SEMI FINALS COVERAGE

Chapter 4 (…continuation part 1)

PHYSICAL ASSESSMENT

Let’s Begin!
THORAX AND LUNGS ASSESSMENT

 How to measure the chest. Take the measurement at the nipple level with a tape measure;
observe for chest size, shape, movement of the chest with breathing, and any retractions.
 Adolescents. In the older school-age child or adolescent, note evidence of breast development.
 Assess respiratory characteristics. Evaluate respiratory rate, rhythm, and depth; report any noisy
or grunting respirations.
 How to assess breath sounds. Using a stethoscope, the nurse listens to breath sounds in each
lobe of the lung, anterior and posterior, while the patient inhales and exhales; describe,
document, and report absent or diminished breath sounds, as well as unusual sounds such as
crackling or wheezing.

BODY PART TECHNIQUE NORMAL FINDINGS

Thorax and Lungs Inspection.
(Anterior and Have the client sit comfortably.
Posterior) Inspect for the shape, position of the
spine, slope of the ribs, retraction of
the intercostal spaces (ICS) on
inspiration, and bulging of the ICS on
expiration.
Observe for symmetry of the
chest wall during respiration
» The chest contour is symmetrical and the
chest is twice as wide as deep
(anteroposterior diameter in a 1:2 ratio).
The spine is straight. Posteriorly the ribs
tend to slope across and down. The ribs
are prominent in a thin person. There is
no bulging or retraction of the ICS during
breathing. The chest wall moves
symmetrically during respiration.

Palpation
Palpate for lumps, masses, areas
of tenderness.
Measure chest excursion (to
determine the depth of breathing).
Place hands on the lower portion of
the rib cage with the thumbs 2
inches apart pointing towards the
spine and fingers.
Elicit tactile fremitus (a thrill felt by
the hand on the chest wall while the
client is speaking). Place the palms
of the hand bilaterally symmetrical
on the chest. Start from the top of
» No lumps, masses, areas of tenderness.
» Sides of the thorax expand symmetrically.
The examiner’s thumb separate
approximately 3-5 centimeters during
excursion.
» Vibrations are prominent over the areas
near the bronchi. It increases with
intensity of the voice. Vibrations are
strongest between the first and second
ribs along the sternum anteriorly and
between the scapulae posteriorly.
the chest wall going down. Each
time the hands move, ask the client
to say “ninety-nine” or “one--one—
one” with the same intensity of
voice

» Percussion note varies with the thickness

Percussion
For the anterior thorax, the client
is preferably in a lying position. For
posterior thorax, the client is in a
sitting position with the arms folded
across the chest. This position will
separate the scapulae to further
expose the lungs for assessment.
Using indirect percussion, percuss in
the ICS over symmetrical areas of
the chest starting from the
supraclavicular area. Compare one
side of the chest to another.
of the chest wall:
» Resonance- sound created by air-filled
lungs. It is clear, long, low pitch.
» Dull- short, high pitch, soft and thudding,
heard over the heart.
» Flat- absolute dullness; absence of air in
the underlying tissue.
» Tympany- moderately loud with music
quality with specific pitch. Noted in the
left upper quadrant of the abdomen.

Location Percussion Note

L R

Supra-

clavicular Flat

1st ICS Resonant

2nd ICS Dull Resonant

3rd ICS Dull Resonant

4th ICS Dull Resonant

5th ICS Dull Resonant

6th ICS Resonant Resonant

7th ICS Tympanic Dull

8th ICS Tympanic Dull

9th ICS Tympanic Dull

 » Normal breath sounds differ in character
depending on the area of the lung being
auscultated.

» Bronchovesicular sounds are medium-

pitched sound or medium intensity,
heard posteriorly between the scapulae.
The sounds have a blowing quality with
the inspiratory phase equal to the
expiratory phase.
Auscultation

To assess the movement of air
through the tracheobronchial tree,
room must be quiet.
» Vesicular sounds are heard over the lung
periphery. The sounds are created by air
moving through the smaller airways.
They are soft, breezy, and low-pitched
and the inspiratory phase is about three
times longer than the expiratory phase.

