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Musculoskeletal System

  • Composed of two systems: the muscular system and the skeletal system

  • Commonly referred to as 'musculoskeletal' because of their main common functions of movement and support

  • Made up of hard and soft tissues

  • Hard tissue includes bones and cartilages

  • Soft tissues include muscles, tendons, synovial membranes, joint capsule, and ligaments

Functions of the Musculoskeletal System

  • Protection of vital structures

  • Provision of body forms

  • Stability

  • Storage of salts (e.g., calcium)

  • Formation and supply of new blood cells

Muscles

  • Largest soft tissues of the musculoskeletal system

  • Muscle cells produce contractions that move body parts, including internal organs

  • Associated connective tissue binds muscle fibers into fascicles or bundles

  • Functions of muscles: production of movement, support of the body, stability of joints, production of body heat, provision of form to the body

Types of Muscles

  1. Skeletal muscle: moves bones and other structures (e.g., the eyes)

  2. Cardiac muscle: forms most of the walls of the heart and adjacent great vessels

  3. Smooth (Visceral) muscle: forms part of the walls of most vessels and hollow organs, controls movement through blood vessels

Tendons and Ligaments

  • Tendons: tough, flexible bands of fibrous connective tissue that connect muscles to bones

  • Tendons transmit the force from muscle contractions to the bones, causing movement

  • Tendons and ligaments are made of dense fibrous connective tissue (DFCT) with an abundance of collagen fiber bundles arranged in parallel

  • Tendons are generally rounded cords and thick, while ligaments are flatter in shape and attach bone to bone

Joint Capsule and Synovial Membrane

  • Synovial membranes line the synovial cavity and secrete synovial fluid that lubricates most joints to reduce friction

  • Synovial fluid also serves as a source of nutrients for tendons, ligaments, and articular cartilages

  • Joint capsules are composed of dense fibrous connective tissue and surround synovial joints

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Skeletal System

  • Composed of bones and cartilages, making up the hard tissue of the musculoskeletal system

  • Functions of the skeletal system: support of the body, shock absorption, storage for salts, production of blood cells, protection of vital organs, mechanical basis for movements

  • Consists of two main parts: the axial skeleton (bones of the head, neck, and trunk) and the appendicular skeleton (bones of the limbs and pectoral/pelvic girdles)

Bones

  • Made up of compact bone (superficial layer) and spongy bone (deeper layer), except where replaced by a medullary cavity

  • Blood cells are formed within the medullary cavity and between the spicules of spongy bones

  • Typical bone has a head, neck, body/shaft, and various markings for passage and attachments to soft tissues

  • Classification of bones: long bones (e.g., humerus), short bones (e.g., tarsals), flat bones (e.g., skull bones), irregular bones (e.g., hip bone)

Cartilages

  • Cartilages line the articulating surfaces of bones, found deep within a joint

  • Great for weight bearing and reduce friction inside a joint

  • Synovial joints possess hyaline cartilage

Joints

  • Formed where two or more bones meet

  • Promote movements of body parts, but movement is not necessary for all joints

  • Factors guaranteeing the integrity or stability of a joint include bony congruence and other structures crossing the joint

  • Joints can be classified broadly by the connective tissues found between the bone ends: fibrous joints (little to no movement, e.g., sutures of the skull), cartilaginous joints (allow movement, held together by cartilage)

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  • Joints in the body

    • Synovial joints

      • Allow more movement than fibrous or cartilaginous joints

      • Held together by a joint capsule made of connective tissue

  • Skeletal muscle movement

    • Flexion: bending limb at joint

    • Extension: straightening limb at joint

    • Abduction: moving limb away from midline of the body

    • Adduction: moving limb toward the midline of the body

    • External rotation: hands behind head with elbows out

    • Internal rotation: hands placed on scapula coming from waist to back

    • Rotation: moving head around central axis, hips too

    • Pronation: turning forearm so that palm is down

    • Supination: turning forearm so that palm is up

    • Inversion: moving sole of foot inward at ankle

    • Eversion: moving sole of foot outward at ankle

  • Inspection and palpation

    • Gait

      • Observe client's gait for base of support, weight-bearing stability, foot position, stride and length, cadence of stride, arm swing, and posture

    • Temporomandibular Joint (TMJ)

      • Test movement of the jaw

    • Sternoclavicular Joint

      • Inspect for location, color, swelling, and masses

      • Palpate for tenderness or pain

    • Cervical, Thoracic, and Lumbar Spine

      • Observe for symmetry in height of shoulders, iliac crests, and buttock creases

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  • Test Range of Motion of the Cervical Spine

    • Flexion and hyperextension

  • Test lateral bending

  • Evaluate rotation

  • Test ROM of the thoracic and lumbar spine

  • Test for lateral bending capacity of the thoracic and lumbar spines

  • Test for back and leg pain

  • Measure the leg length

  • Inspection and palpation of shoulders and arms

  • Test Range of Motion of shoulders and arms

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  • Inspection of elbows

  • Palpation of elbows

  • Test Range of Motion of elbows

  • Inspection and palpation of wrists and hands

  • ROM of fingers

  • Muscle resistance/strength of wrists and hands

  • Assess for carpal tunnel syndrome

    • Perform Phalen's test

    • Perform test for Tinel's sign

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Health Assessment | Ayen Malacad Test for Thumb Weakness

  • Ask the client to raise thumb up from the plane of the palm.

  • Ask the client to stretch on the pad of the little finger pad.

  • Normal: client can raise thumb up from the plane and stretch the thumb finger pad to the little finger pad.

  • Abnormal: Client cannot raise the thumb up from the plane and stretch the thumb pad to the little finger pad.

Hips

  • Inspect for the symmetry and shape of the hips.

  • Palpate stable and symmetric, with no tenderness or crepitus.

  • ROM with palpation:

    • Flexion for 90 and 120-125 degrees; internal rotation, external rotation, abduction, adduction.

    • Limitation of abduction of hip while supine is most common motion dysfunction found in hip disease.

  • Normal: Equal in size, iliac crest is symmetric in height. Hips are stable, no-tender, without crepitus.

  • Abnormal: Inability to stand or deform hip area indicative of fractured hip. Presence of tenderness, edema, decreased ROM, and crepitus.

Knees

  • With the client o supine then sitting with knees dangling, inspect for size, shape, symmetry, swelling, deformities, and alignment. Observe for quadriceps, muscle atrophy.

  • Normal: Knees are symmetric, hollows and present on both sides, no swelling, no deformities. Lower leg is aligned with the upper leg.

  • Abnormal: Presence of swelling indicate synovial joint inflammation.

  • Palpate for tenderness, warmth, consistency, and nodules.

  • Normal: Nontender and cool. Muscles firm, no nodule.

  • Abnormal: Tenderness and warmth with a boggy consistency is a symptom of synovitis.

Test for Swelling

  • Perform bulge test to determine if there is swelling.

  • Assist the client in supine position, use the ball of your hand firmly to stroke the medial side of the knee upward, three to four times to displace any accumulated fluid.

  • Normal: No bulge of fluid appears on medial side of the knees.

  • Abnormal: There is bulge of fluids on the medial side of knee.

Perform Ballotte Test

  • This test helps to detect large amounts of fluids in the knees.

