes

Diarrhea:

• Causes include infection (e.g., C. difficile), food intolerances, or medication side effects

Hidden allergies: gluten & lactose intolerance → GI distress

Past abdominal/pelvic surgery: may cause scarring/adhesions → bowel obstruction → use rest, IV, NPO, surgery

Excessive alcohol: damages GI lining & liver

• Lower caloric intake

Recent travel: risk for Hepatitis A (spread via fecal-oral route)

• Temporary

Teaching & Health promotion for GI:

Colorectal cancer: 2nd leading cause of death

• >45 years

• Stool DNA (sDNA) → every 3 yrs

• Colonoscopy → every 10 yrs

Hepatitis

• Hep A: fecal-oral, more severe in adults, usually resolves <1 yr

• Hep B/C: blood/body fluids; can cause chronic disease

• Hep B: perinatal transmission common, complications → cirrhosis, cancer; preventable with vaccine

• Hep C: high-risk groups → healthcare, IV drug use, penile-anal intercourse; no vaccine; chronic in >50% → fibrosis, cirrhosis, liver cancer

• Immunizations:

  • Hep B at birth

  • Hep A at 12 months

  • At-risk adults (blood exposure, travel, healthcare, food services, sex workers)

Common Symptoms related to GI:

• Indigestion​

• Anorexia​

  • nervosa: on purpose

• Nausea, vomiting, hematemesis​

• Abdominal pain​

• Dysphagia

• Odynophagia: pain w/swallowing​

  • Stress, obstruction, GERD, infection, tumor​

• Constipation​

  • V fluid, fiber, meds, irritable bowel syndrome (from stress)

• Diarrhea:​ C-diff​, Stress, food intolerance​

• CVA; pain = UTI is high up​

  • dysuria, hematuria

  • r/x for Pyelonephritis

  • use ulnar edge of the forearm → percuss​

• Ureteral colic: kidney stones​

  • High pain meds​

  • Immense pain​

GI Disorders:

• G6PD: low enzyme for RBC making -> anemia​

  • aspirin meds -> hemolysis​

Thalassemias: hereditary hypochromic anemias; often confused with iron-deficiency anemia or lead poisoning; do not respond to iron; may show minor pallor & splenomegaly​

Lactose intolerance: familial; can develop any age; abdominal discomfort, bloating, belching, diarrhea​

​

Abdominal Assessment:

• Preparation:

  • Warm, private environment; adequate lighting

  • Patient empties bladder, lies supine, arms at sides

  • Explain procedure, assess slowly & systematically

  • Examine painful areas last to avoid muscle guarding

• Clinical Significance:

  • Assessment order: Inspection → Auscultation → Percussion → Palpation

    • percussion/palpation before auscultation can alter bowel sounds

• Inspection: urine, emesis, stool

• Auscultation: bowel sounds, vascular sounds

• Percussion: kidneys, liver, spleen, bladder

• Palpation:

  • Light palpation

  • Deep palpation: liver, spleen, kidneys, abdominal aorta, bladder, lymph nodes

Specific things to look at when assessing abdomen:

Cirrhosis

• Liver flat edge, enlarged

Bruit

• Heard above obstruction

• Indicates partial or complete vascular obstruction

Obstruction Assessment

• OLDCARTS for symptom analysis

• NPO if obstruction suspected → prevents vomiting

• No bowel sounds: suggests obstruction

• High-pitched bowel sounds in upper regions → early obstruction

• CT scan often used for diagnosis

• Provider manages care and orders tests/interventions

• Most common issues: vomiting, constipation, abdominal distention

Advanced Abdominal Assessment

Bladder Scan

• Measures bladder volume & emptying; guides need for catheterization

• Male setting if hysterectomy

• >600 ml without voiding: abnormal

• >200 ml post-void: suggests incomplete emptying

Abdominal Reflex

• Superficial cutaneous reflex: stroke abdomen toward umbilicus in all quadrants

• Absent in upper/lower motor neuron disease

Ascites Assessment

• Detectable after ≥500 ml fluid

• Common in cirrhosis or liver tumors

• Shifting dullness: percuss supine → lateral positions; dullness moves to dependent area

• Fluid wave: patient’s hand midline; tap one side, palpate other for transmitted wave

Peritoneal Irritation

• Blumberg sign (rebound tenderness): press 90° and release quickly

  • Pain on release: peritoneal irritation/peritonitis (appendicitis)

  • Normal: no pain

• Cough test: localized tenderness → peritoneal irritation

Gallbladder Inflammation

• Murphy sign: fingers beneath liver border, patient inhales deeply

  • Positive: sharp pain + inspiratory arrest → cholecystitis

  • Negative: no pain

Appendicitis

• Iliopsoas test: (PSOAS) supine, lift right leg, push down on lower thigh while patient resists

  • Pain: RLQ, indicates inflamed/perforated appendix

Rovsing:

• Test for appendicitis

• Press on left lower abdomen, then release

• Pain felt in right lower quadrant → positive sign

Bruits

• Swishing sounds → turbulent blood flow from vessel constriction or dilation

• Hepatic area bruit: may indicate liver cancer or alcoholic hepatitis

• Aorta or renal artery bruit: suggests partial obstruction

• From smokers & diabetics

GI Diagnostics:

• Basic Metabolic Panel (BMP): electrolytes, kidney function, acid-base status

• Liver Function Tests (LFTs): assess liver health and damage

• H. pylori:

  • Bacteria that thrives in stomach acids

  • Causes gastritis, reflux, ulcers

  • Breath test: detects presence of bacteria

  • Endoscopy (EGD): can biopsy tissue

• Barium Enema: imaging of colon/rectum

  • Outlines large intestine using barium sulfate

  • Detects IBD or colon cancer

• Colonoscopy: visualizes colon; can biopsy/remove polyps

  • Assesses colon & rectum, detects polyps, ulcers, tumors

  • Conscious sedation, scope passed through rectum

• ERCP: Evaluates liver & pancreatic ducts, removes gallstones, diagnoses pancreatic cancer

• CT Scan / MRI: detailed imaging of abdominal organs

Bones

• Living structure: organic matrix + calcium phosphate

• 206 bones (excluding teeth & small cartilage bones)

• Bone types:

  • Compact bone: shaft & outer layer

  • Spongy/cancellous bone: ends & center

• Shapes: short, flat, irregular, long

• Long bones: hollow tube of compact bone, ends = cancellous bone

• Growth: lengthen at epiphyses

• Functions:

  • Framework & protection

  • Mineral storage: calcium, phosphate

  • Bone marrow: hematopoiesis (blood cell production)

Muscles:

• Three types: cardiac, smooth, skeletal

• Skeletal muscles: 600 in body; voluntary

• Structure: fibers in bundles → attached to bone by tendons

• Functions:

  • Force & movement

  • Body shape

  • Heat production during activity

• Connective tissue: supports, structures, binds body together

Joints

• Definition: where two bones meet; provide mobility

• Types by cartilage:

  • Fibrous (synarthrotic): immovable (e.g., cranial sutures)

  • Cartilaginous (amphiarthrotic): slightly movable (e.g., costal cartilage, symphysis pubis)

  • Synovial (diarthrotic): freely movable; major movements:

    • Ball & socket: hip, shoulder

    • Hinge: elbow, knee

    • Pivot: atlas/axis

    • Condyloid: wrist

    • Saddle: thumb

    • Gliding: intravertebral

Joint Real Examples (Read Over):

Temporomandibular Joint (TMJ)