» Bronchial sounds are hollow high pitched;

whistling sounds which are normal if
heard over large airways like the
trachea.

Overview

1. The thorax and lungs should be assessed anteriorly, posteriorly, and laterally

Nursing Points
General

1. Supplies needed

a. Stethoscope

Assessment

1. Anterior

a. Inspect

i. Size and shape of thorax

1. Anterior-Posterior diameter should be approximately ½ the lateral diameter

2. Barrel Chest – COPD

ii. Symmetry

1. Expansion should be symmetrical on inspiration

 iii. Ribs should slope downward from the sternum outward

iv. Observe for signs of distress

1. Tachypnea

2. Retractions

3. Cyanosis

v. Observe the overall rate and rhythm of respirations

vi. Inspect skin color and condition on thorax

b. Palpate

i. Using 2 fingers, press lightly on skin over anterior chest, feeling for crepitus – feels like “rice

crispies” under skin

1. Indicates subcutaneous air

c. Percuss

i. Starting at the Apex, percuss in the intercostal spaces moving left to right and downward

ii. Should hear resonance

iii. May hear dullness over heart and liver

d. Auscultate

i. Listen for audible cough, wheezing, or stridor

ii. Lung sounds

1. Bronchial

a. Upper areas

b. High pitch

c. Insp < Exp

2. Bronchovesicular

a. Middle areas

b. Moderate pitch

c. Insp = Exp

3. Vesicular

a. Outer areas
 b. Low pitch

c. Insp > Exp

iii. Listen from left to right starting at the apex and moving downward, including the lateral areas.

1. The only way to hear the right middle lobe is to listen near the axilla on the right side.

iv. Should listen in 10-12 areas on the front

v. BEST heard with stethoscope directly on skin

vi. Listen to one full respiration in each area

vii. Make note of any adventitious sounds

1. Crackles

2. Rhonchi

3. Wheezes

4. Stridor

5. *See Lung Sounds lesson in Respiratory Course for details

2. Posterior

a. Inspect – same as anterior

b. Palpate – same as anterior, plus:

i. Tactile fremitus

1. Use the palm of your hands to palpate from the apex down in 5 places as the patient says

the word “ninety-nine”

2. Should feel vibrations equally bilaterally

a. Decreased vibration = fluid consolidation

ii. Expansion

1. Place hands on lower rib cage with thumbs touching, ask patient to inhale deeply

2. Should see hands expand and return symmetrically

c. Percuss – same as anterior,

i. Avoid scapula

d. Auscultate – same as anterior

i. Avoid scapula
 ii. 8-10 locations

HEART (CARDIAC) and GREAT VESSELS ASSESSMENT

Inspection of the Heart

 The chest wall and epigastrium is inspected while the client is in supine position. Observe for
pulsation and heaves or lifts
Normal Findings:

 Pulsation of the apical impulse may be visible. (this can give us some indication of the cardiac
size).
 There should be no lift or heaves.

Palpation of the Heart

 The entire precordium is palpated methodically using the palms and the fingers, beginning at the
apex, moving to the left sternal border, and then to the base of the heart.
Normal Findings:

 No, palpable pulsation over the aortic, pulmonic, and mitral valves.
 Apical pulsation can be felt on palpation.
 There should be no noted abnormal heaves, and thrills felt over the apex.

Percussion of the Heart

 The technique of percussion is of limited value in cardiac assessment. It can be used to determine
borders of cardiac dullness.

