ASSESSING BREAST AND LYMPHATIC SYSTEM • Fatty tissue- determine the size and shape of the

STRUCTURE AND FUNCTION breast.

• The breast are paired with mammary glands that

lie over the muscles of the anterior chest wall,
anterior to the pectoralis major and serratus
anterior muscles.
• The male and female breast are similar until
puberty.
• Female breast tissue enlarges in response to the
hormones estrogen and progesterone, which are LYMPH NODES
released from the ovaries.
• The female breast is an accessory reproductive • The major axillary lymph nodes consist of the
organ with two functions: anterior (pectoral), posterior (subscapular),
- To produce lateral (brachial), and central (midaxillary) nodes
- Store milk that provides nourishment for
newborns and to aid sexual stimulation. • The anterior nodes drain the anterior chest wall
and breasts.
EXTERNAL BREAST
• The posterior chest wall and part of the arms are
• Skin of the breast is smooth and varies in color
drained by the posterior nodes.
depending on the client’s skin tone.
• Nipple, which is located in the center of the • The lateral nodes drain most of the arms, and the
breast, contains tiny openings of the lactiferous central nodes receive drainage from the anterior,
ducts through which milk passes.
posterior, and lateral lymph nodes.
• Areola surrounds the nipple (generally 1 to 2 cm
radium) and contains elevated sebaceous glands
(Montgomery glands) that secrete a protective
lipid substance during lactation.
• Smooth muscle fibers in the areola cause the
nipple to become more erectile during
stimulation.
• The nipple and areola typically have darker
pigment than the surrounding breast. Their color
ranges from dark pink to dark brown, depending
on the person’s skin color. The amount of COLLECTING SUBJECTIVE DATA
pigmentation increases with pregnancy, then
decreases after lactation. • Lumps may be present with benign breast

INTERNAL BREAST conditions (fibrocystic breast disease),

fibroadenomas, or malignant tumors.
Female breasts consist of three types of tissue:
• Any lump should be assessed further, and the
• Glandular tissue- allows milk production client should be referred to a physician.

• Fibrous tissue- composed of bands called • Premenstrual breast lumpiness and soreness that
coopers ligament that supports the glandular subside after the end of the menstrual cycle may
tissue. indicate benign breast disease (fibrocystic breast
changes).
 • Redness and warmth indicate inflammation. A are round and may vary in size. Small
dimpling or retraction of the nipple or fibrous Montgomery tubercles are present.
tissue may indicate breast cancer. • Abnormal: Peau d’orange skin, associated with
• Pain and tenderness of the breasts are common in carcinoma, may be first seen in the areola. Red,
fibrocystic breasts, especially just before and scaly, crusty areas may appear in Paget disease.
during menstruation.
Inspect the Nipples
COLLECTING OBJECTIVE DATA
• Normal: Nipples are nearly equal bilaterally in
BREAST size and are in the same location on each breast.
Nipples are usually everted, but they may be
Inspect size and symmetry
inverted or flat.
• Have the client disrobe and sit with arms hanging • Abnormal: A recently inverted nipple that was
freely. previously everted suggests malignancy. Any
• Normal: Breasts can be a variety of sizes and are type of spontaneous discharge should be referred
somewhat round and pendulous. One breast may for cytologic study and further evaluation.
normally be larger than the other.
FIBROADENOMAS
• Abnormal: A recent increase in the size of one
breast may indicate inflammation or an abnormal are usually 1–5 cm, round or oval, mobile, firm, solid,
growth. elastic, nontender, single or multiple benign masses found
in one or both breasts.
Inspect color and texture
MILK CYSTS
• Normal: Color varies depending on the client’s
skin tone. Texture is smooth, with no edema. • s (sacs filled with milk) and infections (mastitis)
Linear stretch marks may be seen during and after may turn into an abscess and occur if
pregnancy or with significant weight gain or loss. breastfeeding or recently given birth.
• Abnormal • If one’s breast is bruised from an injury, there will
- Redness is associated with breast be a blood collection that appears as a lump,
inflammation. which goes away in days or weeks, or the blood
- A pigskin-like or orangepeel (peau may have to be drained by a health care provider.
d’orange) appearance results from edema,
LIPOMAS
which is seen in metastatic breast disease.
- The edema is caused by blocked lymphatic are a collection of fatty tissue that may also appear as a

drainage. lump.

Inspect the Areolas INTRADUCTAL PAPILLOMA

• Normal: Areolas vary from dark pink to dark a is a small growth inside a milk duct of the breast, often

brown, depending on the client’s skin tones. They near the areola. It is harmless and occurs in women ages
35–50.
 AXILLAE

Inspect and palpate the axillae

• Ask the client to sit up. Inspect the axillary skin

for rashes, infection, swelling, or inflammation.
• Normal: No rash, infection, swelling, or
inflammation noted.
• Abnormal: Redness and inflammation may be
seen with infection of the sweat gland. Dark,
velvety pigmentation of the axillae (acanthosis
nigricans) may indicate an underlying
malignancy.
• Hold the client’s elbow with one hand, and use
the three fingerpads of your other hand to palpate
firmly the axillary lymph nodes and
supraclavicular lymph nodes.
• Normal: No palpable nodes or one to two small
(less than 1 cm), discrete, nontender, movable
nodes in the central area
• Abnormal: Enlarged (greater than 1 cm) lymph
nodes may indicate infection of the hand or arm.
Large nodes that are hard and fixed to the skin
may indicate an underlying malignancy.

