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HEALTH ASSESSMENT REVIEWERTOPICS COVERED Musculoskeletal Abdominal Genitourinary Breast/Axilla. A. MUSCULOSKELETAL SYSTEMThe musculoskeletal system encompasses the muscles, bones, and joints. Completeness of an assessment of this system depends largely on the needs and problems of the individual cli...

Description

HEALTH ASSESSMENT REVIEWER TOPICS COVERED - Musculoskeletal - Abdominal - Genitourinary - Breast/Axilla.

A. MUSCULOSKELETAL SYSTEM The musculoskeletal system encompasses the muscles, bones, and joints. Completeness of an assessment of this system depends largely on the needs and problems of the individual client. The nurse usually assesses the musculoskeletal system for muscle strength, tone, size, and symmetry of muscle development, and for tremors. A tremor is an involuntary trembling of a limb or body part. Tremors may involve large groups of muscle fibers or small bundles of muscle fibers. An intention tremor becomes more apparent when an individual attempts a voluntary movement, such as holding a cup of coffee. A resting tremor is more apparent when the client is relaxed and diminishes with activity. A fasciculation is an abnormal contraction of a bundle of muscle fibers that appears as a twitch. Bones are assessed for normal form. Joints are assessed for tenderness, swelling, thickening, crepitation (a crackling, grating, sound), and range of motion. Body posture is assessed for normal standing and sitting positions. QUESTIONS TO ASK THE PATIENT Do you have any pain in your joints or muscles? Do you have any stiffness, weakness, or twitching? Have you fallen recently? Are you able to care for yourself? Is your activity limited by any physical factors? How would you describe your physical activity? Do you exercise on a regular basis? Do you exercise or participate in sports? For postmenopausal women, how tall are you? Do you take calcium supplements? ASSESSING THE PATIENT: MUSCLE

ASSESSMENT

NORMAL FINDINGS

DEVIATIONS FROM NORMAL

Inspect the muscles for size. Compare the muscles on one side of the body (e.g., of the arm, thigh, and calf) to the same muscle on the other side. For any discrepancies, measure the muscles with a tape.

Equal size on both sides of the body.

Atrophy (a decrease in size or hypertrophy (an increase in size), asymmetry.

Inspect the muscles and tendons for contractures (shortening).

No contractures.

Inspect the muscles and tendons, for example by having the client hold the arms out in front of the body. Test muscle strength. Compare the right side with the left side. Sternocleidomastoid: Client turns the head to one side against the resistance of your hand. Repeat with the other side.

Malposition of body part, e.g., foot drop (foot reflexed downward).

No tremors.

Presence of tremor.

Equal size on both sides of the body.

GRADING MUSCLE STRENGHT: 0: 0& of normal strength; complete paralysis. 1: 10% of normal strength; no movement, contraction of muscle is palpable or visible.

Trapezius: Client shrugs the shoulders against the resistance of your hands.

2: 25% of normal strength; full muscle movement against gravity, with support.

Deltoid: Client holds arms up and resists while you try to push it down.

3: 50% of normal strength; normal movement against gravity.

Biceps: Client fully extends each arm and tries to flex it while you attempt to hold in extension.

4: 75% of normal strength; normal full movement against gravity and against minimal resistance.

Triceps: Client flexes each arm and then tries to extend it against your attempt to keep arm in flexion.

5: 100% of normal strength; normal full movement against gravity and against full resistance.

Wrist and finger muscles: Client spreads the fingers and resists as you attempt to push the fingers together.

Grip strength: Client grasps your index and middle fingers while you try to pull the fingers out. Hip muscles: Client is supine, both legs extended; client raises one leg at a time while you attempt to hold it down. Quadriceps: Client is supine, knee partially extended; client resists while you attempt to flex the knee. Muscle of the ankles and feet: Client resists while you attempt to dorsiflex the foot and resists while you attempt to flex the foot.

ASSESSING THE PATIENT: MUSCLE ASSESSMENT

NORMAL FINDINGS

DEVIATIONS FROM NORMAL

Inspect the skeleton for structure.

No deformities.

Bones misaligned.

Palpate the bones to locate any areas of edema or tenderness.

No tenderness or swelling.

