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Head To Toe Assessments
1) General Overview: appearance, posture, grooming, mental state, VS, HT & WT
2) Integumentary System: skin, hair, & nails
3) Head: eyes, ears, oral-pharyngeal cavity, lymph nodes of the neck
4) Breast
5) Chest & Lungs (Respiratory Assessment)
Head to Toe Assessments
6) Cardiovascular system
7) Abdomen (Gastrointestinal system)
8) Musculo-skeletal system
9) Neurological system
10) Genitourinary system
Head-To-Toe Assessment: Objectives
At the completion of this unit you will be able to:
1) Explain and demonstrate the components of a head-to-toe-assessment
2) Compare and contrast normal and abnormal assessment findings.
Integumentary Assessment
Integumentary Assessment
ColorColor: Varies according to age, culture,
ethnicity (pigmentation) Exposed areas are usually darker Variations with neonates & infants Capillary hemangiomas Common Color Variations (p. 441
box21-5)
Integumentary Assessment
Temperature:Temperature: Use dorsum of hand Normally skin is warm, but varies with
environmental temperature Causes of coolness: hypothyroidism,
poor peripheral circulation, shock Causes of warmth: hyperthyroidism,
infection, inflammatory responses
Integumentary Assessment
Moisture:Moisture: Normal skin: warm & dry Excessive moisture: hyperthermia,
hyperthyroid, & anxiety. Hyperhidrosis = excessive sweating Dry skin: dehydration, CRF,
Hypothyroidism, excessive sun exposure, harsh soaps
Integumentary Assessment
Skin Turgor:Skin Turgor: Turgor = elasticity of skin. Pinch test Tenting: > 3 seconds to return to
natural position. Dehydration and loss of skin elasticity
decreased turgor (tenting)
Integumentary Assessment
Edema: Edema: excessive amount of fluid in the tissues.
Abnormal finding Causes: compromised CV status,
kidney disease, PVD, ↓ albumin levels Assessing edema & pitting edema:
(p.442, fig. 21-19 & box 21-7)
Integumentary Assessment
Integumentary Assessment
Skin Lesions:Skin Lesions: Primary skin lesion: result directly from disease
or condition; i.e.: acne, solar lentigines Secondary skin lesion: result from generalized
illness. i.e.: plaques from psoriasis, ulcers from poor peripheral perfusion.
Evaluate for size, shape, pattern, color, distribution, tenderness, pain, itching, etc.
Integumentary Assessment: Skin Lesions
Solar Lentigines Psoriasis
(Seborrheic Keratosis) Plaques
Integumentary Assessment
Examples of Skin Lesions:Examples of Skin Lesions: Normal variations: milia, nevi, skin tags,
freckles, striae, birthmarks Primary lesions: macule, papule, vesicle,
wheal, pustule Secondary lesions: fissure, ulcer, scales,
scar, keloid, plaque, crusts
Integumentary Assessment
Hair:Hair: Color: i.e. graying, albinism Texture: i.e.: fine VS. coarse Distribution: hair is normally evenly distributed. Men have more facial and body hair Alopecia: hair loss; may be normal or abnormal Patchy hair loss: i.e.: fungal infections, or
autoimmune disorder
Integumentary Assessment
Male & Female Pubic Hair Patterns
Diamond Triangle
Integumentary Assessment
Hair:Hair: Hirsutism: excessive facial or trunk hair.
May result from steroid use or endocrine disorders.
Scalp: normally smooth, firm, symmetrical, nontender, & without lesions
Abnormalities: scales, fungal infection, psoriasis, fungal infection, cradle cap
Integumentary Assessment
Cradle cap: scaling of an infants head
Integumentary Assessment
Nails:Nails: Assessments: Color Shape Texture Variations in color, shape, or texture may
indicate health problems
Integumentary Assessment
Nail Color:Nail Color: Pale or cyanotic (nail beds): i.e. anemia,
hypoxia, respiratory disorders, CV disorders Mee’s lines: transverse white lines in the nail
bed. Splinter hemorrhages: associates with
trauma and bacterial endocarditis. White spots: may indicate zinc deficiency
Integumentary Assessment
Finger nail ridges Beau’s Lines(Vertical = Normal) (Associated with
Malnutrition, chemo,
& metabolic abnorms)
Integumentary Assessment
Nail Shape:Nail Shape: Normal angle of nail is about160º Nail clubbing: nail plate angle > 180º;
associated with long-term hypoxia (i.e.: COPD) Spoon shape nails may result from zinc
deficiency Nail clubbing
Integumentary Assessment
Nail Texture:Nail Texture: Normal = smooth Thickened: poor circulation Yellowing with thickening: fungal infection
(onychomycosis) Brittle nails: hyperthyroidism, malnutrition,
calcium or iron deficiency, repeated use of harsh nail products.
