PERFORMANCE CHECKLIST IN BREASTS AND AXILLAE
ASSESSMENT SKILL
1. Gather equipments (centimeter
ruler, small pillow, gloves,
client handout on breast self-
examination, and slide for
specimen.
2. Explain procedure to the client.
3. Ask client to put on a gown.
FEMALE BREASTS
1. Inspect breasts
a. Size and symmetry
b. Color and texture
c. Superficial venous patterns
d. Retraction and dimpling
e. Bilaterally, note color, size,
shape and texture of areolas.
f. Bilaterally, note size and
direction of nipples.
2. Palpate breasts
a. Texture and elasticity
b. Tenderness and temperature
c. Masses: noting location, size in
centimeters, shape , mobility,
consistency, and tenderness.
d. Palpate nipples by
compressing nipple gently
RATIONALIZATION
It is easier for the nurses to get the equipments
needed for the procedure. It will also save time
and energy.
The patient will know what will going t happen in
the procedure. This will reduce the patient’s
anxiety.
The nurses can easily access the part of
the patient's body being treated.
Inspect breast to see if there is infection or
abnormalities.
Breast can be a variety of sizes and are
somewhat round and pendulous. One breast may
normally larger than the other.
To check if there is redness from local infection or
inflammatory carcinoma.
Observe visibility and pattern of breast veins.
To inspect for changes or flattening of the normal
convex breast. Ask the patient to raise her arms
over her head, then press her hands against her
hips to contract the pectoral muscles. Inspect the
breast contours carefully in each position.
Areolas vary from dark pink to dark brown on the
patient’s skin tones. They are round and may vary
in size.
Nipples are nearly equal bilaterally in size and are
in the same location on each breast.
Be sure to palpate every side of the breast, from
nipples, areola to the periphery of the breast
tissue and up into the tail of Spence.
To know if there is dimples, puckers, bulges or
ridges on the skin of your breast and to know if
there is loss of skin elasticity.
To check if there is heaviness, tightness in the
chest, burning in the skin and general soreness.
Palpate carefully for any lumps or mass that is
qualitatively different from or larger than the rest
of the breast tissue.
Palpate each nipple, noting its elasticity.
Thickening of the nipples and loss of elasticity
 between thumb and index suggest an underlying cancer.
finger, observe for discharge.
e. Palpate mastectomy site, if Palpate gently along the scar, these tissues are
applicable, observing the scar may be unusually sensitive. Use a circular motion
and any remaining breast or with two or three fingers.
axillary tissue for redness,
lesions, lumps, swelling or
tenderness
MALE BREASTS
1. Inspect and palpate the Normal male breast has a flat disc of
breasts, areolas, and nipples undeveloped breast tissue beneath the nipple.
for selling nodules or Should be even with no nodules.
ulcerations.
AXILLAE
1. Inspect for rashes or Ask the patient to sit up. Normally there is no
inspection. infection or rashes.
2. Hold the elbow with one hand Use the 3 fingers of your dominant hand and
and use the three fingerpads of reach as high as you can toward the apex of
your other hand to palpate axilla. Warn the patient that this may feel
firmly the axillary lymph nodes. uncomfortable.
3. Palpate high into the axillae, Your fingers should lie directly behind the pectoral
moving downwad against the muscles, pointing toward the midclavicle. Now
ribs to feel for the central press your fingers toward the chest wall of the
nodes. Continue down the axillary nodes, these are the most often palpable.
posterior axillae to feel for the
posterior nodes.
4. Use bimanual palpation to feel To locate if there is any abnormalities or lumps
for the anterior axillary nodes. while doing the procedure.
5. Palpate down the inner aspect To check if there is any lesions or redness
of the upper arm. including bone fractures or joint dislocations
ANALYSIS OF DATA
1. Formulate nursing diagnoses Helps identify nursing priorities and help direct
(wellness, risk, actual) nursing interventions based on identified
priorities. To identify health care needs.
2. Formulate collaborative Collaborative problems using physician-
problems. prescribed and nursing-prescribed interventions.
3. Make necessary referrals. To know if there’s an increased circulation due to
malignancy. An asymmetric venous pattern may
be due to malignancy.