ABNORMAL FINDINGS

ABNORMALITIES NOTED ON INSPECTION OF

THE BREAST

PEAU D’ORANGE

Resulting from edema, an orange peel appearance of the

breast is associated with cancer.
 MASTITIS

PAGET DISEASE WITH INVASIVE Reddened, painful area on breast warm to palpation.
INTRADUCTAL CARCINOMA

• Redness and flaking of the nipple may be seen

early in Paget disease and then disappear.
• However, further assessment is needed because
this does not mean the disease is gone. Tingling,
itching, increased sensitivity, burning, discharge,
and pain in the nipple are late signs of Paget MASTECTOMY
disease. It may occur in both breasts, but is rare.
(A) Radical mastectomy
(B) Modified radical mastectomy.

NIPPLE INVERSION FROM BREAST CANCER

Nipple inversion may suggest malignancy.

CARCINOMA OF THE BREAST (NOTE

BULGING AND SKIN CANCER)

RETRACTED BREAST TISSUE

 ARTERIES

• Arteries are the blood vessels that carry

oxygenated, nutrient-rich blood from the heart to
the capillaries.
• The arterial network is a high-pressure system.
• Blood is propelled under pressure from the left
GYNECOMASTIA ventricle of the heart. Because of this high
pressure, arterial walls must be thick and strong;
the arterial walls also contain elastic fibers so
that they can stretch.
• Each heartbeat forces blood through the arterial
vessels under high pressure, creating a surge. This
surge of blood is the arterial pulse.

MAJOR ARTERIES OF THE ARM

ABNORMALITIES NOTED ON PALPATION OF BRACHIAL ARTERY

THE BREAST
• is the major artery that supplies the arm.
CANCEROUS TUMORS • can be palpated medial to the biceps tendon in and
above the bend of the elbow.
• These are irregular, firm, hard, not defined
masses that may be fixed or mobile. • The brachial artery divides near the elbow to
become the radial artery (extending down the
• They are not usually tender and usually occur
thumb side of the arm) and the ulnar artery
after age 50.
(extending down the little finger side of the arm).
FIBROADENOMAS
RADIAL PULSE
• These lesions are lobular, ovoid, or round.
Can be palpated on the lateral aspect of the wrist.
• They are firm, well-defined, seldom tender, and
usually singular and mobile. They occur more ULNAR PULSE
commonly between puberty and menopause.
• located on the medial aspect of the wrist, is a
BENIGN BREAST DISEASE deeper pulse and may not be easily palpated.

• Also called fibrocystic breast disease, benign

breast disease is marked by round, elastic,
defined, tender, and mobile cysts.
• The condition is most common from age 30 to
menopause, after which it decreases.

ASSESSING PERIPHERAL VASCULAR SYSTEM

 • are the blood vessels that carry deoxygenated,
nutrient-depleted, waste-laden blood from the
tissues back to the heart.
• The veins of the arms, upper trunk, head, and
neck carry blood to the superior vena cava, where
it passes into the right atrium.
• Blood from the lower trunk and legs drains
upward into the inferior vena cava.
• The veins contain nearly 70% of the body’s blood
volume. Because blood in the veins is carried
MAJOR ARTERIES OF THE LEG
under much lower pressure than in the arteries,
FEMORAL ARTERY the vein walls are much thinner.

• is the major supplier of blood to the legs. • Three types of Veins:

• Its pulse can be palpated just under the inguinal - Deep veins

ligament. - Superficial veins

- Perforator veins
• This artery travels down the front of the thigh
then crosses to the back of the thigh, where it is
termed the popliteal artery.

POPLITEAL PULSE

• can be palpated behind the knee.

• divides below the knee into anterior and posterior
branches.
• The anterior branch descends down the top of
the foot, where it becomes the dorsalis pedis
artery. Its pulse can be palpated on the great toe
ABNORMAL ARTERIAL FINDINGS
side of the top of the foot.
• The posterior branch is called the posterior NECROTIC GREAT TOE WITH BLISTERS ON
tibial artery. The posterior tibial pulse can be TOES AND FOOT
palpated behind the medial malleolus of the
Arterial ulcer. Great toe is necrotic with blisters on the
ankle.
toes and foot seen in arterial insufficiency.
• The dorsalis pedis artery and posterior tibial
artery form the dorsal arch, which, like the
superficial and deep palmar arches of the BOX
22-1 hands, provides the feet and toes with extra
protection from arterial occlusion

VEINS
 Characteristics of Ulcer of Arterial Insufficiency

Ulcer characteristics

• Location: Tips of toes, toe webs, heel or other

pressure areas if confined to bed
• Pain: Very painful
• Depth of ulcer: Deep, often involving joint space
• Shape: Circular Ulcer base: Pale black to dry and
RAYNAUD DISEASE
gangrene
Dramatic blanching of fingers on both hands in Raynaud
• Leg edema: Minimal unless extremity kept in
phenomenon.
dependent position constantly to relieve pain.