• Mandible + temporal bone

• Movements: open/close, protrusion/retraction, side-to-side

• Palpable: below & anterior to tragus of ear

Shoulder

• Humerus + glenoid fossa of scapula (ball-and-socket)

• Stability: rotator cuff muscles & tendons

• Protection: bursa

• Landmarks: acromion, greater tubercle, coracoid process

Elbow

• Humerus + radius + ulna (hinge)

• Movement: flexion/extension; pronation/supination

• Landmarks: olecranon, medial/lateral epicondyles; ulnar nerve (“funny bone”)

• Bursa: between olecranon & skin

Wrist & Hand

• Wrist (radiocarpal): radius + carpal row (condyloid) → flexion/extension, deviation

• Midcarpal: flexion, extension, some rotation

• Fingers: metacarpophalangeal & interphalangeal joints → flexion, extension, abduction

Hip

• Acetabulum + femur head (ball-and-socket)

• Stability: muscles, ligaments, fibrous capsule, femur insertion

• Bursae: 3 facilitate movement

Knee

• Femur + tibia + patella

• Structures: medial/lateral menisci, cruciate ligaments, collateral ligaments, bursae

• Palpable landmarks: tibial tuberosity, medial/lateral condyles, patella, femoral epicondyles

Ankle & Foot

• Ankle (tibiotalar): tibia + fibula + talus (hinge) → dorsiflexion, plantar flexion

• Stability: medial/lateral malleoli & ligaments

• Subtalar: inversion/eversion

• Weight distribution: metatarsal heads & calcaneus via longitudinal arch

• Toes: metatarsophalangeal & interphalangeal joints → flexion, extension, abduction

Spine

• 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 3–4 coccygeal

• Intervertebral disks: cushion vertebrae

• Palpable landmarks: C7/T1, inferior scapula (T7–T8), iliac crest line (L4)

• Curves: cervical & lumbar = concave; thoracic & sacrococcygeal = convex

• Functions: absorb shock

• Abnormal postures: kyphosis, scoliosis, lordosis

Trendelenburg Sign

• Test for: congenital hip dislocation or hip abductor weakness

• Positive sign: hip drops on the side opposite the stance leg or in babies, leg elevates when standing/walking

Dorsiflexion & Plantarlexion

Dorsiflexion: Bending the ankle so that the toes move toward the head

Plantar flexion: Moving the foot so that the toes move away from the head

Musculoskeletal Changes with Aging

• Bone: osteoporosis = resorption > deposition; rapid loss post-menopause; risk: small frame, smoking, low calcium, alcohol, inactivity; teach: weight-bearing exercise, fall prevention

• Bony prominences: more visible → skin breakdown; nursing: reduce pressure

• Cartilage: degenerates → stiffness; nursing: warm baths before activity

• Joints/ligaments: stiff, lax → ↓ROM; nursing: active ROM, assistive devices for ADLs

• Muscle: atrophy → ↓strength after 30, worse after 60; nursing: isometric exercises, nutrition

• Posture/spine: height loss (disks & osteoporosis); kyphosis

• Fat: ↑abdomen/hips after 40; ↓subcutaneous fat after 80 → prominent bones

Cultural Variations & Health Disparities – Musculoskeletal System

Bone density: more related to BMI & physical activity than genetics

Femur Curvuture

Sex & hormones: testosterone → larger/stronger bones; estrogen ↓ post-menopause → rapid bone loss (≈20% in 5–7 yrs); white women at highest osteoporosis risk

Work risks: heavy lifting → back strain; physically demanding jobs → sprains/strains/fractures; repetitive motion → carpal tunnel, pitcher’s elbow, vertebral degeneration; poor desk ergonomics → musculoskeletal injuries

Musculoskeletal Assessment

• Inspection: limb/joint/spine alignment; symmetry in size, shape, position, movement

• Swelling/tenderness: → likely strain or sprain

• Bone/joint misalignment: bone → fracture; joint → dislocation

• Safety: do not attempt to realign; immobilize and keep patient calm

• Soft-tissue injury: check swelling, pain, numbness, bleeding; apply pressure if needed; monitor distal pulses, color, temp, capillary refill

• GALS screen: gait, arms, legs, spine; 11 tasks + ask about pain/stiffness and difficulty with ADLs (washing, dressing, climbing stairs)

Vital signs, monitoring pulses, assessingcolor, temperature, capillary refill distal toinjury

Neurovascular Test:

Checking for the "5 P's": pain, pallor (color), pulses, paresthesia (sensation/tingling), and paralysis (motor function), along with capillary refill time (<2 secs) and temperature.

Priority assessment btw

R/x for Musculoskeletal issues:

Osteoporosis, RA, OA,

Any high repetitive motion​

• Use of hands drills, carpal tunnel syndrome, trigger finger​

• Asks ab complain ​

• Knee, foot, feet (runners)

Musculoskeletal Teaching & Health Promotion

• Health History: identify areas needing teaching; link to Healthy People 2030 goals:

  • ↑ osteoporosis screening

  • ↓ hip fractures

  • ↑ physical activity in adults with health problems

• Functional Assessment: use Short Musculoskeletal Function Assessment (SMFA)

• Lifestyle Recommendations:

  • Maintain healthy weight

  • Weight-bearing exercise ≥3x/week

  • Alternate shoulder bag or use backpack → prevent scoliosis

  • Use proper body mechanics, protective equipment, seat belts

  • Exercises to improve strength, flexibility, posture → ↓ fall risk

• Bone Density & Osteoporosis:

  • Calcium + vitamin D important for all ages

  • Preventive measures: active lifestyle, weight-bearing exercises, joint protection, limit caffeine, discuss risk with provider, bone density test, medications if needed (bisphosphonates, calcitonin, HRT, raloxifene, parathyroid hormone)

  • Weight-bearing exercise crucial after 30 to prevent bone loss and muscle wasting; walking preferred

• Scoliosis Screening (more on females):

  • Lateral curvature of spine; structural or functional

  • Early detection in adolescence prevents progression

  • Severe cases → breathing interference

  • Screen via hip, scapula, shoulder symmetry; forward bend test

  • Older adults may present undiagnosed cases

Common musculoskeletal symptoms

• Pain/Discomfort: Myalgia (muscle pain), Arthralgia (joint pain)

• Weakness: Reduced strength or fatigue

• Stiffness / Limited Movement: Contractures or reduced range of motion

• Deformity: Visible bone or joint abnormality

• Balance & Coordination Issues: Ataxia (unsteady gait, falls)

• Crepitus: Crackling or popping in joints (common in shoulder, knee)

  • Overuse of joint or OA

Specific Joint Deformities

• Genu Valgum (“knock knees”): Knees angle inward; medial sides touch, lateral sides apart

  • diagnosed during school-aged

• Genu Varum (“bow-legged”): Knees angle outward; lateral sides apart, medial sides do not touch

Both cause chronic knee pain in the future

musculoskeletal assessment equipment

• Goniometer: Measures joint angles and range of motion (ROM)

• Tape Measure: Measures limb length, circumference, or deformities

Romberg Test:

• Assesses balance and proprioception (sensory input from joints/muscles)

• Procedure:

  1. Have patient stand with feet together, arms at sides.

  2. Observe balance with eyes open, then eyes closed for 20–30 seconds.

Initial Musculoskeletal Survey:

1. Posture: Look for alignment of head, spine, shoulders, and hips.

2. Gait & Mobility: Observe walking patterns; note any limping, shuffling, or wide-based steps.

   • Ataxic gait: Uncoordinated, unsteady walking → may indicate cerebellar or sensory deficits.

