Health Assessment

PERIPHERAL VASCULAR ASSESSMENT

Focus of assessment
o o o o o Assessment of Skin Hair Nails Pulses Temperature  Pain and sensation

Arterial Pulses
Palpate the central and peripheral pulses j j j j j j j Carotid Brachial Radial Femoral Popliteal Dorsalis pedis Posterior tibial

Arms
Inspection  Arm: size, pattern and presence of edema  Hands: color Palpation

Health Assessment
      Palpate the fingers, hands, and arms, and note the temperature Palpate to assess the capillary refill Palpate radial pulse Palpate ulnar pulse Palpate the brachial pulses if you suspect arterial insufficiency Palpate the epitrochlear lymph nodes

 Perform Allen's test

Legs
Inspection  Observe skin color while inspecting both legs from the toes to the groin  Inspect distribution of hair  Inspect for lesions or ulcers  Inspect for edema  Inspect for varicosities and thrombophlebitis Palpation  Palpate edema  Palpate bilaterally for temperature of the feet and legs  Palpate the superficial inguinal lymph nodes  Palpate femoral, popliteal, dorsalis pedis, and posterior tibial pulses Check for Homan s Sign  Perform position test for arterial insufficiency  Use ankle- brachial pressure index (ABPI)  Manual compression test  trendelenburg

Abnormal Findings
Arterial Insufficiency Pain: unrelenting, constant Pulses: diminished or absent Skin characteristics: dependent rubor o o Elevation pallor of foot Dry, shiny skin

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o Coo-to-cool temperature o Loss of hair over toes and dorsum of foot o Nails thickened and ridged Ulcer Characteristics: Location: tips of toes, toe webs, heel or other pressure areas if confined to bed Pain: very painful Depth of ulcer: deep, often involving joint space Shape: circular Ulcer base: pale black to dry and gangrene Leg edema: minimal unless extremity kept in dependent position constantly to relieve pain Venous Insufficiency Pain: aching, cramping Pulses: present but difficult to palpate through edema Skin Characteristics: o Pigmentation in gaitor area o Skin thickened and tough o Maybe reddish-blue in color o Frequently associated w/ dermatitis Ulcer Characteristics: Location: medial malleolus or anterior tibial Pain: minimal pain but very painful (superficial) Depth of Ulcer: superficial Shape: irregular border Ulcer base: granualation tissue Leg edema: moderate to severe Edema Associated with Lymphedema Caused by abnormal or blocked lymph vessels Nonpitting Usually bilateral: maybe unilateral No skin ulceration or pigmentation Edema Associated with Chronic Venous Insufficiency Caused by ostruction or insufficiency of deep veins Pittting, documented as: 1+ = slight pitting 2+ = deeper than 1+ 3+ = noticeably deep pit: extremely looks larger 4+ = very deep pit: gross edema in extremity Usually unilateral; may be bilateral Skin ulceration and pigmentation may be present

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FEMALE AND MALE GENITALIA ASSESSMENT

Female Genitalia
l Menstrual Cycle occurs approximately every 18-5 days; average length is 3-7 days. l During menstrual period, you may experience cramps, bloating, moodiness and breast tenderness.  Menarche (beginning of menstruation)  Irregular periods (Amenorrhea)- may be due to pregnancy, depression, ovarian tumors and cyst, autoimmune disease and hormonal imbalance.

Menopause
l Premature and delayed menopause may be due to genetic disposition, an endocrine disorder or genetic dysfunction. l Signs and symptoms: hot flashes & night sweats, mood swings, decrease appetite, vaginal dryness, spotting and irregular vaginal bleeding.  HRT: Hormonal replacement therapy.

Vaginal Discharge, Pain, Masses

l Maybe caused by infection. l Pain in the vulva, vagina, uterus, cervix or ovaries may indicate infection.  Older client is more susceptible to vaginal infection because of atrophy of thevaginal mucosa associated with aging.  Lumps, swelling or masses in genital area may indicate infection, lymphoma, or cancer.

Urination
l Dysuria (): signs of infection (UTI or STD) whereas hesitancy or straining could indicate blockage; change in color and development of abnormal color could indicate infection. l Incontinence (): indicate urgency or stress incontinence.  Urinary incontinence may develop in older women from weakness or loss of urethral elasticity.

