–Rolling Hiatal Hernia. The upper portion of the stomach but not the lower esophageal sphincter moves through the diaphragm; no GERD.

–Sliding Hiatal Hernia. The upper portion of the stomach and the lower esophageal sphincter moves through the diaphragm; GERD.

–Paralytic Ileus:

○Diminished or absent bowel sounds. Related to decreased peristalsis.

▪Vomiting. Related to purging the backup of intestinal contents into the stomach.

▪Constant abdominal pain. Related to increased intestinal pressure.

▪Abdominal distention. Related to increased intestinal pressure.

–Obstruction:

○Vomiting. Related to purging the backup of intestinal contents into the stomach.

○Constipation. Related to a hard mass of stool and narrowing of the intestine.

○High-pitched bowel sounds. Related to narrowing of intestine.

○Abdominal tenderness. Related to increased intestinal pressure.

○Abdominal cramping. Related to bowel spasm.

○Abdominal distention. Related to increased intestinal pressure.

–NPO. Inability of the gastrointestinal tract to process food.

–Insert NG tube. Suction stomach contents.

–Parenteral nutrition and vitamin supplements. Related to malabsorption.

–Monitor vital signs. Identify patient status.

–Monitor intake and output. Identify fluid balance.

–Assess bowel sounds. Identify peristalsis status.

–Administer as ordered:

○Antiemetic. Decreases vomiting.

○IV fluids. Replaces fluids.

–Acute. Autodigestion of the pancreas by pancreatic enzymes.

–Chronic. Fibrosis resulting in decreased pancreatic function.

–Cullen’s sign. Bluish-gray discoloration of periumbilical area and abdomen. Related to bleeding behind the peritoneum.

–Turner’s sign. Bluish-gray discoloration of flank areas. Related to bruising of the flanks, between the last rib and the top of the hip. Can predict a severe attack of acute pancreatitis.

–Abdominal pain. Related to inflammation.

–Pain radiating to back or left shoulder (acute). Related to inflammation.

–Gnawing continuous pain (chronic). Related to inflammation.

–Epigastric pain. Related to inflammation.

–Knee-chest position reduces pain. Decreases the stretch of the pancreas.

–Nausea. Related to inflammation.

–Vomiting. Related to inflammation.

–Fatigue. Related to malnutrition.

–Hyperglycemia. Related to decreased production of insulin.

–Weight loss. Related to malnutrition.

–Fever. Related to infection.

–Blood Test:

○Increased:

▪Amylase. Related to rupture of pancreatic cells.

▪Lipase. Related to rupture of pancreatic cells.

▪WBC. Related to inflammation.

▪Glucose. Related to decrease insulin production.

–NPO (acute). Decreases the need to produce pancreatic enzymes.

–NG tube. Suction stomach contents.

–Monitor vital signs. Identify changes in patient status.

–Monitor intake and output. Identify fluid balance.

–Monitor blood glucose. Related to decreased insulin production.

–Monitor lung sounds. Identify plural effusion.

–Assess abdomen for bowel sounds, tenderness, masses, ascites.

–Schedule rest periods. Decreases risk for fatigue.

–Take pancreatic enzymes with meals. Assists in digestion.

–No alcohol. Decreases inflammation of the pancreas.

–No caffeine. Decreases inflammation of the pancreas.

–Bland, low fat, high protein, high calorie diet. Decreases pancreatic enzyme production.

–Small frequent meals. Decreases pancreatic enzyme production.

–Administer as ordered:

○No morphine. Causes spasm of the sphincter of Oddi.

○IV fluids. Increases fluids.

○Total parenteral nutrition. Bypasses the pancreas.

○Vitamin supplements. Increases nutrition.

○Analgesia. Decreases pain.

○Insulin (chronic). Replaces decreased insulin production by pancreas.

–Abdominal rebound pain. Related to inflammation.

–Abdominal distention. Related to increased intestinal pressure.

–Rigid abdomen. Related to inflammation.

–Decreased bowel sounds. Related to decreased peristalsis.

–Fever. Related to infection.

–Tachycardia. Related to infection.

–Nausea. Related to infection.

–Vomiting. Related to infection.

–Decreased urine output. Related to progressive kidney failure.

–Increased WBC. Related to infection.

–NPO. Inability of the gastrointestinal tract to process food.

–Elevate head of bed. Decreases the backflow of stomach acid and juices into the esophagus.

–Monitor vital signs. Identify patient status.

–Monitor intake and output. Identify fluid balance.

