HEALTH ASSESSMENT

LAB / RLE Module #17

THE REPRODUCTIVE
SYSTEM
 THE FEMALE REPRODUCTIVE SYSTEM
External parts -The function of your external genitals are to protect the internal
parts from infection and allow sperm to enter your vagina. Your vulva is the
collective name for all your external genitals.
•Labia majora: Your labia majora (“large lips”) enclose and protect the other
external reproductive organs. During puberty, hair growth occurs on the skin of
the labia majora, which also contain sweat and oil-secreting glands.
•Labia minora: Your labia minora (“small lips”) can have a variety of sizes and
shapes. They lie just inside your labia majora, and surround the opening to your
vagina (the canal that joins the lower part of your uterus to the outside of your
body) and urethra (the tube that carries pee from your bladder to the outside of
your body). This skin is very delicate and can become easily irritated and
swollen.
•Clitoris: Your two labia minora meet at your clitoris, a small, sensitive
protrusion that’s comparable to a penis in men or people assigned male at birth
(AMAB). Your clitoris is covered by a fold of skin called the prepuce and is very
sensitive to stimulation.
•Vaginal opening: Your vaginal opening allows menstrual blood and babies to
exit your body. Tampons, fingers, sex toys or penises can go inside your vagina
through your vaginal opening.
•Hymen: Your hymen is a piece of tissue covering or surrounding part of your
vaginal opening. It’s formed during development and present during birth.
•Opening to your urethra: The opening to your urethra is the hole you pee
from.
 THE FEMALE REPRODUCTIVE SYSTEM
Internal parts
•Vagina: Your vagina is a muscular canal that joins the cervix (the lower part
of uterus) to the outside of the body. It can widen to accommodate a baby
during delivery and then shrink back to hold something narrow like a
tampon. It’s lined with mucous membranes that help keep it moist.
•Cervix: Your cervix is the lowest part of your uterus. A hole in the middle
allows sperm to enter and menstrual blood to exit. Your cervix opens
(dilates) to allow a baby to come out during a vaginal childbirth. Your cervix
is what prevents things like tampons from getting lost inside your body.
•Uterus: Your uterus is a hollow, pear-shaped organ that holds a fetus
during pregnancy. Your uterus is divided into two parts: the cervix and the
corpus. Your corpus is the larger part of your uterus that expands during
pregnancy.
•Ovaries: Ovaries are small, oval-shaped glands that are located on either
side of your uterus. Your ovaries produce eggs and hormones.
•Fallopian tubes: These are narrow tubes that are attached to the upper
part of your uterus and serve as pathways for your egg (ovum) to travel
from your ovaries to your uterus. Fertilization of an egg by sperm normally
occurs in the fallopian tubes. The fertilized egg then moves to the uterus,
where it implants into your uterine lining.
 Five phases of a woman’s reproductive
health
1. Prepuberty (premenstruation) - Before puberty, the period during which secondary
sex characteristics start to develop and the capability for sexual reproduction is
attained. secondary sex characteristics include enlarged breasts and widened hips of
females, facial hair and Adam's apples on males, and pubic hair on both.
2. Puberty (menarche) - is when you get your first period. Said another way, menarche
refers to the first time you menstruate. Your first period isn’t just the beginning of your
reproductive years. It’s also a defining part of your body’s transition from childhood to
adulthood, called puberty. most people experience menarche around 12 and 12 ½.
3. Childbearing (menstruation) - is the monthly shedding of the lining of your uterus.
Menstruation is also known by the terms menses, menstrual period, menstrual cycle or
period. Menstruation is just one part of the menstrual cycle, a monthly sequence of
events that prepares your body for a potential pregnancy. Average length of a
menstrual cycle is 28 days. However, a cycle can range in length from 21 days to about
35 days and still be normal.
4. Perimenopausal - period of years during which a woman transitions to menopause
5. Menopausal - absence of menses for 12 consecutive months, usually occurring
between 48 and 55 years
 Health History
There are three parts to a woman’s reproductive history:
❖ Menstrual history
❖ Obstetric history
❖ Sexual history