  • Position client in supine then firmly press your nondominant thumb and index finger on each side of the patella.

  • Then with dominant fingers, push the patella down on the femur.

  • Feel for a fluid wave or a click.

  • Normal: No movement of the patella is noted. Patella rest firmly over the femur.

  • Abnormal: Fluid wave or click palpated with large amounts of joint effusion. A positive ballottement test is present.

Ankles and Feet

  • With the client sitting, standing, and walking, inspect position, alignment, shape, and skin.

  • Normal: Toe is point forward and lie flat. Toes and knees are aligned with the lower leg. Skin is smooth and free of corns and calluses. Most of the weight-bearing is on the foot midline.

  • Abnormal: Lateral deviation of the great toe. Painful thickening of the skin over bony prominences and at pressure points. Presence of corns, calluses.

Palpate Ankles and Feet for Tenderness, Health, Swelling, or Nodules

  • Palpate the toes from the distal end, proximally, noting tenderness, swelling, bony prominences, nodules, or crepitus of each interphalangeal joint.

  • Normal: No swelling, pain, heat, or nodules are noted.

  • Abnormal: Sprains, tenderness, pain reddened hot and swelling of the great toe. Presence of nodules in the ankle.

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Health Assessment | Ayen Malacad Health Promotion Diagnoses

Risk Diagnoses

  • Risk for Trauma related to repetitive movements of wrists or elbows with recreation or occupation.

  • Risk for Injury: Pathologic fractures related to osteoporosis.

  • Risk for Injury to joints, muscles, or bones related to environmental hazards.

  • Risk for Disuse Syndrome

  • Risk for Urinary Tract Infection related to urine stasis secondary to immobility.

Actual Diagnoses

  • Impaired Physical Mobility related to impaired joint movement, decreased muscle strength, or fractured bone.

  • Activity Intolerance related to muscle weakness or joint pain.

  • Constipation related to decreased gastric motility and muscle tone secondary to immobility.

  • Ineffective Sexuality Pattern related to lower back pain.

  • Acute (or Chronic) Pain related to joint, muscle, or bone problems.

  • Impaired Skin Integrity related to prolonged pressure on the skin secondary to immobility.

  • Impaired Social Interaction related to depression or immobility.

  • Disturbed Body Image related to skeletal deformities.

Abnormal Spinal Curvature

  • Flattening of the lumbar curvature may be seen with a herniated lumbar disc or ankylosing spondylitis.

  • A rounded thoracic convexity (kyphosis) is commonly seen in older adults.

  • An exaggerated lumbar curve (lumbar lordosis) is often seen in pregnancy or obesity.

  • A lateral curvature of the spine with an increase in convexity on the side that is curved is seen in scoliosis.

Abnormalities Affecting the Wrist, Hands, and Fingers

Acute Rheumatoid Arthritis

  • Tender, painful, swollen, stiff joints are seen in acute rheumatoid arthritis.

Chronic Rheumatoid Arthritis

  • Chronic swelling and thickening of the metacarpophalangeal and proximal interphalangeal joints, limited range of motion, and finger deviation toward the ulnar side are seen in chronic rheumatoid arthritis.

  • Flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint (boutonniere deformity) and hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint (swan-neck deformity) are also common in chronic rheumatoid arthritis.

Osteoarthritis

  • Nodules on the dorsolateral aspects of the distal interphalangeal joints (Heberden’s nodes) are due to the bony overgrowth of osteoarthritis. Usually hard and painless, they may affect middle-aged or older adults and often, although not always, are associated with arthritic changes in other joints. Flexion and deviation deformities may develop.

Abnormalities of the Feet and Toes

Acute Gouty Arthritis

  • In gouty arthritis, the metatarsophalangeal joint of the great toe is tender, painful, reddened, hot, and swollen.

Corn

  • Painful thickenings of the skin that occur over bony prominences and at pressure points. The circular, central, translucent core resembles a kernel of corn.

Callus

  • Nonpainful, thickened skin that occur at pressure points.

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Health Assessment | Ayen Malacad

  • Plantar Wart:

    • Painful warts (verruca vulgaris) that often occur under a callus, appearing as tiny dark spots.

  • Hammer Toe:

    • Hyperextension at the metatarsophalangeal joint with flexion at the proximal interphalangeal joint (hammer toe) commonly occurs with the second toe.

  • Neurologic System:

    • CNS: The Brain & Spinal Cord:

      • Peripheral: all the nerve fibers OUTSIDE the brain and the spinal cord.

      • 12 pairs of cranial nerves.

      • 31 pairs of spinal nerves and all their branches.

      • This system carries:

        • Sensory (afferent) messages TO the CNS from sensory receptors.

        • Motor (efferent) messages FROM the CNS out to the muscles and glands.

        • Autonomic messages that govern the internal organs and blood vessels.

    • The Brain:

      • Three major units: Cerebrum, Cerebellum, Brainstem (Medulla, Pons, Midbrain).

      • Frontal: motor cortex.

      • Parietal: sensory.

      • Temporal: perception. Interpretation of sounds, taste, smell, and balance.

      • Wernicke's Area in Temporal Lobe:

        • Associated with language comprehension.

        • When damaged in the person's dominant hemisphere, receptive aphasia results; person hears sound, but it has no meaning, like hearing a foreign language.

      • Broca's Area in Frontal Lobe:

        • Mediates motor speech.

        • When injured in the dominant hemisphere, expressive aphasia results; person cannot talk; person can understand language and knows what they want to say, but can produce only garbled sound.

    • Central Nervous System:

      • Basal Ganglia:

        • Large bands of gray matter in two cerebral hemispheres that form subcortical associated motor system (extrapyramidal system).

        • Initiate and coordinate movement and control automatic associated movements of the body.

      • Thalamus:

        • Main relay station where sensory pathways of the spinal cord, cerebellum, and brain stem form synapses.

        • Crucial to human emotion and creativity.

      • Hypothalamus:

        • Major respiratory center with many basic functions, such as appetite, sex drive, temperature, heart rate, blood pressure, sleep, anterior and posterior pituitary gland regulation, and coordination of autonomic nervous system, stress response, and emotional status.

      • Cerebellum:

        • Coiled structure located under the occipital lobe concerned with coordination of voluntary movements, equilibrium, and muscle tone.

        • Does not initiate, but coordinates and smooths movements.

        • Coordinates many different muscles needed in playing piano, swimming, or juggling.

        • Adjusts and corrects voluntary movements but operates entirely below conscious level.

      • Brain Stem:

        • Central core of the brain consists of nerve fibers.

        • Cranial nerve (CN) III through XII originate from nuclei in the brain stem.

        • Midbrain: most anterior part of the brain stem with a tubular structure of the spinal cord; merges into the thalamus and hypothalamus; contains many motor neurons and tracts.

        • Pons: enlarged area containing ascending sensory and descending motor tracts.

        • Medulla: continuation of the spinal cord in the brain; contains all fiber tracts connecting the brain and spinal cord.

      • Spinal Cord:

        • Long cylindrical structure of nervous tissue that occupies the upper two-thirds of the vertebral canal from the medulla to lumbar vertebrae L1 to L2.

