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165 Cards in this Set
- Front
- Back
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What are the four types of data? |
1. complete 2. focused (or problem centered) 3. follow-up 4. emergency |
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What are the 6 phases of the nursing process? |
1. assessment 2. diagnosis 3. outcome identification 4. planning 5. implementation 6. evaluation ADOPIE |
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How do you set priorities? |
1. Assess high priority first level priority problems 2. attend to second-level priority problems 3. address third-level priority problems |
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What's considered first priority? |
- airway - breathing - cardiac - vital sign concerns |
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What's considered second priority? |
- mental status change - untreated medical problems requiring immediate attention (diabetic not on insulin) - acute pain - acute urinary elimination problems - abnormal lab values - risks of infection, safety, or security |
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What's considered third priority? |
- health problems that don't fit into first or second priority categories (lack of problems with activity, rest, family coping, etc.) |
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What is functional assessment? |
Measures a person's self-care ability in the areas of general physical health or absence of illness; ADLs (bathing, dressing, toileting, etc.). May include instrumental activities of daily living (those needed for independent living). |
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What is the review of systems? |
The 6th step in health history sequence. 1. evaluate the past and present health state of each body system 2. double check in case any significant data were omitted in the present illness section 3. evaluate health promotion practices |
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What is the order of the skills performed in a physical examination? |
1. inspection 2. palpation 3. percussion 4. auscultation |
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What are the characteristics of percussion notes? |
1. amplitude (or intensity) - loud or soft sound 2. pitch (or frequency) - high pitched or low pitched 3. quality - a subjective difference due to a sounds distinctive overtones. Allows you to distinguish a C note on a piano to a C note on a violin 4. duration - the length of time the note lingers |
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Where do you normally hear resonant percussion notes? |
Over normal lung tissue |
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Where do you normally hear hyperresonant percussion notes? |
- over normal child's lung - abnormal in the adult, over lungs with increased amount of air as in emphysema |
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Where do you normally hear tympany percussion notes? |
Over stomach or intestine |
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Where do you normally hear dull percussion notes? |
over a relatively dense organ such as liver or spleen |
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Where do you normally hear flat percussion notes? |
over thigh muscles, bone or a tumor |
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What does the general survey include? |
- physical appearance - body structure - mobility - behavior |
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When conducting a general survey of physical appearance, what is being assessed? |
- age - sex - level of consciousness (LOC) - skin color - facial features - signs or no signs of acute distress |
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When conducting a general survey of body structure, what is being assessed? |
- stature (height normal for age or genetics?) - nutrition (weight) - symmetry - posture (lordosis, kyphosis) - position (relaxed?) - body, build & contour (arm span equals height) |
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When conducting a general survey of mobility, what is being assessed? |
- full range of motion (deliberate and accurate) - no involuntary movements |
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When conducting a general survey of behavior, what is being assessed? |
- facial expression (eye contact, thoughtful) - mood and affect (interacts pleasantly) - speech (clear and understandable) - dress (appropriate for the weather) - personal hygiene (groomed, brushed) |
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What are the vital signs? |
- temperature - pulse (rate and force) - respirations - blood pressure |
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What 12 factors affect blood pressure? |
- age - gender - race - diurnal cycle - weight - exercise - emotions or stress - Cardiac output - peripheral vascular resistance - blood volume - viscosity - elasticity of vessel walls |
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What 9 questions are asked to assess pain? |
1. Do you have pain? 2. Where is your pain? 3. When did your pain start? 4. What does your pain feel like? (sharp, aching) 5. How much pain do you have now? (1-10) 6. What makes your pain better or worse? 7. What does your pain prevent you from doing? 8. How do you usually react to pain? 9. What does this pain mean to you? (why?) |
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What are the differences between acute and chronic pain? |
Acute is shorter term (less than 6 months), people may respond to it such as diaphoresis, change in vital signs, moan, restless, etc. Chronic Pain lasts longer than 6 months and sufferers adapt to the pain and are not as outwardly obvious that they are in pain. |