Presence of tenderness or swelling (may indicate fracture, neoplasms, or osteoporosis).

ASSESSING THE PATIENT: JOINTS ASSESSMENT

NORMAL FINDINGS

DEVIATIONS FROM NORMAL

Assess joint range of motion.

Joints move smoothly.

Limited range of motion in one or more joints.

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Ask the client to move selected body parts. The amount of joint movement can be measured by a goniometer, a device that measures the angle of a joint in degree.

Document findings in the client record using printed or electronic forms or checklists supplemented by narrative notes when appropriate.

LIFESPAN CONSIDERATIONS OLDER ADULTS Muscle mass decreases progressively with age, but wide variations are seen among different individuals. The decrease in speed, strength, resistance to fatigue, reaction time, and coordination in the older person is due to a decrease in nerve conduction and muscle tone. The bones become more fragile and osteoporosis leads to a loss of total bone mass. As a result, older adults are predisposed to fracture and compressed vertebrae. In most adults, osteoarthritic changes in the joints can be observed. Note any surgical scars from joint replacement surgeries.

B. ABDOMINAL ASSESSMENT The nurse locates and describes abdominal findings using two common methods of subdividing the abdomen: - Quadrants - Regions To divide the abdomen into quadrants, the nurse imagines two lines: a vertical line from the xyphoid process to the pubic symphysis, and a horizontal line across the umbilicus. These quadrants are labeled right upper quadrant, left upper quadrant, right lower quadrant and left lower quadrant. Using the second method, division into nine regions, the nurse imagines two vertical lines that extend superiorly from the midpoints of the inguinal ligaments , and two horizontal lines , one at the level of the edge of the lower ribs and the other at the level of the iliac crests. Specific organs or parts of organs lie in each abdominal region.

Practitioners often use certain landmarks to locate abdominal signs and symptoms. These are the xyphoid process of the sternum, the costal margins, the anterosuperior iliac spine, the umbilicus, the inguinal ligaments, and the superior margin of the pubic symphysis. ASSESSMENT OF THE ABDOMEN INVOLVES ALL FOUR METHODS OF EXAMINATION. - Inspection - Auscultation - Palpation - Percussion Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel mobility and thus heighten bowel sounds, creating false results. Preparing and positioning the client includes having the client void prior to the abdominal examination. Then, position the client lying supine with his arms at his sides and with his knees slightly bent. QUESTIONS THE NURSE SHOULD ASK INCLUDE: Do you ever have nausea or vomiting? Have you had any changes in your appetite? Do you have any food intolerances? Any recent weight changes? Do you have any swallowing difficulties? Do you have any problems with your bowels? Do you get diarrhea? Constipation? When was your last bowel movement? Do you often use laxatives or enemas? Have you had any black or tarry stools? Do you frequently use aspirin or ibuprofen? Do you ever have heartburn? When? How often? Have you had any low abdominal or back pain? Any tenderness in these areas? Do you have a family history of colon cancer? If over 50, are you getting routine colonoscopies? Are you aware of the signs and symptoms of colon cancer? Do you drink alcohol? If so, how much? What is your typical day’s intake of food and fluid? Do you have any dietary restrictions or special practices?

Assessment

Normal Findings

Deviations from Normal

Inspect the abdomen for skin Unblemished skin integrity. Uniform color

Presence of rash or other lesions

Ask the client to take a deep No evidence of enlargement of breath and to hold it. Rationale: liver or spleen This makes an enlarged liver or spleen more obvious.

Evidence of enlargement of liver or spleen

Assess the symmetry of contour Symmetric contour while standing at the foot of the bed.

Asymmetric contour, e.g., localized protrusions around umbilicus, inguinal ligaments, or scars (possible hernia or tumor)

Tense, glistening skin (may indicate ascites, edema Silver-white striae (stretch Purple striae (associated with marks) or surgical scars Cushing’s disease or rapid weight gain and loss) Observe the abdominal contour Flat, rounded (convex), or Distended (profile line from the rib margin scaphoid (concave) to the pubic bone) while standing at the client’s side when the client is supine.