        • Main highway for ascending and descending fiber tracts that connect the brain to spinal nerves, and it mediates reflexes.

        • Nerve cell bodies, or gray matter, arranged in a butterfly shape with anterior and posterior "horns".

      • Reflexes:

        • Basic defense mechanisms of the nervous system.

        • Involuntary; below the level of conscious control permitting quick reaction to potentially painful or damaging situations.

        • Four types of reflexes:

          • Deep tendon reflexes (myotatic), e.g., knee jerk.

          • Superficial, e.g., corneal reflex, abdominal reflex.

          • Visceral, e.g., pupillary response to light.

          • Pathologic (abnormal), e.g., Babinski's reflex or extensor plantar reflex.

      • Spinal Nerves:

        • 31 pairs of spinal nerves arise from the length of the spinal cord and supply the rest of the body.

        • Named for the region of the spine from which they exit: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal.

        • "Mixed" nerves, they contain both sensory and motor fibers.

        • Each innervates a segment of the body.

        • Dermal segmentation is the cutaneous distribution of various spinal nerves.

      • Autonomic Nervous System:

        • Peripheral nervous system composed of cranial nerves and spinal nerves.

        • Carry fibers divided functionally into two parts:

          • Somatic fibers innervate skeletal (voluntary) muscles.

          • Autonomic fibers innervate smooth (involuntary) muscles, cardiac muscle, and glands.

        • Autonomic system mediates unconscious activity.

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Health Assessment | Ayen Malacad

  • Cranial Nerve I:

    • Olfactory nerve (not tested routinely).

    • Test sense of smell in those who report loss of smell, head trauma, and abnormal mental status, and when the presence of an intracranial lesion is suspected.

    • With the person's eyes closed, occlude one nostril and present a familiar aromatic substance, e.g., coffee, orange, vanilla, soap, or peppermint.

    • Normally, a person can identify an odor on each side of the nose; normally decreased with aging; any asymmetry in the sense of smell is important.

  • Cranial Nerve II: Optic Nerve:

    • Test visual acuity and visual fields by confrontation.

    • Ask the client to read a magazine or newspaper paragraph to assess or Snellen chart.

    • Normal: 20/20 vision OD (right eye) and OS (left eye).

  • Cranial Nerves III (Oculomotor), IV (Trochlear), and VI (Abducens):

    • Check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation PERRLA.

    • Abnormal:

      • Dilated pupil (6-7 mm): oculomotor nerve paralysis.

      • Argyll Robertson Pupil: CNS syphilis, meningitis, brain tumor, and alcoholism.

      • Unilaterally dilated pupil unresponsive to light or accommodation: Damage to cranial nerve III (oculomotor).

      • Constricted pupil unresponsive to light or accommodation: lesions of the sympathetic nervous system.

      • Bilateral muscle weakness is seen with peripheral or central nervous system dysfunction.

      • Unilateral muscle weakness may indicate a lesion of cranial nerve V (trigeminal).

    • Assess extraocular movements by cardinal positions of gaze.

    • Normally, the eye moves in a smooth, coordinated motion in all directions.

    • Abnormal:

      • Nystagmus is back-and-forth oscillation of eyes.

      • Limited eye movement.

      • Paralytic strabismus: paralysis of the oculomotor, trochlear, or abducens nerves.

  • Cranial Nerve V: Trigeminal Nerve:

    • Motor function: assess muscles of mastication by palpating temporal and masseter muscles as a person clenches teeth.

    • Muscles should feel equally strong on both sides; try to separate jaws by pushing down on the chin; normally you cannot.

    • Sensory function: with the person's eyes closed, test light touch sensation by touching a cotton wisp to designated areas on the person's face: forehead, cheeks, and chin.

    • Tests all three divisions of CN V: ophthalmic, maxillary, and mandibular.

Page 11: Health Assessment - Cranial Nerves VII, VIII, IX, X, XI

Cranial Nerve VII: Facial Nerve

  • Motor function:

    • Note mobility and facial symmetry

    • Test various facial movements (smile, frown, close eyes tightly, lift eyebrows, show teeth, puff out cheeks, purse lips)

    • Normal: symmetric movements

    • Abnormal: inability to close eyes, wrinkle forehead, and paralysis of the lower part of the face (Bell's Palsy)

  • Sensory function:

    • Not routinely tested

    • If indicated, touch anterior two-thirds of the tongue with a moistened applicator dipped in salt, sugar, or lemon juice

    • Normal: client can identify the flavor

    • Abnormal: inability to identify correct flavor (impairment of cranial nerve VII)

Cranial Nerve VIII: Acoustic/Vestibulocochlear Nerves

  • Test hearing acuity:

    • Ability to hear normal conversation

    • Whispered voice test

    • Normal: client can hear whispered words from 1-2 feet

  • Weber and Rinne's Test:

    • Assess cochlear (auditory) component of cranial nerve VIII

    • Weber Test: vibration is heard equally well in both ears

    • Rinne Test: air conduction is twice as long as bone conduction

  • Abnormal: vibratory sound lateralizes to good ear in sensorineural loss, air conduction not twice as long in sensorineural loss

Cranial Nerve IX (Glossopharyngeal) and X (Vagus) Nerves

  • Test Motor function:

    • Depress tongue with tongue blade and note pharyngeal movement as person says "ahhh" or yawns

    • Normal: uvula and soft palate rise bilaterally and symmetrically on phonation

    • Abnormal: soft palate does not rise with bilateral lesions of cranial nerve X (vagus)

  • Test gag reflex:

    • Touch posterior pharyngeal wall with tongue blade and note gag reflex

    • Normal: gag reflex is intact

    • Abnormal: absent gag reflex

  • Check client's ability to swallow and voice quality:

    • Give the client a drink of water

    • Normal: client swallows without difficulty, no hoarseness noted

    • Abnormal: dysphagia or hoarseness of the voice

Cranial Nerve XI: Spinal Accessory Nerve

  • Examine sternomastoid and trapezius muscles for equal size

  • Check equal strength by asking person to rotate head against resistance applied to side of chin

  • Normal: strong contraction of sternocleidomastoid muscles on the side opposite the turned face, symmetric and strong contraction of trapezius muscles

  • Abnormal: atrophy with fasciculations, deviation to the affected side, asymmetric muscle contraction or drooping of the shoulder

Cranial Nerve XII: Hypoglossal Nerve

  • Assess strength and mobility of the tongue

  • Inspect tongue for wasting or tremors

  • Note forward thrust in midline as person protrudes tongue

  • Ask person to say "light, tight, dynamite" and note clear and distinct lingual speech

  • Normal: symmetric and smooth tongue movement, bilateral strength

  • Abnormal: fasciculation and atrophy, deviation to the affected side

Page 12: Cerebellar Functions, Balance Tests, Spinothalamic Tract, Deep Tendon Reflexes

Cerebellar Functions

  • Balance Tests:

    • Gait observation: person walks 10 to 20 feet, turns, and returns to starting point

    • Walking straight line in heel-to-toe fashion

    • Walking on toes and heels

  • Romberg Test:

    • Person stands up with feet together and arms at sides, then closes eyes and holds position for about 20 seconds

    • Normal: person can maintain posture and balance even with visual orienting information blocked

  • Rapid Alternating Movements (RAM):