Auscultation of the Heart

  Anatomic areas for auscultation of the heart:
 Aortic valve – Right 2nd ICS sternal border.
 Pulmonic Valve – Left 2nd ICS sternal border.
 Tricuspid Valve – – Left 5th ICS sternal border.
 Mitral Valve – Left 5th ICS midclavicular line
Positioning  the client for auscultation:

1. If the heart sounds are faint or undetectable, try listening to them with the patient seated and
leaning forward, or lying on his left side, which brings the heart closer to the surface of the chest.
2. Having the client seated and leaning forward is best suited for hearing high-pitched sounds
related to semilunar valves problem.
3. The left lateral recumbent position is best suited low-pitched sounds, such as mitral valve
problems and extra heart sounds.
Auscultating the heart:

1. Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral
2. Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of semilunar valve). S1 sound
is best heard over the mitral valve; S2 is best heard over the aortic valve.
3. Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.
4. Count heart rate at the apical pulse for one full minute.

Auscultation of Heart Sounds

Normal Findings:

 S1 & S2 can be heard at all anatomic site.

 No abnormal heart sounds are heard (e.g. Murmurs, S3 & S4).
 Cardiac rate ranges from 60 – 100 bpm.
BODY PART TECHNIQUE NORMAL FINDINGS

HEART Inspection and Palpation

Place client in supine position.

Stand on the client’s right side. Ask
the client not to talk. Inspect and
palpate the valve areas of the heart.

 Aortic Valve – found at the 2nd  No pulsations

ICS on the left of the angle of
Louis (felt as a prominence on
the sternum)

 Pulmonic area – at the 2nd ICS

 No pulsations
on the left of the angle of Louis.

 Tricuspid area – move the

fingers along the client’s left  No pulsations
sternal border to the 5th ICS.

 Apical area – move the fingers

laterally to the left mid-  Pulsations visible and palpable
clavicular line (LMCL) which is
slightly below the nipple. This
point where the apex touches
the anterior chest is known as
the point of maximal impulse
(PMIO)

 Epigastric area – at the base of

the sternum.

Auscultation  Abdominal aortic pulsations visible and

Auscultate the heart in all 4
anatomical sites: aortic, pulmonic,
tricuspid, and apical (mitral).
Eliminate all sources of room noise.
palpable.
 The two sounds are audible in all areas
but loudest at apical area.
 Heart sounds are of low intensity
and other noise hinders the ability of
the examiner to hear them.

Identify the 1st sound (S1). This is a

dull low – pitched sound described
as “lub”. Then identify the 2nd sound  Cardiac rate ranges from 60-100
(S2). This is higher – pitched than beats/minute.
S1, described as “dub”. Use the bell-
shaped diaphragm.

Once S1 and S2 are identified

count the heart rate for one minute.
Each combination of S1 and S2
counts as one heartbeats.

Overview

1. Major heart assessments:

a. Sounds

b. Murmurs

c. Apical pulse

2. The great vessels to be assessed  are:

a. Carotid arteries

b. Jugular veins

c. Aorta

Nursing Points
General

1. Supplies needed

a. Pen light

b. Stethoscope

Assessment

1. Inspect

a. Anterior chest for visible apical pulse

i. 5th ICS, Left MCL

 b. Abdomen for pulsation

i. May indicate an abdominal aortic aneurysm

c. Jugular venous pulse

i. Lay patient at 30-45 degrees, turn head away

ii. Shine penlight on neck

iii. May see slight pulsation

iv. Jugular vein should flatten at 45 degrees or higher

v. Jugular venous distention (engorged at 30 degrees or higher) may indicate heart failure and/or

volume overload

2. Palpate

a. Carotid pulses – locate by sliding two fingers laterally from thyroid

i. ONE AT A TIME

ii. Compare bilaterally

b. Apical pulsation to locate point of maximum impulse (PMI)

i. Should be 5th ICS, Left MCL

3. Auscultate

a. Heart Sounds

i. APE To Man

1. Aortic

a. 2nd ICS, RSB

2. Pulmonic

a. 2nd ICS, LSB

3. Erb’s Point

a. 3rd ICS, LSB

4. Tricuspid

a. 4th ICS, LSB

5. Mitral
 a. 5th ICS, Left MCL

ii. Listen with Diaphragm, then Bell (for murmurs)

iii. Make note of quality and timing, presence of extra sounds

b. Carotid bruit – listen over carotid with bell

c. Auscultate to count Apical pulse (5th ICS, Left MCL) for a full minute.