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Sexual Dysfunction
l Change in sexual activity or libido.  As women age, their estrogen production decreases,causing atrophy of the vsginsl mucosa.  Infertility: unprotectes sex for 1 year without pregnancy. i i i i STD-Sexually Transmitted Disease Pap Smear- screening test for cervical cancer Diabetes- predisposes women to vaginal yeast infection. Smoking & Contraceptive- increase the risks of cardiovascular problems. i Cervical Cancer

Physical Assessment
External Genitalia  Inspection a) Mons Pubis  Pubic hair should be inverted triangular pattern and there are no signs of infestation.  Absence of hair in the adult client id abnormal.  Lice or nits at the base of the pubic hairs indicate infestation with pediculosis pubis. b) Inguinal Lymph Nodes  There should be no enlargement or swelling of the lymph nodes.  Enlarge inguinal nodes may indicate a vaginal infection or may result of irritation from shaving pubic hairs. c) Labia Majora and Perineum  Observe for lesions, swelling, excoriation.  The labia majora are equal in size.  A healed tear or episiotomy scar may be visible on the perineum if the client has given birth.  The perineum should be smooth. d) Labia Minora, Clitoris, Urethral Meatus, and Vaginal Opening.  Appear symmetric, dark pink, and moist.  Clitoris: small mound of erectile tissue, sensitive to touch; normal size varies.  Urethral Meatus: small and slitlike.  Vaginal Opening: positioned below the urethral meatus; size depends sexual activity or vaginal delivery; it may be covered partially or completely by a hymen.

Health Assessment
 Asymmetric labia may indicate abscess; lesions, swelling, bulging in the vaginal opening , and discharge are abnormal findings; excortation may result from the client scratching or self-treating a perineal irritation.  Palpation a) Palpate Bartholin s Glands  Usually soft, nontender, and drainage free.  Swelling, pain, and discharge may result from infection and abscess; if you detect a discharge, obtain a specimen to send to the laboratory for culture. b) Palpate the Urethra  No drainage should be noted from the urethral meatus; the area is normally soft and nontender.  Drainage from the urethra indicates possible urethritis; any discharge should be cultured. Internal Genitalia  Inspection a) Inspect the size of the vaginal opening and the angle of the vagina  Normal vaginal opening: varies in size according to the client s age, sexual history, and whether she has given birth vaginally; the vagina is typically tilted posteriorly at a 45r angle.  Any loss of hymen tissue between the 3 o clock position and 9o clock position indicates trauma (penetration by digits, penis or foreign objects) in children. b) Inspect the vaginal musculature  The client should be squeeze around the examiner s finger; typically, the nulliparous woman can squeeze tighter than the multiparous woman; no bulging and no discharge.  Absent or decreased ability to squeeze the examiner s finger indicates decreased muscle tone. Decreased tone may decrease sexual satisfaction. Bulging of the anterior wall may indicate a cystocele. Bulging of the posterior wall may indicate a rectocele. If the cervix or uterus protrudes down, the client may have uterine prolapsed. If urine leaks out, the client may have stress incontinence. c) Inspect the cervix  Surface of the cervix is normally smooth, pink, and even. Normally it is midline in position and projects 1-3 cm into the vagina.  Cervical secretions are normally clear or whithout unpleasant odor. Secretions may vary according to timing within the menstrual cycle.  In pregnant client, the cervix appears blue.

Health Assessment
In older women, the cervix appears pale after menopause. In a nonpregnant woman, a bluish cervix may indicate cyanosis; in a nonmenopausal woman, a pale cervix may indicate anemia. Redness may be from inflammation.  Cervical enlargement of projection into the vagina more than 3 cm may be from prolapsed or tumor, and further evaluation is needed.  Asymmetric, reddened areas, strawberry spots, and white patches are also abnormal as is colored, malorous, or irritating discharge; a specimen should be obtained for culture. Cervical lesions may result from polyps, cancer, or infection. d) Inspect the vagina  The vagina should appear pink, moist, smooth, and free of lesions and irritation. It should be free of any colored, malodorous discharge.  Reddened areas, lesions, and colored, malodorous discharge are abnormal and may indicate vaginal infections, STD s, or cancer. Altered pH may indicate infection. Bimanual Examination  Palpation a) Palpate the vaginal wall  Palpate for contour, consistency, mobility and tenderness.  The vaginal wall should feel smooth, and the client should not report any tenderness.  Tenderness or lesions may indicate infection. b) Palpate the cervix  The cervix should fell firm and soft (like the tip of your nose). It is rounded, and can be moved somewhat from side to side without eliciting tenderness.  A hard, immobile cervix may indicate cancer. Pain with movement of the cervix may indicate infection. c) Palpate the uterus  The fundus, the large upper end of the uterus, is normally round, firm, and smooth. In most women, it is at the level of the pubis; he cervix is aimed posteriorly (anteverted position).  The normal uterus moves freely and is not tender.  An enlarge uterus above the level of the pubis is abnormal; an irregular shape suggests abnormalities such as myomas (fibrois tumors) or endometriosis.  A fixed or tender uterus may indicate fibroids, infections, or masses. d) Palpate the ovaries  