CHARACTERISTICS OF ARTERIAL AND

VENOUS INSUFFIENCY
VENOUS INSUFFIENCIENCY
ARTERIAL INSUFFIENCY
Pain: Aching, cramping
Pain: Intermittent claudication to sharp, unrelenting,
Pulses: Present but may be difficult to palpate through
constant
edema
Pulses: Diminished or absent Skin characteristics:
Skin characteristics:
Dependent rubor.
• Pigmentation in gaiter area (area of medial and
• Elevation pallor of foot
lateral malleolus)
• Dry, shiny skin
• Skin thickened and tough
• Cool-to-cold temperature
• May be reddish-blue in color
• Loss of hair over toes and dorsum of foot
• Frequently associated with dermatitis
• Nails thickened and ridged
Hyperpigmented lower limbs due to chronic venous
insufficiency.

Ulcer characteristics:

• Location: Medial malleolus or anterior tibial area

• Pain: If superficial, minimal pain; but may be
very painful
• Depth of ulcer: Superficial
• Shape: Irregular border LYMPHEDEMA

• Ulcer base: Granulation tissue—beefy red to A 44-year-old female with massive, localized
yellow fibrinous in chronic ulcer lymphedema.
• Leg edema: Moderate to severe

VARICOSE VEINS ON A FEMALE’S LEGS

NEUROPATHIC ULCER

TYPES OF PERIPHERAL EDEMA

ABNORMAL VENOUS FINDINGS EDEMA ASSOCIATED WITH LYMPHEDEMA

SUPERFICIAL THROMBOPHLEBITIS • Caused by abnormal or blocked lymph vessels

• Nonpitting Usually unilateral; may be bilateral.
Superficial thrombophlebitis resulting from thrombus
• No skin ulceration or pigmentation.
formation in the superficial veins. Often seen with
unilateral localized pain, achiness, edema, redness, and
warm to touch.
EDEMA ASSOCIATED WITH CHRONIC VENOUS
INSUFFIENCIENCY

• Caused by obstruction or insufficiency of deep

veins
• Pitting, documented as: 1+ = slight pitting
• 2+ = deeper than 1+
• 3+ = noticeably deep pit; extremity looks larger
• 4+ = very deep pit; gross edema in extremity
• Usually bilateral; may be unilateral
• Skin ulceration and pigmentation may be present

ASSESSING THE ABDOMEN

STRUCTURE AND FUNCTION

• The abdomen is bordered superiorly by the costal

margins, inferiorly by the symphysis pubis and
inguinal canals, and laterally by the flanks.
• It is important to understand the anatomic
divisions known as the abdominal quadrants, the
COLLECTING SUBJECTIVE DATA
abdominal wall muscles, and the internal
anatomy of the abdominal cavity in order to ABDOMINAL PAIN

perform an adequate assessment of the abdomen.