Soft or boggy nails: seen with poor oxygenation
Head Assessment
Includes
Head
Eyes
Ears
Nose
Throat
Head Assessment
Head & Face Assessment
Head Assessment
Skull & Face:Skull & Face: Normal = skull rounded,
face symmetrical in appearance & in movement.
Acromegaly: a large head during adolescence or adulthood
Micromegaly: abnormally small head
Head Assessment
Skull & Face:Skull & Face: Head flattening or abnormal shape: i.e.
trauma during vaginal birth, placing baby in same position for several hours.
Hydrocephalus: accumulation of cerebrospinal fluid cause the head to enlarge in infants & children
Head Assessment
Skull & Face:Skull & Face: Facial or head asymmetry may result
from trauma, paralysis, or occur congenitally.
Skull should be smooth to palpation with not unusual bulges or contours.
Jaw motion should be symmetrical, painless, & without clicking or crepitus.
Head Assessment
Eyes:Eyes:
Snellen chart
Head Assessment
Eyes:Eyes: Focused history questions Pterygium: a growth or thickening of
the conjunctiva
Head Assessment
Eyes:Eyes: Sclera: normally smooth, glistening,
white, & with tiny vessels visible. Yellow sclera: icteric Arcus senilis: a white ring encircling
the rim of the cornea
Head Assessment
Eyes:Eyes: Pupils: normally equal, round, reactive to
light, & accommodate (PERRLA). Constricted pupils: 2 cm or less Dilated pupils 5-6 cm. Normal/usual size: 3-4 cm. Pupil accommodation: bilateral pupils dilate
or constrict equally as eyes converge on an object as it moves nearer or further.
Head Assessment
Dilated pupilDilated pupil Constricted pupilConstricted pupil
Head Assessment
Eyes:Eyes: Snellen chart: distance vision, prescribed
lenses should be worn during exam The top number of the fraction indicates the
distance the person was standing from the chart.
The bottom number is the distance at which a person with normal vision can read the chart. i.e.: 20/30
Head Assessment
Eyes:Eyes: Myopia: diminished distance vision Anisocoria: unequal pupils Color blindness: inability to distinguish
color (ishihara cards) Extraoccular movements (EOMs):
visual fields
Head Assessment: Eyes, ishihara cards
Head Assessment
Eyes:Eyes: Peripheral vision: the boundaries of
the visual fields while the eye is in a fixed position.
Opthalmoscope used to examine the internal structures of the eye.
Head Assessment
Ears & hearing: Ears & hearing: InspectionInspection External ear: sound be symmetrical, equal in External ear: sound be symmetrical, equal in
& appearance& appearance Pinna normally at the level of the corner of Pinna normally at the level of the corner of
the eye. the eye. Abnormal placement may indicate genetic Abnormal placement may indicate genetic
disorders (I.e.: Down syndrome) or hearing disorders (I.e.: Down syndrome) or hearing deficits.deficits.
Head Assessment
Ears & hearing: Ears & hearing:
Head Assessment
Ears & hearing: Ears & hearing: PalpationPalpation External ear is normally smooth, External ear is normally smooth,
pliable, nontender, & without nodules. pliable, nontender, & without nodules. Painful or tender auricles may indicate Painful or tender auricles may indicate
otitis externa. Tenderness behind the otitis externa. Tenderness behind the ear may indicate otitis mediaear may indicate otitis media
Head Assessment
Ears & hearing: Ears & hearing: Middle earMiddle ear Otoscopic examinationOtoscopic examination Examine the auditory canal for cerumen; Examine the auditory canal for cerumen; Chars: black, red, gray, brown, waxy, Chars: black, red, gray, brown, waxy,
odorless, hard or softodorless, hard or soft Tympanic membrane chars: pearly gray, Tympanic membrane chars: pearly gray,
shiny, & translucent. shiny, & translucent.
Head Assessment
Ears & hearing:Ears & hearing: Provide quiet room.Provide quiet room. Whisper test: test for low tones; can Whisper test: test for low tones; can
normally hear and repeat words normally hear and repeat words whispered 1 to 2 feet behind her. whispered 1 to 2 feet behind her.