It is usually more comfortable for the patient if the nurse begins with the
menstrual and obstetric history and saves the sexual history questions for
last. However, if the woman comes to you with a sexual problem, it is
appropriate to follow her lead with questions relating to the issue
 A. MENSTRUAL HISTORY
Menses—monthly flow of bloody fluid from the uterus.
▪ Menarche - age at onset of menses
▪ Menopause - absence of menses for 12 consecutive months, usually occurring
between 48 and 55 years
▪ Perimenopause - period of years during which a woman transitions to
menopause
▪ Postmenopausal bleeding - bleeding occurring 6 months or more after
cessation of menses
▪ Amenorrhea - absence of menses
▪ Dysmenorrhea- pain with menses, often with bearing down, aching, or
cramping sensation in the lower abdomen or pelvis
 A. MENSTRUAL HISTORY

▪ Premenstrual syndrome (PMS) - a cluster of emotional, behavioral, and

physical symptoms occurring 5 days before menses for three consecutive cycles
▪ Abnormal uterine bleeding - bleeding between menses; or infrequent,
excessive, prolonged, or postmenopausal bleeding
▪ Frequency - measured from the first day of one menses to the first day of the
next menses. The interval between periods ranges roughly from 24 to 32 days.
▪ Duration - number of days the flow lasts, usually 3 to 7 days
 B. OBSTETRIC HISTORY (Please refer to page 753 – 752, and for
detailed discussion please refer to SAS # 3 Health History for Pediatrics and Obstetrics)

▪ Pregnancy - Pregnancy (or gestation) is calculated as 40 weeks and starts

from the first day of your last menstrual period.
B. OBSTETRIC HISTORY (Please refer to page 753 – 752, and for
detailed discussion please refer to SAS # 3 Health History for Pediatrics and Obstetrics)
B. OBSTETRIC HISTORY (Please refer to page 753 – 752, and for
detailed discussion please refer to SAS # 3 Health History for Pediatrics and Obstetrics)
 B. OBSTETRIC HISTORY (Please refer to page 753 – 752, and for
detailed discussion please refer to SAS # 3 Health History for Pediatrics and Obstetrics)

▪ Contraception - also known as birth control, is the use of medicines, devices, or

surgery to prevent pregnancy.
▪ Vulvovaginal symptoms - Vulvovaginitis is inflammation of your vulva and vagina. It’s
also called vaginitis or vulvitis. It’s a common condition -- as many as one-third of
women will have it during their lifetime. Sx: itching, irritation, burning, redness,
swelling, dryness, rash
Example:
1. Yeast infection - You always have some candida in your vagina, but an overgrowth
causes yeast and symptoms of vaginitis.
2. Bacterial vaginosis - when the bad bacteria start to outnumber the good bacteria.
3. Trichomoniasis - It's considered a STD and comes from a tiny, one-
celled parasite called Trichomonas vaginalis. You get it through having sex with someone
who’s infected. Men who have the parasite don’t usually have any symptoms.
 C. SEXUAL HEALTH HISTORY (Please refer to page 754 –
756)

Tips for taking Health History

✓ Explain why you are taking the sexual history.
✓ Note that you realize this information is highly personal, and encourage the
patient to be open and direct.
✓ Relate that you gather this history on all your patients.
✓ Affirm that your conversation is confidential.
✓ Sexual Orientation and Gender Identity
✓ Sexual response
✓ Sexually transmitted disease (STIs)
PHYSICAL EXAMINATION Please refer to page 756 - 759