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What is the demographic profile of the US? |
- 310 million people in the US in 2010 - 1 in 8 was an immigrant - about 1 in 3 US residents was part of a group other than single-race, non-Hispanic white - Hispanics are the largest and fastest growing - median age of total population was 36.6 years yet all the minorities ages were younger |
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What is the National Standards for Culturally and linguistically appropriate services in health care? |
It is a set of 14 rules stating what needs to be done to be culturally sensitive and inclusive. Includes the necessity for a translator fluent in other languages any time one is needed. |
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What is a health disparity? |
The unusual and disproportionate frequency of a given health problem within a population when compared with other populations. |
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What is heritage consistency? |
A concept that describes the degree to which ones own lifestyle relfects his or her respective traditional heritage. |
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What is culture? |
It has 4 basic characteristics; 1. it is learned from birth through the processes of language acquisition and socialization 2. it is shared by all members of the same cultural group 3. it is adapted to specific conditions related to environmental and technical factors and to the availability of natural resources 4. it is dynamic and ever changing |
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What is socialization? |
The process of being raised within a culture and acquiring the characteristics of that group. |
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What are the purposes of a nutritional assessment? |
1. identify individuals who are malnourished or are at risk for developing malnutrition 2. provide data for designing a nutrition plan of care that will prevent or minimize the development of malnutrition 3. establish baseline data for evaluating the efficacy of nutritional care |
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What are the components of a comprehensive nutritional assessment? |
- dietary history and clinical information - physical examination for clinical signs - anthropometric measures - laboratory tests |
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What are the laboratory studies performed for a nutritional assessment? |
- glucose (blood sugar) - hemoglobin (iron level) - hematocrit (cell volume/ iron status) - cholesterol (risk for cardiovascular disease) - triglycerides (risk for coronary artery disease) - serum proteins/ serum albumin (visceral protein status) - serum transferrin (visceral protein status too) - prealbumin (protein status) - C-reactive protein (protein marker for inflammatory status) |
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What are the names and locations of the lymph nodes located in the head and neck? |
1. preauricular (in front of the ear) 2. posterior auricular (superficial to the mastoid process) 3. occipital (base of the skull) 4. submental (midline under the chin) 5. submandibular (halfway between angle and tip of mandible) 6. jugulodigastric (under the angle of the mandible) 7. superficial cervical (overlying the sternocleidomastoid muscle) 8. deep cervical (under sternocleidomastoid muscle) 9. posterior cervical (in the posterior triangle along trapezius) 10. supraclavicular (above and behind clavicle at sternocleidomastoid muscle
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How do you inspect and palpate the neck? |
1. inspect for symmetry 2. note range of motion and test muscle strength 3. Using a gentle circular motion with the pads of the fingers, palpate the lymph nodes in the order of the names and locations. 4. palpate for a tracheal shift 5. palpate the thyroid gland |
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What is the pupillary light reflex? |
The normal constriction of the pupils when bright light shines on the retina. The direct light reflex is when one eye is exposed to bright light and constrict, the other eye then constricts which is consensual reflex. |
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What is fixation? |
A reflex direction of the eye toward an object attracting a person's attention. |
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What is accommodation? |
Adaptation of the eye for near vision. |
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What are the two main processes by which pain is developed? |
- Nociceptive processing - Neuropathic processing |
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How is neuropathic pain described? |
As a burning or numbing sensation. |
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What are the sources of pain? |
Visceral pain is from larger interior organs Deep somatic pain is from blood vessels, joints, tendons, muscles and bones. Cutaneous pain comes from the skin surface and subcutaneous tissue. Referred Pain originates from another site. |
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What affects does aging have on the eye structures? |
The skin around the eyes loses elasticity, causing wrinkling and drooping. Fat tissue and muscles atrophy Lacrimal glands involute causing dry eyes and less tear production. Pupil size decreases Lens loses elasticity and accommodation (presbyopia) Possible cataracts, glaucoma, macular degeneration |
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What is the Snellen eye chart? |
Alphabet chart in a well lit spot to test eyesight of individuals at a distance of 20 feet. |
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What three parts make up the ear? |
- external ear - middle ear - inner ear |
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What does the external ear consist of? |
