3130 or 3160 ex4

Gastrointestinal and Abdominal Assessment

  • Abdominal Inspection & Contour:

    • A rounded contour of the abdomen is characterized as an inward concavity of the anterior abdominal wall.

  • Abdominal Auscultation:

    • Normal bowel sounds occur at a frequency of 5–30 times/min5\text{--}30\text{ times/min}. Findings within this range should be documented as NORMAL.
    • During an abdominal assessment, bowel sounds must be auscultated in all 44 quadrants.

  • Splenic Palpation Sequence:

    • When tenderness is identified in the spleen, palpate in the specific sequence: 3,1,2,43, 1, 2, 4.

  • Colorectal Health & Cancer:

    • Dietary promotion: Foods that promote good colon health include multigrain foods and cereal with wheat germ.
    • Educational needs: A client statement requiring additional teaching includes: "My brother had colon cancer but since it’s not inherited, I don’t need to worry."

  • Gastrointestinal Alterations & Pain:

    • Pain experienced in the bottom during a bowel movement (BM) indicates the presence of fissures.
    • Age-related GI changes: A client statement demonstrating the need for additional teaching regarding age-related gastrointestinal changes is: "I will metabolize my medications fast."

Renal, Genitourinary, and Reproductive System Assessment

  • Urinary & Renal Assessment:

    • UTI Follow-up: For a client treated with medication for a urinary tract infection (UTI) 2 weeks2\,\text{weeks} ago, the nurse should ask: "Noticed any discharge or itching?"
    • Costovertebral Angle (CVA): Pain elicited along the costovertebral angles indicates kidney inflammation.
    • Oliguria: Defined as almost no urination output.
    • Urine Color Variations: If urine appears orange in color, the nurse should ask: "Have you eaten beets or berries in the last day or 2?"

  • Female Reproductive & Gynecological Care:

    • Lithotomy Positioning: When placing a female client in the lithotomy position, ensure the stirrups for the legs are not overly abducted.
    • Postmenopausal Considerations:
      • A postmenopausal woman is at an increased risk of dyspareunia because of decreased vaginal secretions.
      • A statement regarding post-menopausal symptoms that requires additional teaching is: "I may have intermittent menstrual cycles."

  • Male Genitourinary Assessment & Sexual Health:

    • Examination of Glans Penis: Smegma may be normally present under the foreskin of an uncircumcised male.
    • Phimosis: Documented when the foreskin will not retract due to a narrowed opening of the prepuce.
    • Age-Related Sexual Function: An age-related change associated with sexual intercourse is that the return to a flaccid state after ejaculation will be quicker.

Musculoskeletal System and Motor Function Assessment

  • Musculoskeletal Assessment Principles:

    • Assessment Sequence: The correct technique when performing a musculoskeletal assessment is assessing proximal to distal.
    • Contraindicated Assessment Technique: Assessing all pulses on one side of the body and then moving to the other side requires clinical intervention.
    • Skeletal Muscle Actions: Extension is defined as straightening the arm at a joint.
    • Assistive Devices: Document the client’s use of assistive devices under the General Appearance section.

  • Joint Function, Terminology, & Pathophysiology:

    • Crepitation: An audible and palpable grating sound produced when moving a joint (such as the knee).
    • Ankylosis: Defined as stiffness in joints accompanied by fixation of the hip or joint.
    • Temporomandibular Joint (TMJ): If clicking is noted when chewing, perform a focused assessment of the TMJ.

  • Range of Motion (ROM) & Motor Testing:

    • Cervical Spine ROM: Assess range of motion by asking the client to touch each shoulder with their ear.
    • Hip ROM: Assess range of motion by asking the client to bend their knees up to the chest.
    • Hip Motor Dysfunction: Assess for motor dysfunction in the hip by abducting the hip while the client is lying supine.
    • Lower Extremity Assessment: Palpate lower legs and feet for temperature, pulses, and tenderness; palpate hips for stability.

  • Bone Density & Lifestyle Health Factors:

    • Bone Mineral Density (BMD): An elevated BMD correlates with a lower risk of acquiring a fracture.
    • Fracture Risk Factors: A client who smokes is at an increased risk for bone fractures.
    • Delaying Bone Loss: The best way to delay bone loss is engaging in regular physical activity, such as fast walking.

Neurological System, Cranial Nerves, and Cerebellar Assessment

  • Cranial Nerve Testing:

    • Cranial Nerve V (Trigeminal): Assessing the skin of the face using a piece of cotton evaluates CN 55 sensory function.
    • Cranial Nerves IX (Glossopharyngeal) & X (Vagus): Tested when asking the patient to say "Ahhh" and observing a positive gag reflex.
    • Uvula Assessment: Instructing the patient to say "Ahhhh" facilitates direct inspection of the uvula.

  • Cerebellar & Sensory Function:

    • Cerebellar Function Assessment: Evaluated by having the client run each heel down the opposite shin.
    • Romberg Test Safety: When performing the Romberg test, stand close to the client to prevent falls.
    • Reflex Testing Intervention: Assessing the ankle incorrectly during deep tendon reflex testing requires clinical intervention.

Cardiovascular, Respiratory, and Physical Examination Fundamentals

  • Cardiovascular System Findings:

    • Thrill: Defined as a fine, palpable vibration felt over the precordium.
    • Expected Cardiovascular Findings: Assessment should reveal S1S_1 and S2S_2 heart sounds present, blood pressure at 124/86 mmHg124/86\,\text{mmHg}, and skin that is warm with turgor present.

  • Respiratory & Chest Assessment:

    • Posterior Chest Assessment: When assessing the posterior chest, also assess for costovertebral angle (CVA) tenderness.
    • Emphysema Skin Assessment: When assessing the skin of a client with emphysema, palpate using the dorsa of the hand.

Sensory, HEENT, Breast, and Physical Assessment Techniques

  • HEENT & Visual Assessments:

    • Confrontation Test: Performed to assess visual fields.
    • Corneal Light Reflex: Checked to evaluate the alignment and function of the extraocular muscles.
    • Adult Otoscopic Examination: When inspecting the ear of an adult, pull the pinna up and back.
    • Mouth & Oral Examination: Gloves should always be worn when palpating the mouth and tongue.

  • Breast Examination:

    • Positioning: Place the client in a supine position with the head flat when performing a breast exam.
    • Palpation Sequence: After palpating the areola and all 44 quadrants of each breast, palpate the tail of Spence next.

  • Specialized Diagnostic Tests & Positioning Sequence:

    • Phalen Test: Instruct the client to hold their hands back-to-back while flexing the wrists at 90∘90^\circ
    • Head-to-Toe Examination Sequence: When performing a head-to-toe assessment, the client should sit upright while the head and neck are examined.