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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
Skeletal muscle: moves bones and other structures (e.g., the eyes)
Cardiac muscle: forms most of the walls of the heart and adjacent great vessels
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:
Risk for injury related to disturbed sensory-perceptual patterns
Risk for aspiration related to impaired gag reflex
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
Impaired verbal communication related to aphasia, psychological impairment, or organic brain disorder
Acute or chronic confusion related to dementia, head injury, stroke, or alcohol and drug abuse
Impaired memory related to dementia, stroke, head injury, or drug abuse
Ineffective impulse control related to substance abuse, co-dependency, developmental disorder, or organic brain disorders
Impaired swallowing related to absent gag reflex or decreased muscle strength for mastication or facial paralysis
Sexual dysfunction related to peripheral neuropathy
Self-care deficit related to paralysis, weakness, or confusion
Reflex urinary incontinence related to spinal cord or brain damage
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
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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
Risk of Ineffective Therapeutic Regimen Management (monthly external genitalia examination) related to lack of knowledge of the importance of the examination.
Risk for Infection related to unprotected sexual intercourse.
Risk for Disturbed Body Image related to perceived effects on feminine role and sexuality.
Risk for Ineffective Health Maintenance related to lack of knowledge of need for recommended colorectal examination.
Risk for Impaired Skin Integrity in rectal area related to chronic irritation secondary to diarrhea.
Actual Diagnoses
Fear of ovarian cancer related to high incidence of risk factors.
Ineffective Sexuality Pattern related to decreased libido.
Ineffective Therapeutic Regimen Management related to lack of knowledge of external genitalia self-examination.
Acute Pain: Dysuria related to infection.
Anticipatory Grieving related to impending loss of reproductive organs secondary to gynecologic surgery.
Ineffective Sexuality Pattern related to perceptions of effects of surgery on sexual functioning and attractiveness.
Acute Pain related to surgical incision.
Acute Pain: Dyspareunia (painful intercourse) related to inadequate vaginal lubrication.
Acute Pain: Rectal.
Diarrhea related to chronic inflammatory bowel disease.
Ineffective Sexuality Patterns related to feelings of loss of femininity/masculinity and sexual attractiveness secondary to chronic diarrhea or pain.
Situational Low Self-Esteem related to loss of control over bowel elimination.
Bowel Incontinence related to chronic diarrhea.
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