ABDOMINAL ASSESSMENT

 In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the
client in a supine position with the knees slightly flexed to relax abdominal muscles.

Inspection of the abdomen

 Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus).
 Contour (flat, rounded, scaphoid)
 Distension
 Respiratory movement.
 Visible peristalsis.
 Pulsations

Normal Findings:

 Skin color is uniform, no lesions.

 Some clients may have striae or scar.
 No venous engorgement.
 Contour may be flat, rounded or scaphoid
 Thin clients may have visible peristalsis.
 Aortic pulsation may be visible on thin clients.

Auscultation of the Abdomen

 This method precedes percussion because bowel motility, and thus bowel sounds, may be
increased by palpation or percussion.
 The stethoscope and the hands should be warmed; if they are cold, they may initiate contraction
of the abdominal muscles.
  Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. Intestinal
sounds are relatively high-pitched, the bell may be used in exploring arterial murmurs and
venous hum.

Peristaltic sounds

 These sounds are produced by the movements of air and fluids through the gastrointestinal tract.
Peristalsis can provide diagnostic clues relevant to the motility of bowel.
 Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:
o Divide the abdomen into four quadrants.

o Listen over all auscultation sites, starting at the right lower quadrants, following the
cross pattern of the imaginary lines in creating the abdominal quadrants. This
direction ensures that we follow the direction of bowel movement.
o Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen
for at least 5 minutes, especially at the periumbilical area, before concluding that no
bowel sounds are present.
o The normal bowel sounds are high-pitched, gurgling noises that occur approximately
every 5 – 15 seconds. It is suggested that the number of bowel sound may be as low
as 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound.
o Some factors that affect bowel sound:
 Presence of food in the GI tract.

 State of digestion.
 Pathologic conditions of the bowel (inflammation, Gangrene, paralytic
ileus, peritonitis).
 Bowel surgery
 Constipation or Diarrhea.
 Electrolyte imbalances.
 Bowel obstruction.

Percussion of the abdomen

 Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites), gaseous distension,
and masses, and in assessing solid structures within the abdomen.
 The direction of abdominal percussion follows the auscultation site at each abdominal guardant.
 The entire abdomen should be percussed lightly or a general picture of the areas of tympany and
dullness.
 Tympany will predominate because of the presence of gas in the small and large bowel. Solid
masses will percuss as dull, such as liver in the RUQ, spleen at the 6th or 9th rib just posterior to
or at the midaxillary line on the left side.
 Percussion in the abdomen can also be used in assessing the liver span and size of the spleen.
Percussion of the liver

 The palms of the left hand are placed over the region of liver dullness.
 The area is strucked lightly with a fisted right hand.
 Normally tenderness should not be elicited by this method.
 Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.

Renal Percussion

 Can be done by either indirect or direct method.

 Percussion is done over the costovertebral junction.
 Tenderness elicited by such method suggests renal inflammation.

Palpation of the Abdomen

Light palpation

 It is a gentle exploration performed while the client is in supine position. With the examiner’s
hands parallel to the floor.
 The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without
digging, but gently palpating with slow circular motion.
 This method is used for eliciting slight tenderness, large masses, and muscles, and muscle
guarding.
 Tensing of abdominal musculature may occur because of:
o The examiner’s hands are too cold or are pressed to vigorously or deep into the
abdomen.
o The client is ticklish or guards involuntarily.
o Presence of subjacent pathologic condition.
Normal Findings:

 No tenderness noted.
 With smooth and consistent tension.
 No muscles guarding.
Deep Palpation

 It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces
of the fingers into the abdominal wall.
 The abdominal wall may slide back and forth while the fingers move back and forth over the
organ being examined.
  Deeper structures, like the liver, and retroperitoneal organs, like the kidneys, or masses may be
felt with this method.
 In the absence of disease, pressure produced by deep palpation may produce tenderness over
the cecum, the sigmoid colon, and the aorta.