3. Balance & Coordination:

   • Tests: Romberg, heel-to-toe walking, finger-to-nose.

4. Extremities: Inspect and palpate for deformities, swelling, tenderness, or asymmetry.

5. Joints & Spine:

   • Inspect, palpate, assess ROM and muscle strength of each joint and spine.

Fall-Risk Assessment

• Tools: Morse Fall Scale, Hendrich II Fall Risk Model

• Interventions for high-risk patients:

  • Encourage supervised walking in the hallway

  • Provide assistive devices like walkers

  • Monitor closely for repeated falls

Musculoskeletal Lab Tests:

• Muscle Injury:

  • Creatine kinase (CK), lactate dehydrogenase (LDH), ALT, AST → indicate muscle damage.

• Bone Damage:

  • Alkaline phosphatase → elevated with bone turnover or injury.

• Inflammation:

  • ESR, C-reactive protein (CRP), rheumatoid factor → elevated in rheumatoid arthritis, lupus, and other inflammatory conditions.

• Gout:

  • Uric acid → elevated in gouty arthritis.

• X-ray: Detects bone fractures; limited for soft tissue.

• CT scan: Shows bone and soft-tissue structures; more detailed than X-ray.

• MRI: Most sensitive for soft-tissue injuries (ligaments, tendons) and stress fractures.

• Bone Density Scan (DEXA): Assesses osteoporosis risk and fracture susceptibility.

(Musculoskeletal injuries are most painful post-op)​

• A lot of blood transfusions from bone marrow being taken out

Brain:

• Neuron structure: cell body (control center), dendrites (receive impulses), axon (transmits impulses).

• Gray matter: cell bodies (outer cortex).

• White matter: axons (inner brain tissue).

• Synapses: spaces between neurons for communication.

Cerebrum:

1. Cerebrum:

   • Two hemispheres:

     • Left: language, logic, math.

     • Right: spatial, creative, emotional.

   • Cerebral cortex: controls motor, sensory, intellect, and language.

   • Lobes and functions:

     • Frontal: cognition, personality, motor control, Broca’s area (speech).

       • Precentral gyrus: Motor control (opposite side of body)

     • Parietal: sensory perception, size/shape recognition.

     • Temporal: hearing, memory, behavior, Wernicke’s area (language comprehension).

       • Postcentral gyrus: Sensory input (temp, touch, pressure, pain) from opposite side

     • Occipital: vision and visual interpretation.

     • Limbic (5th lobe): emotion, memory, survival behaviors.

   • Basal ganglia: modulate automatic movements.

   • Thalamus: sensory/motor relay.

   • Hypothalamus: autonomic control (temp, HR, BP, hormones, sleep).

   • Limbic system: emotions, fear, aggression, affection.

Aphasia Types:

• Stroke in right brain → left-sided deficits.

• Stroke in left brain → right-sided deficits + language problems.

  • Wernicke damage: receptive aphasia (can’t understand).

  • Broca damage: expressive aphasia (can’t speak).

  • Global aphasia: both receptive + expressive.

Cerebellum:

Coordinates voluntary movement, posture, muscle tone, and balance

• Ensures smooth, balanced movement through connections with motor cortex & brainstem

• Alcohol impairs cerebellum → loss of balance and coordination

• Cerebellum Ataxia: very impaired coordination; bad Romberg performance​

Cerebellar Ataxia:

Cause: Cerebral palsy or alcohol intake
Characteristics: Wide-based gait, staggers and lurches side to side, unable to perform Romberg test due to trunk swaying
Reason: Cerebellar dysfunction → poor balance and coordination

Brain Stem

Connects brain and spinal cord; controls vital reflexes.

• Components: midbrain, pons, medulla, reticular formation.

• Functions:

  • Medulla: cardiac, respiratory, and vasomotor control; reflexes (swallowing, coughing, sneezing, vomiting).

  • Pons: regulates breathing rhythm with medulla.

  • Reticular Formation: Relays sensory info and provides excitatory/inhibitory control to spinal motor neurons

    • wakefulness, attention, and cortical responsiveness

  • Cranial nerves III–XII originate here.

Brain Protection:

Protection: Skull and meninges cover the brain
Ventricles & CSF: Fluid-filled cavities circulate cerebrospinal fluid around brain, brainstem, and spinal cord

• Cushions brain, carries nutrients, allows fluid shifts

• ↑CSF pressure → brain herniation → brainstem compression → impaired breathing, ↓LOC, possible death

Spinal Cord:

Extends from brainstem → coccyx

• Gray matter (H-shaped, center) = cell bodies: voluntary & autonomic motor neurons, sensory neurons

• White matter (surrounds gray) = axons in ascending & descending tracts

Cells Aligned

Ascending Tracts (Sensory):

• Dorsal/posterior columns → localized touch, deep pressure, vibration, proprioception, movement → synapse in medulla → cross → sensory cortex

Descending Tracts (Motor)

• Motor function & muscle movement (voluntary)

Cranial Nerves:

• I. Olfactory (Sensory): Smell & interpretation (stimulates peristalsis, salivation, sexual response).

• II. Optic (Sensory): Vision — acuity & peripheral.

• III. Oculomotor (Motor): Eye movement (up, medial, down, up/in), raises eyelid, pupil constriction.

• IV. Trochlear (Motor): Eye movement — down & in.

• V. Trigeminal (Sensory + Motor):
  • Ophthalmic — cornea, forehead, nose.
  • Maxillary — cheeks, upper jaw, teeth.
  • Mandibular — lower jaw sensation & chewing.

• VI. Abducens (Motor): Lateral eye movement.

• VII. Facial (Sensory + Motor): Taste (ant. ⅔ tongue), facial expression, salivary & lacrimal glands.

  • Bells palsy: unable to wrinkle forehead

• VIII. Acoustic / Vestibulocochlear (Sensory): Hearing & balance (cochlear + vestibular fibers).

• IX. Glossopharyngeal (Sensory + Motor): Taste (post. ⅓ tongue), swallowing, speech, parotid secretion, sensation (ear & pharynx).

• X. Vagus (Sensory + Motor): Parasympathetic control — digestion, defecation, ↓HR, speech & swallowing.

• XI. Spinal Accessory (Motor): Swallowing, speech, shoulder shrug, head turn.

• XII. Hypoglossal (Motor): Tongue movement.

Spinal Nerves:

• Arise from: Spinal cord → innervate rest of body.

• Composition:
  • Afferent (sensory) fibers → dorsal root.
  • Efferent (motor) fibers → ventral root.
  • Combined = spinal nerve.

• Total: 31 pairs
  • 8 Cervical (C1–C8)
  • 12 Thoracic (T1–T12)
  • 5 Lumbar (L1–L5)
  • 5 Sacral (S1–S5)
  • 1 Coccygeal

• Dermatome: Skin area innervated by sensory fibers of a single spinal nerve.

  • Level of injury to the spinal cord affects function at and below the site of trauma

    • C1-C3: issues with movement of below neck​

      C4-C6: shoulder & diaphragm; Breathing​

      C7-C8: fingers & grasping, self care​

      T1-5: Trunk stability
      T6-12: thoracic muscle & upper back → respiratory & transfer strength​

      L1-2: Legs & Pelvis​

      L3-L4: Ankle, hamstring

• Function: Each level controls motor & sensory activity for specific body regions (head → toe).

Autonomic Nervous System:

• Function: Maintains involuntary control of cardiac, smooth muscle, and glands → keeps homeostasis.

