Breasts and regional lymphatics - CH17

● Structure and function

○ Remember the tail of Spence
○ nipple and areola are same color
○ nipple darken for baby to see it better
● Internal anatomy
○ main purpose - produce milk
○ glandular tissues
○ Cooper’s ligaments
■ keep breasts perky
■ in aging breakdown of these leads to breast sagging
● 4 quadrants
○ used to identify and locate abnormalities
● Lymphatics
○ know drainage patterns, not names
● Developmental care
○ Tanner Scale - adolescence measure
○ unbalanced maturation rate is norma
○ aging woman
■ dec of estrogen leads to replacing breast tissue with fibrous tissue
■ dec of adipose tissue
○ men
■ can get breast cancer
■ gynecomastia
● somewhat normal, temporary breast growth during puberty
● Subjective evaluation
○ Breast
■ pain
● localized or generalized?
● PQRSTU
■ lump
● fixed or moveable
● change during period?
● associated skin changes
■ discharge
● unless pregnant or lactating NEVER OK
● assess color, odor, thickness, both breasts?
■ rash
● where? on nipple and areola?
■ swelling
● unilateral, changes in breast size
■ trauma
■ History of breast disease
 ● benign breast disease - may be normal, but makes it more difficult
to recognize problems.
■ Surgery
● breast augmentation/reduction, mastectomy,
■ Self-care Behavior
● self exam
● last exam
● self exam between days 3-7 of cycle
● mammograms - annual after 40 if you have a history, every 3
years with no history.
■ Axilla
● tenderness
■ Preadolescents
● changes in breasts
● hair
● how do they feel about it?
■ Pregnancy
● plans to breastfeed
● enlargement - fitting bras
■ Menopausal
● changes, location, sagging of breasts
■ changes throughout menstrual cycle
● Objective exam
○ disrobe to waist
○ inspect
■ general color and appearance
■ nipples look about same size shape and direction
■ screen for retraction
● arms above head
○ breasts lift symmetrical
● hands on hip and press
○ breasts should line up
● lean forward and let breasts swing
● put them on the glass
■ inspect and palpate axillae
■ look for supernumerary nipples
○ Breasts
■ normal sized breasts, palpate supine, place cloth under shoulder
■ large breasts - bimanual palpation
■ use any palpation method, just cover all the breast tissue
■ expected findings
● no lumps
● wear gloves and squeeze nipple to check for discharge
■ if lump is found
 ● location: 7:00, 3cm from nipple
● size
● shape
● consistency
● tenderness
● palpable lymph nodes
○ Teach self exam
■ schedule
● 3rd-7th day of cycle
■ correct techniques
● recommend checking in shower
■ return demonstration
● make sure that the PT can demonstrate proper self exam
○ Male breast
■ can be cause by testosterone deficiency
■ can be in adolescence
■ Should be temporary
■ In older adults, can indicate problems, should be referred to a specialist

