HEALTH ASSESSMENT (RLE) - Finals

BS NURSING - 1B 2nd Sem – 2023

LESSON: ABDOMINAL ASSESSMENT • Pain in abdomen

• Change in appetite
SUBDIVISION OF ABDOMEN
• Chewing and swallowing problems
❖ Right Upper Quadrant – RUQ
• Heartburn
• Liver
• Nausea, vomiting, reguritation
• Gallbladder
• Rectal bleeding
• Duodenum
• Elimination
• Head of Pancreas
• Hemorrhoids
• Right Kidney and Adrenal
• Voiding difficulty
• Hepatic Flexure of Colon
• Previous surgery
• Part of Ascending and Transverse
• Weight gain or loss
Colon
• Type of diet
❖ Right Lower Quadrant – RLQ
• Medications
• Cecum
• Appendix
SEQUENCE OF ASSESSMENT
• Right Ovary and Tube
(Inspection, Auscultation, Percussion, Palpation)
• Right Ureter
❖ Left Upper Quadrant – LUQ
INSPECTION
• Stomach
• Entire patient
• Spleen
• Skin
• Left Lobe of Liver
a. Pigmentation
• Body of Pancreas
b. Lesions
• Left Kidney And Adrenal
c. Striae
• Splenic Flexure of Colon
d. Turgor
• Parts of Transverse And Descending
• Superficial vessels
Colon
• Hair distribution
❖ Left Lower Quadrant - LLQ
• Umbilicus
• Part of Descending Colon
• Contour
• Sigmoid Colon
a. Flat
• Left Ovary and Tube
b. Rounded
• Left Ureter
c. Scaphoid
ABDOMINAL QUADRANTS d. Protuberant (distended)
• Peristalsis

AUSCULTATION
• Active bowel sounds 5-
30/min
• Hypoactive 4/min or less
• Hyperactive 30 or more
/min
ABDOMINAL REGIONS
• Bruits
a. Aorta
b. Renal
c. Iliac
• Friction rub

PERCUSSION
PREPARATION • To determine the size of solid organs and
• Equipment - stethoscope, marking pen, ruler presence of masses, fluid and gas
• Patient lie on back, pillow under head, knees • Tympanic sound
slightly flexed • Percuss in all four quadrants
• Empty bladder • Percuss for liver
• Short fingernails • Percuss for spleen
History Questions: • Percuss bladder if indicated

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HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023

• If dullness in flanks - check for shifting dullness • Murphy’s Sign

• If indicated check for fluid wave • Rovsing’s Sign
• Iliopsoas Test

PALPATION
• Light palpation to evaluate general condition,
nature of any distention, and gross
abnormalities and painfulness
• Deep palpation to detect any organ
enlargement, abdominal masses or swellings
• Palpate for liver and spleen
PALPATION OF LIVER
RULES IF IN ABDOMINAL PAIN
• Do not administer pain medications,
antispasmodics, anticholinergics, or smooth
muscle relaxants before a medical exam b/c
mask pain
CONTRAINDICATIONS FOR ABDOMINAL
ASSESSMENT
• Never palpate if suspected appendicitis or
dissecting abd. Aortic aneursym
• Never palpate with polycystic kidneys
• Do not palpate of percuss transplanted
organs

LESSON: NEUROLOGIC ASSESSMENT

PALPATION OF SPLEEN
ANATOMY AND PHYSIOLOGY
Major Divisions of the NERVOUS SYSTEM:
A. Peripheral Nervous System (PNS)
- the vast network of spinal and cranial nerves
linking the body to the brain and spinal cord
- PNS is subdivided into:
a. Autonomic Nervous System - involuntary
control of: internal organs, blood vessels,
smooth and cardiac muscle
REBOUND TENDERNESS
• Sympathetic Nervous System
• Parasympathetic Nervous System
b. Somatic Nervous System - voluntary
control of: skin, bones, joints, skeletal
muscle
B. Central Nervous System (CNS)
- consisting of the brain and spinal cord
On back - these two structures collect and interpret
voluntary and involuntary and sensory stimuli
• Check for renal bruits
• Costovertebral angle tenderness

PERCUSION OF KIDNEY

IF ABDOMINAL PAIN
THE CEREBRUM
• Tachypneic - largest portion of the brain is the cerebrum
• Leaning Forward