–Daily weight. Assess for fluid retention.

–Administer as ordered:

○Antibiotic. Decreases infection.

○IV fluids. Increases fluids.

–Gastric Ulcer. Mucosal layer of the stomach is eroded, lessening the curvature of the stomach.

–Duodenal Ulcer. Mucosal layer of the duodenal is eroded resulting in penetration to the muscular layer.

–Bloating. Related to pressure on the stomach.

–Loss of appetite. Food increases pain (gastric ulcer).

–Blood Test:

○Decreased RBC. Related to bleeding.

○Decreased hemoglobin. Related to bleeding.

○Decreased hematocrit. Related to bleeding.

–Stool occult blood positive. Related to upper GI bleeding.

–Epigastric pain:

○Worse after eating (gastric ulcer). Related to irritation of the stomach.

○Worse 1 to 3 hours after eating or at night (duodenal ulcer). Related to irritation of the duodenum.

–Weight Change:

○Loss (gastric ulcer). Related to food intake causing pain and patients avoiding eating.

○Gain (duodenal ulcer). Related to food easing pain and patients increasing eating.

–Bleeding:

○Vomiting red, maroon blood (hematemesis) (gastric ulcer). Related to upper GI bleed.

○Coffee-ground emesis (gastric ulcer). Related to upper GI bleed and digested blood.

○Tarry stool (melena) (duodenal ulcer). Related to upper GI bleed.

–Perforation:

○Sudden, sharp pain relieved with knee-chest position which decreases the stretch of the stomach and duodenum.

○Tender, rigid abdomen. Related to inflammation.

–Hypovolemic shock. Related to bleeding.

–Monitor intake and output. Identify fluid balance.

–Monitor vital signs. Identify changes in patient status.

–Monitor bowel sounds. Identify peristalsis status.

–Monitor abdomen tenderness, rigidity. Assess inflammation.

–Small frequent meals. Decreases irritation to stomach.

–No caffeine. Related to irritation to stomach.

–No alcohol. Related to irritation to stomach.

–No acidic foods. Related to irritation to stomach.

–No NSAIDs medication. Related to irritation to stomach.

–No smoking. Related to irritation to stomach.

–Administer as ordered:

○Antacids. Decreases stomach acid.

○Proton pump inhibitors. Decreases production of stomach acid.

○Sucralfate. Adheres to ulcer sites and provides protection from acids, enzymes, and bile salts.

○Antibiotic. Decreases infection by H. pylori.

–Chronic bloody diarrhea with pus. Related to infection.

–Tenesmus (spasms of the anal sphincter, feeling need to defecate with no stool present). Related to inflammation.

–Weight loss. Patients avoid eating to reduce symptoms.

–Abdominal pain. Related to inflammation.

–Blood Test:

○Decreased RBC. Related to bleeding.

○Decreased hemoglobin. Related to bleeding.

○Decreased hematocrit. Related to bleeding.

○Increased erythrocyte sedimentation rate. Related to inflammation.

–NPO during exacerbations. Inability of the gastrointestinal tract to process food.

–Monitor intake and output. Identify fluid balance.

–Monitor stool output. Assess for bloody diarrhea with pus.

–Daily Weight. Assess changes in the patient’s weight.

–Monitor for toxic megacolon. Distended, tender abdomen, fever, distended colon.

–Keep stool diary. Identify irritating foods.

–Low fiber, high protein, high calorie diet. Less irritating to the GI tract.

–Perianal skin care area:

○Sitz bath.

○Apply barrier cream to skin. Protects the skin.

○Witch hazel. Soothes sensitive skin.

○No fragranced products. Risks of irritating the skin.

–Administer as ordered:

○Antidiarrheal medication. Decreases diarrhea.

○Corticosteroids (during exacerbations). Decreases inflammation.

○Anticholinergics. Decreases gastrointestinal cramps.

○Salicylate. Decreases pain.

–Pain

–Paralysis

–Paresthesia

–Pulse

–Pallor

–Adduction: Moving the limb close to the body (adding to the body).

–Abduction: Moving the limb away from the body (subtracting from the body).

–Initial Questions:

○What makes you feeling that something is wrong?

○What happened prior to noticing this problem?

○Have you recently undergone any medical procedure?

–Follow up questions:

○When did this problem start?

○How long have you had this problem?

○Can you describe the problem?

○How bad does the problem bother you?

○Where do you feel uncomfortable?

○Is the problem spreading or does is the problem remain in one place?

○Does anything make the problem worse?