Watch ticking: test for high tones; can Watch ticking: test for high tones; can normally hear 5 inches from earnormally hear 5 inches from ear
Head Assessment
Ears & hearing:Ears & hearing:Weber test: tuning fork is used to assess Weber test: tuning fork is used to assess
the transmission of sound vibrations the transmission of sound vibrations should generate cranial nerve should generate cranial nerve impulses. impulses.
Rinne test: a tuning fork is used to Rinne test: a tuning fork is used to compare air conduction and bone compare air conduction and bone conduction of sound wavesconduction of sound waves
Head Assessment
Nose & Sinus Assessment:Nose & Sinus Assessment:
History (Subjective data collection): History (Subjective data collection):
List items to includeList items to include
Head Assessment
Head Assessment
Nose & Sinus assessment:Nose & Sinus assessment:
Inspection: should be at midline, smooth, and Inspection: should be at midline, smooth, and without tendernesswithout tenderness
Abnormal findings: asymmetry (trauma or Abnormal findings: asymmetry (trauma or congenital), flaring (respiratory distress), congenital), flaring (respiratory distress), clear drainage( allergy), yellow/green clear drainage( allergy), yellow/green drainage (upper resp. infection), bleeding drainage (upper resp. infection), bleeding (HTN, trauma, bleeding disorder)(HTN, trauma, bleeding disorder)
Head Assessment
Nose & Sinus assessment:Nose & Sinus assessment: Patency: Ask client to close mouth, occlude Patency: Ask client to close mouth, occlude
one naris, & breathe through the other naris.one naris, & breathe through the other naris. A nasal speculum is used to inspect the A nasal speculum is used to inspect the
inner structures of the nose.inner structures of the nose. Nasal mucosa is inspected for color, edema, Nasal mucosa is inspected for color, edema,
lesions, or discharge.lesions, or discharge.
Head Assessment
Nose & Sinus assessment:Nose & Sinus assessment:
Four sets of sinusesFour sets of sinuses The sinuses are palpated for tenderness. The sinuses are palpated for tenderness. Tenderness may indicate infectious or Tenderness may indicate infectious or
allergic sinusitisallergic sinusitis
Head AssessmentFour Sets of Sinuses
Name the four sets of sinuses and locate them on yourself.
Head Assessment
Mouth & Oropharynx AssessmentMouth & Oropharynx Assessment
History (Subjective data collection): History (Subjective data collection):
List items to includeList items to include
Head Assessment
Mouth & Oropharynx AssessmentMouth & Oropharynx Assessment Inspect oral mucosa and gums (gingiva)Inspect oral mucosa and gums (gingiva) Oral mucosa & gingiva is normally pink, moist, Oral mucosa & gingiva is normally pink, moist,
intact, and without lesionsintact, and without lesions Abnormal findings: receding gums, sponginess, Abnormal findings: receding gums, sponginess,
bleeding, inflammation, gingival hyperplasia, bleeding, inflammation, gingival hyperplasia, ulcerations, lesions, loose teeth, poor condition of ulcerations, lesions, loose teeth, poor condition of teeth. teeth.
Head Assessment
Mouth & Oropharynx AssessmentMouth & Oropharynx Assessment Inspect lips & tongueInspect lips & tongue Tongue abnormalities: deviation from midline, Tongue abnormalities: deviation from midline,
limited mobility (cranial nerve deficits), glossitis, dry limited mobility (cranial nerve deficits), glossitis, dry & furry tongue (dehydration), black & hairy tongue & furry tongue (dehydration), black & hairy tongue (fungal infection), absence of papillae, reddened (fungal infection), absence of papillae, reddened mucosa, ulcerations, swelling, nodules, smooth & mucosa, ulcerations, swelling, nodules, smooth & red tongue (iron, B3 or B12 deficiency).red tongue (iron, B3 or B12 deficiency).
Head Assessment
Mouth & Oropharynx AssessmentMouth & Oropharynx Assessment
Head Assessment
Mouth & Oropharynx AssessmentMouth & Oropharynx Assessment The hard palate, soft palate, & oropharynx The hard palate, soft palate, & oropharynx
should be pink, moist & intact. No lesions, should be pink, moist & intact. No lesions, exudate, swelling or discharge should be exudate, swelling or discharge should be present. present.
The uvula is at midline and should rise with The uvula is at midline and should rise with phonation.phonation.