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HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023
- consists of two hemispheres that are
connected together at the corpus callosum
- often divided into five lobes that are
responsible for different brain functions
- The cerebrum’s surface—the neocortex – is
convoluted into hundreds of folds.
- The neocortex is where all the higher brain
functions take place.
LOBES OF THE CEREBRUM
1. FRONTAL LOBE
- area of the brain responsible for higher
cognitive functions
These include:
• Problem solving
• Spontaneity
• Memory
• Language
• Motivation
• Judgment
• Impulse control
• Social and sexual behavior
2. TEMPORAL LOBE
- plays a role in emotions
- responsible for smelling,
tasting, perception,
memory, understanding
music, aggressiveness, and
sexual behavior.
- contains the language area of the
brain
3. PARIETAL LOBE
- plays a role in our sensations
of touch, smell, and taste
- processes sensory and
spatial awareness, and is a
key component in eye-hand
coordination and arm
movement
- contains a specialized area called
Wernicke’s area - responsible for matching
written words with the sound of spoken
speech
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4. OCCIPITAL LOBE
- at the rear of the brain
and controls vision and
recognition.
5. LIMBIC LOBE
- located deep in the brain,
and makes up the limbic
system
THE LIMBIC SYSTEM
- area of the brain that
regulates emotion and
memory
- directly connects the lower
and higher brain functions.
THALAMUS
- “Inner room” in Greek, as it sits deep in the
brain at the top of the brainstem.
- gateway to the cerebral cortex, as nearly all
sensory inputs pass through it to the higher
levels of the brain.
HYPOTHALAMUS
- sits under the thalamus at the top of the
brainstem.
It controls many critical bodily functions:
• Controls autonomic nervous
system
• Center for emotional response
and behavior
• Regulates body temperature
• Regulates food intake
• Regulates water balance and
thirst
• Controls sleep-wake cycles
• Controls endocrine system
The hypothalamus is shaded blue. The pituitary
gland extends from the hypothalamus.
BRAIN STEM (extension of the spinal cord)
A. Medulla Oblongata - contains cardiac,
respiratory, vomiting, and vasomotor centers
(heart rate, respiration, blood vessel diameter,
sneezing, vomiting, swallowing, coughing)
B. Pons - respiratory center
C. Midbrain - responsible for motor coordination
contains the visual reflex and auditory relay
centers
HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023

MENINGES
- coverings of the nervous
tissue in the brain and in
the spinal cord
- supports, protects and
nourishes

CEREBRO SPINAL FLUID

- serves as a liquid cushion
for nervous tissue and
helps support the brain’s
weight CRANIAL NERVE NAME
Only One Of The Two Atletes Felt Very Good,
NEUROTRANSMITTER
Victorious, And Healthy

CRANIAL NERVE FUNCTIONS

Some Say Marry Money, But My Brother Says Big
Brain Matter Most
(S) = Sensory, (M) = Motor, (B) = Both
PERIPHERAL NERVOUS SYSTEM
Includes the peripheral and cranial nerves.
• PERIPHERAL – transmit the stimuli from skin
(DERMATOME), muscles, and other sensory
organs.
• CRANIAL – primary motor and sensory
pathways between brain, head and neck

SPINAL CORD
- primary pathway for messages between the
peripheral areas of the body and the brain
- Mediates the sensory to motor path (REFLEXES)