External Examination

Important Areas of Examination ❑ Then, with a gloved hand, separate the

● Mons pubis ● Labia majora and minora ● labia majora and checked: Clitoris (no
Urethral meatus, clitoris ● Vaginal introitus ● excoriation, nodules, rash, lesions) Labia
Perineum minora are dark pink and moist, usually
symmetric. Urethral opening is slit-like
INSPECTION : Assess the following: and is midline. Vaginal opening (introitus)
❑ Skin colour may appear as a narrow vertical slit or as
❑ Hair distribution (inverted triangle) a larger opening. Perineum is smooth.
❑ Labia majora are symmetric, plump, and ❑ A well-healed episiotomy scar may be
well formed. In nulliparous – labia meet in present after vaginal birth. Anus has
the midline. After delivery – labia are coarse skin of increased pigmentation.
gaping and slightly shrivelled.
❑ No lesions should be present.
PHYSICAL EXAMINATION
External Examination

Abnormal Findings: PALPATION

✔ Absence of pubic hair by age 13 ● Assess the urethra and Skene’s gland.
(delayed puberty) ● Use water soluble lubricants to lessen the trauma during
✔ Swelling, excoriation, nodules, insertion of the fingers.
rash, lesions, polyps ● Insert the index finger into the vagina and gently milk the
✔ Foul-smelling, irritating urethra by applying pressure up and out.
discharge. ✔ There should be NO pain. If discharge is present,
✔ Induration along urethra, culture may warrant.
urethral discharge. ● Assess Bartholin’s gland. Palpate the posterior parts of
the labia major with the index finger in the vagina and the
thumb outside.
✔ Normally, the labia feels soft.
PHYSICAL EXAMINATION
External Examination

Skene’s glands - are two small ducts on either side of your urethra. They help lubricate your
vagina during sex and protect it from certain infections.
Bartholin's glands (or greater vestibular glands) - primary function is the production of a
mucoid secretion that aids in vaginal and vulvar lubrication.

Abnormal Findings:
✔ Swelling, induration, pain with palpation.
✔ Erythema around or discharge from duct opening.

● Assess the support of pelvic musculature: - Palpate the perineum

- Feels thick, smooth and muscular in the nulliparous woman.
- Feels thin and rigid in the multiparous woman.
PHYSICAL EXAMINATION
External Examination

o Ask the patient to squeeze the vaginal opening around your fingers.
- Feels tight in the nulliparous woman
- Have less tone in the multiparous woman.

o Using the index and middle fingers, separate the vaginal orifice. Instruct the patient to bear
down. There should be NO bulging of vaginal walls or urinary incontinence.

Abnormal Findings:
✔ Paper – thin perineum
✔ Absent or diminished vaginal tone.
✔ Bulging of the vaginal wall (cryptocele, rectocele, or uterine prolapse)
✔ Urinary incontinence
PHYSICAL EXAMINATION: Internal Examination