• Abdominal pain occurs when specific digestive
organs or structures are affected by chemical or
 mechanical factors such as inflammation, exercise intake of fatty or protein-rich foods
infection, distention, stretching, pressure, (especially in close proximity to exercise),
obstruction, or trauma. prolonged fasting, various supplements (caffeine,
sodium bicarbonate, ketones), certain drugs
INDIGESTION
(antibiotics, opioids), GI infections, and
• Indigestion (pyrosis), often described as precompetition anxiety.
heartburn, may be an indication of acute or
APPETITE
chronic gastric disorders including hyperacidity,
gastroesophageal reflux disease, peptic ulcer • Loss of appetite (anorexia) is a general complaint
disease, and stomach cancer. often associated with digestive disorders, chronic
• The main symptom of GERD in adults is frequent syndromes, cancers, and psychological disorders.
heartburn, which is acid indigestion, a • Carefully correlate appetite changes with dietary
burningtype pain in the lower part of the mid- history and weight monitoring. Significant
chest, behind the breast bone, and in the appetite changes and food intake may adversely
midabdomen. Some adults have GERD without affect the client’s weight and put the client at
heartburn, but instead may have a dry cough, additional risk.
asthma symptoms, or trouble swallowing.
BOWEL ELIMINATION
NAUSEA AND VOMITING
• Changes in bowel patterns must be compared
• Nausea may reflect gastric dysfunction and is also with usual patterns for the client. Normal
associated with many digestive disorders and frequency varies from 2 to 3 times/day to 3
diseases of the accessory organs, such as the liver times/week.
and pancreas, as well as with renal failure and • Constipation is usually defined as a decrease in
drug intolerance. the frequency of bowel movements or the passage
• Nausea may also be precipitated by dietary of hard and possibly painful stools. Signs and
intolerance, psychological triggers, or symptoms that accompany constipation may be a
menstruation. Nausea may also occur at particular clue as to the cause of constipation, such as
times, such as early in the day with some pregnant bleeding with malignancies or pencil-shaped
clients (“morning sickness”), after meals with stools with intestinal obstruction.
gastric disorders, or between meals with changes • Diarrhea is defined as the frequency of bowel
in blood glucose levels. movements producing unformed or liquid stools.
• Exercise-related nausea and vomiting, especially It is important to compare these stools with the
with strenuous exercise, has been associated with client’s usual bowel patterns.
multiple potential causes. Wilson (2019) lists • Bloody and mucoid stools are associated with
many, including catecholamine secretion, inflammatory bowel diseases (e.g., ulcerative
hypohydration, heat stress, hyponatremia, colitis, Crohn disease); claycolored, fatty stools
altitude exposure, excessive fluid/food may be from malabsorption syndromes.
consumption, hypertonic beverage intake, pre-
 TYPES OF PAIN • Cholecystitis
• Cystitis
Abdominal pain may be formally described as visceral,
• Dyspepsia
parietal, or referred.
• Glomerulonephritis
• Visceral pain occurs when hollow abdominal
• Incarcerated or strangulated hernia
organs—such as the intestines— become
• Irritable bowel syndrome
distended or contract forcefully, or when the
• Hepatocellular cancer
capsules of solid organs such as the liver and
• Pancreatitis Pancreatic cancer
spleen are stretched. Poorly defined or localized
• Perforated gastric or duodenal ulcer
and intermittently timed, this type of pain is often
• Peritonitis Peptic ulcer disease
characterized as dull, aching, burning, cramping,
• Prostatitis
or colicky.
• Parietal pain occurs when the parietal BURNING, GWANING
peritoneum becomes inflamed, as in appendicitis
• Dyspepsia
or peritonitis. This type of pain tends to localize
• Peptic ulcer disease
more to the source and is characterized as a more
• Cramping (“crampy”)
severe and steady pain.
• Acute mechanical obstruction
• Referred pain occurs at distant sites that are
• Appendicitis
innervated at approximately the same levels as
• Colitis
the disrupted abdominal organ. This type of pain
• Diverticulitis
travels, or refers, from the primary site and
• Gastroesophageal reflux disease (GERD)
becomes highly localized at the distant site. The
accompanying illustrations show common PRESSURE
clinical patterns and referents of pain.
• Benign prostatic hypertrophy
• Prostate cancer
• Prostatitis
• Urinary retention

COLICKY

• Colon cancer

CHARACTERISTICS OF ABDOMINAL PAIN AND SHARP, KNIFELIKE

IMPLICATIONS
• Splenic abscess
DULL, ACHING • Splenic rupture

• Appendicitis • Renal colic

• Acute hepatitis • Renal tumor

• Biliary colic • Ureteral colic

 • Vascular liver tumor
VARIABLE
• Stomach cancer
COLLECTING OBJECTIVE DATA
OBSERVE THE COLORATION OF THE SKIN
Normal Findings
• Abdominal skin may be paler than the general
skin tone because this skin is so seldom exposed
to the natural elements.
Abnormal Findings
• Purple discoloration at the flanks (Grey Turner
Sign) indicates bleeding within the abdominal
wall. Possibly from trauma to the kidneys,
pancreas, or duodenum or from pancreatitis.
• The yellow hue of jaundice may be more apparent
on the abdomen.
• Pale, taut skin may be seen with ascites
(significant abdominal swelling indicating fluid
accumulation in the abdominal cavity).
• Redness may indicate inflammation.
• Bruises or areas of local discoloration are also
abnormal.
NOTE THE CASCULARITY OF THE
ABDOMINAL SKIN
Normal Findings
• Scattered fine veins may be visible.
• Blood in the veins located above the umbilicus
flows toward the head; blood in the veins located
below the umbilicus flows toward the lower body.
Abnormal Findings
• Dilated veins may be seen with cirrhosis of the
liver, obstruction of the inferior vena cava, portal
hypertension, or ascites.
• Dilated surface arterioles and capillaries with a
central star (spider angioma) may be seen with
liver disease or portal hypertension.
NOTE ANY STRIAE (stretch marks)
• due to past stretching of the reticular skin layers
due to fast or prolonged stretching.
Normal Findings
• New striae are pink or bluish in color; old striae
are silvery, white, linear, and uneven stretch
marks from past pregnancies or weight gain.
Abnormal Findings
• Dark bluish-pink striae are associated with
Cushing syndrome.
• Striae may also be caused by ascites, which
stretches the skin.
• Ascites usually results from liver failure or liver
disease.
UMBILICUS
• Normally it is midline and inverted, with no sign
of discoloration, inflammation, or hernia
• Becomes everted and pushed upward with
pregnancy
• Umbilicus is common site for piercings in young
women; site should not be red or crusted.
Skin color/scars
• Surface smooth and even, with homogeneous
color; good area to judge pigment because often
protected from sun.
 • Striae, moles (nevi), lesions, surgical scars, overwhelming generalized sepsis, such as with
papules If a scar is present, draw its location in peritonitis
person’s record, indicating length in centimeters.
Hyperactive
• Surgical scar alerts you to possible presence of
underlying adhesions and excess fibrous tissue. • Increased bowel sounds may occur with
gastroenteritis, early intestinal obstruction, or
Pulsation or movement
hunger.
• Normally you may see pulsations from aorta • High-pitched tinkling sounds, with rushes and
beneath skin in epigastric area, particularly in thin tinkles.
persons with good muscle wall relaxation. • Suggest intestinal fluid and air under pressure, as
in early obstruction or phase of ileus resolution.
AUSCULTATE FOR THE BOWEL SOUNDS
Absent
Normal Findings
• Referring to an inability to hear any bowel sounds
• Use the diaphragm of the stethoscope and make
after 5 minutes of continuous listening
sure that it is warm before you place it on the
client’s abdomen. VASCULAR SOUNDS
• Apply light pressure or simply rest the
• As you listen to abdomen, note presence of any
stethoscope on a tender abdomen.
vascular sounds or bruits.
• Begin in the RLQ and proceed clockwise,
• Using firmer pressure, check over aorta, renal
covering all quadrants.
arteries, especially in people with hypertension.
• Listen for at least 5 minutes before determining
• Usually no such sound is present.
that no bowel sounds are present and that the
bowels are silent. PERCUSSION AND TYMPANY