If distention is present, measure Symmetric movements caused the abdominal girth by placing a by respiration tape around the abdomen at the level of the umbilicus. If girth will be measured repeatedly, use a skin-marking pen to outline the upper and lower margins of the tape placement for consistency of future measurements. ASSESSMENT OF THE PATIENT: ABDOMEN

Assessment

Normal Findings

Deviations from Normal

Observe abdominal movements associated with respiration, peristalsis, or aortic pulsations

Symmetric movements caused by respiration

Limited movement due to pain or disease process

Visible peristalsis in very lean people

Visible peristalsis in nonlean clients (possible bowel obstruction) Marked aortic pulsations

Aortic pulsations in thin people at epigastric area Observe the vascular pattern

No visible vascular pattern

Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs. Warm the hands and the stethoscope diaphragms. Rationale: Cold hands and stethoscope may cause client to contract abdominal muscles, and these contractions may be heard during auscultation.

Audible bowel sounds

Assessment Use the flask-disk diaphragm. Rationale: Intestinal sounds are relatively high pitched and best accentuated by the diaphragm. Light pressure with he stethoscope is adequate.

Normal Findings

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Visible venous pattern (dilated veins) is associated with liver disease, ascites, and venocaval obstruction Hypoactive, i.e., extremely soft and infrequent (e.g., one per minute)

Deviations from Normal Hypoactive sounds indicate decreased motility and are usually associated with manipulation of the bowel during surgery, inflammation, paralytic ileus, or late bowel obstruction. Hyperactive/increased, i.e., highpitched, loud, rushing sounds that occur frequently (e.g. every 3 seconds) also known as borborygmi. Hyperactive sounds indicate increased intestinal motility and are usually associated with diarrhea, an early bowel obstruction, or the use of laxatives. True absence of sounds (none

heard in 3 to 5 minutes) indicates a cessation of intestinal motility Assessment Normal Findings Ask when the client last ate. Rationale: Shortly after or long after eating, bowel sounds may normally increase. They are loudest when a meal is long overdue. Four to 7 hours after a meal, bowel sounds may be heard continuously over the ileocecal valve area (right lower)while the digestive contents from the small intestine empty through the valve into the large intestine. Place the diaphragm of the stethoscope in each of the four quadrants of the abdomen. Listen for active bowel soundsirregular gurgling noises occurring about every 5 to 20 seconds. The duration of a single round may range from less than a second to more than several seconds

Deviation from Normal

Assessment

Normal Findings

Deviation from Normal

Use the bell of the stethoscope over the aorta, renal arteries, iliac arteries, and femoral arteries

Absence of arterial bruits

Loud bruit over aortic area (possible aneurysm)

Listen for bruits

Bruit over renal or iliac arteries

Peritoneal friction rubs are rough, grating sounds like two pieces of leather rubbing together. Friction rubs may be caused by inflammation, infection, or abnormal growths.

Absence of friction rub

Friction rub

Percuss several areas in each of the four quadrants to determine presence of tympany (sound indicating gas in stomach and intestines) and dullness (decrease, absence, or flatness of resonance over solid masses of fluid.) Use a systematic pattern: Begin in the lower right quadrant, proceed to the upper right quadrant, and the upper left quadrant, and the lower left quadrant.

Tympany over the stomach and gas-filled bowels; dullness, especially over the liver and spleen, or a full bladder

Large dull areas (associated with presence of fluid or a tumor)

Assessment Normal Findings Perform light palpation first to No tenderness; detect areas of tenderness abdomen with and/or muscle guarding. consistent tension Systematically explore all four quadrants. Ensure that the client’s position is appropriate for relaxation of the abdominal muscles, and warm the hands. Rationale: Cold hands can elicit muscle tension and thus impede palpatory evaluation.

relaxed smooth,

Deviations from Normal Tenderness and hypersensitivity

Superficial masses Localized areas of increased

tension Assessment Hold the palm of your hand slightly above the client’s abdomen, with your fingers parallel to the abdomen. Depress the abdominal wall lightly, about 1cm or to the depth of the subcutaneous tissue, with he pads of your fingers. Move the finger pads in a slight circular motion. Note the areas of tenderness or superficial pain, masses, and muscle guarding. To determine the areas of tenderness, ask the client to tell you about them and watch for changes in the client’s and onto the abdomen to continue the examination If the client is excessively ticklish, begin by pressing the hand on top of your client’s hand while pressing lightly. Then slide your hand off the client’s and onto the abdomen to continue the examination.