○Does anything make the problem better?

○Did you have this problem or a similar problem in the past?

○Have you been diagnosed with any medical condition?

○What medications do you use?

○Do you use an assistive device?

○Do you have you recently fallen?

○Do you have a history of falling?

○Do you have any vision problems?

–Lifestyle questions:

○What is your occupation?

○Do you perform repetitive actions?

○Do you or did you exercise?

○Do you or did you play sports?

○Do you consume caffeine?

○Do you drink alcohol?

○Do you use recreational drugs or prescription drugs that are not prescribed to you?

○Do you use tobacco?

–Family history:

○Does anyone in your family have or had osteoarthritis?

○Does anyone in your family have or had rheumatoid arthritis?

○Does anyone in your family have or had osteoporosis?

○Does anyone in your family have or had spondyloarthropathies?

○Does anyone in your family have or had cancer?

–Assess the patient’s gait.

–Does the patient have difficulty bearing weight?

–Is the patient guarding the site of the injury?

–Does the patient have pain during movement or at rest (assess facial expression)?

–Muscles:

○Weakness

○Swelling

○Bruising

–Bone:

○Skin breakage

○Deformed skeleton

○Impaired range of motion. Never force range of motion movement.

–Range of Motion Assessment:

○Temporomandibular Joint (TMJ):

▪Place first two fingers on patient’s ear.

▪Ask patient to open and close his mouth.

▪Place fingers into the depression over the joint.

▪Ask patient to open and close his mouth.

▪The patient should easily open and close his mouth without pain or discomfort.

–Neck:

○If there is no suspected neck or spinal injury, ask the patient to:

▪Touch right ear to right shoulder.

▪Touch left ear to left shoulder.

▪Touch chin to chest (45 degrees is normal).

▪Tilt head back and look at the ceiling (55 degrees is normal).

▪Turn head to each side.

▪Move head in a circle (70 degrees is normal).

–Spine:

○If there is no suspected neck or spinal injury, ask the patient to:

▪Bend at the waist.

▪Let arms hang at sides.

○Palpate the spine with your fingers.

○Palpate the spine with the side of your hands.

○The spine should be symmetrical with no tenderness or swelling.

–Shoulders:

○Shoulders should be symmetric and not deformed.

○Palpate the:

▪Bony landmarks with your fingers

▪Shoulder muscles with your hand

•Muscles should be firm and symmetrical

▪Elbow and ulna

○Ask the patient to:

▪Extend his arms straight at the side (neutral position).

▪Lift arms straight to shoulder level.

▪Bend elbows at 90 degrees.

▪Extend arms out parallel to the floor, palms down and fingers extended.

▪Extend forearms up with fingers pointed to the ceiling. Forearms should move 90 degrees.

▪Extend forearms down with fingers pointing to the floor. Forearms should move 90 degrees.

▪Extend arms straight at the side (neutral position).

▪Move arms forward and up over head.

▪Extend arms straight at the side (neutral position).

▪Move arms as far back as possible. Arms should bend 30 degrees.

▪Extend arms straight at the side (neutral position).

▪Move arms away from body (abduction). Arms should move 180 degrees.

▪Extend arms straight at the side (neutral position).

▪Move arms across the front of the body (adduction). Arms should move 50 degrees.

▪Extend arms straight at the side (neutral position).

▪Flex elbows. Elbows should flex 90 degrees.

▪Place the side of the hand (thumbs facing up) on a flat surface.

▪Rotate the palm of hand down to the surface (pronation). The elbow should rotate 90 degrees.

▪Rotate the palm of hand upward from the surface (supination). The elbow should rotate 90 degrees.

–Wrists and hands:

○Examine the hands. Look for:

▪Deformities

▪Swelling

○Feel bones in the fingers and wrist. Look for tenderness.

○Ask the patient to:

▪Rotate the wrist in a waxing motion. There should be 55 degrees of movement away from the body (lateral movement) and 20 degrees of movement towards the body (medial movement).

▪Move the wrist backward with fingers pointing upward. The wrist should move 70 degrees.

▪Move the wrist downward with fingers pointing to the floor. The wrist should move 90 degrees.

▪Move only the fingers to the ceiling (extension). Fingers should move 30 degrees.

▪Move only the fingers towards the floor (flexion). Finger should move 90 degrees.

▪Touch little finger with thumb.

▪Form a fist (adduction).

▪Spread fingers (abduction).

▪Compare the length of the patient’s arms. There should be no more than 1 cm difference in length.