Health Assessment
It is normal for the ovaries to be difficult or impossible to palpate in obese women, in postmenopausal women because the ovaries atrophy, or in women are tense during the examination.

 

Ovaries are approximately 3x2x1 cm (walnut size) and almond shaped. Large amount of colorful, frothy, or malodorous secretions are abnormal. Ovaries that are palpable 3 to 5 years after menopause are also abnormal.

Rectovaginal Examination
  Rectovaginal septum is normally smooth, thin, movable, and firm. The posterior uterine wall is normally smooth, round, movable, and nontender. Maeese, thickened structure, immobility, and tenderness are abnormal.

ABNORMALITIES OF THE EXTERNAL GENITALIA AND VAGINAL OPENING  Syphilitic Chancre  Genital Warts  Genital Herpes Simplex  Cystocele  Rectocele  Uterine Prolapse ABNORMALITIES OF THE CERVIX  Cyanosis of the Cervix  Cancer of the Cervix  Cervical Polyp  Cervical Erosion  Mucopurulent Cervicitis  Malformations From Exposure to Diethylstilbestrol (DES)

VAGINITIS  Trichonas Vaginitis (Trichomoniasis)  Atrophic Vaginitis  Candidal Vaginitis (Moniliasis)  Bacterial Vaginosis UTERINE ENLARGEMENT  Normal Enlargement: Pregnancy  Uterine Fibroids (Myomas)  Uterine Cancer (Cancer of the Endometrium)  Endometriosis ADNEXAL MASSES  Pelvic Inflammatory Disease (PID)  Ovarian Cyst  Ovarian Cancer  Ectopic Pregnancy

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Male Genitalia Assessment

Inspection  Penis: inspect base and pubic hair for growth pattern, erythema or infestation at the base of the penis and within the pubic hair;absence or scarcity of pubis hair maybe seen in client receiving therapy. Lice ot nits infestation at the base of the penis or pubic hair (pediculosis pubis) or crabs  skin of the shaft: rashes, lesions or lumps (if present may indicate STD or cancer)  foreskin: color, location and integrity (skin of penis should be wrinkled and hairless)  glans: size, shape and lesions or redness  Scrotum: size, shape, position for swelling, lumps or bulges  scrotal skin for color, integrity and lesions or rashes  Inspect for inguinal and femoral hernia for bulges Palpation  Penis: shaft note for any hardened or tender areas  urethral discharge  Scrotum: scrotal contents (testis and epididymis) note for size, shape, consistency, nodules and tenderness  spermatic cord and vas deference for any nodules, swelling or tenderness  Inguinal area: inguinal hernia & inguinal nodes for any bulges  inguinal lymph nodes note for the size, consistency, mobility or tenderness  femoral hernia feel for any bulges  scrotal hernia

Auscultate the scrotum

 Transilluminate the scrotal contents

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 Transilluminate should not be done if abnormal mass or swelling was noted in the scrotum. Darken the room and shine a light from the back of the scrotum through the mass. Look for a red glow.