The external ear is made up of cartilage and serves to funnel sound waves into the external auditory canal, which is 2.5 to 3 cm long and ends at the ear drum or tympanic membrane. |
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Describe the tympanic membrane. |
It separates the external and the middle ear. It is a translucent pearly gray color. It receives sound vibrations and transmits them to the auditory ossicles. |
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What does the middle ear do? |
Has three functions: - conducts sound vibrations to the inner ear - protects the inner ear by reducing the amplitude of loud sounds - eustachian tube allows equalization of air pressure on each side of the tympanic membrane so the the membrane does not rupture. |
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Describe the inner ear. |
- It is embedded in bone. - has a bony labyrinth which contains the sensory organs for equilibrium and hearing. |
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What is the subjective data that would be assessed for the nose? |
1. discharge 2. frequent colds 3. sinus pain 4. trauma 5. epitaxis (nosebleeds) 6. allergies 7. altered smell |
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What is the subjective data that would be assessed for the mouth and throat? |
1. sores and lesions 2. sore throat 3. bleeding gums 4. toothache 5. hoarseness 6. dysphagia 7. altered taste 8. smoking, alcohol consumption 9. self-care behaviors (dental care pattern) |
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How is the mouth inspected? |
1. lips - color, moisture, cracking, lesions 2. teeth and gums - note condition of teeth, check gums for swelling, discolor, bleeding 3. tongue - color, surface characteristics, moisture, lesions, underneath 4. buccal mucosa - check for leukoplakia 5. palate - check for torus palatinus 6. check gag reflex |
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Name the internal structures of the human breast. |
- Glandular tissue (15-20 lobes) - Cooper's ligaments that contract in breast cancer that cause pits and dimples in overlying skin. - adipose tissue - 4 quadrants (upper outer quadrant that has the axillary tail of Spence - site of most breast cancers) - 4 groups of axillary nodes |
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Name the 4 groups of axillary lymph nodes. |
- central axillary nodes - pectoral (anterior) nodes - subscapular (Posterior) nodes - lateral (along the humerus) |
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What is the tail of Spence? |
An extension of breast tissue that extends into the axilla. Where most breast cancers are found. |
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What are the statistics regarding breast cancer? |
- higher incidence in black women (before 45) - higher incidence in white (starting at 45) - higher mortality in black than white (all ages) - lowest risk is American Indian, Asian, Hispanic |
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Describe Breast self exams (BSE). |
- should start at age 20 - should be done monthly after menses - arm up of the side being checked - vertical strip pattern is best |
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What is nulliparity? |
Describing a woman who has never borne a child. |
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What are the anterior thoracic landmarks? |
- suprasternal notch (u-shaped above sternum) - sternum - sternal angle (Angle of Louis) - costal angle (between the ribs) - know where the midsternal and midclavicular lines are - |
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What are the posterior thoracic landmarks? |
- vertebra prominens - spinous processes - inferior border of the scapula (7th or 8th rib) - 12th rib - know where the vertebral and scapular lines are |
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What are the 4 major functions of the respiratory system? |
1. supplies oxygen to the body for energy 2. removes carbon dioxide 3. maintains homeostasis 4. maintains heat exchange |
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What percussion sound is typically heard over the majority of the lung tissue? |
Resonance |
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What are adventitious lung sounds? Name them and what they sound like. |
Lung sounds heard with a stethoscope that indicate pathology. - fine crackles (sound like small crackles) - course crackles (louder than fine crackles) - wheezes (long musical note) - rhonchi (snoring) - stridor (loud crowing sounds may not need a stethoscope to hear - indicates emergency) |
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What is tactile fremitus? |
Using the balls of the fingers, touching the person's chest, there is a palpable vibration when the patient says the word "99" |
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How do you assess the carotid arteries and what is assessed for? |
The carotid arteries are auscultated for a bruit which is a swooshing sound indicating turbulence due to a narrowing of the arteries. This is dangerous and displays an increased risk of stroke. |
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What is a normal heart rate for an adult (based on the health assessment book)? |
50-90 beats per minute over 90 beats is tachycardia under 50 is bradycardia |
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Can you name 20 symptoms of heart failure? |
- dilated pupils - skin pale, gray or cyanotic - dyspnea - orthorpnea - coughing with frothy pink or white sputum - decreased BP - N/V - ascites - pitting edema in legs or sacrum - anxiety - falling O2 sat - confusion - jugular vein distention - infarct - fatigue - S3 gallop - enlarged liver and spleen - decreased urine output - weak pulse - cool, moist skin
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How is jugular venous distention estimated? |