–Hips:

○Examine the hips. Look for symmetry.

○Palpate the hips and note any tenderness.

○Assess the patient’s hip:

▪Flexion. Place your hand under the lumbar spine. Ask the patient to raise knee to chest. The patient’s lumbar spine should touch your hand. The opposite thigh and hip should remain flat. Repeat the test with the other hip.

▪Abduction. Press the superior iliac spine. Move the patient’s leg by the ankle away from the other leg. You should feel movement of the iliac spine. The leg should move 45 degrees.

▪Adduction. Press the superior iliac spine. Move the patient’s leg by the ankle toward the other leg. You should feel movement of the iliac spine. The leg should move 30 degrees.

▪Extension. Ask the patient to lie face down. Ask the patient to raise the thigh upwards. Repeat the test with the other hip.

▪Internal and external rotation. Ask the patient to lie on his or her back and raise one leg while keeping the knee straight. Turn the patient’s leg away from the other leg (external rotation) and then turn the patient’s leg towards the other leg (internal rotation). The leg should turn 45 degrees.

○Repeat the test with the other hip.

–Knees:

○Ask the patient to stand.

○Examine the knees. Look for:

▪Deformities

▪Swelling

▪Tenderness

○Ask the patient to bring the heel to:

▪Buttocks (flexion). The leg should move 120 degrees. If the patient is unable to stand, then ask the patient to lie down on his or her back and raise knee to chest. The thigh should touch the calf.

▪The floor.

–Ankles and feet:

○Examine the ankles and feet. Look for:

▪Deformities

▪Swelling

○Feel bones in the feet and ankle. Look for tenderness.

○Ask the patient to:

▪Sit.

▪Point toes towards the floor (plantar flexion). The toes should move 45 degrees.

▪Point toes to the ceiling (dorsiflexion). The toes should move 20 degrees.

▪Turn feet inward (inversion). The feet should move 45 degrees.

▪Turn feet outward (eversion). The feet should move 20 degrees.

▪Clench and release toes (metatarsophalangeal joints). Toes should move freely without tenderness.

○Compare the length of the patient’s legs. There should be no more than 1 cm difference in length.

–Muscles:

○Measure the circumference of the same muscle on each side of the body. They should have relatively the same measurement.

○Repeat the range of motion assessment (see above) except you move the limb (passive range of motion). You should feel slight resistance to the motion (muscle tone).

○The limb should return easily to the neutral position when you finish the range of motion assessment.

○Ask the patient to extend arms with palms up for 30 seconds (strength of shoulder girdle).

○Place your hands on the patient’s palm and press down. You should feel resistance.

○Ask the patient to:

▪Bend the arm. Pull down on the patient’s arm (bicep strength). You should feel resistance.

▪Bend the arm and then try to straighten the arm as you push the forearm upward (triceps strength). You should feel resistance.

▪Flex the wrist, then push against it. You should feel resistance.

▪Extend the wrist then push down on it. You should feel resistance.

▪Squeeze your hand. You should feel resistance.

▪Have the patient lie on his or her back.

•Raise both legs simultaneously. Both legs should raise to the same distance at the same time.

•Lower legs.

•Raise each leg as you push down on the leg (quadriceps strength). You should feel resistance.

•Bend knees and place feet on the bed.

○Pull the patient’s leg forward (lower leg strength). You should feel resistance.

○Ask the patient to:

▪Bend the knee as you push against it. You should feel resistance.

▪Push foot down against your hand as you push the foot up (ankle strength). You should feel resistance.

▪Pull foot up as you push the foot down. You should feel resistance.

○Measure muscle strength by using the muscle grade (Table 8.5).

–Unsteady gait

–Swelling (edema)

–Pain or tenderness, especially during movement

–Discoloration of skin

○Pale (neurovascular problem)

○Purple bruising (ecchymosis)

–Skin temperature cool at site (neurovascular problem)

–Unstable joint(s)

–Difficulty with range of motion

–Loss of sensation (paresthesia) or abnormal sensation (neurovascular problem)

–Decrease or absence of pulse (reduced blood supply to site)

–Asymmetric skeletal structure

–Misaligned skeletal structure

–Weakness and pain in the hand. Related to nerve compression.

–Paresthesia in the hand. Related to nerve compression.

–Tingling in the hand. Related to nerve compression.

–Numbness in the hand. Related to nerve compression.

–Positive Tinel’s sign. Tapping over the carpal tunnel area causes tingling, numbness, or pain in the hand.