Abnormal Findings

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Penis  Syphilitic Chancre  Herpes Progenitalis  Genital Warts  Cancer of the Glans Penis  Phimosis  Paraphimosis  Hypospadias  Epispadias Scrotum  Hydrocele  Scrotal Hernia  Testicular tumor  Cryptorchidism  Epididymitis  Orchitis  Small Testes  Varicocele  Torsion of Spermatic Cord  Spermatocele Inguinal & Femoral Hernias  Indirect Inguinal Hernia  Direct Inguinal Hernia  Femoral Hernia

ANUS, RECTUM, AND PROSTATE ASSESSMENT

Inspection

Anus and rectum

 Lumps, ulcers, lesions, rashes, redness, fissures, thickening of the epithelium   Anal opening: bulges or lesions Sacrococcygeal area: swelling, redness, dimpling, hair

Health Assessment
 Prostate Gland
Stool: color, and test the feces for occult blood Palpation

Anus and rectum

  Anus: tenderness, nodules, and hardness Rectum: tenderness, irregularities, nodules, and hardness

Prostate Gland
 Size, shape, consistency of the prostate, nodules or tenderness 1) Musculoskeletal Assessment Inspection and Palpation

Gait
       Base of support Weight-bearing stability Foot position Stride & length and cadence of stride Arm swing Posture Assess for the risk of falling

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Temporomandibular Joint (TMJ)
   TJM Range Of Motion (ROM)

Sternoclavicular Joint: inspect location in midline, color, swelling and masses;

palpate for tenderness or pain

Cervical, Thoracic, and Lumbar Spine

   symmetry(shoulder heights, iliac crests and buttocks creases) palpate spinous processes and paravertebral muscles on both sides ofthe spine for tenderness or pain ROM of the cervical spine by asking the client to touch the chin to the chest (flexion) and to look up at the ceiling (hyperextension) ROM of the thoracic and lumbar spine by asking the client to bend forward and touch the toes (flexion), observe for the symmetry of the shoulders, scapula, and hips test for back and leg pain Measure leg length

 

Shoulders, Arms, Elbows

 Inspect and palpate shoulders and arms: inspect anteriorly and posteriorly symmetry, color, swelling, and masses Palpate for tenderness, swelling, or heat

 Test for ROM

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Elbows
  Inspect size, shape, deformities, redness or swelling Test ROM

Wrists
    Inspect wrists size, shape, symmetry, color, and swelling Palpate for tenderness and nodules Test ROM Test for carpal tunnel syndrome: perform Phalen s test or Tinel s test(optional)

Hands and Fingers

 Inspect size, shape, symmetry, swelling and color

 Palpate fingers for tenderness, swelling, boney prominences, nodules or crepitus  Palpate each metacarpal of the hands, noting tenderness and swelling  Test ROM

Hips
 Inspect symmetry and shape  Palpate for stability, tenderness, and crepitus  Test ROM

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Knees
 Inspect for size, symmetry, swelling, deformities and alignment  Palpate for tenderness, warmth consistency and nodules  Test for swelling  Perform Ballottement test  Test ROM  Test for pain and injury

Ankles and Feet

 Inspect for position, alignment, shape, skin  Palpate ankles and feet for tenderness, heat, swellin, or nodules  Test ROM

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5) ASSESSMENT OF THE ENDOCRINE
8 major endocrine glands
1) Hypothalamus: located in the lower central part of the brain is the main link between the endocrine system and the nervous system. 2) Pituitary Gland: The located at the base of the brain just below the hypothalamus. It is the most important part in the endocrine system.

a.

The anterior lobe: regulates the activity of the thyroid, adrenals, and the reproductive glands. The anterior lobe also produces hormones like: o Growth Hormone: To stimulate the growth of the bones and tissues. It also plays a role in the body's absorption of nutrients and minerals. o Prolactin: To activate the production of milk in lactating mothers o Thyrotropin: To stimulate the thyroid gland to produce thyroid hormones o Corticotropin: To stimulate the adrenal glands to produce certain hormones. b. The posterior lobe: produces antidiuretic hormone that helps to control the water balance in the body. Oxytoxins that trigger the contractions of the uterus in a woman who is in labor is secreted by the posterior lobe.

1) Thyroid Gland: It is situated in the front part of the lower neck that is shaped like a bow tie or butterfly. Thyroid produces thyroxine and triiodothyronine, that control the rate at which the cells use up energy from food for production of energy. 2) Parathyroids: These are four tiny glands that are attached to the thyroid gland. They release the parathyroid hormone that helps in regulating the level of calcium in blood along with another hormone produced by thyroid called as calcitinin. 3) Adrenal Glands: On each of the two kidneys, there are two triangular adrenal glands situated. 4) Reproductive Glands or Gonads: In men, the gonads are related to testes. The testes are located in the scrotum and secrete androgens. The most important hormone for men testosterone is secreted from the testes. In women, ovaries are the gonad. They produce estrogen and progesterone hormones. Estrogen is involved during the sexual maturation of the girl, that is, puberty. Progesterone along with estrogen are involved in the regulation of menstruation cycle

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5) Pancreas: These glands are associated with the digestive system of the human body. They secrete digestive enzymes and two important hormones insulin and glucagon. 6) Pineal: The pineal gland is located in the center of the brain. Melatonin is secreted by this gland that helps

 The endocrine system is a collection of glands that secrete different hormones for the various functions and chemical reactions occurring within the body. regulate the sleeping cycle of a person.