• Normally, there is a series of soft click and Listen for Venous Hum
gurgles are heard at a rate of 5-30 per minute.
• Using the bell of the stethoscope. Listen for the
- Hyperactive sounds referred to as
venous hum in the epigastric and umbilical areas.
borborygmus may also be heard indicates
stomach growling. • Venous hum is not normally heard over the

- Normal bowel sounds epigastric and umbilical areas.

- Created by the normal waves of peristalsis Auscultate for a friction rub over the liver and spleen
and segmentation.
• Listen over the right and left lower rib cage with
Abnormal Findings the diaphragm of the stethoscope.

Hypoactive • No friction rub over liver or spleen is present.

• If present it is associated with hepatic abscess or
• Reflects diminished motility “ileus“, often
metastases, splenic infarction, tumor, or
follows surgery, viral illness, severe trauma or
infection.
Percuss for tone
• Lightly and systematically percuss all quadrants.
• Normal finding: Generalized tympany over the
abdomen because of air in the stomach and
intestines. Dullness is heard over the liver and
spleen.
• Normal finding: Generalized tympany over the
abdomen because of air in the stomach and
intestines. Dullness is heard over the liver and
spleen.
PERCUSSION OF THE ABDOMEN
Percuss the span or height of the liver by determining
its lower and upper borders
• The lower border of the liver dullness is located
at the costal margin to 1 to 2 cm below.
• On deep inspiration the lower border of the liver
dullness may descend from 1 to 4 cm below the
costal margin.
• The upper border of the liver dullness is located
between the left fifth and seventh intercostal
space.
PERCUSS THE SPLEEN
• Begin posterior to the left mid-axillary line and
percuss downward, noting the change from lung
resonance to splenic dullness.
• Normally the spleen is an oval area of dullness
approximately 7cm wide near the left tenth rib
and slightly posterior to the mid-axillary line.
• Abnormal finding: Splenomegaly or enlargement
of the spleen characterized by an area of dullness
greater than 7cm.
• Begin posterior to the left mid-axillary line and
percuss downward, noting the change from lung
resonance to splenic dullness.
• Normally the spleen is an oval area of dullness
approximately 7cm wide near the left tenth rib
and slightly posterior to the mid-axillary line.
• Abnormal finding: Splenomegaly or enlargement
of the spleen characterized by an area of dullness
greater than 7cm.
PERCUSS THE LIVER
• Place the left hand flat against the lower right
anterior rib cage. Use ulnar side of the right fist to
strike the left hand.
• Normally there is no tenderness is elicited.
• Tenderness elicited over the liver may be
associated with inflammation or infection.
PERCUSS THE KIDNEY
• Percuss the kidney at the costovertebral angles
over the 12th rib.
• Normally, there is no tenderness or pain is elicited
or reported by the client. The examiner sense only
a dull thud.
• Tenderness or sharp pain elicited over the CVA
suggests kidney infection (pyelonephritis), renal
calculi.
PALPATION OF THE ABDOMEN
Perform light palpation
• Use to identify areas of tenderness and muscular
resistance.
• Using the fingertips begin with a nontender
quadrant and compress to a depth of 1cm in a
dipping motion. Then gently lift the fingers and
move on the next area.
• Abdomen is nontender and soft and there is no
guarding
Deeply palpate all quadrant to delineate abdominal
organs and detect masses
 • Normally, mild tenderness is possible over the
xyphoid, aorta, cecum, sigmoid colon, and
ovaries on deep palpation.
• Severe tenderness or pain may be related to
trauma, peritonitis, infection, tumors, or enlarged
or diseased organs
Palpate for masses
• Not the location. size, shape, consistency,
demarcation, pulsatility, tenderness, and mobility.
• Normally, there is no palpable masses are present.
• If mass detected in any quadrant may be due to a
tumor, cyst, abscess, enlarged organ, aneurysm,
or adhesions.
Palpate the umbilicus and surrounding areas for
swellings, bulges, or masses
• There should be free of swellings, bulges, or
masses.
• Abnormal finding: presence of hard nodule.
PALPATE THE LIVER
• Note for consistency and tenderness
• Stand at the client’s right side and place you left
hand under client’s back at the level of the 11th to
12th ribs.
• The liver is usually not palpable but if the lower
edge is felt it should be firm, smooth, and even.
• Abnormal findings: A hard firm liver may
indicate cancer. Tenderness may be from vascular
engorgement and abscess.
THE TEST OF APPENDICITIS
Assess for Rebound Tenderness
• If the client has abdominal pain or tenderness test
for rebound tenderness by palpating deeply at 90
degrees into the abdomen away from the painful
or tender area.
• Listen and watch for the client’s expression of
pain.
• Ask the client to describe which hurts more, the
pressing in or the releasing and where on the
abdomen the pain occurred.
• Normally, there is no rebound tenderness is
present.
• Abnormal: Has rebound tenderness when the
client perceive sharp, stabbing pain as the
examiner releases the pressure from the abdomen
(Blumberg’s sign).
• Palpate deeply in the LLQ and quickly release
pressure
• Normally, there is no rebound pain is elicited
• Abnormal: Pain in the RLQ during pressure in the
LLQ is a positive Rovsing’s Sign.
ASSESS FOR PSOAS SIGN
• Ask the client to lie on the left side. Hyperextend
the right leg of the client.
• Normally, there is no pain present
• Abnormal: Pin in the RLQ pain (Psoas sign) is
associated with irritation of the iliopsoas muscle
due to appendicitis (inflammation of the
appendix).
 ABDOMINAL CONTOUR