PERFORMANCE CHECKLIST IN HEART & NECK VESSELS

ASSESSMENT SKILL RATIONALIZATION
1. Gather equipment (stethoscope with It is easier for the nurses to get the
bell diaphragm, small pillow, penlight equipments needed for the procedure. It will
or moveable exam light, watch with also save time and energy.
second hand, two centimeter rulers.)
 2. Explain the procedure to the patient. The patient will know what will going t
happen in the procedure. This will reduce
the patient’s anxiety.
3. Ask patient to wear gown. The nurses can easily access the part of
the patient's body being treated.
NECK VESSELS
1. Auscultate carotid arteries for bruits. Palpate each carotid artery alternately by
placing the pads of the index and middle
fingers medial to the sternocleidomastoid
muscle on the neck. Note amplitude and
contour of the pulse, elasticity of the artery,
and any thrills.
2. Palpate each carotid artery for This ensures adequate blood flow through
amplitude and contour of the pulse, the other artery to the brain
elasticity of the vessel, and thrills.
3. Inspect for jugular venous pulse. Inspect the jugular venous pulse by
standing on the right side of the client. The
client should be in a supine position with the
torso elevated 30 to 45 degrees. Make sure
the head and torso are on the same plane.
4. Measure jugular venous pressure. Evaluate jugular venous pressure by
watching for distention of the jugular vein. It
is normal for the jugular veins to be visible
when the client is supine; to evaluate jugular
vein distention, position the client in a
supine position with the head of the bed
elevated 30, 45, 60, and 90 degrees.
HEART PRECORDIUM
1. Inspect for visible pulsation (note if With the client in supine position with the
apical or other) head of the bed elevated between 30 and
45 degrees, stand on the client’s right side
and look for the apical impulse and any
abnormal pulsations.
2. Palpate for apical pulse for location, Remain on the client’s right side and ask the
size, strength, and duration of client to remain supine. Use the palmar
pulsation. surfaces of your hand to palpate the apical
impulse in the mitral. After locating the
pulse, use one finger pad for more accurate
palpation
3. Palpate for abnormal pulsation or Use your palmar surfaces to palpate the
vibration at apex, left sternal border apex, left sternal border, and base. No
and base. pulsations or vibrations are palpated in the
areas of the apex, left sternal border, or
base.
4. Auscultate heart sounds for rate and Rate should be 60 to 100 beats per minute
rhythm (apical and radial pulses, with regular rhythm. A regularly irregular
 pulse rate deficit, S1 and S2.
5. Auscultate S1 and S2 heart sounds
for sound locations and with
respiration, splitting of S2.
6. Auscultate for extra heart sounds
(clicks, rubs) and murmurs (systolic
or diastolic, intensity grade, pitch,
quality, shape, or pattern, location,
transmission, effect of ventilation
and position.
rhythm, such as sinus arrhythmia when the
heart rate increases with inspiration and
decreases with expiration, may be normal in
young adults. Normally the pulse rate in
females is 5 to 10 beats per minute faster
than in males.
Auscultate the first heart sound (S1 or “lub”)
and the second heart sound (S2 or “dubb”).
Remember these two sounds make up the
cardiac cycle of systole and diastole. S1
starts systole, and S2 starts diastole. The
space, or systolic pause, between S1 and
S2 is of short duration (thus S1 and S2
occur very close together), whereas the
space, or diastolic pause, between S2 and
the start of another S1 is of longer duration.
Use the diaphragm first then the bell to
auscultate over the entire heart area. Note
the characteristics of any extra sound heard.
Auscultate during the systolic pause (space
heard between S1 and S2).

7. Auscultate with the client on the left Ask the client to assume left lateral position.
lateral position and with the client Use the bell of the stethoscope and listen to
stirring up, leaning forward, and the apex of the heart.
exhaling.
ANALYSIS OF DATA
1. Formulate nursing diagnoses Helps identify nursing priorities and help
(wellness, risk, actual) direct nursing interventions based on
identified priorities. To identify health care
needs.
2. Formulate collaborative problems Collaborative problems using physician-
prescribed and nursing-prescribed
interventions.
3. Make necessary referrals. To know if there’s an increased circulation
due to malignancy. An asymmetric venous
pattern may be due to malignancy.

STUDENT'S SIGNATURE: __________________________________

CLINICAL INSTRUCTOR'S SIGNATURE: ______________________