FUNCTIONS OF ENDOCRINE SYSTEM:

1. WATER BALANCE The production and 2. UTERINE CONTRACTION AND MILK RELEASE secretions of the 3. GROWTH, METABOLISM, AND TISSUE MALNUTRITION hormones of the thyroid 4. ION REGULATION glands are controlled by 5. HEART RATE AND BLOOD PRESSURE REGULATION thyrotropin secreted by the 6. BLOOD GLUCOSE CONTROL 7. IMMUNE SYSTEM REGULATION 8. REPRODUCTIVE FUNCTIONS CONTROL  The hormones are the chemical messengers of the body that travel down to the various body parts concerned transferring information. There are many hormones secreted by the endocrine system, and each individual type of hormone affects only those body cells that have a genetic program that allows them to react only to those hormones that are related to them.  The glands release the hormones into the blood stream and are transported to the various cells and body parts. When the hormones reach the target site, they bind to the receptor cells with a lock and key mechanism. Once bound to the receptor, the hormones transmit a signal that triggers an action by the site.

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Endocrine dysfunction may result from excessive or deficient hormone secretion, transport abnormalities, an inability of the target tissue to respond to a hormone or inappropriate stimulation of the target tissue receptor.

Subjective Data
1. Health Information Past health history: - The patient should be questioned about general state of health and previous and current endocrine abnormalities. Medications: - The patient should be questioned about the use of all medications and dietary supplements. Surgery or other treatment :- Nurse should enquire about previous surgery, chemotherapy or radiotherapy 2. Functional health patterns Heredity - plays a major role in a major role in the occurrence of endocrine problems. The patient should be questioned about endocrine conditions in family members.

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Nutritional or metabolic pattern - Reported change in appetite and weight can indicate endocrine dysfunction. Weight loss with increased appetite may indicate hyperthyroidism or diabetes mellitus. Weight loss with decreased appetite may indicate hypopituitarism or hypocortisolism. Weight gain indicates hypothyroidism. Difficulty in swallowing or a change in neck size indicates thyroid disorder or inflammation. Elimination pattern - Increased thirst and urination can indicate Diabetes Mellitus or Insipidus. Frequent defecation may indicate hyperthyroidism. Constipation is also seen in patients with diabetes mellitus, hypothyroidism, hypoparathyroidism or hypopituitarism. Sleep-rest pattern - The patient with diabetes will complain of nocturia which can severely disrupt normal sleep patterns. The hyperthyroid patient may complain about inability to sleep. The hypothyroidism and hypopituitarism patient may sleep all the time, yet still being fatigued. Cognitive-perceptual pattern - A patient with an endocrine dysfunction will frequently manifest apathy and depression. Memory deficits and an inability to concentrate are common in endocrine disorders.

Objective Data
Physical Examination 1. Vital signs Variations in temperature may associate with thyroid dysfunction. Cardiovascular changes such as bradicardia, tachycardia, hypotension or hypertension maybe seen with endocrine problems. 2. Integument The nurse should note the color and text of the skin, hair, and nails. The hair distribution should be noted on the head, face, trunk, and extremities. Dull brittle hair, excessive hair growth or hair loss indicates endocrine dysfunction. 3. Height and weight Changes in weight may be associated with endocrine problems. Growth pattern abnormalities suggest problems associated with growth hormone. Thyroid disorders and diabetes mellitus are example for disorders that can affect body weight.

Health Assessment
2 types of thyroid palpation. For anterior palpation the nurse stands in front of the patient, with patients neck flexed. The thumb is placed over the cricoid cartilage and moved over the isthmus as the patient swallows. Then each lateral lobe is palpated before and while the patient swallows water. For posterior palpation, examiner stands behind the patient. With thumb of both hands rest on nape of the neck of the patient, uses the index and middle fingers for the thyroid isthmus and for the anterior surfaces of the lateral lobes. The thyroid is palpated for size shape, symmetry, tenderness and for any nodules.