• Divisions:
  • Sympathetic (T1–L2) = “Fight or flight” → ↑ HR, BP, contractility. Neurotransmitter: Epinephrine & Norepinephrine.
  • Parasympathetic (Brainstem & S2–S4) = “Rest & digest” → ↓ HR, promotes digestion. Neurotransmitter: Acetylcholine.

• Receptors:
  • Chemoreceptors & Baroreceptors detect changes → trigger ANS response.

Reflexes:

Involuntary, protective responses → tone & posture.

• Reflex Arc:
  Receptor → Sensory neuron → Spinal cord → Motor neuron → Effector (muscle).

  • Patellar reflex (knee jerk) → tests spinal reflex & muscle strength.

• Types:
  • Deep tendon (patellar)
  • Superficial (corneal, abdominal)
  • Visceral (pupillary light)
  • Neonatal (rooting, grasp,

  • Babinski (disappears before age of 2): feet go outward

    • Spinal cord/systematic nervous system injury

Older adults and issues with Nervous System:

• Structural brain changes​

• ↓ Brain volume due to neuron shrinkage & fewer synaptic spines/synapses. 

• Reduction in cognitive abilities​

• Risk for poor balance, postural hypotension, falls, injury​

• Light touch, pain sensation reduced​

• Ventricles enlarge → possible normal pressure hydrocephalus (ataxia, vision problems, gait issues, mild dementia, incontinence).

• Peripheral neuropathy: symptom of smth else( Diabetes, B12 deficiency)​

  -Inspect feet everyday, SHOES,​

  -Be careful of heating pads

Cultural Variations Regarding Nervous System:

• Stroke Risk:
  • African Americans = 2× higher death rate (↑ BP, obesity, diabetes, smoking).
  • Hispanics & Native Americans = ↑ risk; Asian Americans = ↓ risk.
  • Many delay care or stop treatment early → poorer outcomes.

• Post-Stroke Functional Limitations:
  • More common in African Americans & Hispanics.
  • Recovery depends on therapy access & support systems.

Priority Urgent Assessment related to Nervous system:

• 🧠 Acute mental change → restlessness, agitation, confusion

  • CHECK FOR BASELINE FIRST

• 😴 ↓ LOC → harder to arouse, unresponsive (not drug-related)

• ⚡ Seizures

• 💪 Posturing:
  • Flexor (decorticate) – arms flexed, legs extended
  • Extensor (decerebrate) – arms/legs extended, plantar flexion

• 👁 Pupil change → size or reactivity altered (one is fixed) BAD PERRLA

• 👀 Eye deviation (conjugate/dysconjugate)

• 🦵 Progressive weakness/paralysis (watch for facial droop)

• ✋ Sensory loss

• ❤ Vital sign changes:
  • ↑/↓ BP → risk of hemorrhage or infarct
  • Irregular HR/rhythm (e.g., Afib → emboli/stroke)
  • Fever → infection, autonomic dysfunction
  • Cushing’s Triad (↑ BP + ↓ pulse + ↓ respirations) → ↑ ICP
  • Irregular breathing → brainstem compression

Rapid Acute Neuro Exams:

• LOC (Glasgow Coma Scale)

  • Eye Opening (4): Spontaneous → Voice → Pain → None

  • Verbal (5): Oriented → Confused → Inappropriate → Incomprehensible → None

  • Motor (6): Obeys → Localizes → Withdraws → Flexion → Extension → None

  • Score range: 3 (coma) – 15 (normal)

  • If <8 → intubation

• Pupils: Check size, symmetry, & light response

• Motor Strength: Lift each limb vs. gravity & resistance

• Face: Check for asymmetry at rest & with movement

• Sensation: Light touch on limbs & face (if communicative)

• CNs (if ↓ consciousness): EOMs, gag reflex, corneal reflex

• Vitals: Monitor for cause/result of neuro change

Act F.A.S.T. for strokes → tissue necrosis → death​

-Sudden severe headaches with no cough; blurry vision,​

-Cautious with ppl how take blood thinners​

Assessment of Risk factors:

Check for past medical history; head-spinal trauma

Chronic Conditions:

• Meningitis: fever, stiff neck, drowsiness, photosensitivity

• Multiple sclerosis (MS)/Degenerative: weakness, tingling, vision difficulty, elimination issues

• Parkinson’s

Infections:

• Meningitis

• Spider

• Ticks → lyme disease 

• Snakes

Stroke History:

• Pts with history may stay with s/s of strokes → not urgent (X code)

Location of issue:

• sudden loss of hearing → temporal

obstructive sleep apnea (OSA) → * risk for A fib → stroke

Multiple sclerosis: no known cause (AI)

Teaching & Health promotion for strokes:

Risk factors (modifiable):

• Smoking 🚭

• Dyslipidemia (high cholesterol)

• Hypertension

• Diabetes mellitus

• Abdominal obesity

• Psychosocial stress

Prevention strategies:

• Control BP (healthy diet + prescribed meds)

• Encourage smoking cessation

• Eat low-saturated fat, high-fruit & veggie diet

• Weight management & calorie reduction

• Regular exercise (vigorous walking 30 min, 3–5×/week)

Chronic Neurological Conditions

• Examples: MS, Parkinson’s, Alzheimer’s, ALS, Huntington’s, Epilepsy

• Causes: genetic, viral, environmental, or lifestyle factors (often unknown)

Common Symptoms regarding Neuro System:

Headaches: make sure HPI is thorough​

-location, quality, severity, progressively worse?

Localized weakness

Generalized weakness (MS)
Involuntary tremors

• not all are parkinsons

• stress

Balance/coordination issues

Dizziness/vertigo:​

-benign paroxysmal vertigo

-may be Meniere disease

Swallowing issues: stroke/Parkinsons

Intellectual changes: Alzeihmeres

Speech/language difficulties​

Changes in senses of taste, touch, or smell

Double blurred vision: X normal​

Sudden hearing loss: X normal​

-Tenitis: does not go away

CVA risk:

​

• Increased age: 2x each decade after 55​

• Male​

• African Americans​

• HTN​

• Smoking​

• OSA: affects atrium -> poor conduction -> quiver -> A-fib -> clots are made -> travels to brain -> CVA​

• Make sure to do a sleep study!​

• 3+ alcohol beverages/day

Equipment for Neurological Assessment:

Penlight or flashlight

Tongue blade

Cotton swab

Tuning fork: is for sensation feeling -> neuropathy risk​

- Pt should stop feeling it when nurse does too

reflex hammer

Basic and Advanced Techniques: Neurological System

​Dysarthria: slurred speech

Gag reflex; tests vagus for aspiration/swallow patterns

Neurological Assessment: Motor, Cerebellar, and Sensory Functions

1⃣ Motor Function

• Assess: Muscle bulk & tone, muscle strength, balance.

• Practical tests:

  • Squeeze nurse’s hands → checks hand grip strength.

  • Romberg test → patient stands feet together, eyes closed; swaying suggests proprioceptive/vestibular issues.

• Abnormal findings: Atrophy, hypertrophy, flaccidity, spasticity, weakness.

2⃣ Cerebellar Function

• Assess: Coordination and smoothness of movement.

• Key terms:

  • Ataxia: Unsteady, uncoordinated movements.

  • Adiadochokinesia: Inability to perform rapid alternating movements.

• Practical tests: Rapidly pronate/supinate hands, finger-to-nose test.

3⃣ Sensory Function

• Basic senses: Light touch, superficial pain (pinprick).

• Advanced senses (specialty/advanced practice):

  • Temperature sensation

  • Point localization → can patient identify touch location?