With the patient lying at a 45 degree angle a ruler is placed at the sternal angle. A straight edge is placed at the top of where the jugular vein can be seen and leveled across to the ruler. The measurement on the ruler estimates the jugular venous distention. Normal is less than 3cm. |
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How is the heart auscultated? |
- aortic area - 2nd intercostal space to the right of the sternum (for S1 or murmurs) - pulmonic area - 2nd intercostal space to the left of the sternum (for S2 or murmurs) - Erb's point - 3rd intercostal space to the left of the sternum - Tricuspid area - 4th intercostal space to the left of the sternum (can hear any S3 sounds here) - Mitral area - 5th intercostal space along the midclavicular line (can hear any S4 sounds here) |
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How is a pulse graded? |
On a 3 point scale, with 2+ being normal. |
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What is capillary refill? |
An index of peripheral perfusion and cardiac output. Depressed and blanched nail beds should refill in in less than 1 or 2 seconds. If not, it signifies vasoconstriction or decreased cardiac output. |
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What is claudication distance? |
The distance a person can walk or number of stairs a person with arterial peripheral vascular disease can take before they have pain. |
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What are the risk factors for venous stasis? |
- Long periods of immobility like driving, flying, bed rest or an orthopedic cast. - hypercoagulable states and vein wall trauma |
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Name the pulses palpable for examination. |
1. brachial pulse in the arm 2. radial pulse in the forearm 3. the abdominal aorta in thinner people 4. the femoral artery in the upper thigh 5. the popliteal artery behind the knee 6. the posterior tibial artery near the ankle 7. dorsalis pedis artery on the top of the foot |
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What differences are there regarding ulcers with arterial and venous insufficiency? |
Arterial - the ulcers are extremely painful, appear on the lower third of the leg and toes, lack of granulation tissue, edges are smooth and well defined and they are deep Venous - the ulcers have mild to moderate pain, are irregularly shaped and are shallow. |
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If a patient was to get an ulcer on the ankle, where would it be if it were from arterial insufficiency? Venous insufficiency? |
Arterial insufficiency would cause an ulcer on the lateral malleolus whereas a venous insufficiency would cause an ulcer on the medial malleolus. |
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What difference is there regarding pulses with arterial and venous insufficiency? |
With arterial insufficiency, the pulses are not palpable (or reduced) With venous insufficiency, the pulses are normal |
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What is a deep vein thrombosis (DVT)? |
A condition in which a blood clot forms in a vein deep beneath the skin, typically the calf or pelvic area. Immobility and lack of exercise increase this risk. |
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What is lymphedema? |
The accumulation of lymph in soft tissue with accompanying edema often in an extremity. Caused by inflammation, a blockage or removal of lymph nodes (common in breast cancer). |
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What is the ankle-brachial index (ABI)? |
Using the doppler stethoscope can help determine the extent of peripheral arterial disease (PAD). The ABI is calculated by dividing the systolic pressure of the ankle by the systolic pressure of the arm (brachial). |
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What is a weak, thready pulse graded as? How about a full bounding pulse? What is a normal pulse graded as? |
1+ 3+ 2+ |
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What organs are located in the upper right quadrant of the abdomen? |
- most of the liver - the gallbladder - some of the ascending colon and transverse colon - some small intestine - a small portion of the stomach |
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What organs are located in the upper left quadrant of the abdomen? |
- most of the stomach - some of the liver - the spleen - some of the transverse and descending colon - some small intestine |
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What organs are located in the lower left quadrant of the abdomen? |
- the descending colon - the sigmoid colon - small intestine |
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What organs are located in the lower right quadrant of the abdomen? |
- some of the ascending colon - cecum - small intestine - appendix |
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What is the stomach auscultated for? |
Bowel Sounds; If they are hypoactive or hyperactive. Also some vascular sounds may be heard with pathology. A bruit may be heard over the aorta, the iliac arteries, the femoral arteries or the renal arteries. |
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What is the subjective data (9 items) that should be assessed during an abdominal exam? |
1. appetite 2. dysphagia 3. food intolerance 4. abdominal pain 5. N/V 6. bowel habits 7. past medical history 8. medications 9. nutritional assessment |
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What is rebound tenderness, or Blumberg's sign? |
An indication of peritonitis in which pain is felt upon sudden release of steadily applied pressure on a suspected area of the abdomen. |
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What is inspiratory arrest (Murphy's sign)? |