Speculum examination
● Select proper size of vaginal speculum.
● Warm and lubricate speculum with warm water
● Ease insertion of the vaginal speculum by pushing the introitus down and open to
relax the pubococcygeal muscle. Ask the patient to bear down. This relaxes the
perineal muscles and also opens the introitus.
● Insert the vaginal speculum in a 45- degree angle downward toward the small of
the patient’s back. This is the NATURAL CURVATURE of the vagina.
● After the blades of the vaginal speculum are fully inserted, open the blades by
squeezing the handles together.
● Insert it to the cervix and its os (is the opening in the cervix at each end of the
endocervical canal)
PHYSICAL EXAMINATION: Internal Examination
Normal Findings:
✔ Colour – the cervical mucosa is pink and even. During the second month of pregnancy it
appears blue (Chadwick’s sign) After menopause, it appears pale.
✔ Position – midline, projects 1 – 3 cm into the vagina.
✔ Size – Diameter is 2.5 cm (1inch)
✔ Os – this is small and round in the nulliparous patient. It is horizontal irregular slit, in the
parous patient (may also show healed lacerations on the sides). ✔ Surface – smooth.
Cervical eversion is normal after vaginal deliveries.
✔ Cervical secretions – may be clear and thin, or thick opaque and stringy (depending on the
day of menstrual cycle). Secretions should be odourless and non-irritating. If secretions are
copious, swab the areas with thick – tipped rectal swab to have a better view of the
structures.
● Obtain cervical smears and culture. o Papanicolau (Pap) smear detects cancer cells. ▪ Do
not obtain specimen during menstruation. ▪ Do not douche, avoid intercourse, do not put
anything into the vagina within 24 hours before collecting the specimen
 Changes with menopause
Menopause is a point in time when a person has gone 12 consecutive months without
a menstrual period. Menopause is a natural part of aging and marks the end of your
reproductive years. On average, menopause happens at age 51.
 Cervical cancer screening:
o Papanicolaou (Pap) smear - also called a Pap test, is a procedure to test for
cervical cancer in women. A Pap smear can also detect changes in your cervical cells
that suggest cancer may develop in the future.
In women older than age 30, the Pap test may be combined with a test for human
papillomavirus (HPV) — a common sexually transmitted infection that can cause
cervical cancer.
Generally, recommend repeating Pap testing every three years for women ages 21 to
65.
o Human papilloma virus (HPV) infection – some type of gentil HPV can cause
cervical cancer. These infections are often transmitted sexually or through other skin
to skin contact. Vaccines can help protect against the strains of HPV most likely to
cause genital warts or cervical cancer.
 Early prenatal care
It includes medical history, physical exam, lab test, Tests for fetal
concerns (may include ultrasound or blood tests to check for certain fetal
genetic problems, such as Down syndrome.), lifestyle issues, and discomfort of
pregnancy.

Options for family planning

Sexually transmitted diseases and HIV

 MALE REPRODUCTIVE SYSTEM
Penis is the male organ for sexual intercourse.
Scrotum is the loose, pouch-like sac of skin that hangs behind the
penis. It holds the. It protects your testicles and provides a sort of
“climate-control system.
Testicles (testes) are oval-shaped organs that lie in your scrotum.
They’re about the size of two large olives.
Epididymis is a long, coiled tube that rests on the back of each testicle.
It carries and stores the sperm cells that your testicles create.
Vas deferens is a long, muscular tube that travels from the epididymis
into the pelvic cavity, just behind the urinary bladder. The vas deferens
transports mature sperm to the urethra in preparation for ejaculation.
Each testicle has a vas deferens that joins with seminal vesicle ducts to
form ejaculatory ducts.
Urethra is the tube that carries pee from your bladder outside of your
body.
Seminal vesicles are sac-like pouches that attach to the vas deferens
near the base of the bladder.
Prostate is a walnut-sized gland that rests below your bladder, in front
of your rectum. The prostate adds additional fluid to ejaculate, which
helps nourish sperm.
Bulbourethral (cowper) glands are pea-sized structures on the sides
of your urethra, just below your prostate.
PHYSICAL EXAMINATION: PENIS
Inspection:
● The skin normally looks wrinkled, hairless and without lesions.
● The dorsal vein may be apparent.
Abnormal Findings:
✔ Inflammation –appears reddish and swollen.
✔Lesions –nodules, solitary ulcer (chancre), wartlike papulae.
● The glans penis appears smooth and without lesions.
● If the patient is uncircumcised, ask him to retract the foreskin or the examiner will
retract it.
● It should move easily.
● After inspection, slide the foreskin back to the original position.
● The urethral meatus is positioned medially at the tip of the penis.
● At the base of the penis, pubic hair distribution is consistent with age. Hair is without
lice inhabitants.
PHYSICAL EXAMINATION: PENIS
Abnormal Findings:
✔ Inflammation –lesions on glans or corona.
✔Phimosis –unable to retract the foreskin.
✔Paraphimosis –unable to return foreskin to original position.
✔Hypospadias –ventral (underside of the penis) location of the urethra. ✔Epispadias –
dorsal (on topside of the penis
✔Pubic lice or nitscan be seen with unaided eye. Excoriated skin usually accompanies
pediculosis pubis (Pubic lice, commonly called crabs, are tiny insects found in your genital
area).
✔Stricture– narrowed opening of the urethral meatus.
✔Priapism– prolonged painful erection of penis without sexual desire
PHYSICAL EXAMINATION: PENIS
Palpation:
● Compress the glans anteroposteriorly between your thumb and forefinger.
● The meatus edge should appear pink, smooth, and without discharge.