    • Finger to thumb: touching thumb to each finger on the same hand, starting with the index finger

    • Finger-to-finger test: using index finger to touch examiner's finger and then their own nose

    • Heel-to-shin test: placing heel on opposite knee and running it down shin to ankle

    • Normal: smooth and accurate movements

Spinothalamic Tract

  • Superficial Pain:

    • Testing person's ability to perceive pinprick

    • Touching body in random order and places with a broken tongue blade

  • Stereognosis:

    • Testing person's ability to recognize objects by feeling their forms, sizes, and weights

    • Different objects for each hand

Vibratory Sensation

  • Testing person's ability to feel vibration

  • Striking a low tuning fork on the heel of the hand and holding the base on the distal radius

  • Asking the client if they feel the vibration on each side

Deep Tendon Reflexes (DTR)

  • Measurement of stretch reflexes:

    • Limb should be relaxed and muscle partially stretched

    • Stimulating reflex by directing a short, snappy blow of reflex hammer onto muscle's insertion tendon

  • Comparing right and left sides for equal responses

  • Reflex response graded on a 4-point scale

  • Subjective scale requires clinical practice, not completely reliable

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Health Assessment | Ayen Malacad

Test Biceps Reflex C5 to C6

  • Support the person's forearm on yours

  • Place your thumb on biceps tendon and strike a blow on your thumb

  • Normal response is contraction of biceps muscle and flexion of forearm

Test Triceps Reflex C7 to C8

  • Tell person to let arm "just go dead" as you strike triceps tendon directly above the elbow

  • Normal response is extension of forearm

Assess Patellar Reflex

  • Ask the client to let both legs hang freely off the side of the examination table

  • Using the flat side of the reflex hammer, tap the patellar tendon below the patella

  • Repeat on the other side

  • Normally, response is plantar flexion of the foot (ranges from 1+ to 3+)

  • Abnormal: Exaggerated response

Test Achilles Reflex

  • With the client's legs still hanging freely, dorsiflex the foot

  • Tap the Achilles tendon with the flat side of the reflex hammer

  • Repeat on the other side

Test the Plantar Reflex

  • Using the end of the hammer, stroke the lateral aspects of the sole from the heel to the ball of the foot, curving medially across the ball

  • Repeat on the other side

  • Normally, flexion of the toes occurs

  • Abnormal: Positive Babinski reflex

Health Promotion Diagnoses

Risk Diagnoses:
  1. Risk for injury related to disturbed sensory-perceptual patterns

  2. Risk for aspiration related to impaired gag reflex

  3. Risk for self-directed violence, related to depression, suicidal tendencies, developmental crisis, lack of support systems, loss of significant others, poor coping mechanism and behaviors

Actual Diagnoses
  1. Impaired verbal communication related to aphasia, psychological impairment, or organic brain disorder

  2. Acute or chronic confusion related to dementia, head injury, stroke, or alcohol and drug abuse

  3. Impaired memory related to dementia, stroke, head injury, or drug abuse

  4. Ineffective impulse control related to substance abuse, co-dependency, developmental disorder, or organic brain disorders

  5. Impaired swallowing related to absent gag reflex or decreased muscle strength for mastication or facial paralysis

  6. Sexual dysfunction related to peripheral neuropathy

  7. Self-care deficit related to paralysis, weakness, or confusion

  8. Reflex urinary incontinence related to spinal cord or brain damage

  9. Unilateral neglect related to poor vision on one side trauma or neurologic disorder

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Health Assessment | Ayen Malacad

Abnormalities in Cranial Nerve

CN I: Olfactory Nerve
  • Anosmia

CN II: Optic Nerve
  • Defect or absent central vision

  • Defect in peripheral vision, hemianopsia

  • Absent light reflex

  • Papilledema

  • Optic atrophy

  • Retinal lesions

CN III: Oculomotor Nerve
  • Dilated pupil, ptosis, eye turns out and slightly down

  • Failure to move eye up, in, down

  • Absent light reflex

CN VI: Abducens Nerve
  • Failure to move laterally, diplopia on lateral gaze

CN VII: Facial Nerve
  • Absent or asymmetric facial movement

  • Loss of taste

CN VIII: Acoustic Nerve
  • Decrease or loss of hearing

CN IX: Glossopharyngeal Nerve
  • No gag reflex

CN X: Vagus Nerve
  • Uvula deviates to side

  • No gag reflex

  • Voice quality: Hoarse or brassy, nasal twang or husky

  • Dysphagia, fluids regurgitate through nose

CN XI: Spinal Accessory Nerve
  • Absent movement of sternomastoid or trapezius muscles

CN XII: Hypoglossal Nerve
  • Tongue deviates to side

  • Slowed rate of tongue movement

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Health Assessment - Ayen Malacad

Female Genitalia - External Genitalia

  • The area is sometimes referred to as the vulva or pudendum

  • Extends from the mons pubis to the anal opening

  • The mons pubis is the fat pad located over the symphysis pubis

  • The labia majora are two folds of skin that extend posteriorly and inferiorly from the mons pubis to the perineum

    • Composed of adipose tissue, sebaceous glands, and sweat glands

    • Outer surface covered with pubic hair, inner surface is pink, smooth, and moist

  • The labia minora are hairless and usually darker pink

    • Contains numerous sebaceous glands that promote lubrication and maintain a moist environment in the vaginal area

  • The clitoris is located at the anterior end of the labia minora

    • Small, cylindrical mass of erectile tissue and nerves with three parts: the glans, the corpus, and the crura

  • The skin folds of the labia majora and labia minora form a boat-shaped area called the vestibule

  • The vestibule contains several openings

    • Located between the clitoris and the vaginal orifice is the urethral meatus

  • The hymen is a fold of membranous tissue that covers part of the vagina

    • Openings to Bartholin's glands are located on either side of and slightly posterior to the vaginal orifice

    • These glands secrete mucus, which lubricates the area during sexual intercourse

    • Often referred to as the greater vestibular glands

Internal Genitalia

  • Includes the vagina, cervix, uterus, fallopian tubes, and ovaries

  • The vagina is a muscular, tubular organ that extends up and slightly back toward the rectum from the vaginal orifice to the cervix

    • Approximately 10 cm long

  • The vaginal wall comprises four layers

    • Outer layer composed of pink squamous epithelium and connective tissue

    • Second layer is the submucosal layer containing blood vessels, nerves, and lymphatic channels

    • Third layer composed of smooth muscle, fourth layer consists of connective tissue and the vascular network

  • The cervix is composed of smooth muscle, muscle fibers, and connective tissue

    • Two types of epithelium cover the external os or ectocervix: pink squamous epithelium and red, rough-looking columnar epithelium

    • Functions to allow the entrance of sperm into the uterus, allow the passage of menstrual flow, secrete mucus, and prevent the entrance of vaginal bacteria

  • The uterus is a pear-shaped muscular organ with two components: the corpus (body) and the cervix (neck)

    • The corpus is divided into the fundus (upper portion), the body (central portion), and the isthmus (narrow lower portion)

    • Usually situated in a forward position above the bladder at approximately a 45-degree angle to the vagina when standing