It is a sharp pain on inspiration during palpation of the liver. It indicates cholecystitis. |
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What is cholecystitis? |
Inflammation of the gall bladder. |
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What is the iliopsoas muscle test? |
With the person supine, lift the right leg straight up, flexing at the hip, then push down over the lower part of the right thigh as the person tries to hold the leg up. It is painful in the lower right quadrant if the test is positive for appendicitis. |
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What is tympany? |
The predominate sound heard when percussing the abdomen because air in the intestines rises to the surface when supine. |
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When percussing the abdomen, what else can be assessed at this time? |
The size of the liver and location of the spleen |
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What type of joint motion is inversion and eversion? |
An ankle moving sideways toward the median and eversion, away from the median. |
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What type of joint motion is rotation? |
Joint rotating on it's axis, like the head turning to look sideways. |
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What type of joint motion is protraction? Retraction? |
The neck joint pushing the face forward. Pushing the face backward. |
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What type of joint motion is elevation? Depression? |
The shoulder joint as if to shrug. Can also lower them in depression. |
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What type of joint motion is flexion? Extension? |
Flexion - Bending at the joint. Extension - straightening or extending the limb. |
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What type of joint motion is abduction? adduction? |
Abduction - Moving a limb away from the body. Adduction - moving a limb toward the body. |
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What type of joint motion is pronation? supination? |
Pronation is as turning the palm to face the floor. Supination is as turning the palm face up. (Supination - holding a bowl of soup. Pronation - P - pour the soup). |
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What type of joint motion is circumduction? |
Circular as if pitching a softball. (shoulder joint) |
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What three bones articulate at the knee? |
The tibia, patella and femur. |
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What is the largest joint in the body? |
The knee |
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What type of joint is the knee? |
Hinge joint |
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What is the suprapatellar pouch? |
The knee's synovial membrane, the largest in the body. |
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What are the two wedge shaped cartilages called that cushion the tibia and femur? |
The medial meniscus and the lateral meniscus. |
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What are the names of the ligaments that criss cross within the knee? |
The cruciate ligaments. |
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What do the collateral ligaments do? |
They connect the knee at both sides and give medial and lateral stability and prevent dislocation. |
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What is osteoporosis? |
The gradual loss of bone density due to bone loss occurring more rapidly than new bone formation. Women are more affected than men because for 5 years after menopause, the lack of estrogen leads to accelerated bone loss. |
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What affect does osteoporosis have on the elderly? |
- decreased height - kyphosis - backward head tilt (to compensate for kyphosis) - slight flexion of hips and knees |
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Describe Rheumatoid arthritis. |
It is an autoimmune disease that attacks the joints symmetrically. Affects younger adults. The patient stiffens with inactivity and wakes stiff. After some movement, it improves somewhat. Crepitation occurs with it. |
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What are the three bones that articulate in the elbow joint? |
The radius, ulna and humerus. |
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What kind of joint is the elbow? |
Elbow is a hinge joint. |
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Where does the olecranon bursa lie? |
Between the olecranon process and the skin. |
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What are the palpable landmarks of the elbow? |
The medial and lateral epicondyles of the humerus and the large olecranon process of the ulna in between them. |
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What is gout? |
A metabolic disorder of disturbed purine metabolism associated with elevated serum uric acid. Occurs primarily in men over 40. Can cause gouty arthritis and affect the joints. |
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How does the mental status change with the aging adult? |
Mental status is mostly intact with aging. It can be affected, however, from other age related changes such as vision loss can result in social isolation or depression. Other age related changes can do this as well, such as hearing loss. Response time is slower and can affect new learning. The grief and despair of losses can cause disorientation, disability and/ or depression. |
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What cognitive functions are assessed? |
- orientation - attention span - recent memory - remote memory - new learning |
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How would orientation be assessed? |