Liver palpation

 There are two types of bimanual palpation recommended for palpation of the liver. The first one
is the superimposition of the right hand over the left hand.
o Ask the patient to take 3 normal breaths.
o Then ask the client to breathe deeply and hold. This would push the liver down to
facilitate palpation.
o Press hand deeply over the RUQ
 The second methods:
o The examiner’s left hand is placed beneath the client at the level of the right 11th and
12th ribs.
o Place the examiner’s right hands parallel to the costal margin or the RUQ.
o An upward pressure is placed beneath the client to push the liver towards the
examining right hand, while the right hand is pressing into the abdominal wall.
o Ask the client to breathe deeply.
o As the client inspires, the liver maybe felt to slip beneath the examining fingers.
Normal Findings:

 The liver usually cannot be palpated in a normal adult. However, in extremely thin but otherwise
well individuals, it may be felt the coastal margins.
 When the normal liver margin is palpated, it must be smooth, regular in contour, firm and non-
tender.

BODY PART TECHNIQUE NORMAL FINDINGS

ADBOMEN Divide the abdomen into 4

imaginary quadrants. Draw a vertical
line from the xiphoid process to the
symphysis pubis and a horizontal
line across the umbilicus. These
quadrants are labeled right upper
quadrant (RUQ), left upper quadrant
(LUQ), right lower quadrant (RLQ),
and left lower quadrant (LLQ).

Ask client if he needs to void.

Drape the upper chest and legs.
Expose the abdomen from the
xiphoid process to the symphsis
pubis. The client lies in supine
position with arms down at the sides
a small pillow may be placed under
the head.

Inspection

Inspect the abdomen for skin

integrity, color, contour, symmetry,
movement or pulsations and color
and placement of umbilicus.

» Skin is unblemished, no scars, color is

uniform, flat, rounded (convex), or
scaphoid (concave),
» Symmetrical movements caused by
respiration, aortic pulsation at epigastric
area visible in thin persons
» Umbilicus is flat or concave, positioned
midway between the xiphoid process
and the symphysis pubis
» Color is the same as the surrounding skin.
Auscultation

Warm the diaphragm of the
stethoscope. Cold stethoscope may
cause the client to contract the
abdominal muscles and the
contractions may be heard during
auscultation. Diaphragm is used
because intestinal sounds are high –
pitched sounds. Place the diaphragm
in each of the 4 quadrants over all
auscultation sounds.
» There are clicks and gurgles, the frequency
of which has been estimated at from 5-
34 per minute. Occasionally,
borborygmi (loud prolonged gurgles of
hyperperistalsis) the familiar “stomach
growling” can be heard.

Percussion

Reveals presence of air in the » Tympany predominates because of the

presence of air in the stomach and
stomach and abdomen.
intestines
To identify the boarders start » Percussion is dull at the liver’s lower
percussion at the right iliac rest boarder.
upward along the midclavicular line.
Percuss each quadrant starting from
the right clockwise.
 Palpation

Perform light palpation first to

detect areas of tenderness, muscle
guarding, (Voluntary tightening of
abdominal muscles), lumps of
masses, consistency and
» Soft abdomen, no tenderness, no muscle
organomegaly.
guarding, no lumps, or masses, or
Depress the abdominal wall organomegaly.
lightly, about 1 cm. with the pads of
your fingers. Move the finger pads in
a slight circular motion. Palpate all 4
quadrants.

Palpate the liver using deep

palpation. Stand on the client’s right
side. Place your left hand on the
posterior thorax at about the 11th or
12th rib and then apply upward
pressure. With the fingers of the
right hand pointing upward, place
the hand on the RUQ well below the
liver’s lower boarder, then press
gently until you reach the depth of
1 ½ - 2 inches. Ask the client to take
a deep breath using the abdominal
muscles. As he inhales, try to » Liver’s edge feels firm and not tender.
palpate the liver’s edge as it
descends.