–Inflating the blood pressure cuff on the upper arm causes pain, tingling, and burning sensation in the wrist and hand. Related to nerve compression.

–Physical therapy. Maintains mobility.

–Administer as ordered:

○Anti-inflammatory. Decreases inflammation.

○Corticosteroids. Decreases inflammation.

–Shoulder. Resulting from a fall with the arm extended.

–Acromioclavicular separation. Resulting from blunt force trauma to the shoulder.

–Elbow. Resulting from a fall with the arm extended.

–Wrist. Resulting from a fall with the hand extended.

–Finger. Resulting from blunt force trauma to the fingertip or a fall with the hand extended.

–Hip. Resulting from blunt force trauma to a bent knee (for example, knee hitting the dashboard in a motor vehicle accident).

–Knee. Resulting from blunt force trauma to the knee (for example, sports injury).

–Patella. Resulting from twisting the leg with the foot planted on the ground or blunt force trauma to the knee.

–Ankle. Resulting from blunt force trauma to the foot (for example, pushing the brake pedal in a motor vehicle accident.)

–Pain or tenderness in the joint. Related to pressure on nerves.

–Deformity at the joint. Related to the dislocation.

–Reduced range of motion. Related to the dislocation.

–Swelling. Related to inflammation.

–Enlargement of joint. Related to inflammation.

–Pain management. Decreases pain.

–Immobilize the site. Decreases pain and tissue damage.

–Administer as ordered:

○Anti-inflammatory. Decreases inflammation.

○Analgesics. Decreases pain.

–Incomplete fracture: The fracture is not complete through the bone.

–Complete fracture: The fracture is completely through the bone. Types include greenstick, spiral, comminuted, transverse, oblique, and impacted.

–Open fracture: The fracture penetrates the skin.

–Closed fracture: The fracture does not penetrate the skin.

–Edema. Related to inflammation.

–Abnormal range of motion. Related to obstruction to range of motion.

–Local bleeding. Related to damage to blood vessels.

–Muscle spasms. Related to involuntary contraction of muscles.

–Monitor vital signs. Identify changes in patient status.

–Monitor circulation in area of the fracture. Identify decreased circulation at site.

–Monitor signs of bleeding. Increased pulse, increased respiration, decreased blood pressure.

–Perform range of motion exercises. Maintains muscle tone.

–Complications:

○Fat embolism. Yellow bone marrow releases fat into the blood stream resulting in emboli.

○Delayed union. A fracture that is not joined within 6 months.

○Compartment syndrome. Nerves, blood vessels and muscles are compressed leading to tissue necrosis.

○Deep vein thrombosis (DVT). Clots form as a result of immobility from fracture.

○Misalignment. Bone pieces are not anatomically aligned.

○Muscle wasting. Deterioration of muscle as a result of immobilization related to the fracture.

–Dark “black-and-blue” mark beneath the skin. Related to bleeding.

–Yellow-green color at the site 48 hours after the bleeding. Related to metabolism of blood.

–Swelling. Related to inflammation.

–Discomfort when the site is touched or with movement. Related to inflammation.

–Assess if the patient is on anticoagulant therapy. Anticoagulant therapy increases bleeding time.

–Assess if bleeding has stopped. Circle site of contusion. If “black and blue” color moves beyond the circled site, then bleeding has not stopped.

–Administer as ordered:

○Analgesics. Decreases pain.

○NSAIDs. Decreases inflammation.

–Swollen joint. Uric acid crystals deposited in the joint.

–Red, tender joint. Uric acid crystals deposited in the joint.

–Joint pain especially at night. Uric acid crystals deposited in the joint.

–Kidney stones (nephrolithiasis) Uric acid crystals deposited in the kidneys.

–Monitor serum uric acid levels. Identify increased uric acid levels.

–Immobilize the joint. Reduces pain.

–Don’t touch joint. Reduces pain.

–Increase daily fluids (3 liters) of fluid. Decreases crystallization of uric acid.

–Avoid fructose sweetened drinks. Decreases crystallization of uric acid.

–Low fat, low cholesterol diet. Decreases uric acid production.

–Avoid foods that are high in purine proteins. Turkey, organ meats, sardines, smelts, mackerel, anchovies, herring, and bacon. Increases uric acid production.

–Avoid alcohol. Inhibits renal excretion of uric acid.

–No aspirin. Aspirin retains uric acid.

–Administer as ordered:

○Xanthine oxidase inhibitor. Decreases uric acid level.