  • Vibration sensation → tuning fork

  • Motion/position sense (proprioception) → detect limb movement

  • Stereognosis: Identify object by touch alone

  • Graphesthesia: Recognize writing traced on skin

  • Two-point discrimination: Distinguish two points on skin

  • Extinction: Detect simultaneous touch on both sides

• Practical test for stereognosis: Place a familiar object in patient’s hand.

Reflex Testing & Carotid Arteries Testing

Deep tendon reflexes, superficial reflexes​

DTR: bicep, tricep, brachial reflex, patellar, achilles​

0- none​

1+- diminished​

2+- normal​

3+-brisk*​

4+-Hyperractive, very brisk

Carotid Arteries: carries to brain​

-Bruits​

- Major cause of Syncopal episode (major cause is cardiac related)

Extra Neuro Assessments:

Meningeal signs for Meningtitis

• inflammation, virus check

• ​Brudzinski: flex hip​

  • Lay them down -> flex neck -> significant pain ​

• Kernig Sign: flexing legs at hips​

• Nuchal rigidity: stiff neck​

• Intercranial hemorrhage ​

​

Dolls eye maneuver:​

Turning head to one side -> eyes move opposite way (intact brain stem)

If remain midline or move with head: severe brainstem injury/issue​

​

Glasgow Coma Scale: 3-15; know table!​

• Eye opening response (4)​

• Best vertebral response (5)​

• Best motor response (6)

Labs related to Neuro

Angiography: Inject dye into vessel -> check for every vessels​

• Helps find very small strokes/aneurysm​

• ​

EEG: electrical pole activity of brain​

​

Lumbar puncture: collect CSF amount -> lab -> check for meningitis, virus & bacteria in it​

• Be careful when taking out -> too much = loss of cushion lubricant of spine​

• Lay them flat in bed due to severe headache

Testicles:

Production of sperm & testosterone​

• 3.5°F (2°C) lower than core body temperature

Prepuce: Foreskin

Full bladder -> penile erection

Epididymis → Vas deferens → Ejaculatory duct → Urethra

• Rete Testis: collect sperm from the seminiferous tubules and transport them into the epididymis via the efferent tubules.

• Epididymis:.

  • Functions: storage, maturation, and transport of sperm.

• Vas deferens (ductus deferens):

  • Transports sperm from epididymis to ejaculatory duct.

  • Along with arteries, veins, and nerves, forms the spermatic cord.

  • The spermatic cord ascends through the external inguinal ring → inguinal canal.

  • Joins the seminal vesicle before entering the prostate to form the ejaculatory duct.

• Ejaculatory duct:

  • Passes through the prostate gland and opens into the posterior urethra.

• Urethra:

  • Length: 18–20 cm (7–8 in.), from bladder to meatus.

  • Divided into three parts:

    1. Posterior

    2. Membranous

    3. Cavernous (anterior)

Seminiferous Tubules

• Located inside each testicle.

• Consist of coiled ducts where spermatogenesis (sperm production) occurs.

• Sperm maturation cycle: approximately every 90 days.

Erection:

• Caused by psychogenic or local mechanisms.

• Psychogenic erection: triggered by sensory input such as auditory, tactile, visual, or imaginative stimuli.

• Local reflex erection: initiated by tactile stimulation.

• A full bladder can also induce an erection.

Internal Genitalia, Rectum, Anal Canal,Anus (MEN)

Prostate is below bladder​

• Enlargement > 50 years​

• ​

Provide privacy & comfort

Lifespan considerations regarding male genatalia:

Newborns & Infants

• Circumcision is a family choice, not a medical requirement.

• States that benefits outweigh risks based on:

  • ↓ Urinary tract infections (UTIs)

  • ↓ Ulcerative sexually transmitted infections (STIs)

• Uncircumsized → ^ UTI (1st year of life)

Children & Adolescents

• Tanner’s Stages of Maturation used to assess puberty and development.

• Based on primary and secondary sexual characteristics (external changes).

Older Adults

• Rectal changes:

  • Degeneration of afferent neurons → ↓ sensation of rectal fullness.

  • Reduced sphincter tone → possible fecal retention or incontinence.

• Testosterone declines → ↓ libido and sexual function.

• Testes drop lower in scrotum

• Benign prostatic hyperplasia (BPH)​: too big -> obstruction for bladder -> necrosis​

• Some meds can v psi -> if not then surgery

• Erectile Dysfunction: v libido/inability to ejaculate​

Do not joke around duh

Piercings and tattoos​​

Transgender does not change the fact that they have a prostate​

Priority Urgent Assessment for Male Genitea:

Torsion -> ischemia; young ppl; familial & can happen again with past torsions​
Epididymitis → inflammation

Feature	Testicular Torsion	Epididymitis
Pain onset	Acute, sudden	Gradual
Nausea/Vomiting	Present in ~50%	Rare
Fever	Rare	Present in ~50%
Blue dot sign	Tender blue nodule on testis	Absent
Voiding symptoms / discharge	Rare	Present in ~50%
Urinalysis results	Abnormal in 0–30%	Diagnostic in 20–95%
Relief with elevation	No relief	Pain lessens
Treatment	Immediate surgery (urologic emergency)	Antibiotics (infection/inflammation)

Fournier Gangrene:

• Severe, rapidly spreading infection of perineal/genital tissue.

• Often originates from perianal or retroperitoneal infection.

• Common in diabetics.

• Symptoms:

  • Pain, redness, swelling in perineum.

  • Progresses rapidly within hours.

  • Tenderness, induration, crepitus (gas pockets).​

75% of hospital UTIs are catheter-associated (CAUTI).

Anorectal Disorders

• Can cause pain, embarrassment, and delayed care.

• Early detection = lower mortality.

• Rectal bleeding (Hemorrhoids) → needs rapid assessment.

Colorectal cancer may mimic benign conditions → always investigate; adults

Subjective data collection regarding male genatalia

1. Past Medical History

• Ask about chronic illnesses: diabetes, hypertension, neurological disorders, COPD, cardiovascular disease, depression.
  → ↑ Risk for ED, UTIs, epididymitis, proctitis.

• Age, Gender, Ethnicity

2. Medical & Surgical History

• Ask about genitourinary surgeries: prostate, testicular cancer, torsion

• Sexual behavior, condoms​

• Medications used -> erectile dysfunction​

• r/x for cancer

Sexual History – The “Five P’s”

1. Partners:

   • Ask number, gender identity, and new or multiple partners.

   • Include partner risk factors: injection drug use, known infections, or anonymous encounters.

2. Practices:

   • Ask about vaginal, oral, and anal sex (insertive/receptive), and use of sex toys or douching.

3. Protection:

   • Ask: “How do you protect yourself from STIs?”

   • Discuss condom use, testing frequency, and partner communication.

4. Past History of STIs:

   • Document specific infections, recurrence, and partner treatment.

5. Pregnancy Prevention:

   • Ask, “Are you trying to get pregnant?”

   • Identify contraceptive methods and family planning goals.

• Opportunity to discuss HPV vaccination, HIV PrEP/PEP, and STI prevention.

Teaching & Health promotion regarding male genatalia

Self-examination: more common in young people

• Establish a “baseline normal” and detect early testicular cancer.