Overview

1. Remember the order of assessment is different!

a. Inspect

b. Auscultate

c. Percuss

d. Palpate

Nursing Points
General

1. Supplies needed
 a. Stethoscope

b. Pen light (optional)

Assessment

1. Inspect

a. Shape and contour

i. Look across abdomen left to right

ii. Can use pen light to look for visible bulging or masses

iii. Look for distention

b. Umbilicus – discoloration, inflammation, or hernia

c. Skin texture and color

d. Lesions or scars

i. Note details – length, color, drainage, etc.

e. Visible pulsations

f. Respiratory movements (belly breather)

2. Auscultate

a. Start in RLQ → RUQ → LUQ → LLQ

i. This follows the large intestine

b. Use diaphragm of stethoscope to listen for 1 full minute per quadrant

i. Active – Should hear 5-30 clicks per minute

ii. Hypoactive

iii. Hyperactive

iv. Absent – must listen for 5 minutes per quadrant to confirm this

c. Use bell of stethoscope to listen for bruits

i. Aorta – over the epigastrium

ii. Iliac and femoral arteries – Inguinal are

iii. Renal arteries – A few cm above and to the side of the umbilicus

1. Press firmly
 iv. The presence of a bruit could indicate narrowing of the arteries – if this is a new finding, report

to provider

3. Percuss

a. Percuss x 4 quadrants, starting in RLQ as with auscultation

b. Expect to hear tympany

c. Dullness could indicate a mass, fluid-filled bladder, blood in the belly, or significant adipose tissue

i. Exception – dullness over the liver is expected

d. CVA tenderness

i. Place nondominant hand flat over the costovertebral angle (flank).

ii. Strike your hand with the ulnar surface of your dominant hand

iii. Should be nontender

iv. Repeat bilaterally

4. Palpate

a. Light palpation – small circles in all 4 quadrants

i. Can do 4 small areas in each quadrant to be thorough

b. Deep palpation – deeper circles in all areas

c. Palpating for masses – make note of size, location, consistency, tenderness, and mobility

d. Make note of any guarding or tenderness

e. Assess for rebound tenderness

i. Press down slowly and deeply

ii. Release quickly

iii. Ask patient which hurt most (down or up)

iv. Rebound tenderness over RLQ could indicate appendicitis

f. If distended, perform Fluid-Wave test to look for ascites:

i. Place patient’s hand over umbilicus

ii. Place your hand on right flank, then tap or push on the left flank with your other hand

iii. If you feel the tap/push on the opposite hand, that’s a Positive Fluid-Wave test

1. Indicates Ascites
 iv. You may also see the patient’s hand ‘wave’ with the fluid

Nursing Concepts

1. Ask patient if they have had any difficulty with bowel movements

a. Frequency

b. Consistency

c. Color

i. Bleeding?

2. If a bowel movement is available, asses the stool for color, consistency, character

BREAST EXAMINATION

Inspection of the Breast

 There are 4 major sitting position of the client used for clinical breast examination. Every client
should be examined in each position.
o The client is seated with her arms on her side.
o The client is seated with her arms abducted over the head.
o The client is seated and is pushing her hands into her hips, simultaneously eliciting
contraction of the pectoral muscles.
o The client is seated and is learning over while the examiner assists in supporting and
balancing her.
 While the client is performing these maneuvers, the breasts are carefully observed for symmetry,
bulging, retraction, and fixation.
 An abnormality may not be apparent in the breasts at rest a mass may cause the breasts, through
invasion of the suspensory ligaments, to fix, preventing them from upward movement in position
2 and 4.
 Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and shortened
suspensory ligaments.
Normal Findings:

 The overlying the breast should be even.

  May or may not be completely symmetrical at rest.
 The areola is rounded or oval, with same color, (Color varies from light pink to dark brown
depending on race).
 Nipples are rounded, everted, same size and equal in color.
 No “orange peel” skin is noted which is present in edema.
 The veins may be visible but not engorge and prominent.
 No obvious mass noted.
 Not fixated and moves bilaterally when hands are abducted over the head, or is leaning forward.
 No retractions or dimpling.