    • Normal-sized uterus is approximately 7.5 cm long, 5 cm wide, and 2.5 cm thick

  • The endometrium, myometrium, and peritoneum are the three layers of the uterine wall

    • The endometrium is the inner mucosal layer composed of epithelium, connective tissue, and a vascular network

    • The myometrium is the middle layer composed of three layers of smooth muscle fibers that surround blood vessels

    • The peritoneum is the outer uterine layer that covers the uterus and separates it from the abdominal cavity

  • The ovaries are a pair of small, oval-shaped organs situated on a lateral aspect of the pelvic cavity

    • Connected to the uterus by the ovarian ligament

    • Functions to develop and release ova and produce hormones such as estrogen, progesterone, and testosterone

    • The ovum travels from the ovary to the uterus through the fallopian tubes

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Health Assessment - Ayen Malacad

Inspection and Palpation - External Genitalia

  • Inspect the mons pubis

    • Note the distribution of pubic hair and signs of infestation

    • Normal: Pubic hair is distributed in an inverted triangular pattern and no signs of infestation

    • Abnormal: Absence of pubic hair in the adult client is abnormal

  • Observe and palpate inguinal lymph nodes

    • Normal: No enlargement or swelling of the lymph nodes

    • Abnormal: Enlarged inguinal nodes may indicate a vaginal infection or irritation from shaving pubic hairs

  • Inspect the labia majora and perineum

    • Observe for lesions, swelling, and excoriation

    • Normal: Labia majora are equal in size and free of lesions, swelling, and excoriation

    • Abnormal: Lesions may be from an infectious disease such as herpes or syphilis, excoriation and swelling may be from scratching or self-treatment of the lesions

Page 17:

Health Assessment of External Genitalia

  • Inspect the labia minora, clitoris, urethral meatus, and vaginal opening

    • Use gloved hand to separate labia majora and inspect for lesions, excoriation, swelling, and/or discharge

    • Normal: Labia minora appear symmetric, dark pink, and moist. Clitoris is a small mound of erectile tissue, sensitive to touch. Urethral meatus is small and slit-like. Vaginal opening is positioned below the urethral meatus. Hymen may cover the vaginal opening partially or completely.

    • Abnormal: Asymmetric labia may indicate abscess. Lesions, swelling, bulging in the vaginal opening, and discharge are abnormal findings. Excoriation may result from scratching or self-treating a perineal irritation.

  • Palpate Bartholin's glands if there is labial swelling or history of it

    • Check for swelling, tenderness, and discharge

    • Normal: Bartholin's glands are usually soft, nontender, and drainage-free

    • Abnormal: Swelling, pain, and discharge may indicate infection and abscess. Obtain a specimen for culture if discharge is detected.

  • Palpate the urethra if there are urethral symptoms or suspected inflammation of Skene's glands

    • Insert gloved index finger into superior portion of vagina and milk the urethra from the inside

    • Normal: No drainage should be noted from the urethral meatus. Area is normally soft and nontender.

    • Abnormal: Drainage from the urethra indicates possible urethritis. Any discharge should be cultured. Urethritis may occur with infection with Neisseria gonorrhoeae or Chlamydia trachomatis.

  • Inspect the size of the vaginal opening and the angle of the vagina

    • Insert gloved index finger into the vagina to note size of opening and thinning or dryness of vaginal lining

    • Attempt to touch the cervix to determine speculum size and insertion angle

    • Normal: Vaginal opening varies in size. Vagina is tilted posteriorly at a 45-degree angle and should feel moist.

    • Abnormal: Vaginal atrophy due to lack of estrogen. Loss of hymenal tissue between the 3 o'clock and 9 o'clock positions indicates trauma.

  • Inspect the vaginal musculature

    • Keep index finger inserted in the vaginal opening

    • Ask the client to squeeze around the finger and bear down

    • Normal: Client should be able to squeeze around the examiner's finger. No bulging or urinary discharge.

    • Abnormal: Absent or decreased ability to squeeze the examiner's finger indicates decreased muscle tone. Bulging of the anterior may indicate decreased sexual satisfaction.

Page 18:

Health Assessment of Internal Genitalia

  • Inspect the cervix with the speculum inserted

    • Observe cervical color, size, and position

    • Normal: Surface of the cervix is smooth, pink, and even. Midline in position and projects 1-3 cm into the vagina. In pregnant clients, the cervix appears blue (Chadwick's sign).

    • Abnormal: Bluish cervix may indicate cyanosis in nonpregnant woman, pale cervix may indicate anemia. Redness may be from inflammation.

  • Inspect the vagina as the speculum is removed

    • Note vaginal color, surface, consistency, and any discharge

    • Normal: Vagina should appear pink, moist, smooth, and free of lesions and irritation. Free of colored or malodorous discharge.

    • Abnormal: Reddened areas, lesions, and colored, malodorous discharge are abnormal and may indicate vaginal infections, STIs, or cancer.

  • Bimanual examination

    • Palpate the vaginal wall

      • Apply water-soluble lubricant to gloved fingers

      • Insert index and middle fingers into the vaginal opening

      • Apply pressure to posterior wall and palpate for texture and tenderness

      • Normal: Vaginal wall should feel smooth, and client should not report any tenderness

      • Abnormal: Tenderness or lesions may indicate infection

    • Palpate the cervix

      • Advance fingers until they touch the cervix and run fingers around the circumference

      • Palpate for contour, consistency, mobility, and tenderness

      • Normal: Cervix should feel firm and soft, rounded, and can be moved somewhat from side to side without tenderness

      • Abnormal: Hard, immobile cervix may indicate cancer. Pain with movement of the cervix may indicate infection (Chandelier's sign).

    • Palpate the uterus

      • Move fingers intravaginally into the opening above the cervix

      • Gently press the hand resting on the abdomen downward, squeezing the uterus between the two hands

      • Note uterine size, position, shape, and consistency

      • Normal: Fundus is normally round, firm, and smooth. In most women, it is at the level of the pubis; the cervix is aimed posteriorly (anteverted position).

      • Abnormal: Enlarged uterus above the level of the pubis is abnormal; irregular shape suggests abnormalities such as myomas or endometriosis.

    • Palpate the ovaries

      • Slide intravaginal fingers toward the left ovary in the left lateral fornix

      • Place abdominal hand on the left lower abdominal quadrant

      • Press abdominal hand toward intravaginal fingers and attempt to palpate the ovary

      • Normal: Ovaries are approximately 3x2x1 cm and almond-shaped

      • Abnormal: Enlarged size, masses, immobility, and extreme tenderness are abnormal and should be evaluated.

Page 19: Health Assessment | Ayen Malacad Inspection and Palpation Anus and Rectum

  • Inspect the perianal area

    • Spread the client's buttocks and inspect the anal opening and surrounding area

    • Look for lumps, ulcers, lesions, rashes, redness, fissures, and thickening of the epithelium

    • Normal: Anal opening should appear hairless, moist, and tightly closed. Skin around the anal opening is coarser and more darkly pigmented. Perianal area should be free of redness, lumps, ulcers, lesions, and rashes.

    • Abnormal: Lesions may indicate STIs, cancer, or hemorrhoids. Thrombosed external hemorrhoid appears swollen, itchy, painful, and bleeds when passing stool.