Dwarfism- It is sometimes defined as an adult height of less than 4 feet 10 inches.

Gigantism- is a condition characterized by excessive growth and height significantly above average.

4. Neck When inspecting the thyroid gland first observation should be made in the normal position, then in slight extension, and then as the patient swallows some water. The trachea should be in midline and neck should appear symmetric. If there is no noticeable enlargement of the thyroid gland, palpation can be done.

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A buffalo hump, which is extra fat around the neck and upper part of the back, is a symptom of Cushing's syndrome.

Goiter- is an enlargement of the thyroid gland. It is a common cause of Iodine deficiency.

5. Head The size of the head should be examined. Facial features should be symmetric. Eyes should be inspected for position shape and eye movement.

Graves' disease- is an autoimmune disease where the thyroid is overactive

Cushings syndrome- is a hormonal disorder caused by prolonged exposure of the bodys tissues to high levels of the hormone cortisol.

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6. Extremities The size, shape, symmetry, and general proportion of hand and feet should be noted. Muscle strength and deep tendon reflexes should be noted. In the upper extremities, the presence of tremors is assessed by placing a piece of paper in the outstretched fingers, palm down. Acromegaly - is a syndrome that results when the pituitary gland produces excess growth hormone (hGH) after epiphyseal plate closure at puberty. acromegaly is caused not by pituitary tumors but by tumors of the pancreas, lungs, and adrenal glands.

Enlargement of extremitiessymptom of acromegaly .

Diagnostic studies Parathyroid studies

Parathyroid hormone(PTH)

Measures PTH level in serum.

Total serum calcium

Normal 9-11 mg/dl. Hypercalcemia indicate hyperparathyroidism

Serum phosphate

hyperphosphatemia indicates hypoparathyroidism. Normal 2.8-4.5 mg/dl.

Pancreatic studies

Serum studies Fasting blood sugar(FBS) o Measures circulating glucose level. Normal 70-110mg/dl.

Health Assessment
Oral glucose tolerance o Patient drinks 75g of glucose, samples for glucose are drawn immediately, and at 30,60,120 minutes. Normal values: <200mg/dl at 30,60 min. and <140mg/dl at 1 hr.

Urine studies Glucose o Normal value is negative.

Ketones

Normal value is negative.

Radiologic studies Computed tomography(CT) o Used to identify tumors or cysts.

Pituitary Test

Growth hormone (GH)(somatotrophin)

<5ng/ml in men, <10ng/ml in women, values >50ng /ml suggest acroegaly. normal values are 135-250ng/ml

Somatomedin C

IGF-1 low level- GH deficiency, high level-GH excess.

Growth hormone Stimulation test.

Measures GH secretion in response to insulin. Baseline blood levels for GH, glucose obtains before administration of IV insulin GH should rise twofold over baseline. Response is subnormal in GH deficiency.

Water deprivation test

Use to find cause of polyuria. ADH is administered IV or subcutaneously. In central DI, urine osmolality increases after ADH administration. In nephrogenic DI there is no response to ADH.

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Radiologic studies MRI o Useful in identification of tumor involving hypothalamus or pituitary.

Thyroid function tests Thyroid function tests (TFTs) is a collective term for blood tests used to check the function of the thyroid. TFTs may be requested if a patient is thought to suffer from hyperthyroidism (overactive thyroid) or hypothyroidism (underactive thyroid), or to monitor the effectiveness of either thyroid-suppression or hormone replacement therapy.

Thyroid stimulating hormone(TSH)

normal 0.3-5.4mu/L

Thyroxine(T4)

51-142nmol/L. useful in evaluating thyroid function

Triiodothyronin(T3)

65-195ng/dl. Helpful in diagnosing hyperthyroidism.

Free T4

1-3.5ng/dl

T3 resin uptake Radiological studies

Indirectly measures binding capacity of thyroid- binding Globulin. Normal 25%-35%.

Radioactive iodine uptake

Patient is given radioactive iodine orally or IV. The uptake by the thyroid gland is measured with a scanner at intervals of 2to 4 hours and at 24 hours. Normal values are 3%-19% for 2-4 hours and 11%-30% for 24 hours.

Thyroid scan

Radioactive isotopes are given orally or IV. In scan benign nodules appear as warm spots. Malignant tumors appear as

Health Assessment
cold spots. Adrenal studies

Cortisol

5-25mg/dl at 8am,10mg/dl at 8pm.