○Anti-inflammatory. Decreases inflammation.

○Uricosuric. Decreases uric acid level.

–Internal. Caused by the pressure of a build-up of blood in muscle or beneath the skin (contusion), frostbite, infiltration of an IV, snake bite, or by a fracture.

–External. Caused by the pressure of an immobilization device such as a cast or dressing.

–Swelling. Related to inflammation.

–Decreased pulse or pulselessness. Related to decreased circulation.

–Decreased temperature at site. Related to inflammation.

–Numbness or tingling (paresthesia). Related to nerve compression.

–Pain disproportionate to the underlying injury. Related to inflammation.

–Pallor. Related to decreased circulation.

–Paralysis. Related to nerve compression.

–Remove immobilizing device. Returns circulation to site.

–Stabilize site. Prevents tissue damage.

–Apply ice to the site 20 minutes on, 20 minutes off. Decreases inflammation.

–Administer as ordered:

○Analgesics. Decreases pain.

–Crepitus (grating sound or sensation). Friction between bone and cartilage or bone and bone.

–Joint pain on movement relieved with rest. Related to bone on bone contact on movement of the joint.

–Stiff joints for a short time in morning, usually 15 minutes or less. Related to immobility.

–Heberden’s nodes (enlargement of joint). Related to calcific spurs.

–Enlargement of joint.

–Exercise. Maintains mobility.

–Reduce weight. Decreases stress on joints.

–Administer as ordered:

○Analgesics. Decreases pain.

○Anti-inflammatory. Decreases inflammation.

–Pain. Related to inflammation.

–Malaise. Related to infection.

–Fever. Related to infection.

–Chills. Related to attempts to cool the body.

–Increased WBC. Related to infection.

–Monitor vital signs. Identify changes in patient status.

–Administer as ordered:

○Analgesics. Decreases pain.

○Antibiotics. Decreases bacterial infection.

–Asymptomatic

–Decreased height. Related to spinal compression.

–Kyphosis (hunchback appearance). Related to spinal compression.

–Unexplained fractures. Related to decreased bone density.

–Back pain. Related to spinal fractures.

–Perform weight-bearing activity. Reduces bone reabsorption.

–Perform range of motion exercises. Maintains mobility.

–Administer as ordered:

○Bisphosphonate. Inhibits bone reabsorption.

○Forteo (teriparatide). Stimulates collagenous bone growth

○Calcium. Increases availability of calcium

○Vitamin D. Enhances absorption of calcium.

–Swelling. Related to inflammation.

–Bruising (ecchymosis). Related to ruptured blood vessels.

–Pain caused by movement. Related to inflammation.

–Spasms. Related to involuntary muscle movement.

–Loss of function (third degree). Related to ligament stretches and tears.

–Protrusion at the trauma site (third degree). Related to ligament stretches and tears.

–Unstable joint (third degree). Related to ligament stretches and tears.

–Apply ice 20 minutes on and 20 minutes off for the first 24 hours. Reduces swelling.

–Apply heat 20 minutes on and 20 minutes off for the second 24 hours to enhance the inflammation process repairing the tissue. Increases inflammation response.

–Elevate trauma site. Reduces swelling.

–Rest. Decreases pain and encourages healing.

–Immobilize site (second and third degree). Reduces pain and injury.

–Keep site free from any binding such as jewelry. Inhibits circulation when the site is swollen.

–Gradually reuse the muscle. Regain range of motion.

–Administer as ordered:

○Analgesics. Decreases pain.

○Anti-inflammatory. Decreases inflammation.

–Kidneys

–Ureters

–Bladder

–Urethra

–Male:

○Penis

○Scrotum

○Testicles

○Epididymis

○Vas deferens

○Seminal vesicles

○Prostate gland

–Female:

○Vagina

○Uterus

○Ovaries

○Fallopian tubes

○Vulva

○Labia majora

○Labia minora

○Clitoris

○Urethral meatus

○Skene’s Glands

○Bartholin’s Glands

–Initial Questions:

○Why did you come to the hospital today?

○What makes you feeling that something is wrong?

○What happened prior to noticing this problem?

○Have you recently undergone any medical procedure?

–Follow up questions

○When did this problem start?

○How long have you had this problem?

○Can you describe the problem?

○How bad does the problem bother you?

○Where do you feel uncomfortable?

○Is the problem spreading or does the problem remain in one place?

○Does anything make the problem worse?

○Does anything make the problem better?

○Did you have this problem or a similar problem in the past?