  • Palpate the anus

    • Inform the client about the internal examination

    • Explain that it may feel like the bowels are going to move, but it won't happen

    • Lubricate gloved index finger and ask the client to bear down

    • Place the pad of the index finger on the anal opening and apply slight pressure to relax the sphincter

    • Normal: Client's sphincter relaxes, permitting entry

    • Abnormal: Sphincter tightens, making further examination unrealistic

  • Palpate the rectum

    • Insert finger further into the rectum as far as possible

    • Turn hand clockwise and counterclockwise to palpate as much rectal surface as possible

    • Note tenderness, irregularities, nodules, and hardness

    • Normal: Rectal mucosa is soft, smooth, nontender, and free of nodules

    • Abnormal: Hardness and irregularities may be from scarring or cancer. Nodules may indicate polyps or cancer.

  • Health Promotion Diagnoses

    1. Risk of Ineffective Therapeutic Regimen Management (monthly external genitalia examination) related to lack of knowledge of the importance of the examination.

    2. Risk for Infection related to unprotected sexual intercourse.

    3. Risk for Disturbed Body Image related to perceived effects on feminine role and sexuality.

    4. Risk for Ineffective Health Maintenance related to lack of knowledge of need for recommended colorectal examination.

    5. Risk for Impaired Skin Integrity in rectal area related to chronic irritation secondary to diarrhea.

  • Actual Diagnoses

    1. Fear of ovarian cancer related to high incidence of risk factors.

    2. Ineffective Sexuality Pattern related to decreased libido.

    3. Ineffective Therapeutic Regimen Management related to lack of knowledge of external genitalia self-examination.

    4. Acute Pain: Dysuria related to infection.

    5. Anticipatory Grieving related to impending loss of reproductive organs secondary to gynecologic surgery.

    6. Ineffective Sexuality Pattern related to perceptions of effects of surgery on sexual functioning and attractiveness.

    7. Acute Pain related to surgical incision.

    8. Acute Pain: Dyspareunia (painful intercourse) related to inadequate vaginal lubrication.

    9. Acute Pain: Rectal.

    10. Diarrhea related to chronic inflammatory bowel disease.

    11. Ineffective Sexuality Patterns related to feelings of loss of femininity/masculinity and sexual attractiveness secondary to chronic diarrhea or pain.

    12. Situational Low Self-Esteem related to loss of control over bowel elimination.

    13. Bowel Incontinence related to chronic diarrhea.

    14. Constipation related to low intake of high fiber foods.

Page 20: Health Assessment | Ayen Malacad Common Variations of the Cervix

  • Cervical Eversion

    • Normal finding in many women

    • Occurs after vaginal birth or when taking oral contraceptives

    • Columnar epithelium from within the endocervical canal is everted and appears as a deep red, rough ring around the cervical os

  • Nabothian Retention Cyst

    • Normal finding after childbirth

    • Small (less than 1 cm), yellow, translucent nodules on the cervical surface

    • Normal odorless and nonirritating secretions may be present on pink, healthy tissue

  • Unilateral Transverse Laceration

    • Trauma to the cervix during vaginal birth may cause tears or lacerations

    • Healed lacerations may be a normal variation

  • Abnormalities of the External Genitalia and Vaginal Opening

    • Syphilitic Chancre

      • Silvery white papules that become superficial red ulcers

      • Painless and sexually transmitted

    • Genital Warts

      • Caused by human papilloma virus (HPV)

      • Moist, fleshy lesions on the labia and within the vestibule

      • Painless and sexually transmitted

    • Genital Herpes

      • Initial outbreak may have small, painful ulcers with erythematous base

      • Recurrent lesions are usually less extensive

    • Cystocele

      • Bulging in the anterior vaginal wall caused by thickening of the pelvic musculature

      • Bladder prolapses into the vagina

    • Rectocele

      • Bulging in the posterior vaginal wall caused by weakening of the pelvic musculature

      • Part of the rectum protrudes into the vagina

    • Uterine Prolapse

      • Uterus protrudes into the vagina

      • Graded according to how far it protrudes

  • Abnormalities of the Cervix

    • Cyanosis of the Cervix

      • Normally appears bluish in the first trimester of pregnancy

      • If not pregnant, bluish color indicates venous congestion or diminished oxygen supply to the tissues

    • Cancer of the Cervix

      • Hardened ulcer is usually the first indication

      • May not be visible on the ectocervix

      • In later stages, the lesion may develop into a large cauliflower-like growth

    • Cervical Polyp

      • Develops in the endocervical canal and may protrude visibly at the cervical os

      • Soft, red, and benign

    • Cervical Erosion

      • Inflamed and eroded tissue around the external os

      • Appears reddened and rough

      • Usually occurs with mucopurulent cervical discharge

    • Mucopurulent Cervicitis

      • Produces a mucopurulent yellowish discharge from the external os

      • Indicates infection with Chlamydia or gonorrhea

    • Trichomonas Vaginitis

      • Vaginal infection caused by a protozoan organism

      • Sexually transmitted

      • Discharge is typically yellow-green, frothy, and foul-smelling

Page 21

Female Genitalia

Candidal Vaginitis

  • Infection caused by overgrowth of yeast in the vagina

  • Symptoms: thick, white, cheesy discharge; inflamed and swollen labia; red and rough vaginal walls with small red spots; intense itching and discomfort

Atrophic Vaginitis

  • Occurs after menopause when estrogen production is low

  • Symptoms: minimal blood-tinged discharge; atrophic labia and vaginismus; pale, dry vaginal mucosa with areas of abrasion that bleed easily; itching, burning, dryness, and painful urination

Bacterial Vaginitis

  • Cause is unknown, possibly sexually transmitted

  • Symptoms: thin, gray-white discharge with a fishy smell; coats vaginal walls and ectocervix

Adnexal Masses

  • Pelvic Inflammatory Disease (PID): caused by infection of the fallopian tubes or fallopian tubes and ovaries with an STI (gonorrhea, Chlamydia); extremely tender and painful bilateral adnexal masses

  • Ovarian Cyst: benign masses on the ovary; smooth, mobile, round, compressible, and nontender

  • Ovarian Cancer: cancerous masses are solid, irregular, nontender, and fixed

Male Genitalia

External Genitalia

Penis
  • Male reproductive organ

  • Composed of three cylindrical masses of vascular erectile tissue (two corpora cavernosa on the dorsal side and the corpus spongiosum on the ventral side)

  • Glans: acorn-shaped, covered by foreskin or prepuce if uncircumcised

Scrotum
  • Thin-walled sac suspended below the pubic bone, posterior to the penis

  • Function: protective covering for the testes, epididymis, and vas deferens; helps maintain cooler-than-body temperature necessary for sperm production

  • Contains sweat and sebaceous glands, folds of skin (rugae), and the cremaster muscle

Internal Genitalia

Testes
  • Divided into two portions by a septum, each containing one testis

  • Covered by the tunica vaginalis, a serous membrane

  • Function: production of sperm

Spermatic Cord
  • Suspends the testes in the scrotum

  • Contains blood vessels, lymphatic vessels, nerves, and the vas deferens

  • Epididymis: comma-shaped, coiled, tubular structure that curves over the upper and posterior surface of the testis