Head Assessment
Mouth & Oropharynx AssessmentMouth & Oropharynx AssessmentAbnormal findings: redness, edema, lesions, plaque, Abnormal findings: redness, edema, lesions, plaque,
drainage, reddened or swollen tonsils, white or drainage, reddened or swollen tonsils, white or pale patches of exudate, asymmetrical rise of pale patches of exudate, asymmetrical rise of uvula. uvula.
Tongue abnormalitiesTongue abnormalitiesReview figures 21-8 & 21-9 (p. 430) Review figures 21-8 & 21-9 (p. 430)
Head Assessment
Mouth & Oropharynx AssessmentMouth & Oropharynx AssessmentGag reflex: test by touching the back of the Gag reflex: test by touching the back of the
throat with a tongue blade. throat with a tongue blade. Absence of gag reflex may be seen with Absence of gag reflex may be seen with
over-sedation, head injury, & cranial over-sedation, head injury, & cranial nerve damage as seen with CVA nerve damage as seen with CVA
NECK ASSESSMENT
• Assess for complains of stiffness, pain, difficulty swallowing, or masses/lumps.
Inspect for symmetry, ROM, and visible swollen lymph nodes.
Lymph nodes are gently palpated with one or two finger pads in a circular movement. Palpable lymph nodes descend into the supraclavicular area.
NECK ASSESSMENT
Lymph nodes are found in chains and are generally supple & non palpable.
Lymphadenopathy indicates inflammation or infection in the area that they drain or malignancy.
NECK ASSESSMENT
Lymph
Nodes
NECK ASSESSMENT
The thyroid cartilage, cricoid, hyoid bone, & tracheal rings are palpable and should be at midline.
When assessing the structures of the neck, ask the patient to slightly flex the neck as you lightly palpate.
BREAST & AXILLAE ASSESSMENT
Breast self-examinations is an important health promotion activity.
Breast tissue extends into the axillary area.
Gynecomastia is an abnormal finding in males.
Mastitis: swelling & erythema most often seen with infection.
CHEST & LUNG ASSESSMENT
Pulmonary Structures
CHEST & LUNG ASSESSMENT
Normal ChestNormal Chest: Symmetrical Rises and falls with respiration Diameter expands with inspiration The anteriorposterior to lateral ratio is
1:2.
CHEST & LUNG ASSESSMENT
Chest AbnormalitiesChest Abnormalities:
Kyphosis: Excessive curvature of the thoracic spine
Scoliosis: Lateral curvature of the spine
Barrel Chest: The lateral aspect of the chest is increased. Occurs with COPD
CHEST & LUNG ASSESSMENT
Breath Sounds:Breath Sounds:
Normal: rate 12-20, regular rhythm, unlabored, equal bilaterally
Auscultate breath sounds for one complete respiratory cycle.
Compare breath sounds bilaterally
Preferred position: sitting
CHEST & LUNG ASSESSMENT
Breath Sounds:Breath Sounds:Diminished breath sounds: heard with
poor inspiratory effort and with restricted air flow.
Adventitious breath sounds: respiratory sounds that are heard louder then normal. (Have patient cough to clear secretions.)
CHEST & LUNG ASSESSMENTAbnormal breath sounds (define each):
(reference p. 435)
Crackles
Rhonchi
Wheezes
Pleural Rub
Stridor
CHEST & LUNG ASSESSMENTRespiratory Patters (define each term
(reference table p. 432, 21-3)
Eupnea
Tachypnea
Bradypnea
Kussmaul’s
Chyne Stokes
Apnea
CHEST & LUNG ASSESSMENT
Sequence for anterior auscultation
(p. 436, fig. 21-14A)
Sequence for lateral auscultation
(fig 21-14B)• Sequence for posterior auscultation
(fig. 21-14C)
https://www.youtube.com/watch?v=5JA6D1Mguh0
CHEST & LUNG ASSESSMENT
Cardiovascular assessment:Cardiovascular assessment:
CHEST & LUNG ASSESSMENT
Cardiovascular assessment:Cardiovascular assessment:
Able to hear heart sounds from any location on the anterior chest.
Point of maximal impulse (PMI): 5th intercostal space (left) & midclavicular line (apex of the heart)
CHEST & LUNG ASSESSMENT
Cardiovascular assessment:Cardiovascular assessment:
Cardiac auscultation sites (P. 437, fig. 21-15 & 21-16)
Aortic valve: 2nd ICS, R sternal border
Pulmonic valve: 2nd ICS, L sternal border
Tricuspid valve: 4th ICS, L sternal border
Mitral valve: 5th ICS, MCL
CHEST & LUNG ASSESSMENT
Abnormal findings: Abnormal findings:
Murmur: extra sounds produced by turbulent blood flow through the heart.