Palpation of the Breast

 Palpate the breast along imaginary concentric circles, following a clockwise rotary motion, from
the periphery to the center going to the nipples. Be sure that the breast is adequately surveyed.
Breast examination is best done 1-week post menses.
 Each areolar areas are carefully palpated to determine the presence of underlying masses.
 Each nipple is gently compressed to assess for the presence of masses or discharge.
Normal Findings:

 No lumps or masses are palpable.

 No tenderness upon palpation.
 No discharges from the nipples.
 NOTE: The male breasts are observed by adapting the techniques used for female clients.
However, the various sitting position used for woman is unnecessary.

BODY PART TECHNIQUE NORMAL FINDINGS

BREASTS Inspection Females: variable in size depending on body

build.
Ask client to remove the top gown
or drape to allow simultaneous * Obese - large and pendulous.
visualization of both breasts. Have
the client sit comfortably with arms
at the side. Inspect the breast for *Slender - thin and small.
size, symmetry and contour or
shape. Inspect the skin of the breast
for color, retraction or dimpling. *Young clients - firms, elastic in consistency,
cone shaped symmetrical, skin surface
smooth.

*older women - breasts sag, nipples lower,

 stringy and nodular.

Palpation
Males: flat, symmetrical. If obese, may be
Assist the client in a supine slightly rounded.
position. This position allows the
breast tissues to flatten evenly
against the chest wall facilitating
palpation. Ask client to raise his/her
hand and place it under the head. » Color of the skin same with the abdomen,
Palpate the breasts for lumps or no retraction, no dimpling.
masses, areas of tenderness, and
consistency of breast tissues. » No mass or lump, no areas of tenderness.

» In younger client, borders of the breasts

The palmar surface of the three
are clearly delineated. In older client
fingers is used to compress breast
irregular consistency, glandular/nodular.
tissues against the chest wall.

» Lobular feel of glandular tissue is normal.

Perform palpation in a clockwise
rotary motion from the boarders
going inward.
» The lower edge of the each breast may
feel firm and hard.
» Premenstrual fullness, nodularity and
tenderness may be present.

» Warm to touch and smooth.

AREOLA Inspection

Inspect the size, shape, color, and » Round or oval, color darker than
symmetry. surrounding skin, symmetrical.
» For dark – skinned client, color is darker
than other skin surfaces.

» No masses and areas of tenderness.

Palpation

Palpate for masses and areas of

tenderness.
 NIPPLES Inspection

Inspect for size, shape position,

discharge, and lesions.
» Round or inverted, equal in size, similar in
color, nipples point in one direction, no
discharge, no lesion, no dimpling, and no
crusting.
Palpation
» No masses, no tenderness, no discharge.
Using thumb and index finger,
compress the nipple to determine
any discharge.

MALE GENITALIA EXAMINATION ( Overview) 

Risk Factors for Testicular Cancer

1. Age 20-34 (15-35)

2. History of undescended testes
3. Early puberty
4. Family history
5. White race
6. Higher social class
7. Obesity
8. Never married or late marriage
9. Maternal use of oral contraceptives or diethylstilbestrol during early pregnancy
10. Maternal abdominal/pelvic x-ray during pregnancy
11. Mother or sisters with breast cancer

Warning Signs for Cancer of the Testicle

1. A small, hard, painless lump-about the size of a pea

2. Feeling of heaviness in the testicle
3. Enlargement of the testicle
4. Change in how the testicle feels to the touch
5. Sudden accumulation of fluid/blood in the scrotum
6. Dull ache in the groin
7. Swelling or tenderness in other parts of the body (groin, breast, neck)

Testicular Self-Examination

1. Perform after a warm bath/shower

2. Use both hands and start on right testicle
3. Place index and middle finger underneath testicle
 4. Place thumb on top of testicle
5. GENTLY roll the testicle between thumbs and fingers
6. Check all sides of the right testicle and repeat procedure on left testicle
7. Find the epididymis on the top and back of each testicle.
8. Examine the testes in mirror while standing. Look for unusual contours and swelling of testes
(noting that one usually hangs lower than the other)

End of Chapter 4 (continuation part 1)….