  • Vas Deferens: firm, muscular tube that transports sperm from the testes to the urethra for ejaculation

Inguinal Area
  • Area between the anterior superior iliac spine and the symphysis pubis

  • Inguinal Canal: tube-like structure through which the vas deferens travels as it passes through the lower abdomen

Page 22

Anus and Rectum
  • Anal Canal: final segment of the digestive system; lined with skin that contains no hair or sebaceous glands; contains somatic sensory nerves

  • Anal Opening: distinguished from perianal skin by its hairless, moist appearance; extends over the external anal sphincter

  • External Sphincter: composed of skeletal muscle and under voluntary control

  • Internal Sphincter: composed of smooth muscle and under involuntary control

  • Rectum: lowest portion of the large intestine; approximately 12 cm long; enlarges above the anorectal junction and forms the rectal ampulla

Prostate
  • Approximately 2.5 to 4 cm in diameter

  • Surrounds the neck of the bladder and urethra

  • Secretes a thin, milky substance that promotes sperm motility and neutralizes acidic vaginal secretions

Page 23: Health Assessment - Inspection and Palpation of the Penis and Scrotum

Penis Inspection and Palpation

  • Inspect the base of the penis and pubic hair.

    • Note pubic hair growth pattern and any excoriation, erythema, or infestation.

    • Normal: Pubic hair is coarser than scalp hair, covering the entire groin area.

    • Abnormal: Absence or scarcity of pubic hair may be seen in clients receiving chemotherapy.

  • Inspect the skin of the shaft.

    • Observe for rashes, lesions, or lumps.

    • Normal: The skin of the penis is wrinkled, hairless, and free of rashes, lesions, or lumps.

    • Abnormal: Rashes, lesions, or lumps may indicate STI or cancer.

  • Palpate the shaft.

    • Palpate any abnormalities noted during inspection.

    • Normal: The penis in a nonerect state is usually soft, flaccid, and nontender.

    • Abnormal: Tenderness may indicate inflammation or infection.

  • Inspect the foreskin.

    • Observe for color, location, and integrity of the foreskin in uncircumcised men.

    • Normal: The foreskin, which covers the glans in an uncircumcised male, is intact and uniform in color with the penis.

    • Abnormal: Discoloration of the foreskin may indicate scarring or infection.

  • Inspect the glans.

    • Observe for size, shape, and lesions or redness.

    • Normal: The glans size and shape vary, appearing rounded, broad, or even pointed. The surface is normally smooth, free of lesions and redness.

    • Abnormal: Chancres from syphilis, genital warts, and pimple-like lesions from herpes may be detected on the glans.

  • Palpate for urethral discharge.

    • Gently squeeze the glans between your index finger and thumb.

    • Normal: The urinary meatus is normally free of discharge.

    • Abnormal: Yellow discharge is usually associated with gonorrhea, while clear or white discharge is associated with urethritis.

Scrotum Inspection

  • Inspect the size, shape, and position of the scrotum.

    • Observe for swelling, lumps, or bulges.

    • Normal: The scrotum varies in size and shape, hanging below or at the level of the penis. The left side usually hangs lower than the right side.

    • Abnormal: An enlarged scrotal sac may result from fluid (hydrocele), blood (hematocele), bowel (hernia), or tumor (cancer).

  • Inspect the scrotal skin.

    • Observe color, integrity, and lesions or rashes.

    • Normal: Scrotal skin is thin, rugated (crinkled), with little hair dispersion. Its color is slightly darker than that of the penis. Lesions and rashes are not normally present.

Page 24: Health Assessment

Abnormal Findings in the Scrotal Contents

  • Rashes, lesions, and inflammation are abnormal findings.

Palpating the Testes and Epididymis

  • Palpate each testis and epididymis between your thumb and first two fingers.

  • Note size, shape, consistency, nodules, masses, and tenderness.

Normal Findings
  • Testes are ovoid, approximately 3.5–5 cm long, 2.5 cm wide, and 2.5 cm deep.

  • Testes are equal bilaterally in size and shape.

  • Testes are smooth, firm, rubbery, mobile, free of nodules, and rather tender to pressure.

  • The epididymis is nontender, smooth, and softer than the testes.

Abnormal Findings
  • Absence of a testis suggests cryptorchidism (an undescended testicle).

  • Painless nodules may indicate cancer.

  • Tenderness and swelling may indicate acute orchitis, torsion of the spermatic cord, a strangulated hernia, or epididymitis.

Palpating the Spermatic Cord and Vas Deferens

  • Palpate each spermatic cord and vas deferens from the epididymis to the inguinal ring.

  • The spermatic cord will lie between your thumb and finger.

  • Note any nodules, swelling, or tenderness.

Normal Findings
  • The spermatic cord and vas deferens should feel uniform on both sides.

  • The cord is smooth, nontender, and rope-like.

Abnormal Findings
  • Palpable, tortuous veins suggest varicocele.

  • A beaded or thickened cord indicates infection cysts.

  • A cyst suggests hydrocele of the spermatic cord.

Inguinal Area

Inspecting for Inguinal and Femoral Hernia

  • Inspect the inguinal and femoral areas for bulges.

  • Ask the client to turn their head and cough or to bear down as if having a bowel movement and continue to inspect the areas.

Normal Findings
  • The inguinal and femoral areas are normally free from bulges.

Abnormal Findings
  • Bulges that appear at the external inguinal ring or at the femoral canal when the client bears down may signal a hernia.

Palpating for Inguinal Hernia and Inguinal Nodes

  • Ask the client to shift their weight to the left for palpation of the right inguinal canal and vice versa.

  • Place your right index finger into the client’s right scrotum and press upward, invaginating the loose folds of skin.

  • Palpate up the spermatic cord until you reach the triangular-shaped slit-like opening of the external inguinal ring.

  • Try to push your finger through the opening and, if possible, continue palpating up the inguinal canal.

  • When your finger is in the canal or at the external inguinal ring, ask the client to bear down or cough. Feel for any bulges against your finger. Then, repeat the procedure on the opposite side.

Normal Findings
  • Bulging or masses are not normal.

Abnormal Findings
  • Presence of a bulge may indicate a hernia.

Palpating Inguinal Lymph Nodes

  • If nodes are palpable, note size, consistency, mobility, or tenderness.

Normal Findings
  • No enlargement or tenderness is normal.

Abnormal Findings
  • Enlarged or tender lymph nodes may indicate an inflammatory process or infection of the penis or scrotum.

Palpating for Femoral Hernia

  • Palpate on the front of the thigh in the femoral canal area.

  • Ask the client to bear down or cough. Feel for bulges. Repeat on the opposite thigh.

Normal Findings
  • No bulges palpated.

Abnormal Findings
  • Bulges or masses on palpation.

Anus and Rectum

Inspecting the Perianal Area

  • Spread the client’s buttocks and inspect the anal opening and surrounding area for the following:

    • Lumps, ulcers, lesions, rashes, redness, fissures, thickening of epithelium.

Normal Findings
  • The anal opening should appear hairless, moist, and tightly closed.

  • The skin around the anal opening is more coarse and more darkly pigmented.

  • The surrounding perianal area should be free of abnormalities.