Thorax and lungs - Ch18

● Structure and function
○ review anatomy
○ diaphragm sits right at the xyphoid process
○ Reference lines
■ midsternal
● separate left and right
■ midclavicular line
■ anterior axillary line
■ vertebral line
■ scapular line
■ midaxillary line
■ posterior axillary line
○ Thoracic cavity
■ mediastinum
● includes heart, great vessels, esophagus
■ lobes
● right 3
● left 2
● Four functions of respiratory system
○ supply oxygen to body
■ inspiration
● diaphragm lowers, creating vacuum
● O2 enters acinus and then blood
○ expiration
 ■ passive force
■ hypercapnia is main drive to breathe
○ acid/base balance
■ CO2 is an acid. Respiration can inc or dec CO2 levels
○ Temperature control
■ resp rate increases as body temperature increases
● Subjective questions
○ cough
■ frequency
■ length
■ productive?
● color
● thickness
● bloody - hemoptysis
● continuous thru day?
○ SOB - shortness of breath
■ orthopnea - can’t breathe lying down
■ r/t wheezing?
■ r/t cyanosis?
■ what does pt do when they have SOB?
○ Chest pain
■ localized
■ r/t trauma?
○ History of resp infections
■ family history of allergies
■ unusually frequent colds?
○ Smoking history
■ second hand smoke
■ number/day
■ last time smoking?
○ Environmental exposure
■ valley fever
■ asbestos
○ Self-care behaviors
■ TB test
■ vaccines
■ hospitalization - requires screening for vaccinations and smoking history
● Objective data
○ posterior chest
■ thoracic cage
● shape of chest wall
● accessory muscles - hypertrophy to shoulder muscles
● compare anterior to posterior
○ barrelchest?
 ■ can be COPD (can be chronic bronchitis or
emphysema)
● position of PT
○ tripod/hunching
● skin color/condition
○ symmetric
○ even coloration
■ palpation
● symmetric expansion
● tactile fremitus
○ feel vibrations
○ p423
○ symmetry of vibration is most important
○ weaker fremitus means more air, stronger fremitus means
consolidation
● palpate chest wall
■ percussion
● p435
● predominant note over lung fields
● diaphragmatic excursion
○ percuss to find movement of diaphragm
■ normal 3-5 cm
■ Auscultation
● breath sounds
○ PT breathes through the mouth
○ 9 places to auscultate p 437
● normal noises
○ bronchial breath sounds
■ trachea and mainstem bronchi
■ bronchoveicular
■ vesicular sounds - in the alveoli
○ adventitious sounds (abnormal)
■ crackles
■ wheeze
■ atelectatic crackles
○ Voice sounds
■ bronchophony
■ egophony
■ Anterior chest
● inspect
○ retraction (pulling on intercostals)
● symmetric expansion
● tactile fremitus
● auscultate
 ○ breathing sounds
■ Abnormal findings
● barrel chest - anterior/posterior ratio of 1:1
○ can indicate COPD
● scoliosis
○ can cause pressure on lungs
● kyphosis
○ humped back esp in older people
○ can cause problems in lung volume
● Respiratory findings
○ normal breathing - 12-20 breaths per minute
○ >20 - tachypnea
○ <12 - bradypnea
○ hyperventilation
● Discontinuous sounds
○ crackles
○ wheezes
○ stridor

Heart and neck vessels - Ch 19

● S1 - lub - closing of AV valve
● S2 - dub - closing of semilunar valve
● murmurs can be auscultated
○ can be inversely proportional to the size of the defect
■ ie - small hole = big noise and more turbulence
● Neck vessels
○ carotids are palpable
■ don’t palpate both @ same time
● subjective history
○ chest pain
■ referred pain
■ activity
■ emotion
■ associated symptoms
● pale
● cold sweat
● nausea
○ dyspnea
■ difficulty breathing on exertion
○ fatigue
■ increased fatigue caused by decrease of oxygen delivered to body
■ often worse in the evening
■ new onset?
■ duration
 ○ cyanosis or pallor
■ from low O2 carrying capacity or decrease in cardiac output
○ Edema
■ mostly in lower extremities - dependant edema.
■ does it go away when you put your feet up
■ if related to heart, can be worse in the evening
○ nocturia
■ when sleeping, kidneys are able to work at full capacity
○ cardiac history
■ surgery
■ meds
○ family history
○ personal habits (cardiac risk factors)
■ changeable
● smoking
● diet
● weight
■ non changeable
● genetic
● Objective data
○ carotids
■ equal strength between both
■ auscultate with bell for bruits (whooshing). Not found in healthy PT
○ jugulars
■ inspect, look for venous pulse
○ Precordium
■ inspect anterior chest
● symmetry, expansion, color, abnormal pulsations
■ palpate apical impulse
● 4th intercostal, midclavicular line
■ palpate across precordium
● look for a thrill (abnormal pulsation). Should not be found in
healthy PT
■ percuss to outline cardiac borders
● or just use xray
■ auscultate
● use diaphragm, then bell
● p475 has all locations
■ assess pulse rate and rhythm