Asking person, place and time. Ask them their name, age, birthdate. Ask them the current date and do they know where they are. |
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How would attention span be assessed? |
Note any distractibility or difficulty attending to the conversation at hand. Can give a series of directions to follow and note the correct sequence of behaviors taken. |
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How would recent memory be assessed? |
Recent memory can be assessed during the part of the nutritional assessment where the 24 diet recall is in question. Questions whose answers can be corroborated should be used to be sure they are not filling in memory gaps with made up answers. |
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How would remote memory be assessed? |
Questions about their past health, first job, past birthdays and anniversary dates or historical events relevant to that person. |
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How is new learning assessed? |
With a four unrelated words test. Tell them the four words and ask them to remember them, that you will ask them to repeat them shortly. Be sure they understand and repeat them back. The words should be unrelated and sound different. After 5 minutes ask them to recall the four words. Can ask again in 10 minutes and 30 minutes. For person younger than 60 years, they are typically accurate for 3 or 4 words. |
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What are the levels of consciousness? |
- alert - lethargic - obtunded (between lethargy and stupor - sleeps most of the time, difficult to rouse) - stupor or semi-coma - coma - acute confusional state (delirium) |
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What are the reflexes that are assessed in a neurological assessment? |
- biceps reflex - triceps reflex - brachioradialis reflex - quadriceps reflex - supine quadriceps reflex - achilles reflex - supine achilles reflex |
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What is the sequence for a neurological recheck? |
1. level of consciousness 2. motor function 3. pupillary response 4. VS |
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What is a Romberg test? |
Ask the person to stand with their feet together and their eyes closed. Wait 20 seconds. Normally a person can hold that position. A positive Romberg sign is loss of balance in this position. |
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How do you assess for danger signs of moles? |
ABCDE A - Asymmetry (the two halves don't look the same) B - Border irregularity (scalloping ragged edges) C - Color variation (areas of different colors) D - Diameter greater than 6mm E - Elevation or enlargement (raised) Other symptoms may include, itching, burning, bleeding or rapidly changing. |
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What causes pallor? |
- anemia - shock - arterial insufficiency - expected with anxiety and fear |
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What causes erythema? |
- polycythemia - venous stasis - carbon monoxide poisoning - extravascular presence of RBCs (petechiae, hematoma, ecchymosis) - is expected with a fever (warmth accompanies) |
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How do you assess color changes in a dark skinned person? |
- assess palms and soles of feet, mucosa, conjunctiva and sclera |
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What 9 pieces of subjective data are assessed in a male genitourinary assessment? |
1. frequency 2. dysuria 3. hesitancy and straining 4. urine color 5. past GU history 6. penis - pain, lesion, discharge 7. scrotum, self-care behaviors, lump 8. sexual activity and contraceptive use 9. STI contact |
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What happens to aging males with the genitourinary system? |
- males continue to produce sperm well into their 80's and 90's - after 55 to 60 years, testosterone production declines gradually - penis size decreases - hair decreases and turns gray - scrotal contents hang lower, rugae decrease so the scrotum looks pendulous - testes decrease in size and are less firm - less sperm is produced - slower and less intense sexual response - ejaculation is shorter and less forceful - volume of seminal fluid is less - detumescence (return to flaccid state) is quicker - refractory state lasts longer (can't ejaculate) |
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Describe the testicular self exam. |
T - timing S - in the shower, warm water relaxes scrotal sac E - examine, check for changes, report any right away |
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What is the anal canal? |
- The outlet of the GI tract - is about 3.8 cm long in the adult - merges with rectal mucosa at the anorectal junction |
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What is the anal canal surrounded by? |
- the internal sphincter (involuntary control) - the external sphincter (gives voluntary control) |
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What is the intersphincteric groove? |
The groove that separates the internal and external sphincters and it is palpable. |
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What are the anal columns? |
Folds of mucosa that extend vertically down from the rectum and end in the anorectal junction. At the end of each column is a small crescent fold, the anal valve, and the space above the anal valve is a small recess, the anal crypt. |
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What are some other names for the anorectal junction? |
- mucocutaneous junction - pectinate - dentate line |
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What causes a hemorrhoid? |
Each anal column has an artery and a vein. With increased venous pressure, a vein may enlarge causing a hemorrhoid. |
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What is the rectum? |