• Recommended monthly for individuals age ≥14 years.​

​

1. Reduce the prostate cancer death rate.

2. Increase male participation in family planning and pregnancy prevention.

3. Increase condom use during last sexual intercourse.

Reduce infection rates of:

• Hepatitis (A, B, C)

• HIV

• Chlamydia trachomatis

• Gonorrhea

Family Planning: risk for pregnancy​

-r/x for gonorrhea​
-r/x for cyphils: primary, secondary, tertiary

• primary → discharge ,fevers, rash → goes away → secondary →​ rash spreads to palm & feet → goes away → tertiary → last for years; lives in aortic valve → aortic rupture & other organ failures

-Trichomoniasis: STI; parasites​

• Women get green discharge, pelvic pain → ANAs​

Viruses:​

• HPV: causes cervical (woman) cancer; different types/numbers; warts & other s/s

  • Males can get HPV in other places → oropharyngeal areas​

• Cancer, warts,​

​

Prostate Cancer Screening: up with BPH & cancer

Ages 55–69 years:

• Screening decision should be individualized after discussing risks and benefits.

• Potential small benefit: may lower risk of death from prostate cancer

Digital Rectal Exam: Palpate prostate via rectum​

- Checks for lumps, indurations, ffoggy?​

Common s/s regarding male genatalia issues:

• Pain​

• Difficulties with urination ← BPH​

  • Red urine (hematuria) → infection, malignancy, trauma, or diet (red foods).

  • Cloudy urine → infection.

• Erectile dysfunction (ED)​

  • Curvature of penis during erection (Peyronie disease).

• Penile lesions, discharge, rash​

  • Associated pain, itching, burning, discharge, or odor.

  • Bloody penile discharge → urethritis or malignancy.

• Pain with urine​

  • Uncommon for >1yr patients to have UTIs

• Scrotal enlargement​

  • varicocele, hydrocele, hernia, epididymitis, tumor, or torsion.

  • Pain + enlargement → assume testicular torsion until ruled out (emergency).

• Older adults​

• Cultural considerations

​

Males – Male sex: 1.6-2.3 times more likely → HIV​

• Higher risk for genital herpes & chiphylis: No use of protection​

​

Comprehensive Physical Assessment regarding Male Genatelia: 

• Utilize inspection and palpation as appropriate​

• Groin ​

• Penis ​

  • Hypospadias: urethral meatus on underside.

  • Epispadias: meatus on upper surface.

  • fixed w/surgery

• Scrotum​

• Sacrococcygeal areas​

• Perineal area​

  • Fournier gangrene: necrotic tissue or crepitus on palpation (diabetic risk).

    • Emergency requiring surgical evaluation.

• Inguinal region and femoral areas

  • ​Inguinal areas: Hernia common -> incarceration (compressed) -> ischemia bowel -> necrosis of bowel part

Additional techniques​:

• Testicles​

• Vas deferens​

• Transillumination of the scrotum

  • Hydrocele: fluid-filled mass around testis; firm, transilluminates well.

  • Spermatocele: cystic mass above the testicle, transilluminates well.

  • Torsion of appendix testis: visible “blue dot sign” on upper pole of testis.

  • Solid masses (tumor, hernia) do not transilluminate.​

• Hernias ​

  • Sudden impulse or bulge felt → inguinal or femoral hernia.

• Perianal and rectal examination​: prostate & hemorrhoids

  • Back pain

• Prostate​: usually in early stages due to it being slow

• Stool:

  • Look at exudate & lesions

Labs for Male Genitalia: 

Colorectal cancer screening:

• Begin at age 45–75 years.

• High-risk adults (76–85) → continue screening as indicated.

• Colon cancer: men > women

smear and culture of exudate or scrapings → lab

• Urethral discharge:

  • Perform Gram stain and culture for gonococci and chlamydia.

Urinalysis → UTI

HIV screenings:

• Annual HIV screening for sexually active males who have sex with males (MSM).

• High-risk or symptomatic patients:

  • Consider every 3–6 months screening.

  • Use of PrEp → prevents HIV

Female Genitalia:

Increased UTI r/x​

​

Skene (antieffective): may secrete clear fluid during climax

Bartholic Glands: secrete clear mucus into the vaginal introitus during sexual arousal and intercourse.

• Provide lubrication to facilitate comfort during penetration.

Internal Female Genitalia, Rectum, Anal Canal,Anus

Fallopian Tube: egg becomes fertilized ​

• Ectopic pregnancy: trapped here -> obstruction of flow -> ischemia -> rupture -> shock -> death​

• ​

Swab is used to check for abnormal cells NOT STI’​

Anterior pituitary gland​

• FSH (Follicle-Stimulating Hormone):

  • Stimulates growth and maturation of the ovarian follicle.

• LH (Luteinizing Hormone):

  • Luteinizes the follicle → forms the corpus luteum.

  • Stimulates progesterone production by granulosa cells.

Hypothalamus​

• GnRH (Gonadotropin-Releasing Hormone): triggers release of FSH & LH.

• LnRH (Luteinizing-Releasing Hormone): supports LH release.

• Produces Prolactin-Inhibiting Factor (PIF) → inhibits prolactin release.

• Acts as the central controller for:

  • Menstrual cycle regulation

Ovaries ​

• Estrogen:

  • Regulates secondary sex characteristics (breast, pubic hair, body shape).

  • Promotes growth of vagina, uterus, and fallopian tubes.

  • Stimulates endometrial proliferation (lining thickening).

• Progesterone​:

  • Secreted by the corpus luteum (post-ovulation).

  • Prepares and matures endometrial lining for implantation.

  • Maintains uterine lining if implantation occurs (supports early pregnancy).

  • If no implantation, progesterone levels drop, leading to menstruation.

Life Span Considerations regarding Females:

Pregnancy:

• Ectopic pregnancy:

  • Fertilized egg implants outside the uterus (commonly in fallopian tube or abdominal cavity).

  • OB emergency from low HcG — rupture → internal bleeding → life-threatening if untreated.

• Vaginal hemorrhage: benign/not

• Placenta previa: placenta covers cervical os.

• Gestational hypertension / Preeclampsia:

  • BP ≥ 140/90 mmHg, proteinuria, ± edema.

  • Can lead to organ damage (kidneys/liver).

  • Treatment required to prevent eclampsia (seizures, coma).

• Preterm labor:

  • Painful contractions before 37 weeks, especially >6 in 1 hour → immediate evaluation.

• Decreased fetal movement:

  • Always requires professional assessment for fetal well-being.

Infants, Children, and Adolescents

• Newborn Assessment:

  • Pink vaginal discharge in newborn females = normal → caused by maternal estrogen, resolves in 1–2 weeks.

  • Engorged external genitalia (due to maternal hormones) = normal.

  • Ambiguous genitalia: opp structure of another gender

    • Congenital anomaly → adrenal hyperplasia → excess androgens.

    • Clitoris appears penile, labia fused (scrotum-like).

Puberty:

• Sequence:

  1. Breast budding (thelarche).

  2. Pubic hair development.

  3. Menarche (onset of menses) ~2–3 years after breast budding.

• Triggered by estrogen release via hypothalamic–pituitary–ovarian (HPO) axis.

• Tanner Staging for Female Pubic Hair

Adolescent Examination:

• Encourage open communication about sexuality and relationships.

• Provide honest, nonjudgmental education.

• Annual STI screening for sexually active adolescents.

• Establish a trusting, confidential relationship.

Menopausal and Older Adults

• Definition:

  • 12 consecutive months without menses.

  • Average onset: 50–52 years (wide variation).

• Hormonal Changes:

  • Ovaries cease estrogen & progesterone production.

  • Decreased estrogen →

    • Smaller uterus and ovaries.

    • Reduced vaginal secretions → dryness.

    • Loss of elasticity and fat pad atrophy

    • Dyspareunia → pain w/intercourse

  • Health Risks:

    • Higher risk of endometrial, vaginal, and vulvar cancers.