Abnormal Findings:
✔Edges that are red, everted, swollen, with purulent discharge. These indicate
urethritis.
✔ If urethral discharge is present, collect a smear for laboratory examination (culture).
✔Presence of nodules or indurations.
✔Tenderness
PHYSICAL EXAMINATION: SCROTUM
Inspection:
● Inspect the scrotum as the patient holds the penis out of the way.
● Alternatively, hold the penis out of the way with the back of the examiner’s hand.
● Scrotal size varies with ambient room temperature.
● Asymmetry is normal, with left scrotal half usually lower than the right.
Abnormal Findings:
✔Scrotal swelling may be taut or pitting. This may indicate heart failure, renal failure or
local inflammation.
✔Presence of lesions.
● Spread rugae out between the fingers of the examiners. Lift the sac to inspect the
posterior surface.
● Normally, no scrotal lesions are present.
● Sebaceous cysts are common. These are yellowish, 1 cm nodules and are firm, non-tender,
and often multiple
PHYSICAL EXAMINATION: SCROTUM
Abnormal Findings:
✔ Inflammation in the area

Palpation:
● Palpate gently each scrotal half between your thumb and first two fingers (index and middle finger)
o The scrotal area should slide easily.
o The testis normally feels oval, firm and rubbery, smooth and non-tender.
Abnormal Findings:
✔Cryptorchidism– absent testis / undescended testis
✔Atrophied testis – small and soft.
✔Fixed testis
✔Nodules on testis or epididymis. ✔
Marked tenderness.
✔ Indurated, swollen, and tender epididymis indicates epididymitis.
PHYSICAL EXAMINATION: SCROTUM
● Palpate each spermatic cord between your thumb and forefinger / index finger, along
its length from the epididymis up to the external inguinal ring.
● Normally, it should feel smooth and non-tender.
● No other scrotal contents are present. If a mass is palpated; assess for tenderness,
effect of lying down (does it reduce?)

Abnormal Findings:
✔Varicocele – dilated veins in the scrotum.
✔Presence of hernia, tumor, orchitis, epididymitis or hydrocele.
● Transillumination– performed if swelling or mass is assessed in the scrotum.
HEALTH ASSESSMENT
LAB / RLE Module #18
DOMESTIC VIOLENCE
ASSESSMENT
 DOMESTIC VIOLENCE ASSESSMENT
Wife/Husband/Intimate partner violence, child abuse, and elder abuse are

INTIMATE PARTNER VIOLENCE (IPV)

● Physical and/or sexual violence (use of physical force) or threat of such violence.

● Psychological/emotional abuse and / or coercive tactics when there has been prior
physical and / or sexual violence between persons who are spouses or nonmarital partners
(dating, boyfriend/ girlfriend) or former spouses or nonmarital spouses
 DOMESTIC VIOLENCE ASSESSMENT
CHILD ABUSE
● Neglect is failure to provide a child’s basic needs– physical, educational, medical, and
emotional.

● Physical abuse is physical injury due to punching, beating, kicking, biting, burning,
shaking, or otherwise harming child. Even if the parent or caregiver did not intend to harm
the child, such acts are considered abuse when done purposely.

● Sexual abuse includes fondling a child’s genitals, incest, penetration, rape, sodomy,
indecent exposure and commercial exploitation through prostitution or the production of
pornographic materials.

● Emotional abuse is any pattern of behavior that harms a child’s emotional development
or sense of self-worth. It includes frequent belittling, rejection, threats, and withholding of
love and support
 DOMESTIC VIOLENCE ASSESSMENT
ELDER ABUSE

● Physical abuse is violent acts that result or could result in injury, pain, impairment,
and/or disease.