The distal portion of the large intestine. About 12 cm long |
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What are the valves of Houston? |
The rectal interior has three semilunar transverse folds. (I hope I never have to say "Houston, we have a problem"!) |
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What are the 7 pieces of subjective data assessed in a colorectal exam? |
1. usual bowel routine 2. change in bowel habits 3. rectal bleeding, blood in the stool 4. medications (laxatives, iron, etc) 5. rectal conditions (hemorrhoids, fissure, fistula, pruritus) 6. family history 7. self care behaviors (diet of high-fiber foods, exams) |
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What are the 6 additional areas that should be assessed with a preadolescent and adolescent girl during a genitourinary exam? |
1. ask questions about development of breasts and pubic hair 2. ask about periods and her feelings about it 3. ask about who she talks to about sex info and if she has a trusted adult to talk to, if she's had intercourse, what she uses for protection 4. ask if anyone has talked to her about STDs 5. has she had the HPV vaccine or her parents talked about it 6. ask if anyone has touched her in a way she doesn't want |
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What happens in menopause for women? |
- Hormone levels decrease causing cessation of menses and menopause. - happens around the ages of 48-51 - ovaries stop producing progesterone and estrogen - many dramatic physical changes |
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What are the many dramatic physical changes that occur in women going through menopause? |
- uterus shrinks in size - ovaries atrophy and are not palpable - sacral ligaments relax and pelvic muscles weaken - uterus droops (may protrude or prolapse into vagina) - vagina becomes shorter, narrower, and less elastic - decreased vaginal secretions (becomes dry and at risk for bleeding or vaginitis) |
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What 11 pieces of subjective data should be assessed of a woman during a genitourinary exam? |
1. menstrual history 2. obstetric history 3. menopause 4. self-care behaviors 5. urinary symptoms 6. vaginal discharge 7. past history 8. sexual activity 9. contraceptive use 10. STD contact 11. STI risk reduction |
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What is cyanosis? |
A bluish mottled color that signifies decreased perfusion. Indicates hypoxemia and occurs with shock, heart failure, chronic bronchitis and congenital heart disease. |
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What is jaundice? |
A yellowish skin color indicating a rise in bilirubin in the blood. In a dark skinned person, it can be seen in the sclera up to the iris. Caused by hepatitis, cirrhosis, sickle-cell disease, transfusion reaction and hemolytic disease of the newborn. |
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What is the penis? |
The male organ composed of three cylindric columns of erectile tissue, the two corpora cavernosa on the dorsal side and the corpus spongiosum ventrally. |
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What is the glans? |
At the distal end of the shaft of the penis, the corpus spongiosum expands into a cone of erectile tissue called the glans. |
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What is the urethra in a male? |
A conduit for both the genital and the urinary systems. It transverses the corpus spongiosum and it's meatus forms a slit at the glans tip. |
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What is foreskin? |
Also called prepuce, skin folds in and back on itself forming a hood or flap over the glans. |
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What is a frenulum of the penis? |
A fold of the foreskin extending from the urethral meatus ventrally (on the underside). |
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What is the scrotum? |
The loose protective sac that holds the testes. |
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What is rugae? |
Thin skin lying in folds on the scrotal wall. |
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What is cremaster muscle? |
A muscle in the scrotal sac which controls the size of the scrotum by responding to ambient temperature. |
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What is a testis? |
The organ that produces sperm. Is located in the scrotal sac. Has a solid oval shape and is suspended by the spermatic cord. |
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What is the epididymis? |
A coiled duct system and main storage site of sperm. Sits on top of each testis. |
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What is the vas deferens? |
The lower part of the epididymis is continuous with a muscular duct called the vas deferens |
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What is the spermatic cord? |
A combination of the vas deferens, arteries, veins, lymphatics and nerves, all together. |
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What is the ejaculatory duct? |
The duct of the seminal vesicle. It empties into the urethra. |
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What is the inguinal area? |
The groin |
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What is the inguinal ligament? |
Also called Poupart ligament, it is a ligament that lies along the anterior superior iliac spine and the symphysis pubis. |
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What is the inguinal canal? |
Superior to the inguinal ligament, is this narrow tunnel passing obliquely between layers of abdominal muscle. |
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What is the femoral canal? |
A canal inferior to the inguinal ligament. Is a potential space located 3 cm medial to and parallel with the femoral artery. |