    • Require education on warning signs/symptoms (e.g., postmenopausal bleeding).

Cultural variations regarding Female Genitalia:

Median U.S. age at menarche: 12.4 years

Puberty can begin before 8 ​

• African American: 5.5 months earlier than peers of other racial/ethnic groups.​

​Some with greater sexual fluency and candidnessabout sexuality​

• Sexual activity is personal choice, unrelated toculture and responsibility​

Female Circumcision (Female Genital Cutting)

• African, Middle Eastern, and Asian cultures despite global opposition.

Cervical cancer checked from swabbing​

-HPV ​

* Prevented with vaccination & protection​

Priority Urgent Assessment​ regarding Female Genitalia:

Severe pain​

• Acute infection (PID, UTI), appendicitis, pancreatitis, cholecystitis, strangulated hernia ,musculoskeletal trauma (ruptured bladder, spleen, liver), ectopic pregnancy, ovarian cyst​

Excessive vaginal bleeding​

• Change from normal menstrual cycle, occurring outside normal menses, during pregnancy, trauma​

Subjective Data collection regarding Female Genitalia:

Past history:​

• 5 Ps​

• Pregnancy prevention​

• STI h/x​

• Any pregnancy:

  • Gravida: # of pregnancies

  • Para: delivery past 20 weeks

  • term: # of pregnancies carried > 37 weeks

  • preterm: #​ of pregnancies 20-36 weeks

  • abortion: loss < 20 weeks

  • Living: # of alive children

• Check for term range​

• Any abortions​

• Menopause​

• Gynecological history ​

• Immunizations​

  • HPV → 11-12 yrs or 9 years

• Sexual history

• Lifestyle and personal habits​

• Sexual behavior ​

• Contraception ​

• Sexual transmitted infections​

• Obesity: ^ Diabetes r/x​

• Osteoporosis​: menopause

• Hormonal contraceptive and tobacco use: blood clot; DVT& pulmonary embolism​

• Medications ​

• Family history

Teaching and Health Promotion regarding Female Genitalia:

• Prevention of STIs​

  • Chlamydia -> PID -> potential infertility​

    • r/x in oropharyngeal area; pharyngitis

  • Trichomoniasis:

    • Purulent yellow-to-green frothy discharge → foul odor

    • cervical redness (strawberry looking)  contact bleeding

  • Gonorrhea: yellow vaginal secretions → dysuria & pain with intercourse

    • Purulent discharge from cervix

    • Tenderness in pelvic examination

    • Pharyngeal/anorectal infections

  • Bacterial Vaginosis (NOT ASSOCIATED W/STI!):​

    • Gray color​

    • Fishy odor

    • vaginal itching/burning

    • Flagel med?

• Menopause changes​

• Prevention of HPV and cancer​: >100 types

  • Genital warts, cervix cancer (vaccines only covers this)

• Genital self-examination​

• Elimination of female genital circumcision​

• Appropriate screenings ​

• Immunizations: HPV vaccine

Common symptoms regarding issues w/Female genitalia:

• Pelvic pain​

• Vaginal burning, discharge, itching​

• Menstrual disorders​

• Structural difficulties​

• Sexual dysfunction​

• Hemorrhoids

Equipment for vaginal exam:

• Sheet or drape​

• Nonsterile nonlatex examination gloves​

• Water-soluble vaginal lubricant​

• Lamp with goose neck or speculum light attachment​

• Wooden/plastic spatula​

• Cervical brush​

• Endocervical brush

• Speculum

• Swabs

Patient is in Lithotomy position

• External genitalia​

  • Inspection​

• Internal genitalia​

  • Palpate urethra, Skene glands, Bartholin glands​

  • Assess strength of vagina​

• Speculum examination​

  • Inspect cervix and os​

  • Pap smear and cultures

  • Inspect vaginal wall

• Bimanual examination: lower pelvis palpation; check for masses & ovaries​

• Rectovaginal examination​

Labs for Female Genitalia:

Wet mount analysis, KOH, DNA/RNA diagnostictests, blood tests (LH, FSH, GnRN)

Pap smears: based on case-case​

• When you start sexual intercourse

• stop > 65 years​

• H/x of hysterectomy: removal of ovaries/fallopian tube

Pregnancy Phases:

Average length of pregnancy: 266 days post-fertilization​

• from first day of menstruation (28 day-period)

• Approximation

• Nagele rule:1st day of LMP - 3 months + 7 days

• Pregnancy wheel

• US (1st trimester) is most accurate way to calculate

• Irregular cycle → adjust calculation

Preconception: 3 months before pregnancy

• Prenatal, ^ folic acid, exercise

• many dont know till 17-56 after conception

  • most vulnerable during this time

  • neural tube defects, major brain anomalies, heart defects, limb deficiencies, and various ear and eye defects

  • miscarriage happens

• left & right ovaries ovulate diff cycles → egg → fallopian tube 14 days before next menstrual period → corpus luteum → ^ progesterone

  • v progesterone → endometrial lining sheds → menstruation

First Trimester (0-13 weeks)

• zygote → fallopian tube → fundus → normal small bleed occurs

Second trimester: 13-26 weeks

• significant fetal growth; 3in (<30g) → 15in(>1kg)

• major organs developed

• Fetal survey via US

Third trimester: 26-40 weeks)

• Growth but not as fast as 2nd

• 1kg → 3 ½ kg (7 ½ kg)

• Fetal organs grow, ^ muscle size, strength, & protective fat layer

• last 4 weeks → mother IgE → aids with fetal immune system

  • <37 weeks: no IgE immunity boost

Diastasis recti: when fetus grows → abdominal organs spreads → normal tho

Weeks of Gestation:

• Term: 37 to 42 weeks​ (postterm)

• Early term: 37 weeks to 38 6/7 weeks​

• Full term: 39 weeks to 40 6/7 weeks​

• Late term: 41 weeks to 41 6/7 weeks​

• Postterm: 42 weeks and beyond

  • C section/induced

  • very hard to reach this phase

Nurse role with Pregnancy:

Develop trusting relationship w/patient

• bleed, BP issue, prompt mother to go to clinic

• If not → majority is outpatient

• Dating pregnancy; recording history; obtainingprenatal testing consents; facilitating referrals;orienting client to practice

• Triage: check for issues they have (possible UTI)

• Nonstress test (NST): 3rd trimester; electrodes → checks babies movements & kicks

• Education: Unexpected test results; t/x options, meds, vaccinations

  • Vaccination: Flu, influenza, T-dap -> pertussis -> negative towards baby (family is vaccinated)

Cultural variations regarding pregnant patients:

Vary throughout the world; U.S. has poorest survival rate due to education & diet

Late or no prenatal care common in teens (<20), African American, Hispanic, and less-educated clients. → infant mortality, still birth, premature delivery

Infant health disparities:

• Contributing factors: hypertension, diabetes, obesity.

• Gestational diabetes, HTN

Birthing Parent disparities:

• stress, bias, attitudes, stereotypes → v affects pregnant client

• Midwife contribution → assist in survival rate

Priority Urgent Assessment regarding Pregnancy:

• Ectopic pregnancy

  • Fertilized egg implants outside uterus (often in fallopian tube).

  • Emergency: rupture can cause fatal internal bleeding.

• Pyelonephritis

  • Untreated UTI → infection ascends to kidneys.

  • S/S: fever >38°C (100.4°F), severe flank pain.

  • Requires immediate IV antibiotics to prevent sepsis.