Normal Findings

Deviation from Normal

Assessment Hold the palm of your hand slightly above the client’s abdomen, with your fingers parallel to the abdomen. Depress the abdominal wall lightly, about 1cm or to the depth of the subcutaneous tissue, with he pads of your fingers. Move the finger pads in a slight circular motion. Note the areas of tenderness or superficial pain, masses, and muscle guarding. To determine the areas of tenderness, ask the client to tell you about them and watch for changes in the client’s and onto the abdomen to continue the examination If the client is excessively ticklish, begin by pressing the hand on top of your client’s hand while pressing lightly. Then slide your hand off the client’s and onto the abdomen to continue the examination.

Normal Findings

Deviation from Normal

IMPORTANT THINGS TO REMEMBER Inspection •

Note any guarding or splinting of the abdomen.

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Skin is assessed for:

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o

Lesions – Note any bruising, rashes, or other primary lesions.

o

Scars – Note the location and length.

o

Striae or stretch marks that are silver in color – These are considered expected findings.

o

Dilated veins – An unexpected finding associate with cirrhosis or inferior vena cava obstruction.

o

Jaundice, cyanosis, or ascites – may be associated with cirrhosis.

Shape or contour can be described as: o

Flat – Lies in a horizontal line from the chest to the symphysis pubis.

o

Convex – Rounded

o

Concave – Has a sunken appearance

o

Distended – A large protrusion of the abdomen caused by fat, fluid, or flatus that can be differentiated as follows:

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Fat – The client has rolls of fat tissue along her sides, and the skin does not look taut.

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Fluid – The flanks protrude, and when the client turns onto her side, the protrusion moves to the dependent side.

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Flatus – The protrusion is mainly midline, and the flanks are unchanged.

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Hernias – Protrusions through the abdominal muscle are visible.

Movement of the abdominal wall may be observed as: o

Peristalsis – Wave-like movements are visible in thin adults or in clients with intestinal obstructions.

o

Pulsations – Regular beats of movement seen midline above the umbilicus are expected findings in thin adults, but a pulsating mass would be unexpected.

Umbilicus should be inspected for position, shape, color, inflammation, discharge, or masses. No discharge, inflammation, or masses should be noted.

Auscultation •

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Bowel sounds are produced by the movement of air and fluid in the intestines. The most appropriate time to auscultate bowel sounds in between meals. o

Technique – Listen with the diaphragm of the stethoscope in all four quadrants.

o

Expected sounds – High-pitched clicks and gurgles are heard 5 to 30 times/min. To make the determination of absent bowel sounds, you must listen for a full 5 min without hearing anything.

Friction rubs are abnormal sounds caused by the rubbing together of inflamed layers of the peritoneum. The technique is as follows: o

Listen with the diaphragm over the liver and spleen.

o

Ask the client to take a deep breath while you listen for any grating sounds (like sandpaper rubbing together).

Vascular sounds (bruits caused by narrow vessels disrupting blood flow) o

Abdominal aorta – Just below the xyphoid process

o

Renal arteries – Midclavicular lines above the umbilicus on the abdomen

o

Iliac arteries – Midclavicular lines below the umbilicus on the abdomen

o

Femoral arteries – Over the femoral pulses

Percussion •

Tympany is the expected percussion sound heard over most of the abdomen. A lowerpitch tympany over the gastric bubble in the left upper quadrant may be heard.

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Dullness over the liver or a distended bladder may be heard.

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The liver span is a measurement of liver size taken at the right midclavicular line and can be determined using percussion techniques.

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o

Establish the lower border of the liver by percussing upward from below the umbilicus at the right midclavicular line until tympany turns to dullness.

o

Make a mark.

o

Establish the upper border by percussing downward, starting at the right midclavicular line over the lung until resonance turns to dullness.

o

Make a mark.

o

Measure the distance between the two marks for the size of the liver span.

o

The expected finding is 6 to 12 cm.

Kidney tenderness is assessed by fist percussi...