❖ 7 Cervical
❖ 12 Thoracic
❖ 5 Lumbar
❖ 5 Sacral
❖ 1 Coccygeal

CRANIAL NERVES

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HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023
OTHER TESTS
• Reflex assessment
• Motor function tests
• Sensory function tests
• Extinction phenomenon
• Motor function
LESSON: MUSCULOSKELETAL SYSTEM ASSESSMENT
MUSCULOSKELETAL ASSESSMENT - helps to identify
the functional anatomy associated with clinical
conditions, thereby differentiating the underlying
system involved and could correctly point
towards the condition helping in early diagnosis
and intervention
MUSCULOSKELETAL EXAMINATION - focuses on
assessment of range of motion and evaluation of
painful joints or soft tissue structures
Health History
Taking a detailed and accurate history is crucial
for making the correct diagnosis for patients with
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musculoskeletal diseases. The cardinal symptoms
of musculoskeletal disease are pain, stiffness,
swelling, limitation of motion, weakness, fatigue,
and loss of function
ANATOMY & PHYSIOLOGY
TYPES OF BONE
There are 206 bones in the human body divided
into four categories:
• Long bones ( e.g. Femur)
• Short bones (e.g. Metacarpals)
• Flat bones (e.g. Sternum)
• Irregular bones (e.g. Vertebrae)
TYPES OF JOINTS
• BALL AND SOCKET JOINTS
• HINGES JOINTS
- type of synovial joint that exists in the body
and serves to allow motion primarily in one
plane
- made up of two or more bones with
articular surfaces that are covered by
hyaline cartilage and lubricated by
synovial fluid
• SADDLE JOINTS
- another type of synovial joint
- gets its name because the bone forming
one part of the joint is concave (turned
inward) at one end and looks like a saddle
• PIVOT JOINTS (ROTARY JOINT/TROCHOID
JOINT)
- a freely moveable joint (diarthrosis) that
allows only rotary movement around a
single axis
- the moving bone rotates within a ring that
is formed from a second bone and
adjoining ligament
• GLIDING JOINTS
- allows bones to glide over each other
providing little movement in all directions.
Example: joint at the wrist, between the
carpals
STRUCTURE AND FUNCTION
MUSCULOSKELETAL SYSTEM encompasses the
muscles, bones, and joints.
The nurse usually assesses the musculoskeletal
system for muscle strength, tone, size, and
symmetry of muscle development, and for
tremors
TREMOR - an involuntary trembling of a limb or
body part. Tremors may involve large groups of
muscle fibers or small bundles of muscle fibers.
HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023

An intention tremor becomes more apparent

when an individual attempts a voluntary
movement, such as holding a cup of coffee

Resting Tremor - more apparent when the client is

at rest and diminishes with activity.
A fasciculation is an abnormal contraction of a
bundle of muscle fibers that appears as a twitch.
Bones are assessed for normal form. MUSCLES OF THE BODY
Joints are assessed for tenderness, swelling,
thickening, crepitation (a crackling, grating
sound), and range of motion.
Body posture is assessed for normal standing and
sitting positions

SKELETON
• Spine – cervical, thoracic and lumbar
vertebrae, sacrum and tailbone (coccyx) UNDERSTANDING MAJOR JOINTS
• Chest – ribs and breastbone (sternum)
• Arms – shoulder blade (scapula), collar bone
(clavicle), humerus, radius and ulna
• Hands – wrist bones (carpals), metacarpals
and phalanges

SKELETAL MUSCLE MOVEMENTS

ABDUCTION - moving away from midline of the
body
• Adduction - moving toward midline of the
body
• Circumduction - circular motion
• Inversion - moving inward
• Eversion - moving outward
• Extension - traightening the extremity at the
joint and increasing the angle of the joint
• Hyperextension - joint bends greater than 180
degrees
• Flexion - bending the extremity at the joint
and decreasing the angle of the joint

DORSIFLEXION - toes draw upward to ankle

• Plantar flexion - toes point away from ankle
• Pronation - turning or facing downward
• Supination - turning or facing upward
• Protraction - moving forward
• Retraction - moving backward
• Rotation - turning of a bone on its own long
axis TECHNIQUES FOR THE ASSESSMENT
• Internal Rotation - turning of a bone toward Primary methods used for physical examination of
the center of the body musculoskeletal system are inspection and
• External Rotation - turning of a bone away palpation.
• from the center of the body * Percussion and auscultation are only used in
special situations such as percussion pain of
vertebrae, auscultation for bone crepitus