Causes: incompetent valves, back flow of blood.
CHEST & LUNG ASSESSMENT
Cardiovascular assessment:Cardiovascular assessment:
Carotid arteries and jugular veins run veins run alongside the sternocleidomastoid alongside the sternocleidomastoid musclemuscle
Carotid pulses: stenosis thrills (palpation) or bruits (auscultation).
Caused by turbulent blood flow.
CHEST & LUNG ASSESSMENT
Cardiovascular assessment:Cardiovascular assessment:
Jugular vein distention: begin with head of bed flat, vein becomes distended with blood.
As head of bed is raised, distention should decrease. Should disappear at about 30 to 45 degrees.
CHEST & LUNG ASSESSMENT
Cardiovascular assessment:Cardiovascular assessment:Jugular vein distention (JVD):With HOB elevated, the jugular veins are
normally flat & without distention. If distention remains after HOB is
elevated, fluid overload or cardiac failure is indicated. (Poor venous return).
CHEST & LUNG ASSESSMENT
Cardiovascular assessment:Cardiovascular assessment:
Inspect the periphery for color, temperature, & edema.
Normally the skin is warm, without edema, & with good color.
Pedal pulses (& all pulses) should be regular, strong, & equal bilaterally.
CHEST & LUNG ASSESSMENT
Cardiovascular assessment
CHEST & LUNG ASSESSMENT
Cardiovascular Assessment: Capillary Refill
Purpose: assess tissue perfusion in peripheral parts of the body.
Procedure: press the skin or nail to produce blanching (pale color). Color should return to normal in < 3 seconds.
CHEST & LUNG ASSESSMENT
Cardiovascular Assessment: Peripheral Pulses
Performed to assess the adequacy of peripheral arterial circulation.
Doppler: ultrasonic device
Assess warmth & color of fingers & feet
Abdominal Assessment
Assessed in quadrants or in the nine-region method
Abdominal Assessment
Inspection and auscultation of the abdomen are performed before percussion & palpation.
???Can you guess why?????
Abdominal Assessment
Inspection:
Normally symmetrical with rounded contour.
Striae: “stretch marks” (silver-white color = old, pink color = new.)
Distention: may be due to gas, bowel obstruction, or fluid retention (ascites)
Abdominal Assessment
Auscultation:
Normal bowel sounds are high-pitched, irregular gurgles or clicks lasting one to several seconds and occurring every 5 to 15-30 seconds.
Abdominal Assessment
Auscultation:Auscultation:
Absent or hypoactive bowel sounds may occur after abdominal surgery, infection, nerve abnormalities or with bowel obstruction. (< 5 sounds /min)
Hyperactive bowel sounds (Hyperperistalsis: occurring > 5 seconds or > 30/min) may occur with diarrhea, gastroenteritis, or irritable bowels.
Abdominal Assessment
Auscultation: Auscultation: for bruits over the aorta, renal, femoral, & iliac arteries are performed by experienced practitioners.
Bruits may indicate an aneurysm, stenosis, or occluded blood flow.
Abdominal Assessment
Percussion:Percussion:
Normally: nontender, soft, & without masses.
Tympany: sound heard over bowels filled with gas.
Dullness: sound heard over organs, masses, or fluid collections.
Abdominal Assessment
Palpation:Palpation:
Performed by experienced practitioners
Light palpation: to assess for tenderness or guarding.
Deep palpation: to assess organs for masses or tenderness.
The spleen is not normally palpable; when palpable an abnormal etiology is indicated.
The Musculoskeletal System Assessment
Musculoskeletal System Assessment
Includes:
posture
gait
joint mobility
muscle strength
Much of the MS assessment may be part of the nervous system assessment.
Musculoskeletal System Assessment
Deformities in bone structure affect posture & gait.
The normal four curvatures of the spine should be present.
The head & neck should be at midline
Musculoskeletal System Assessment
Musculoskeletal System Assessment
Common abnormalities of the spineCommon abnormalities of the spine:
Kyphosis: accentuated curve of the thoracic spine
Scoliosis: lateral S deviation of the spine
Lordosis: exaggerated lumbar curve
Musculoskeletal System Assessment: Abnormal curvatures of the Spine
Musculoskeletal System Assessment
Assess spinal curvature by observing the client’s posture while standing erect and having him/her bend forward at the waist while the arms hang free
Normally the cervical & lumber curves are concave; thoracic & sacral curves are convex.