Aldosterone

5-20ng/dl

Adrenocorticotropic hormone(ACTH)

<80pg/ ml-morning, <50pg/dl-evening.

Radiological studies Computed tomography (CT) o Use to detect tumor and size of tumor mass.

IMMUNE AND BLOOD

Immunity- is the ability to resist damage from foreign substances such as microorganisms and other
foreign substances. Categories Innate immunity Mechanical mechanism-prevent the entry of microorganism in two ways (1) the skin and mucous membrane form barriers that prevent their entry, and (2) tears saliva and urine act to wash them from the surfaces of the body. Chemical mediators- kills microorganisms, promote phagocytosis and icrease inflammation. An example of these are lyzozyme in tears and complement in the plasma. Onterferon also is a chemical mediators that prevent the replication of viruses.

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Inflammatory response- A response of the body to an injurious agent, characterized by cardinal signs such as: tumour or swelling dolor or pain calor or heat function laesa or loss of function rubor or erythema

Cellular barriers - Leukocytes (white blood cells) act like independent, single-celled organisms and are the second arm of the innate immune system. The innate leukocytes include the phagocytes (macrophages, neutrophils, and dendritic cells), mast cells, eosinophils, basophils, and natural killer cells. These cells identify and eliminate pathogens, either by attacking larger pathogens through contact or by engulfing and then killing microorganisms. Innate cells are also important mediators in the activation of the adaptive immune system. Adoptive immunity * The adaptive immune system is comprised of B and T lymphocytes that express receptors with remarkable diversity tailored to recognize aspects of particular pathogens, or antigens . B and T lymphocytes circulate in the blood and lymph and home to specialized lymphoid organs such as the spleen and lymph nodes. In these locations, inexperienced or nave lymphocytes scan for the presence of antigens. During an infection, dendritic cells which act as sentinels in the peripheral tissues pick up pathogens in the form of antigenic determinants. These antigens are then presented to T lymphocytes within the lymphoid tissues. T lymphocytes of the appropriate specificity respond robustly to the antigen, and either kill the pathogen directly or secrete cytokine mediators that will encourage a B lympohocyte response. B lymphocytes provide humoral immunity by secreting antibodies specific for the pathogen. In the case of both B and T cells, as the immune response contracts, a small number of antigen-specific cells survive so that if re-exposure to the pathogen occurs, a more robust and rapid immune response can take place. This is termed immunological memory and it is what is conferred upon vaccination. Acquired immunity * Acquired immunity is an immune response that we develop after birth in response to the introduction of new foreign invaders (pathogens, antigens, allergens, etc.) It is activated by the innate immune system, also known as the inflammatory response. As the inflammatory response winds down, the adaptive immunity takes care of what the innate response was unable to dispose of.

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Immunization

Intrauterine- live virus vaccines (measles,mumps,rubella and poliomelytis {sabin type} ) are contraindicated during pregnancy because they may transmit the viral infection to a fetus. Neonate- BCG and hep B vaccination. Infants- DPT(Diphthreria,Pertussis,Tetanus);OPV( Oral Polio Vaccine) ;measles or MMR (Measles-MumpsRubella). Toddlers-Pneumococcal, Hepatitis A and vaccines are recommended. Preschoolers-screening for TB. School age children- MMR, meningococcal, tetanus-diphtheria (adult preparation). Adolescent- adult tetanus-diphtheria vaccine, MMR, hep B vaccination. Young adults - tetanus-diphtheria booster(every 10 years), meningococcal vaccine if not given in early adolescent and hep B vaccination. Middle-aged adults current recommendations for influence vaccine Elders- Annual flu vaccine if over 65, and Pneumococcal vaccine at 65.

Quantitative assessment of blood flow, blood volume and blood oxygenation effects in functional magnetic resonance imaging Assessment of removal of human cytomegalovirus from blood components by leukocyte depletion filters using realtime quantitative PCR To assess removal of cytomegalovirus (CMV) by leukocyte depletion (LD) filters, we developed a spiking model of latent virus using peripheral blood mononuclear cells (PBMCs) infected by coculture with CMV-infected human fibroblasts. Infected PBMCs were purified by dual magnetic column selection and then spiked into whole blood units or buffy coat pools prior to LD by filtration. CMV load and fibroblast contamination were assessed using quantitative CMV DNA realtime PCR and quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) of mRNA encoding the fibroblastspecific splice variant of prolyl-4-hydroxylase, respectively. After correcting for fibroblast-associated CMV, the mean CMV load was reduced in whole blood by LD from 7.42 x 102 to 1.13 copies per microliter (2.8110log reduction) and from 3.8 x 102 to 4.77 copies per microliter (1.910log reduction) in platelets. These results suggest that LD by filtration reduces viral burden but does not completely remove CMV from blood components.