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HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023
DATA COLLECTION
Collecting Subjective Data
Current Symptoms:
• Have you had any recent weight gain?
• Describe any difficulty chewing.
• Is it associated with tenderness or pain?
• Describe any joint, muscle or bone pain
you have.
Past History
• Describe any pain problems or injuries you
have had to your joints, muscle, or bones.
What treatment was given?
• Do you have any after effects from the injury
or problem?
• Have you ever been diagnosed with diabetes
mellitus, sickle cell anemia, SLE Systemic Lupus
Erythematosus?
• For middle aged and female client:
• Have you started menopause? Are you
receive estrogen replacement therapy?
Family History
• Do you have a family history of rheumatoid
arthritis, gout, or osteoporosis?
• Life-style and health practices
• What activities do you engage in to promote
the health of your musculoskeletal system (e.g.
exercise, diet, weight reduction)
• Do you smoke tobacco? How much and how
often?
• Do you drink alcohol or caffeinated
beverages? How much and how often?
• Are you able to consume milk or milk
containing products? Do you take any
calcium supplement? Describe your activities
during typical day. How much time do you
spend in the sunlight?
• Describe your occupation.
• Describe your posture at work and at leisure.
What type of shoes do you usually wear?
• Do you have difficulty performing normal
activities of daily living?
• Do you use assistive devices ( e. g. walker,
cane, braces) to promote your mobility?
• How have your musculoskeletal problem
interfered with your ability to interact with
others?
• How did you view yourself before you had this
musculoskeletal problem and how do you
view yourself now?
ASSESSMENT
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MUSCLES
• Inspect the muscles for size.
• Compare each muscle on one side of the
body to the same muscle on the other side.
• For any apparent discrepancies, measure the
muscles with a tape
Normal Findings: equal size on both sides of body
Abnormal Findings: Atrophy (a decrease in size) or
Hypertrophy (an increased in size
• Inspect the muscles and tendons for
contractures
Normal Findings: no contractures
Abnormal Findings: malposition of body part (foot
drop or foot flexed forward
• Inspect the muscles for tremors.
• Inspect any tremors of the hands and arms by
having the client hold arms out in front of
body.
Normal Findings: no fasciculation
or tremors.
Abnormal Findings: presence of
fasciculation or tremors.
• Palpate muscles at rest to determine muscle
tonicity.
Normal Findings: normally firm
Abnormal Findings: Atonic (lacking tone)
• Palpate muscles while the client is active and
passive for flaccidity, spasticity, and
smoothness of movement.
Normal Findings: smooth coordinated,
movements
Abnormal Findings: Flaccidity (weakness/laxness)
or spasticity (sudden involuntary muscle
contraction
• Test muscle strength.
• Compare the right side with left side
Normal Findings: equal strength on each body
sides
Abnormal Findings: 25% or less muscle strength
GRADING MUSCLE STRENGTH
HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023

• Inspect the skeleton for normal structure and

deformities
Normal Findings: no deformities
Abnormal Findings: bones misaligned
• Palpate the bones to locate any areas of
edema or tenderness
Normal Findings: no tenderness of swelling
Abnormal Findings: presence tenderness of
swelling
TEST MUSCLE STRENGTH
❖ STERNOCLEIDOMASTOID - Client turns the LESSON: FEMALE GENITALS AND
head to one side against the resistance of INGUINAL ASSESSMENT
your hand. Repeat with the other side.
EXTERNAL FEMALE GENITALS
❖ TRAPEZIUS - Client shrugs the shoulders against • mons pubis
the resistance of your hands.
• prepuce
❖ DELTOID - Client holds arm up and resists while
• clitoris
you try to push it down.
• labia majora
❖ BICEPS - Client fully extends each arm and
• labia minora
tries to flex it while you attempt to hold arm in
• urethra
extension
• vagina
❖ TRICEPS - Client flexes each arm and then tries
• vestibule
to extends it against your attempt to keep in
• perineum
flexion
❖ WRIST AND FINGER MUSCLES - Client spreads
INTERNAL FEMALE GENITALS
the fingers and resists as you attempt to push
• fallopian tube
the fingers together
• ovary
❖ GRIP STRENGTH - Client grasps your index
• uterus
finger and middle fingers while you try to pull
• bladder
the fingers out
• urethra
❖ HIP MUSCLES - Client is supine, both legs
• Bartholin’s gland
extended; client raises one leg at a time while
you attempt to hold it down.
❖ HIP ABDUCTION - Client is supine, both legs STAGES OF FEMALE PUBIC HAIR DEVELOPMENT
extended. Place your hands on the lateral
surface of each knee; client spreads the legs
apart against your resistance.
❖ HIP ADDUCTION - Client is in same position as
in hip abduction. Place your hands between
the knees; client brings the legs together
against your resistance.
❖ HAMSTRINGS - Client is supine, both knees
bent. Client resists while you attempt to
straighten the legs.
ASSESSMENT
❖ QUADRICEPS - Client is supine, knee partially
• Genitals (external and internal genitals)
extended; client resists while you attempt to
• Reproductive Tract
flex the knee.
• Inguinal Lymph Nodes
❖ MUSCLES OF THE ANKLE & FEET - Client resists
• Equipment
while you attempt to dorsiflex the foot and
o drape
and again resists while you attempt to flex the
o examination gloves
foot.
o supplemental lighting, if needed