ASSESS FOR OBTURATOR SIGN

ABDOMINAL DISTENTION
• Support the client’s right knee and ankle.
• Flex the hip and knee rotate the leg internally and PREGNANCY (NORMAL FINDING)
externally.
• It causes a generalized protuberant abdomen,
• Normally, there is no presence of abdominal pain
protuberant umbilicus, a fetal heart beat that can
• Abnormal: Pain in the RLQ indicates irritation of
be heard on auscultation, percussible tympany
the obturator muscle due to appendicitis or a
over the intestines, and dullness over the uterus.
perforated appendix.

FAT

PERFORM HYPERSENSITIVITY TEST • Obesity accounts for most uniformly protuberant

abdomens.
• Stroke the abdomen with a sharp object (e.g.,
• The abdominal wall is thick, and tympany is the
broken cotton tipped applicator or tongue blade)
percussion tone elicited. The umbilicus usually
or grasp a fold of skin with your thumb and index
appears sunken.
finger and quickly let go. Do this several times
along the abdominal wall.
• Normally, the client feels no pain and no
exaggerated sensation
• Abnormal: Pain or an exaggerated sensation felt
in the RLQ is a positive skin hypersensitivity test
and may indicate appendicitis.
 • The abdomen distended with gas may appear as a
generalized protuberance (as shown), or it may
appear more localized.
• Tympany is the percussion tone over the area.

FECES

• Hard stools in the colon appear as a localized

distention.
• Percussion over the area discloses dullness.

ASCITIC FLUID

• Fluid in the abdomen causes generalized

protuberance, bulging flanks, and an everted
umbilicus.
• Percussion reveals dullness over fluid (bottom of
abdomen and flanks) and tympany over intestines
FIBROIDS AND OTHER MASSES
(top of abdomen).
• A large ovarian cyst or fibroid tumor appears as
generalized distention in the lower abdomen.
• The mass displaces bowel, thus the percussion
tone over the distended area is dullness, with
tympany at the periphery.
• The umbilicus may be everted.

ABDOMINAL BULGES

UMBILICAL HERNIA
FLATUS
• An umbilical hernia results from the bowel
protruding through a weakness in the umbilical
ring.
• This condition occurs more frequently in infants,
but also occurs in adults.
EPIGASTRIC HERNIA
• An epigastric hernia occurs when the bowel
protrudes through a weakness in the linea alba.
• The small bulge appears midline between the
xiphoid process and the umbilicus.
• It may be discovered only on palpation.
ENLARGED ABDOMINAL ORGANS AND OTHER
DIASTASIS RECTI
• Diastasis recti occurs when the bowel protrudes
through a separation between the two rectus
abdominis muscles.
• It appears as a midline ridge. The bulge may
appear only when the client raises the head or
coughs. The condition is of little significance.
INCISIONAL HERNIA
• An incisional hernia occurs when the bowel
protrudes through a defect or weakness resulting
from a surgical incision.
• It appears as a bulge near a surgical scar on the
abdomen.
ABNORMALITIES
ENLARGED LIVER
• An enlarged liver (hepatomegaly) is defined as a
span greater than 12 cm at the midclavicular line
(MCL) and greater than 8 cm at the midsternal
line (MSL).
• An enlarged nontender liver suggests cirrhosis.
• An enlarged tender liver suggests congestive
heart failure, acute hepatitis, or abscess.