Page 25:

Health Assessment of Anus and Rectum

  • Check for redness, lumps, ulcers, lesions, and rashes

    • Abnormal findings may indicate STIs, cancer, or hemorrhoids

  • Palpate the anus

    • Inform the client about the internal examination

    • Lubricate gloved index finger and ask the client to bear down

    • Normal: Sphincter relaxes, permitting entry

    • Abnormal: Sphincter tightens, making further examination unrealistic

  • Palpate the rectum

    • Insert finger further into the rectum

    • Turn hand clockwise and counterclockwise for maximum palpation

    • Note tenderness, irregularities, nodules, and hardness

    • Normal: Rectal mucosa is soft, smooth, nontender, and free of nodules

    • Abnormal: Hardness and irregularities may indicate scarring or cancer, nodules may indicate polyps or cancer

  • Palpate the peritoneal cavity

    • Palpate above the prostate gland in men

    • Note tenderness or nodules

    • Normal: Smooth and nontender

    • Abnormal: Rectal shelf may indicate a cancerous lesion or peritoneal metastasis, tenderness may indicate peritoneal inflammation

  • Palpate the prostate gland

    • Turn hand fully counterclockwise to palpate the anterior surface of the rectum

    • Normal: Nontender and rubbery with two lateral lobes divided by a median sulcus

    • Abnormal: Swollen, tender prostate may indicate acute prostatitis, enlarged smooth, firm prostate suggests benign prostatic hypertrophy (BPH), hard area or irregular nodules may suggest cancer

Health Promotion Diagnosis

  • Risk for Ineffective Therapeutic Regimen Management related to lack of knowledge of the importance of testicular self-examination (TSE)

  • Risk for Injury related to poor lifting techniques

  • Risk for Infection related to unprotected sexual intercourse

  • Risk for Ineffective Sexuality Pattern related to impending surgery

  • Risk for Ineffective Health Maintenance related to lack of knowledge of need for recommended colorectal and prostate examinations

  • Risk for Impaired Skin Integrity in rectal area related to chronic irritation secondary to diarrhea

Actual Diagnoses

  • Fear of testicular cancer related to existing risk factors

  • Disturbed Body Image related to hernia repair

  • Pain: Dysuria related to gonorrhea, infection, or genital reproductive surgery

  • Acute Pain: Rectal

  • Ineffective Therapeutic Regimen Management related to lack of knowledge of testicular self-examination

  • Sexual Dysfunction related to decreased libido secondary to fear of urinary incontinence, pain in surgical site, anxiety, or fear

  • Sexual Dysfunction related to erectile dysfunction secondary to psychological or physiologic factors

  • Sexual Dysfunction related to lack of ejaculation secondary to surgical removal of seminal vesicles and transection of the vas deferens

  • Ineffective Sexuality Patterns related to feelings of loss of masculinity and sexual attractiveness secondary to chronic diarrhea or pain

  • Anxiety related to impending genital reproductive surgery and lack of knowledge of outcome of surgery

  • Diarrhea related to chronic inflammatory bowel disease

  • Situational Low Self-Esteem related to loss of control bowel elimination

Page 26:

Abnormalities of the Penis

  • Syphilitic Chancre

    • Initially a small, silvery-white papule that develops a red, oval ulceration

    • Painless

    • Sign of primary syphilis that spontaneously regresses, may be misdiagnosed as herpes

  • Herpes Progenitalis

    • Clusters of pimple-like, clear vesicles that erupt and become ulcers

    • Painful

    • Initial lesions of this STI caused by HSV-1 or HSV-2 disappear and the infection remains dormant for varying periods of time, recurrences can be frequent or minimally episodic

  • Genital Warts

    • Single or multiple, moist, fleshy papules

    • Painless

    • STI caused by the human papillomavirus

  • Cancer of the Glans Penis

    • Appears as hardened nodule or ulcer on the glans

    • Painless

    • Occurs primarily in uncircumcised men

Abnormalities of the Inguinal and Femoral Hernias

  • Indirect Inguinal Hernia

    • Bowel herniates through internal inguinal ring and remains in the inguinal canal or travels down into the scrotum (scrotal hernia)

    • Most common type of hernia, more frequent in children

  • Direct Inguinal Hernia

    • Bowel herniates from behind and through the external inguinal ring, rarely travels down into the scrotum

    • Less common than indirect hernia, occurs mostly in adult men older than age 40

  • Femoral Hernia

    • Bowel herniates through the femoral ring and canal, never travels into the scrotum, and the inguinal canal is empty

    • Least common type of hernia, occurs mostly in women

Page 27: Abnormalities of the Anus and Rectum

  • External Hemorrhoid

    • Usually painless papules caused by varicose veins

    • Can be internal or external

    • Thrombosed external hemorrhoid is painful, swollen, itchy, and bleeds with bowel movements

  • Perianal Abscess

    • Cavity of pus caused by infection in the skin around the anal opening

    • Causes throbbing pain, redness, swelling, hardness, and tenderness

  • Anal Fissure

    • Splits in the tissue of the anal canal caused by trauma

    • Swollen skin tag ("sentinel tag") often present below the fissure

    • Causes intense pain, itching, and bleeding

  • Rectal Prolapse

    • Occurs when the mucosa of the rectum protrudes through the anal opening

    • May involve only the mucosa or the mucosa and rectal wall

    • Appears as a red, doughnut-like mass with radiating folds

  • Anorectal Fistula

    • Small, round opening in the skin surrounding the anal opening

    • Suggests an inflammatory tract from the anus or rectum to the skin

    • May be preceded by a previous abscess

  • Rectal Polyps

    • Soft structures that are common and come in varying sizes and numbers

    • Two types: pedunculated (on a stalk) and sessile (on the mucosal surface)

  • Rectal Cancer

    • Usually asymptomatic until it is advanced

    • Can feel like a firm nodule, an ulcerated nodule with rolled edges, or a large, irregularly shaped, fixed, hard nodule

Abnormalities of the Prostate Gland

  • Acute Prostatitis

    • Prostate is swollen, tender, firm, and warm to the touch

    • Caused by a bacterial infection

  • Benign Prostatic Hypertrophy

    • Prostate is enlarged, smooth, firm, and slightly elastic

    • Median sulcus may not be palpable

    • Common in men older than 50 years

  • Cancer of the Prostate

    • Hard area on the prostate or hard, fixed, irregular nodules suggest cancer

    • Median sulcus may not be palpable

Abnormalities of the Scrotum

  • Orchitis

    • Inflammation of the testes often associated with Mumps

    • Symptoms include pain, heaviness, and fever

    • Enlarged and reddened scrotum

    • Palpable swollen and tender testis

  • Varicocele

    • Abnormal dilation of veins in the spermatic cord

    • Symptoms include discomfort and testicular heaviness

    • Palpable tortuous veins feel like a soft, irregular mass or "a bag of worms"

    • Infertility may be associated with this condition

  • Small Testes

    • Small (less than 3.5 cm long), soft testes indicate atrophy

    • Atrophy may result from cirrhosis, hypopituitarism, estrogen administration, extended illness, or orchitis

    • Small (less than 2 cm long), firm testes may indicate Klinefelter's syndrome

  • Spermatocele

    • Sperm-filled cystic mass located on the epididymis

    • Palpable as small, nontender, and movable above