BONES
History

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HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023

• number of live births

• labor or delivery complications
• urgency and frequency of urination at night
• blood in urine
• painful urination
• incontinence
• history of sexually transmitted disease, past PAPANICOLAOU SMEAR
and present

IMPLEMENTATION
1. Explain the procedure to the client.
2. Wash hands, apply gloves and appropriate
infection control procedures.
Inserting a vaginal speculum and obtaining a
3. Provide for client privacy.
specimen
4. Inquire client’s history:
• age of onset of menstruation
NORMAL CERVICAL MUCUS
• last menstrual period (LMP)
a. wet, clear, slippery, fertile mucus
• regularity of cycle, duration, amount of
b. sticky, white, cloudy, infertile mucus (on the
daily flow, and whether menstruation is painful
left)
• incidence of pain during intercourse
• vaginal discharge
• number of pregnancies
5. Position the client supine with feet elevated
on the stirrups of an examination table.
Alternately assist the client into the dorsal a. b.
recumbent position with knees flexed and LIFESPAN CONSIDERATIONS
thighs externally rotated. Infants
6. Inspect the distribution, amount, and
• Can be held in a supine position on the
characteristics of pubic hair.
mother’s lap with knees supported in a flexed
7. Inspect the skin of the pubic area for
position and separated.
parasites, inflammation, swelling and lesions.
• The labia and clitoris may be edematous and
8. Inspect the clitoris, urethral orifice and vaginal
enlarged and there may be white vaginal
orifice when separating the labia minora.
discharge
9. Palpate the lymph nodes.
Children
10. Document findings
• Ensure that you have parent or guardian’s
approval to perform the examination and tell
Internal Genitals
the child what you are going to do.
Involves the following:
• Assessment of adolescent girls is limited to
a. palpating Skene’s and Bartholin’s glands
inspection of the external genital unless, unless
b. asessing the pelvic musculature
the girls is sexually active.
c. inserting a vaginal speculum to inspect the
• The clitoris is a common site for syphilitic
cervix and vagina
chancres in younger females
d. obtaining a Papanicolaou smear
Elders
• Labia are atrophied and flatter
Nursing Responsibilities
• The vulva, fallopian tubes and ovaries atrophy
1. Assembling the equipment
• The clitoris is a common site for cancerous
2. Preparing the client.
lesions
3. Supporting the client during the procedure.
• The vaginal environment becomes dier and
4. Monitoring and assisting the client after the
more alkaline
procedure.
• The cervix and uterus decrease in size
5. Documenting the procedure.
• Ovulation and estrogen production cease
• Prolapse of the uterus
VAGINAL SPECULUM
LESSON: MALE GENITALS AND

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HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023

INGUINAL ASSESSMENT c. Femoral Hernia – is lower

and more lateral than
ANATOMY & PHYSIOLOGY
and inguinal area and
Consist of:
may look like an
• Testis
enlarged lymph node
• Series of Ducts
❖ Cancer of the Prostate Gland – is the most
• Accessory Glands
common cancer in adult men; ages over 50
• Supporting Structures
❖ Testicular Cancer – most commonly found on
• Ducts the anterior and lateral surfaces of the testes;
o Epididymis primarily in young men ages 15-35
o Vas Deferens
o Urethra
ASSESSMENT
• Accessory Glands
Equipment: examination gloves
o Seminal Vesicles
o Prostate Gland
IMPLEMENTATION
o Bulbourethral Glands
1. Explain the procedure to the client.
• Supporting structures
2. Wash hands, apply gloves, and observe
o Scrotum
appropriate infection control procedure.
o Penis
3. Provide for client privacy.
4. Inquires client’s history:
STAGES OF MALE PUBIC HAIR DEVELOPMENT
• usual voiding patterns and any changes
(12-16 Years)
• bladder control
• urinary incontinence, frequency, urgency,
abdominal pain
• any symptoms of STD
• any swelling
• family history of nephritis
• malignancy of the prostate
• malignancy of the kidney