AORTIC ANUERYSM

• A prominent, laterally pulsating mass above the

ENLARGED NODULAR LIVER
• An enlarged firm, hard, nodular liver suggests
cancer.
• Other causes may be late cirrhosis or syphilis.
umbilicus strongly suggests an aortic aneurysm.
• It is accompanied by a bruit and a wide, bounding
pulse.

LIVER HIGHER THAN NORMAL ENLARGED KIDNEY

• A liver that is in a higher position than normal • An enlarged kidney may be due to a cyst, tumor,
span may be caused by an abdominal mass, or hydronephrosis.
ascites, or a paralyzed diaphragm. • It may be differentiated from an enlarged spleen

LIVER LOWER THAN NORMAL by its smooth rather than sharp edge, the absence
of a notch, and tympany on percussion.
• A liver in a lower position than normal with a
normal span may be caused by emphysema
because the diaphragm is low.

ENLARGE SPLEEN

• An enlarged spleen (splenomegaly) is defined by

an area of dullness exceeding 7 cm.
• When enlarged, the spleen progresses downward
and toward the midline.
ELARGED GALLBLADDER
 • An extremely tender, enlarged gallbladder • Provision of form to the body
suggests acute cholecystitis.
Types:
• A positive finding is Murphy sign (sharp pain that
causes the client to hold the breath) Skeletal Muscle- which move bones and other structures
(e.g., the eyes)

Cardiac Muscles- which forms of the walls of the heart

and adjacent great vessels, such as the aorta.

Smooth (Visceral) muscle- which forms part of the walls

of most vessels and hollow organs, move substances
through viscera such as the intestine, and controls
movement through blood vessels.

MUSCULOSKELETAL SYSTEM
STTRUCTURE AND FUNCTION
The musculoskeletal system is composed of two systems
– the muscular system and the skeletal system – but is
commonly referred to as 'musculoskeletal’.
TENDONS
• A tendon is a tough, flexible band of fibrous
connective tissue that connects muscles to bones.
• As muscle contracts, tendon transmits the force to
the bones, pulling on them and causing
movement.

Functions: Functions of Bones

• Protection of vital structures • Support of the body

• Provision of body forms • Protection of soft organs
• Stability • Movement due to attached skeletal muscles
• Storage of salts (e.g., calcium) • Storage of minerals and fats
• Formation and supply of new blood cells • Blood cell formation

MUSCLES

Muscles are the largest soft tissues of the musculoskeletal

system. The muscle cells - muscle fibers - produce

contractions that move body parts, including internal
organs.

Functions: CARTILAGES

• Production of movement • Cartilages line the articulating surfaces of bones.

• Support of the body Thus, cartilages are usually found deep within a

• Stability of joints joint.

• Production of body heat

 • They are great for weight bearing and are Turning or facing upward
extremely slippery to reduce the friction inside a
PROTRACTION
joint (movable joint like synovial joint). Synovial
joints possess hyaline cartilage. Moving forward

JOINTS RETRACTION

Joints are formed where two or more bones meet. They Moving backward

promote movements of body parts. ROTATION

SKELETAL MUSCLE MOVEMENTS Turning of a bone on its own long axis

ABDUCTION INTERNAL ROTATION

Moving away from midline of the body Turning of a bone toward the center of the body

ADDUCTION EXTERNAL ROTATION

Moving toward midline of the body Turning of away from the center of the body

CIRCUMDUCTION COLLECTING OBJECTIVE DATA

Circular Motion INSPECTION AND PALPATION

INVERSION GAIT

Moving inward Observe the client’s gait and note for the following:

EVERSION • Base of support

• Weight-bearing stability
Moving outward
• Foot position
EXTENSION • Stride and length and cadence of stride

Straightening the extremity at the joint and increasing the • Arm swing

angle of the joint • Posture

DORSIFLEXION TEMPOROMANDIBULAR JOINT (TMJ)

Toes draw upward to ankle • Have the client sit. Put up your index and middle
fingers just anterior to the external ear opening.
PLANTAR FLEXION
• Ask the client to open the mouth
Toes point away from ankle • Ask the client to move the jaw from side to side
• Protrude (push out) and retract (pull in) jaw.
PRONATION

Turning or facing downward

SUPINATION
 STERNOCLAVICULAR JOINT

• Inspect for location in midline, color, swelling,

and masses. KYPHOSIS

• Palpate for tenderness or pain A rounded thoracic convexity (kyphosis).

• Abnormal: Swollen, red, or enlarged joint or
tender, painful joint is seen with inflammation of
the joint.

ABNORMAL SPINAL CURVATURE

FLATENNING OF THE LUMBAR CURVE

Flattening of the lumbar curvature may be seen with a

herniated lumbar disc or ankylosing spondylitis.

SCOLIOSIS

A lateral curvature of the spine with an increase in

convexity on the side that is curved is seen in scoliosis.