● Physical neglect is failure of the family member and / or caregiver to provide basic
goods and / or services such as foods, shelter, health care and medications.

● Psychological abuse is behaviors that result in mental anguish.

● Psychological neglect is failing to provide basic social stimulation.

● Financial abuse is intentional misuse of the elderly person’s financial/ material resources
without the informed consent of the person.

● Financial neglect is failure to use the assets of the elderly person to provide services
needed by this elderly person.
 SCREENING TOOLS
❖ SCREENING FOR INTIMATE PARTNER VIOLENCE
● Routine, universal screening for intimate partner violence means asking every woman at every health
care encounter if she has been abused by a husband, boyfriend, or former intimate partner or ex-partner.
● The Abuse Assessment Screen (AAS) as a screening tool for IPV (Intimate Partner Violence) has strong
support for reliability and validity
 SCREENING TOOLS
❖ SCREENING FOR ELDER AND VULNERABLE PERSON ABUSE AND NEGLECT
● The elderly are vulnerable to abuse and / or neglect from other family members and
caregivers. The AMA Nine-question clinically effective screen can be used with elderly who
are cognitively intact
 SCREENING TOOLS
❖ SCREENING FOR ELDER AND VULNERABLE PERSON ABUSE AND NEGLECT
● It is important to assess and document prior abuse, including prior IPV, childhood physical and
sexual abuse, and prior rapes of all kinds (stranger, date, intimate partner).
● Cumulative trauma has been associated with severe mental and physical health problems.
● Traumatic injuries due to abuse more likely have great impact on the patient’s current health
condition – e.g., head trauma, strangulation may be related to neurologic symptoms and problems.
● All survivors of violence must be given of mental status examination, with particular attention to
probable mental problems such as depression, suicidal ideation, post-traumatic stress disorder,
substance abuse, and anxiety.
 SCREENING TOOLS
❖ SCREENING FOR CHILD ABUSE AND NEGLECT
● Child abuse is common in homes where there is ongoing abuse of an adult.
● An important part of evaluating any child for suspected abuse is to determine the child’s age and
developmental level. The history that a 6month old climbing and falling from a chair, causing injury is not
yet developmentally plausible.
● Assess the child for:
✔ Multiple injuries
✔ Injuries in various stages of healing
✔ Unexplained fractures, bruises, burns, and lacerations
✔ Incongruence between explanation and injury
✔ Poor hygiene and unkempt / dishevelled appearance
✔ Medical and physical problems are unattended
✔ Venereal (STI) diseases
✔ Difficulty of walking and sitting
✔ lack of crying when approached by a stranger
PHYSICAL EXAMINATION
● Survivor of IPV and / or Elder Abuse
A complete head-to-toe visual examination reveals physical findings, the following basic
medical forensic terminologies are essential in all documentation:
➢ Abrasion –a wound caused by rubbing the skin or mucous membrane.
➢ Avulsion – the tearing away of a structure or part; partial dislocation.
➢ Bruise –superficial discoloration of the skin due to hemorrhage into the tissues from
ruptured blood vessels beneath the skin surface, without the skin itself being broken. Also
known as ecchymosis or contusion.
➢ Cut o Hemorrhage –the escape of blood from the ruptured vessel, which can be external,
internal, and / or into the skin or other organ. o Incision – a cut or wound made by a sharp
instrument; the act of cutting.
➢ Laceration – the act of tearing or splitting; a wound produced by the tearing and / or
splitting of body tissue, usually from blunt impact over a bony surface.
➢ Lesion –a broad term referring to any pathologic or traumatic discontinuity of tissue or loss
of function of a part.
PHYSICAL EXAMINATION
● Survivor of IPV and / or Elder Abuse