PUBIC HAIR
5. Inspect the distribution, amount, and
DEFINITIONS characteristic of the pubic hair.
❖ Hernia – is a protrusion of the intestine through
the inguinal wall or canal PENIS
a. Indirect Hernia – Is a loop of bowel that enters 6. Inspect the penile shaft and glans penis for
the internal inguinal ring lesions, nodules, swellings, and inflammation.
• located in the groin, a result of a weakness 7. Inspect the urethral meatus
in the inguinal ring for swelling, inflammation and
• the most common type of hernia discharge.
• can be present at birth 8. Palpate the penis for
• may occur later in life tenderness, thickening and
b. Direct Inguinal Hernia – enters the inguinal nodules.
canal directly through a weakness in the
abdominal wall just behind SCROTUM
the external inguinal ring. 9. Inspect the scrotum for appearance, general
• occurs in the inguinal size and symmetry.
area, near the inguinal 10. Palpate the scrotum to assess status of the
ring underlying testes, epididymis, and spermatic
• occur less frequently cord.
than indirect inguinal INGUINAL AREA
hernia 11. Inspect bothers inguinal areas for bulges while
• are more common in men the client is standing.
• usually occur after the age of 40 12. Palpate hernias.

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HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023
13. Document findings.
LIFESPAN CONSIDERATIONS
Infants
The foreskin of the infant is normally tight the first 2
or 3 months of life is not readily retractable.
Children
• The scrotum is usually palpated determine
whether testes are descended.
• Ensure that you have parent or guardian’s
approval to perform the examination and tell
the child what you are going to do.
• In young boys, the cremasteric reflex can
cause the testes to ascend into the inguinal
canal.
Elders
• The penis and testes decreases in size with
age
• Testosterone is produced in smaller amounts.
• More time and direct physical stimulation are
required for an older man to achieve an
erection.
• Seminal fluid is reduced in amount and
viscosity
• Urinary frequency, nocturia, drbbling, and
problems with beginning and ending the
stream
TESTICULAR SELF EXAMINATION (TSE)
LESSON: BREAST AND AXILLA EXAMINATION
BREAST EXAMINATION
• If the patient is female and you doctor are a
male, ALWAYS LOOK FOR A FEMALE
CHAPERONE.
• Be sure to ask if the patient has examined her
breasts lately, how often?, any discomfort,
pain or lumps?, any discharge from the
nipples?
Important
Male breasts and female breasts in human beings
develop from the same embryological tissues. In
females at puberty sex hormones, mainly
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estrogens, promote breast development. In males
this does not happen. As a result, breasts become
more prominent in adult females than in males.
COMMON BREAST TYPES (SHAPES)
❖ PERFECT BREASTS - The perfect breast shape is
quite a rarity. In both medicine and esthetics,
the perfect breast shape is the one in which
the nipple points outwards, parallel to the
ground. There should be no sag and the
breast should be supple and well-toned.
❖ SWOOPING BREASTS - This shape is the one in
which the breast slightly bends inwards above
the areola. There is no sag however. Due to
the bending of the breast, the nipple points
upwards, inclined to the vertical.
❖ SAGGY OR PTOTIC BREASTS - Saggy breasts
are commonly found in women as their age
advances. These breasts droop downwards,
causing the nipple to be pointed downwards
too. Saggy breasts may have more or little
volume, depending on the amount of fat
tissues in them.
❖ SMALL BREASTS - Small breasts are breasts that
have very little volume of fatty tissue in them.
Small breasts also have small nipples and
areolas. There is very little substance between
the nipples and the pectoral muscles.
❖ TUBULAR OR CONSTRICTED BREASTS - These are
actually a defective breast shape which may
be cause due to hernia in the breast tissue.
They are visible as tubular or narrow cylindrical
in shape, with very small nipples and areolas.
Their base is also small, and the two breasts
may be far apart.
❖ AUGMENTED BREASTS - These are a severe
condition of tubular breasts. There are visible
anomalies in the shape of the breasts.
❖ PECTUS CARINATUM OR PIGEON BREASTS -
These are severely deformed breasts which lie
almost flat on the chest. They do not look like
breasts at all. These are caused due to a
congenital defect.
BREAST GENERAL INFORMATION
• It is found within the 2nd and 7th rib. It stems
from the sternal edge to the anterior axillary
line.
HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023
• Clinically is composed of the Nipple Areolar
Complex and the Glandular Portion.
NIPPLE AREOLAR COMPLEX AND
GLANDULAR PORTION
• NAC is pigmented and hairless. It should be
normally at the middle of the aspect of the
arm and, why is this important? Because it
helps in the criteria of ptosis of the breast.
• Glandular Portion is composed of: 15 to 25
lobes that divide into 50 -75 lobules.
• Tail of the breast extends into the axilla, and is
thicker than other areas.
BREAST QUADRANTS
Breast is divided into quadrants.
Upper-Outer Quadrant has the greatest mass.
UOQ is the site of about half of all breast cancers.
TECHNIQUES OF EXAMINATION
Inspection -> Palpation
INSPECTION
Breast and Nipples
• Inspect the breasts and nipples with the
patient in the sitting position and undressed to
the waist.
• Inspect the movement of breast tissue in four
views:
o Arms at sides
o Arms over head
o Arms pressed against hips
o Leaning forward
• In the Breasts inspect:
o Size
o Shape
o Symmetry
o Skin appearance (color, thickening)
o Contour (dimpling, masses, flattening)
• In the Nipples inspect:
o Size.
o Shape.
o Direction (inverted, flat).
o Discharge or bleeding.
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INSPECTION (Axillae and Male Breast)
The inspection of the axillae is performed with the
arms raised over the head preferably in a sitting
position but can be done laying down.
• In the Axillae inspect:
o Skin
o Rash, unusual pigmentation, infection
o Lumps
• In Male Breast inspect:
o Size
o Symmetry
o Skin appearance
o Inspect the nipple and areola for nodules
and ulcerations.
PALPATION
❖ BREAST
• Best performed when the breast tissue is
flattened. The patient should be in a supine
position.
• Palpate a rectangular area. It is important to
be systematic.
• Use the finger pads of the 2nd, 3rd, and 4th
fingers, keeping the fingers slightly flexed.
Although a circular or wedge pattern can be
used, the vertical strip pattern is currently the
best validated technique for detecting breast
masses.
• Palpate in small, concentric circles at each
examining point, if possible applying light,
medium, and deep pressure.
EXAMINATION OF THE BREAST
LATERAL PORTION
• Ask the patient to roll onto the opposite hip,
placing her hand on her forehead but
keeping the shoulders pressed against the
bed or examining table. This flattens the
lateral breast tissue.
• Begin palpation in the axilla, moving in a
straight line down to the bra line, then move
the fingers medially and palpate in a vertical
strip up the chest to the clavicle.
• Continue in vertical overlapping strips until you
reach the nipple, then reposition the patient
to flatten the medial portion of the breast.
MEDIAL PORTION
• Ask the patient to lie with her shoulders flat
against the bed or examining table, placing
her hand at her neck and lifting up her elbow
until it is even with her shoulder.
HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023