• Vaginal Hemorrhage: 

  • Definition: soaking a pad in <30 minutes or showing symptoms of blood loss (light-headedness, dizziness, cold, confusion, anxiety, diaphoresis).

  • Action: go to emergency department immediately.

  • Possible causes:

    • Placenta previa – placenta covers cervical os.

    • Abruptio placentae – premature placental separation.

    • DVT

• Abdominal emergencies: appendicitis, cholecystitis, pancreatitis, bowel obstruction (esp. 3rd trimester), ovarian tumors.

• Gestational Hypertension / Preeclampsia

  • BP ≥140/90 with proteinuria ± edema.

  • Organ damage (kidneys/liver) possible.

  • Treat promptly to prevent eclampsia (seizures, coma).; dip stick too

  • Delivery leads to rapid recovery.

Preterm Labor

• Regular painful contractions before 37 weeks (>6/hour).

• Requires immediate evaluation in facility with NICU access.

Decreased Fetal Movement

• May indicate fetal distress → requires prompt evaluation.

Kick Count Instructions (Box 25.1)

• Start at 26–28 weeks.

• Count daily at the same time (often after dinner).

• If <10 movements in 2 hours or sudden decrease → call provider immediately.

Subjective Data Collection regarding Pregnancy

Assess for psychiatric h/x → depression & anxiety → unable to take SSRI’s for baby’s health

• Eating disorders → screen for it to prevent it when pregnant

• Dysmorphic syndrome: see themselves fat even though they not (anorexia nervosa)

Check for folic acid → v neural tube defects

Family h/x: DM, HTN, genetic illness → screen for

Advanced maternal age → Genetic anomalies (>35); miscarriage

• freeze eggs to prevent this

Teaching + Health promotion regarding Pregnancy:

• Prevent gestational diabetes (preconception phase → 1st → 24-48 weeks).

• Promote good nutrition and oral health.

  • v caffeine → intrauterine growth retardation → v birth weight & baby growth

• Encourage healthy lifestyle habits (EXERCISE), mental health, and safety.

  • Progesterone → v peristalsis → ^ r/x for constipation → hemorrhoids → ^ fluid & exercise

• Prenatal and breastfeeding education: best for 1st kid

• Stress importance of prenatal visits and monitoring.

  • v stress, anxiety, & depression

• Gaining weight:

  • 10lbs -> first trimester​

  • 1lbs -> secondary & third trimester

Common s/s regarding Pregnancy:

• Fatigue​

• Morning sickness​: Idiopathic

  • hormonal, diet, stress; goes away after 1st trimester

  • some have it/some dont

  • if not → Hyperemesis gravidarum: vomiting >5% body weight loss, dehydration, electrolyte imbalance → may require IV fluids/hospitalization → fatal

    • Can continue throught pregnancy​

• Round ligament pain​: 1st trimester; stretching of abdomen → random/sharp pain → indication of growing fetus

• Increased vaginal discharge; increased urination​ (due to ^ progesterone → ^ relaxation)

  • clear = normal from ^ estrogen

  • foul-smelling: infection, STI

  • 3rd trimester → mechanical bladder compression

• Breast tenderness, discharge​: colostrum leaking (3rd) preparing for birth

  • notify provider to check

• Periumbilical pain​

• Fetal hiccups and other spasms​ (3rd trimester): when fetus n.s. matures

• Braxton Hicks contractions: mimic real contractions

  • <5/hr; <30 seconds; slight pain

  • prepare body for labor

Equipment regarding Pregnancy:

• Stethoscope; BP cuff; thermometer​

• Reflex hammer​: test for hype reflexive DTR in preeclampsia pt’s to check for eclampsia

  • +4

• Fetal Doppler sonometer​: look for fetal HR

• Metric measuring tape​: measures height of fundus

• Urine collection cup and dipsticks​

• Speculum, light, swabs for pelvic exam​

• Gown and drape for privacy

Comprehensive physical assessment regarding pregnancy:

General survey & vitals (lungs, heart, baby heart, fundus heigh)

• Poor grooming or flat affect → may indicate depression, abuse, or lack of resources → consider social services referral.

• Inadequate weight gain/loss

• Anemia & IDA → more anemic during pregnancy → supplement them

  • Pica

• Hyperpigmentation: causes distress

  • Melasma: darker skin pigmentation from hormones → goes away after birth

• Epistaxis: vasodilation in nose b.v.

• check for hyper/hypothyroidism as it can v affect fetus

• 2nd trimester → dyspnea during exertion from baby pushing

  • hard going up the stairs

• Systolic murmurs from mother (beginning of the 28 weeks; normal)

• Peripheral vascular system: v CO when supine → edema in lower extremities → carpal tunnel syndrome → pain & numb thickness

• SMC relaxation → GI & GU stasis → constipation + UTI

• Gastric reflux ← fetus compresses & relaxed sphincter

• Bad gallbladder bad contractions → bile salts collection → stones

  • Don’t do anything

  • If infection → take care

• Backaches (2nd & 3rd trimester)

• Varicosities: labia; common

Leopold Maneuvers: palpate abdomen to check fetus position

• Midwife related

Lab tests regarding pregnancy:

• Blood type and antibody screen:  check for hemolytic anemia

  • RhoGam injection avoids attacking Rh factors

  • Transfusion may be needed

• Complete blood count (CBC)

• Hepatitis B surface antigen

• HIV screening

• Rubella titer

• Triple or quad screen (maternal serum screening for fetal anomalies) → genetic testing during 1st trimester

• Nuchal translucency (ultrasound for chromosomal abnormalities) → check for back cervical spine thickness & neural tube defects

• 50-g glucose challenge test (screen for gestational diabetes): drink to check sugar lvs after 1-2 hrs

• Group B streptococcus (GBS) screening: 3rd trimester

  • look for bacteria in rectal area → vagina → baby issues

  • swab vagina & anus → lab → if + → IV ANA (penicillin) during delivery → prevent issues

Total weight gain would be 20-35 lbs throughout pregnancy

Hospital Assessment Types:

Different types, scope, timeframes

• Comprehensive/admission: head→ toe

• Shift/ongoing

• Focused

• Urgent/Immediate

Establish baseline (ox stat, vitals) 

Use clinical judgment

• Assessment begins at admission, continues until client istransitioned to next phase of care.​

• Cannot delegate main functions of assessment, planning,evaluation, nursing judgment​

  • critical thinking & professional judgment req

  • 5 Delegation rights

    • Right task

    • Right circumstance

    • Right Person

    • Right direction

    • Right evaluation (follow-up)

• RN assesses basic care activities before delegating​

  • ADLs, assistive devices; nutrition and oral hydration; elimination; personal hygiene; mobility/immobility; rest and sleep; nonpharmacological comfort interventions​

• RN responsible for delegation​

• Right task, under right circumstances, to right person, with right direction and communication, under rights supervision and evaluation​ (5 RIGHTS)

Saferty risks in hospital setting:

Adverse effect: Hospital crew/RN fault

• Inaccurate assessment

  • Delayed recognizing abnormalities

• Communicating abnormal/wrong results → provider

Failure to rescue: pt dies cuz RN not fast

Cardiac Arrest, Acute MI, stroke

Safety interventions for hospitalized patients

• Improve accuracy of client identification​

• Improve effectiveness of communication​

  • major issue in adverse events

• Improve safety using medications​

• Reduce harm associated with clinical alarm systems​

• Reduce risk of healthcare-associated infections​

  • foley caths, C-line

• Identify clients at risk for suicide​

• Prevent mistakes in surgery​

  • time-out: checked verification at the beginning, middle, and end of procedure

Know scope of practice