Breast & Lymph
This landmark in the upper outer quadrant is a common location for some breast cancers.
What is Tail of Spence?
(upper outer toward axillae)
Twisting of the spermatic cord causing severe pain and swelling.
What is testicular torsion?
Movement of a limb away from the midline plane of the body.
What is abduction?
(Adduction is movement of a limb toward the body midline position)
With arms to side and eyes closed the patient exhibits swaying and moves feet apart to prevent falling.
What is a Positive Romberg test?
(negative test is normal stance, no swaying after 20 seconds)
Begins with the health history interview, cultural and spiritual assessment along with collection of subjective review of each body system.
What is the complete health assessment?
Beginning at this age ACS recommends yearly mammograms for early detection of breast cancer.
What is age 45?
A patient exhibits swelling and inflammation of the testicles along with swollen inguinal lymph nodes.
What is orchitis?
(due to infection such as an STD)
An exaggerated convexity of the thoracic region of the spine.
What is kyphosis?
Inability to identify a scent not due to a congenital or sinus problem.
What is Anosmia?
(Detected through testing cranial nerve Olfactory 1 sensory)
Informs the nurse of need for type, frequency of continuing assessment, determine if interventions are working or for evaluating outcomes.
What is a routine/ongoing assessment?
According to ACS women at this age and older women can switch to mammograms every 2 years.
What is age 55 and older?
(can continue to screen yearly)
A hernia that is formed when the urinary bladder is pushed into the anterior vaginal wall.
What is a cystocele?
A patient has a slight palpable muscle contraction of the thighs but no movement.
What is severe weakness?
(grading muscle strength)
During this nerve assessment there may be abnormal involuntary movement of the eyeballs.
What is Cranial nerve III Oculomotor, assessing for nystagmus?
(Cranial Nerves III, IV, and VI are done together)
Assesses the level of consciousness, location of the patient and overall signs of distress.
What is the rapid assessment?
This body chemical decreases with age but can accelerate the growth of breast tumors.
What is the hormone Estrogen?
(Breast cancer risk increases with age but is typically slow growing due to decreased estrogen levels)
Estrogen hormone replacement therapy, smoking, and never being pregnant.
What are risk factors for ovarian cancer?
Caucasian female, older than 50, smoking, decreased estrogen levels and alcohol consumption.
What are risk factors for Osteoporosis?
Weakness or inability to shrug shoulders or turn the head against resistance are abnormal findings of this motor nerve.
What is Spinal Accessory XI nerve?
The data obtained from this assessment establishes a baseline for future patient care.
What is the comprehensive health assessment?
(also knows as complete health assessment)
During the breast assessment the nurse looks for these concerning symptoms related to malignancy.
What is a recent change in size, texture or to the nipple, dimpling of the skin, inflammation, edema "orange peel" look, and hard fixated nodules?
For females at age 30 this should occur every 2-3 years.
For females at age 30 this should occur every 2-3 years.
In an adult you see extension/dorsiflexion of the big toe and fanning of all the toes outward.
What is a positive Babinski response?
(this is abnormal. A normal response would be plantar flexion and curling inward of the toes this is a normal finding in an adult without any motor neuron complications.)
Rhythmically alternating flexion and extension found in upper motor neuron disease.
What is myoclonus or clonus?
(MS, ALS, TBI's)
Used to assess patient behavior, hygiene, body build and obvious signs of health or illness.
What is the general survey?