• Palpate in a straight line down from the nipple o Also, feel for Infraclavicular Nodes and
to the bra line, then back to the clavicle, reexamine the Supraclavicular Nodes.
continuing in vertical overlapping strips to the
midsternum. Four Main Groups of Problems
• Congenital
BREAST TISSUE • Inflammatory/ Infectious
• Consistency of the tissues. • Tumoral
• Tenderness, as in premenstrual fullness. • Traumatic
• Nodules:
o Location o Size Adolescent Breast Problems
o Shape o Consistency • Asymmetric growth is the rule rather than the
o Delimitation o Tenderness exception.
o Mobility • Mammary hypertrophy:
• Palpate each nipple, noting its elasticity. o Postpone surgical intervention until all
growth has occurred.
❖ MALE BREAST • The majority of the breast masses are 100%
• Palpate the areola and breast tissue for benign and surgery or FNA is almost never
nodules. If the breast appears enlarged, warranted, (disturbs breast architecture and
distinguish between the soft fatty enlargement may be disfiguring).
of obesity and the firm disc of glandular
enlargement, called Gynecomastia. PALPABLE MASSES OF THE BREAST
• A hard, irregular, eccentric, or ulcerating • 15 – 25 years of age: Fibroadenomas
nodule is not gynecomastia and suggests • 25 – 50 years of age: Cysts, Fibrocystic
breast cancer. Changes, Cancer
Gynecomastia - development of abnormally • 50 and over: Cancer
large mammary glands in males resulting in breast • If pregnancy or lactation is present:
enlargement, which can sometimes cause Adenomas, Cysts, Mastitis and Cancer.
secretion of milk.
Clinical Notes: if the patient is a 18 years old girl, it
❖ AXILLAE 99% fibroadenoma, but if the patient is 57 years
• Ask the patient to relax with the left or right old, with multiple masses, then is usually a
arm down. fibrocystic disease but do not exclude CA.
• Cup together the fingers of your right hand
and reach as high as you can toward the SUPERNUMERARY BREASTS: CONGENITAL
apex of the axilla. - relatively common
• Your fingers should lie directly behind the - found along “milk line”
pectoral muscles, pointing toward the - most identified during pregnancy/lactation
midclavicle. - most common in axilla
• Now press your fingers in toward the chest wall - not dangerous
and slide them downward, trying to feel the
central nodes against the chest wall.
• If the central nodes feel large, hard, or tender,
or if there is a suspicious lesion in the drainage
areas for the axillary nodes, feel for the other
groups of axillary lymph nodes:
o Pectoral Nodes - grasp the anterior axillary SUPERNUMERARY NIPPLES:
fold between your thumb and fingers, and CONGENITAL
with your fingers palpate inside the border - more common than
of the pectoral muscle. supernumerary breasts, but
o Lateral Nodes - from high in the axilla, feel is more commonly seen in
along the upper humerus. males than females.
o Subscapular Nodes - step behind the - found along milk line.
patient and with your fingers feel inside - may darken during
the muscle of the posterior axillary fold. pregnancy.