➢ Patterned injury – an injury caused by an object that leaves a distinct pattern on the skin
and / or organ (e.g., being whipped with an extension cord) or an injury caused by a unique
mechanism of injury (immersion burn to the hands [glove burns] or feet [sock burns]).
➢ Patterns of injuries – injuries usually bruises and fractures, in various stages of healing.
➢ Petechiae – minute, pinpoint, non raised, perfectly round, purplish red spots caused by
intradermal or submucous hemorrhage, which later turn blue or yellow.
➢ Puncture –the act or piercing or penetrating with a pointed object or instrument
➢ Stab wound –a penetrating, sharp, cutting injury that is deeper than wide.
➢ Wound –a general term referring to a bodily injury caused by physical means.
PHYSICAL EXAMINATION
Keep in mind the following guidelines when documenting the physical examination:
✔ Bruise can be used interchangeably with contusion.
✔ Lacerations is related to avulsion
✔ Ecchymosis (medical term for bruises) is related to purpura (Purpura measure between 4 and 10 mm in
diameter.)
✔ Petechiae (purpura spots are less than 4 mm in diameter, they are called petechiae) is related to purpura
✔ Rug burn is more accurately described as friction abrasion.
✔ Incision can be used interchangeably with cut.
✔ Cut can be used interchangeably with sharp injury.
✔ Stab wounds are penetrating, deep, sharp injuries.
✔ Hematoma is collection of blood that is often but not always caused by blunt force trauma.
✔ Bruises found on the neck, ears, genitalia, buttocks, or soles of the feet in the elderly should
arouse nurse’s concern.
PHYSICAL EXAMINATION
Keep in mind the following guidelines when documenting the physical examination:

● Children
o Bruising in infants who are not yet cruising, usually infants less than 9 months of age
should ALERT the nurse for possible abuse.
o Bruising in atypical places– buttocks, hands, feet, and abdomen should arouse the
nurse’s concern. Bruises over bony prominences of the front of the body in a child who is
already walking is COMMON
PHYSICAL EXAMINATION
Keep in mind the following guidelines when documenting the physical examination:

● Children
o Bruising in infants who are not yet cruising, usually infants less than 9 months of age should ALERT
the nurse for possible abuse.
o Bruising in atypical places– buttocks, hands, feet, and abdomen should arouse the nurse’s
concern. Bruises over bony prominences of the front of the body in a child who is already walking is
COMMON

DOCUMENTATION OF ABUSE
● This must include detailed, nonbiased progress notes, the use of injury maps and photographic
documentation in the health record.
● Written documentation of histories of abuse need to be verbatim but within reason.
● When quoting or paraphrasing the history, do not “sanitize” the words reportedly heard by the victim. Verbatim
documentation of the reported perpetrator’s threat interlaced with curses and expletives can be extremely
useful in the future court proceedings.
● use the words the child has given to describe how his/her injury occurred. If the child is nonverbal, use the
words of the caregiver.
● The ideal is, full interview about abuse is done by a forensically trained interviewer
ASSESSING FOR RISK OF HOMICIDE
● The Danger Assessment (DA) has been proven as a reliable and valid tool for assessing risk
of homicide among abused patients.
● Studies showed that abused woman who were the victims of homicide had an average of 7.1
on the original 15-item DA
ASSESSING FOR RISK OF HOMICIDE
HEALTH ASSESSMENT
LAB / RLE Module #19
I. PATIENT
A. Prepare the patient physically and psychologically to allay
anxiety.
B. Provide privacy to prevent feelings of embarrassment. Close the
door of the patient’s room or curtain of the unit as necessary.
C. Provide adequate information about the procedure, what to
expect during the procedure, and what is expected of the
client, to gain his / her cooperation.
D. Provide a new, clean gown.
I. EQUIPMENT
II. EQUIPMENT
II. EQUIPMENT
 III. SEQUENCE (Please refer to page 793 – 806)
On entering the room the nurse should:
a. wash his or her hands
b. introduce self and purpose
c. begin history taking component while the patient is dressed and sitting in a chair.
d. During this conversation, the general survey and observation of the patient can be done
simultaneously and throughout the assessment and examination.