LUMBAR HYPERLORDOSIS

Hip flexion contracture and hip extensor weakness drive

the lumbar spine into increasing lordosis to balance head
over pelvis. Note the use of the hands for stability.
ANKYLOSING SPONYLITIS

Clinical manifestations of ankylosing spondylitis.

ABNORMALITIES AFFECTING THE WRISTS,

HANDS, AND FINGERS
 ACUTE RHEUMATOID ARTHRITIS Nontender, round, enlarged, swollen, fluid-filled cyst
(ganglion) is commonly seen at the dorsum of the wrist.
Tender, painful, swollen, stiff joints are seen in acute
rheumatoid arthritis.

OSTEOARTHRITIS

• Osteoarthritis (DJD) nodules on the dorsolateral

BOUTONNIÈRE AND SWAN-NECK aspects of the distal interphalangeal joints
DEFORMITIES SEEN IN CHRONIC (Heberden nodes) are due to the bony overgrowth
RHEUMATOID ARTHRITIS of osteoarthritis.

Flexion of the proximal interphalangeal joint and • Usually hard and painless, they may affect

hyperextension of the distal interphalangeal joint middle-aged or older adults and often, although

(boutonnière deformity) and hyperextension of the not always, are associated with arthritic changes

proximal interphalangeal joint with flexion of the distal in other joints.

interphalangeal joint (swan-neck deformity) are common • Flexion and deviation deformities may develop.

in chronic rheumatoid arthritis. Similar nodules on the proximal interphalangeal

joints (Bouchard nodes) are less common.
Boutonnière deformity
• The metacarpophalangeal joints are spared.

Herbenden nodes

Swan-neck deformity
Bouchard nodes

GANGLION
 FLAT FEET

A flat foot (pes planus) has no arch and may cause pain
and swelling of the foot surface.
TENOSYNOVITIS

Painful extension of a finger may be seen in acute

tenosynovitis (infection of the flexor tendon sheaths).

CALLUS
THENAR ATROPHY
Calluses are nonpainful, thickened skin that occur at
Atrophy of the thenar prominence due to pressure on the
pressure points.
median nerve is seen in carpal tunnel syndrome.

ABNORMALITIES OF THE FEET AND TOES HALLUX VALGUS

ACUTE GOUTY ARTHRITIS • Hallux valgus is an abnormality in which the

great toe is deviated laterally and may overlap the
In gouty arthritis, the metatarsophalangeal joint of the
second toe.
great toe is tender, painful, reddened, hot, and swollen.
• An enlarged, painful, inflamed bursa (bunion)
may form on the medial side.
 ASSESSING NEUROLOGIC SYSTEM

FUNCTIONS OF THE NERVOUS SYSTEM

• Receiving Sensory Input

• Integrating Information
• Controlling muscles and glands
HAMMER TOE
• Maintaining homeostasis
Hyperextension at the metatarsophalangeal joint with • Establishing and maintaining mental activity
flexion at the proximal interphalangeal joint (hammer toe)
commonly occurs with the second toe.

CORN

• Corns are painful thickenings of the skin that

occur over bony prominences and at pressure
points.
• The circular, central, translucent core (arrow)
resembles a kernel of corn.

PLANTAR WART

Plantar warts are painful warts (verruca vulgaris) that

often occur under a callus, appearing as tiny dark spots.
 • Examples include repetitive winking, grimacing,
and shoulder shrugging.
• Causes include Tourette syndrome and drugs such
as phenothiazines and amphetamines.

CRANIAL NERVES: TYPES AND FUNCTION

CHOREIFORM MOVEMENTS OF THE HAND

• Choreiform movements are brief, rapid, jerky,

irregular, and unpredictable.
• They occur at rest or interrupt normal coordinated
movements.
• Unlike tics, they seldom repeat themselves. The
face, head, lower arms, and hands are often
involved.
• Causes include Sydenham chorea (with
rheumatic fever) and Huntington disease.

RESTING (STATIC) TREMORS

• These tremors are most prominent at rest and may

decrease or disappear with voluntary movement.
• Illustrated is the common, relatively slow, fine,
pill-rolling tremor of parkinsonism, about 5 per
second.
ABNORMAL MUSCLE MOVEMENTS

EYE TIC

• Tics are brief, repetitive, stereotyped, coordinated

movements occurring at irregular intervals.
 POSTURAL TREMOR

• These tremors appear when the affected part is

actively maintaining a posture.
• Examples include the fine, rapid tremor of
hyperthyroidism, the tremors of anxiety and
fatigue, and benign essential (and sometimes
familial) tremor.
• Tremor may worsen somewhat with intention.

INTENTION TREMOR OF A POINTED FINGER

• Intention tremors, absent at rest, appear with

activity and often get worse as the target is
neared.
• Causes include disorders of cerebellar pathways,
as in MS.

ATHETOSIS

• Athetoid movements are slower, more twisting

and writhing than choreiform movements, and
have a larger amplitude.
• They most commonly involve the face and the
distal extremities.
• Athetosis is often associated with spasticity.
• Causes include cerebral palsy.