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HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023

- not dangerous. - normal is clear, milky

or green-tinged
INVERTED NIPPLES: CONGENITAL - if bloody, needs
- often will evert with surgical evaluation
stimulation. - if it stains the inside of
- mostly a cosmetic issue. the bra each day,
- successful breastfeeding is that is galactorrhea
usually possible and will need thyroid and pituitary evaluation

PREGNANCY CHANGES FAT NECROSIS

• 1st TM: Tender breasts and nipples - tender, thickened, bruised
• 2nd TM: Non-tender breasts enlarge area of breast
• 2nd-3rd TM: Steady darkening of nipples and - follows trauma
prominent Montgomery’s glands - benign
- resolves spontaneously
PUERPERAL MASTITIS over weeks to months
- rapid onset of red, hot, - atypical cases should
swollen, tender breast have FNA
- high fever
- abscess needs drainage BREAST CYST
- keep breast-feeding - smooth, unilateral mass
- feels like a cyst
NIPPLE LACERATION - infrequently associated with malignancy
Usually at breast feeding by staphylococcus - aspirate
infection into the ducts. Enlargement of breast - watch for reforming of cyst
may occur by galactosyl. May be similar to peau - recurring cysts are more worrisome
d’ orange, how to know? If the patient with
antibiotics does not get better in 10 days, think of
CA.
• Keep clean and dry.
• Stop breast feeding that side and allow to
heal.
• Antibiotics usually not necessary.
PAGET’S DISEASE
- crusty, flaking lesion
- gradual onset over months or years
- associated with
underlying breast
malignancy
CYCLIC BREAST PAIN - diagnosis confirmed by
• worst just before menses. needle biopsy
• thick, tender, nodular breasts. BREAST MASS
• not dangerous but bothersome. - dominant mass
• Rx: ocps (cyclic or continuous). - unilateral
• Rx: danazol (extreme cases). - persists through the
• reduce caffeine? vitamin e? menstrual cycle
NON CYCLIC BREAST PAIN - usually biopsied
• often due to trauma (breast or chest wall) (FNA or excisional)
• may be due to muscle strai - can wait weeks but not months
• usually not may be due to increased levels of
estrogen FIBROADENOMA
• due to cancer
• examine and refer if cause is not obvious

NIPPLE DISCHARGE

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HEALTH ASSESSMENT (RLE) - Finals
BS NURSING - 1B 2nd Sem – 2023

- common
- benign
- solid, rubbery, non-
tender
- round or oval
- rarely grow > 2-3 cm
- fna or excisional bx
- observe in adolescents

BREAST CANCER
- 30% of all cancers in women.
- treatment is successful in ¾
- rare before age 25
- steadily increasing
frequency with
increasing age
- affects 1/9 women
reaching age 90
- in males, only 1% is affected

Risk Factors:
• strong family history
• menopause after age 55
• no term pregnancy prior to age 35
• most (80%) of breast cancer occurs in women
not at increased risk
• question, how do you examine a person with
breast implants?

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