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NUTRITIONAL ASSESSMENT
Body Build
 Body build, muscle mass and fat distribution

Measurements
      Measure height Measure weight BMI Measure mid-arm conference (MAC) Measure triceps skinfold thickness (TSF) Calculate mid-arm muscle circumference (MAMC)

Hydration
  Measure intake and output (I&O) in inpatient setting All settings: Fluid- Related changes  Weight clients at risk for hydration changes daily  Check skin turgor  Check for pitting edema  Observe skin for moisture  Assess venous filling  Observe neck veins w/ client in supine position then w/ the head elevated above 45r

Health Assessment
 Inspect the tongue s condition and furrows  Gently palpate eyeball  Observe eye position and surrounding coloration  Auscultate lung sounds  Take BP w/ client in standing, sitting, and lying position and palpate radial pulse

-composed of an interview and anthropometric measurements, which are used to evaluate the clients physical growth, development, and nutitional status. *General Nutritional Status Interview -questions should solicit information about average daily intake of food and fluids,types of quantities consumed, where and when food was eaten, and any conditions/disease that affect intake or absorption. *Anthropometric Measurements -this helps evaluate the clients physical growth, development, nutritional status, and to determine the clients BMI.

Health Assessment
Nutritional problems
Malnutrition and biochemical indicators -malnutrition is the condition that results from taking an unbalanced diet in which certain nutrients are lacking, in excess (too high an intake), or in the wrong proportions. A number of different nutrition disorders may arise, depending on which nutrients are under or overabundant in the diet. Risk factors:-lower socioeconomical status -workaholic and more meals from fast food -poor food choices -chronic dieting -dental problems -disorder whereby food is self limited or refused -when people are malnourished the body s protein stores are affected.The proteins usually sacrificed early are those that the body considered to be less essential to survival: albumen@globulins,transport protein,skeletal muscle protein,blood protein and immunoglobulins. Overnutrition -increase caloric consumptiuon,especially food high in fat and sugar,with decreased energy expenditure has led to near-epidemic obesity.

Hydration Assessment-dehydration can have have a seriously damaging effect on body cells and the execution of body functions.Overhydration in a healthy person is usually not a problem because the body is effective in maintaining a correct fluid balance.

Health Assessment
*Collecting subjective data:the nursing health history

Health Assessment
-the clients interview privides invaluable info about the clints nutritional status. *Collecting objective dat:physical examination -PE includes observing body build,measuring weight and height, taking anthropometric measurements,and assessing hydration.

Nursing assessment of an adult 1) 2) 3) 4) 5) 6) 7) Identify abnormal findings and client strenghts Identify cue clusters Draw inferences List possible nursing diagnoses Check for defining characteristics Confirm or rule out diagnoses Document conclusion

Health Assessment
References:
http://spudcomics.com/comics/2009-10-13-vulture.png http://upload.wikimedia.org/wikipedia/commons/7/74/Bertillon http://en.wikipedia.org/wiki/Malnutrition http://gasbottle-county.eu/media/2010/dean_ornish-overnutrition.png Health Assessment Webber and Kelly p.119-140 Peter C.M. van Zijl1, Scott M. Eleff1, 2, John A. Ulatowski2, Joni M.E. Oja1, 3, Aziz M. Ulu 1, Richard J. Traystman2 & Risto A. Kauppinen3 Department of Radiology, Johns Hopkins University Medical School, 217 Traylor Building, 720 Rutland Avenue, Baltimore, Maryland 21205, USA Department of Anesthesiology and Critical Care, Johns Hopkins University Medical School, Meyer 8-138, 600 North Wolfe Street, Baltimore, Maryland 21205, USA NMR Research Group, A.L Virtanen Institute, University of Kuopio, Neulaniementic 2, P.O. Box 1627, FIN-70211 Kuopio, Finland
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