Musculoskeletal System Assessment
Balance, coordination, & movement Observe walking: base of support &
stride Balance & movement: heel-to-toe &
Romberg test. Coordination: finger-thumb opposition
& heel-shin slide.
Musculoskeletal System Assessment
Joint Mobility & Muscle Function Normally joints should move freely &
without pain or crepitus Active ROM: independently moves
joint through full ROM. Passive ROM: the joint is moved
through motions by another person.
Musculoskeletal System Assessment
Muscle strength: Test muscle strength by performing
ROM against resistance (i.e.: push hand away, “step on gas”)
Normal: Active against full resistance Hand-out: Muscle Strength Rating
Scale
Assessing the Neurological System
Work of the nervous system is carried out through the transmission of chemical & electrical impulses and functions to maintain homeostasis.
Much of the neurological assessment is done simultaneously with the musculo-skeletal system.
Assessing the Neurological System
The CNS controls all of the body’s activities.
Assessing the Neurological System
Cerebral Function:Cerebral Function:Refers to intellectual, mental, cognitive, &
behavioral function. Level of consciousness (LOC): on
continuum. Glasgow coma scale: (p. 429, tab. 21-2) 3 categories of responses, normal score =
15.
Assessing the Neurological System: Cerebral Function:Cerebral Function:
Orientation level: 4 domains are utilized to describe orientation levels.
1) Time: awareness to time, place & year.2) Place: awareness to surroundings3) Person: recognition of self-identity and
of similar persons. 4) Situation: “Do you know why you are
here?”
Assessing the Neurological System
Cranial Nerve Function: Cranial Nerve Function: Examples
12 cranial nerves are tested.
I. Olfactory nerve: identify smells
II. Optic nerve: visual acuity
III – VI. Ocular motor function: extraoccular movements are tested.
VIII. Acoustic nerve: hearing & balance
Assessing the Neurological System
Cranial Nerve Function: Cranial Nerve Function: Examples cont. 12 cranial nerves are testedIX & X: glossopharyngeal & vagus
nerves: observe ability to talk, swallow, & cough.
XII: hypoglossal nerve: can the client articulate sounds and move tongue completely?
Assessing the Neurological System
Reflex Function: Reflex Function: Automatic responses
Intact sensory & motor pathways are required for normal reflex responses.
Deep Tendon Reflexes (DTR): a slightly stretched muscle tendon is tapped with a rubber percussion hammer
DTR responses are graded:
Assessing the Neurological System
Reflex Function: Reflex Function: Automatic responses
Common DTR Assessments:
1) Achilles reflex
2) Plantar reflex
3) Brachioradialis reflex
4) Tricepts reflex
Assessing the Neurological System
Reflex Function: Reflex Function: Automatic responses
Patellar reflex
Assessing the Neurological System
Reflex Function: Reflex Function: Automatic response
Superficial reflexes: i.e. Babinski response
Assessing the Neurological System
Sensory Function Assessment:Sensory Function Assessment:Sensory function assessment includes light
touch, light pain, temperature, vibration, position sense, stereognosis, graphesthesia, & two-point discrimination
PT is instructed to keep eyes closed while various stimuli are utilized. The PT is instructed to indicate and describe sensations as they are felt.
Assessing the Neurological System
Motor & Cerebellar Function: The cerebellum helps to coordinate
muscle movement, regulate muscle tone, & maintain posture & equilibrium.
Assessing the Neurological System
Disorders of motor & cerebellar function result in pain or problems with movement, gait, or posture.
Assessment of the Male Genitourinary system
Nurse practioners & physicians assess external genitalia and complete comprehensive GU examinations.
Focuses on sexual & reproductive function: requires a straight forward approach to obtaining subjective data.
Assessment of the Male Genitourinary system
The prostate gland is palpated during rectal examination
Assessment of the Female Genitourinary system
Speculum examination: performed to collect specimens and to assess the cervix.
Assessment of the Urinary System
Intake & Output Characteristics of urine Bladder palpation/bladder scan Urine specific gravity (kidneys concentrate urine) Urine & kidney laboratory results
Nursing Assessment
Conclusion
Assessment Closure Activities
Test review activities Read & review key points Review questions page 453-454 Practice skill 21-4 (p.448-449)