HEALTH HISTORY
A. To collect subjective data
B. Use techniques of communication (Interview Techniques)
Observation Open-ended questions Leading questions
Back channeling Direct closed-ended questions
 III. SEQUENCE (Please refer to page 793 – 806)
C. History forms

✓ Biographic data : Name, Address, contact number, Age, Birthdate, marital status
✓ Reason for Seeking care / Chief Complaint : patient’s own words that describes the
reason for the visit. It states one / two signs and symptoms and their duration.
✓ Present Health or History of Present Illness : short statement about general state of
health. Common or concerning symptoms
 III. SEQUENCE (Please refer to page 793 – 806)
C. History forms
✓ Past health history: Medication (past and present), illnesses, surgery, allergies
✓ Family history : age and health or age and cause of death of blood relatives, with heart
diseases, hypertension, stroke, DM, blood dyscrasias, cancer, allergies, obesity, mental
illness, seizures disorders, PTB, genetic testing
✓ Lifestyle and personal habits : alcohol, tobacco, sexual preference, sexual partners

D. Review of systems: CEPHALOCAUDAL

• General Survey and Observation (seated)
- Assess the environment
- Assess the individual

a. Mental status : LOC, facial expression, speech, grooming and hygiene, thought and
perception, mood, posture, gait, body movements
b. Vital signs : temperature, pulse, respirations, blood pressure, pain
c. Body measurements : height, weight, BMI and ideal body weight
d. Integumentary : Inspect changes in the skin for for rashes, lesions, hair color and
distribution, palpate for skin turgor, inspect nails and for capillary refill
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D. Review of systems: CEPHALOCAUDAL

d. Head : inspect the skull’s shape and size, inspect the scalp for tenderness and lesions
e. Face: inspect facial features for symmetry.
Cranial nerve VII: face symmetry (raise eyebrows, frown, close eyes, smile, puff out
cheeks
- assess tmj for pain, swelling and crepitus
- Cranial nerve V: trigeminal ; assess for sharp pain

f. Eyes: Inspect pupils. Cranial nerve II (optic) test for confrontation. Cranial III (occulomotor),
Cranial IV (trochlear), Cranial VI (Abducens) test for accommodation and convergence.
- use of opthalmoscope to check for optic disc
g. Ears : otoscopic examination. Hearing acuity Cranial nere VIII (acoustic) – whisper test,
weber test and rinne test
h. Nose and sinuses : Inspect symmetry, mucous membrane. Palpate frontal and maxillary
sinuses
- Cranial nerve I (Olfactory)test for sense of smell
i. Mouth and Pharynx: inspect the external and internal mouth for any lesions, moisture.
Inspect dentitions for number and placement. Inspect tongue for color, moisture, texture.
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D. Review of systems: CEPHALOCAUDAL
i. Mouth and Pharynx: inspect the rise of palate and uvula
j. Neck : inspect symmetry, trachea, thyroid. Palpate for lymph nodes, and thyroid. Test head
and neck range of motion. Test cranial nerve XI (spinal accessory)
k. Posterior thorax: Inspect shape, deformities, retractions. Palpate tenderness, tactile
fremitus, and respiratory expansion. Percuss and auscultate lung sound.
l. Anterior thorax (patient lying down or seated) : same as the posterior thorax
m. Cardiovascular (patient lying down or seated) : inspect carotid arteries and jugular vein
distension. Auscultate heart sounds
n. Breast (patient lying down or seated) : inspect arms at side, hands pressed into hips, arms
raised over head
palpate axillary nodes (central, lateral, pectoral, subscapular)
o. Abdomen: inspect contour, pulsation, skin integrity. Auscultate bowel sound. Test for
abdominal reflex.
p. Peripheral vascular :
q. Urinary:
r. Reproductive
s. Musculoskeletal :
t. Neurologic : motor, sensory
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E. Functional assessment;
- activities of daily living (ADL)