Reminders: Before proceeding to the exercises, if you have other topics not fully clear to you, feel free to
browse again on the topics and you can also do additional readings from other textbooks and references. No
cheating in the self- assessment exercises. Answer it on your own without looking at your notes. Good Luck
 END CHAPTER ACTIVITIES
Instructions: In a separate sheet of paper, answer the following case scenarios and attach it to this
section once you submit your portfolio and outputs.

Case Analysis

I. THORACIC AND LUNGS ASSESSMENT

Case 1: Nurse Maldita conducted her third home visit to a 60 year old man who was discharged 10 days
ago due to COPD. He stated he feels great today and was able to walk outside for a few minutes today
without his oxygen. He uses oxygen prn at 2 lpm via nc when he has shortness of breath or during mild
exercises. He reports chronic cough as usual but denies sputum production.

You noted his facial color and lips are ruddy, but nail beds are pink. Breathing pattern is regular,
unlabored but tachypneic at 28 cycles per minute, which is his usual rate. Examining his thorax, you note
hew is barrel chested with a transverse to lateral ratio of about 2.5 to 3. Although he is not using
accessory muscles to breathe, you do note he has slight intercostal bulging and rigidity upright posture
in chair. While auscultating his lungs, you note diminished breath sounds bilaterally in most of lower
lobes and a small, discrete area of coarse crackles in upper portion of left lower lobe. You also have
noted the odor of cigarette on his breath.

Tasks.

1. Based on the scenario, identify subjective and objective data.

2. You have assessed the clients’ lung sounds. Explain in order the proper way of auscultating lung
sounds in : a. Anterior Thorax b. Posterior Thorax

3. As per your assessment, you have noted slight intercostal bulging from the client. Explain what does
this indicate and support your answer basing on the clients’ current health condition.

4. From the case scenario identify one specific nursing diagnosis and give 5 nursing interventions needed
to be conducted with its rationale based from your inference.

II. CARDIOVASCULAR ASSESSMENT

Case 2. A 45 year old black male who has HTN and past medical history of angina and myocardial
infarction is being examined in RPGMC ER. Although he is in no acute distress and verbalization of being
fine, physical assessment reveals: BP 210/110 right arm, pulse 88 regular and strong, and respirations 16
regular and moderately shallow, afebrile. Apical pulse is also 88 and strong. S1 and S2 with no murmurs
and clicks but S4 noted. Neck veins are flat at 45 degrees and no carotid bruits noted. Pedal pulses are
strong but with 1 + ankle edema present.

Tasks:
1. Discuss how you will validate the data from your assessment since there seems to be incongruences
from both subjective and objective data. Explain it basing from the case scenario and site some
additional assessment that needs to be done for validation.

2. Explain briefly how to auscultate heart sounds and how will you differentiate the S1 heart sound from
S2 heart sound.

III. ABDOMINAL ASSESSMENT

Case 3. Nikki Yuan, a 22 year old student comes into clinic complaining of undifferentiated abdominal
discomfort. She stated she had not pass stool for the last 4 days. During the interview, she described her
dietary habit is terrible. She eats salty, high fat junk foods and doesn’t drink water regularly. Instead he
drinks lots or regular sodas. During the examination the client’s abdomen reveals a moderately
rounded, slightly firm nontender abdomen with several small quartersized round firm masses in the LLQ.
Bowel sounds are active, moderate pitched gurgles in all four quadrants. The abdomen is mostly
tympanic upon percussion with scattered dullness in the LUQ. Patient’s abdomen is negative for
rebound tenderness upon palpation. A rectal examination reveals hard stools in the ampulla.

Tasks:

1. Explain comprehensively how to orderly auscultate bowel sounds and what are the considerations to
be taken before and during auscultation?

2. As per the case scenario, what is the implication of your assessment? Support your answer basing
from your assessment.

3. What would be your appropriate nursing interventions upon her reporting symptoms and observed
signs? Include rationale.