○Have you been diagnosed with any medical condition?

○What medications do you use?

–Urinary system questions:

○Have there been any recent changes in your urination?

○How often do you urinate?

○Do you experience any burning during urination?

○What color is your urine?

○Does your urine have an odor?

–Reproductive system questions:

○How many sexual partners have you had?

○Do you have risk-taking behaviors?

○What is your sexual preference?

○Have you ever had or do you have a sexually transmitted disease (STD)?

○Do you know your HIV status?

○Do you use birth control?

○Males:

▪Is there any discharge from your penis?

▪Do you experience any tenderness in your genitals?

▪Did you notice any lumps or growths in your genitals?

▪Do you experience any itching (pruritus) in your genitals?

○Females:

▪When was your last menstrual period?

▪Do you experience vaginal dryness?

▪Do you experience vaginal itching?

▪Do you have hot flashes?

▪Do you experience flushing?

▪Do you have mood swings?

▪Describe your menstrual cycle.

▪Do you spot between menstruation cycles?

▪What is the length of your menstrual cycle?

▪When was your first menstrual period?

▪Do you use tampons?

▪Is there any vaginal discharge?

▪Do you experience any unusual uterine bleeding?

▪Do you experience any vaginal itching (pruritus)?

▪Do you experience pain with intercourse?

▪When was your last intercourse?

▪When was your last Pap (Papanicolaou) test?

▪What was the result of your last Pap test?

▪Do you go for routine gynecological examinations?

–Family History.

○Does anyone in your family have or had diabetes?

○Does anyone in your family have or had hypertension?

○Does anyone in your family have or had cardiovascular disease?

○Does anyone in your family have or had kidney stones?

–Snow crystals on the skin (uremic frost). Related to increased retention of metabolic waste caused by decreased renal function.

–Pale skin. Related to decreased hemoglobin caused by decreased renal function.

–The normal abdomen:

○Symmetrical when the patient lies on back.

○Has no discolorations.

○Has no silvery streaks (striae). Silvery streaks indicate ascites related to nephrotic syndrome.

–Normal genitalia:

○Has no discharge.

○Does not appear inflamed.

–Listen for abnormal sounds in the renal arteries.

○A turbulent sound (bruits). Related to a disruption in blood flow in the renal artery.

–Percuss the kidneys:

○The patient sits upright on the edge of the bed.

○Place the ball of one hand on the patient’s back over the kidney at the twelfth rib.

○Strike your hand with your other hand. You should hear a thud.

○Repeat the percussion on the other kidney.

▪Normal: Hearing a thud with no tenderness.

▪Abnormal: Tenderness related to kidney infection.

–Percuss the bladder:

○Have the patient urinate immediately before the examination.

○Ask the patient to lie on his or her back.

○Place a hand on the abdomen.

○Tap the middle finger with your other hand.

○Start at the symphysis pubis and move up over the bladder.

▪Normal: Hear tympany.

▪Abnormal: Dull sound related to urine retention or a mass.

–Palpate the kidneys:

○Ask the patient to lie on his or her back.

○Place one hand under the patient below the kidney.

○Place the other hand above the patient by the kidney.

○The patient inhales.

○Press your hands together.

○Repeat this process on the other kidney.

▪Normal: Should not feel the kidney.

▪Abnormal: Feel kidney related to enlarged kidney.

–Not urinating (anuria)

–Excessive urinating (polyuria)

–Producing small amount of urine (oliguria)

–Painful urination (dysuria)

–Hesitancy

–Involuntary urination (incontinence)

–Getting up from sleep to urinate (nocturia)

–Odor from urine (bacterial infection)

–Cloudy urine (bacterial infection)

–Blood in urine (hematuria)

–Clear urine (over-hydrated)

–Dark urine (dehydrated)

–Males:

○Itchy (pruritus)

○Penile discharge

○Mass on genitals

○Tenderness on genitals

–Females:

○Vaginal discharge

○Vaginal odor

○Uterine bleeding

○Vaginal itching (pruritus)

○Cramps

○Infrequent menstrual periods (oligomenorrhea)

○Short menstrual periods (hypomenorrhea)

○Painful menstrual periods (dysmenorrhea)

○No menstrual periods (amenorrhea)

○Frequent menstrual periods (polymenorrhea)

○Spotting (metrorrhagia)

○Long menstrual periods (hypermenorrhea)

–Intravaginal torsion: Within the tissue covering the testicles. Testis is free to rotate.

–Extravaginal torsion: Outside the tissue covering the testicles. Spermatic cord twists above the testis.

–Scrotal swelling not relieved by elevation of the scrotum. Related to inflammation.

–Severe pain in the scrotum. Related to nerve compression.

–Positive Prehn’s Sign:

○Elevate scrotum to symphysis pubis.

○Positive Prehn’s Sign. Increased pain.

○Negative Prehn’s Sign. Decreased pain related to inflammation of testis (epididymitis).

–Monitor vital signs. Identify changes in patient status.

–Administer as ordered:

○Analgesics. Decreases pain.

–Oliguria. Related to inflammation and infection.

–Hematuria. Related to RBC passing through the glomerulus.

–Peripheral edema. Related to buildup of fluids and salts.

–Increased blood pressure. Related to buildup of fluids and salts.

–Increase BUN. Related to the inability of the kidneys to excrete urea nitrogen in urine.

–Decreased albumin. Related to albumin passing through the glomerulus.

–Decreased glomerular filtration rate. Related to infection reducing the filtering capacity of the kidneys.

–Monitor vital signs. Identify changes in patient status.

–Monitor intake and output. Identify if patient is retaining fluid.

–Weigh daily. Identify if patient is retaining fluid.

–Monitor extremities for edema. Identify if patient is retaining fluid.

–Decrease fluid intake. Due to risk of patient retaining fluid.

–Administer as ordered:

○Antibiotics. Decreases bacterial infection.

○Analgesics. Decreases pain.

○Diuretic. Decreases fluid retention.

–Unilateral extreme flank pain (renal colic). Related to kidney stones.

–Hematuria. Related to irritation of the kidney or ureter.

–Monitor intake and output. Identify fluid imbalance.

–Strain urine. Identify passed kidney stone.

–Increase fluid intake. Increase passage of kidney stone.

–Dietary modification based on makeup of stone. Decreases formation of kidney stone.

–Administer as ordered:

○Analgesics. Decreases pain.

–Flank pain. Related to inflammation.

–Fever. Related to infection.

–Chills. Related to attempts to cool the body.

–Urinary frequency. Related to infection.

–Urinary urgency. Related to infection.

–Costovertebral angle (CVA) tenderness. Percussion in the area of the back over the kidney causes pain.

–Nausea. Related to infection.

–Vomiting. Related to infection.

–Diarrhea. Related to infection.

–Monitor vital signs. Identify changes in patient status.

–Monitor intake and output. Identify fluid imbalance.

–Increase fluid intake. Flush kidneys.

–Administer as ordered:

○Analgesics. Decreases pain.

▪Phenazopyridine. Local analgesic. Turns urine orange.

○Antibiotics. Decreases bacterial infection.

○Antipyretics. Decreases fever.

–Acute. Sudden decrease in renal function.

–Prerenal. Diminished renal perfusion.

–Hypovolemia. Blood or fluid loss.

–Postrenal. Urinary tract obstruction.

–Chronic. Progressive decrease in renal function related to irreversible renal disease.

–Decrease urinary output. Related to decreased kidney function.

–Peripheral edema. Related to backup of fluids.

–Abdominal bruit. Related to renal artery stenosis.

–Weight loss. Related to loss of appetite.

–Uremic pruritus. Related to excessive urea in the blood.

–Elevated BUN. Related to the inability of the kidneys excrete urea nitrogen in urine.

–Elevated creatinine. Related to the inability of the kidneys excrete creatinine in urine.

–Decreased creatinine clearance. Related to the inability of the kidneys excrete creatinine in urine.

–Decreased RBC. Related to insufficient production of erythropoietin (EPO) by the kidneys.

–Decreased hemoglobin. Related to insufficient production of erythropoietin (EPO) by the kidneys.

–Proteinuria. Related to albumin passing through the glomerulus.

–Decreased glomerular filtration rate. Related to decreased kidney function.

–Monitor vital signs. Identify changes in patient status.

–Monitor intake and output. Identify if patient is retaining fluid.

–No contrast dye tests. Kidneys unable to excrete dye.

–Restrict potassium, phosphate, sodium, protein in diet. Related to decreased kidney function to filter and excrete urine.

–Administer as ordered:

○Antibiotics. Decreases bacterial infection.

○Antipyretics. Decreases fever.

○Phosphate binders. Decreases phosphate levels.

○Sodium polystyrene sulfonate. Decreases potassium levels.

○Erythropoietin. Replaces the erythropoietin hormone normally produced by the kidney to form red blood cells.