Health Promotion and Maintenance Part 4
Breasts
Inspection (performed with client in lying, sitting, or standing position)
size: vary from convex to pendulous
symmetry (the left breast is commonly larger than the other)
skin: color, venous pattern, possibly a few hairs around areola
alterations
retraction
dimpling
lesions
edema
inflammation
alterations with pregnancy and lactation
nipple and areola
size
color: ranges from pink to brown
shape
areola: round or oval
nipples: everted
symmetry: normally symmetrical
direction: normally nipples point in same direction
alterations
discharge
inverted nipples
bleeding
Palpation - breast
lymph nodes - normal findings: not palpable
breast tissue
client in supine position with hand placed behind neck
methods of examining breast tissue
consistency:
alteration - fibrocystic disease of the breast
geriatric alterations
Abdomen
History
pain, bowel habits, dietary problems, weight change, difficulty swallowing, flatulence, belching, heartburn, nausea, vomiting, cramping
changes in micturition including: change in amount and color of urine, irritation of the lower urinary tract, obstruction of the urinary tract, urinary incontinence, urinary tract pain
Inspection
landmarks
xiphoid process : marks upper boundary of abdomen
symphysis pubis : marks lower boundary
abdomen divided into four quadrants: RUQ, RLQ, LUQ, LLQ ( illustration )
normal findings
skin texture and color should be consistent with rest of body
stria may be present
umbilicus is normally flat or concave midway between xiphoid and symphysis pubis
abdomen may be flat, concave or convex; all three are normal if there is symmetry
you may note peristalsis movement or aortic pulse
voiding: steady, straight stream with no pain or post void dribble
Percussion
normal findings: tympany over stomach and intestines; dullness over liver, spleen, pancreas, kidneys and distended (>150cc) bladder
liver border
usually noted in the 5th, 6th or 7th intercostal space
distance between upper and lower borders should range between six to 12 cm at right midclavicular line
spleen
left posterior midaxillary line: dullness at sixth to tenth rib
left intercostal space in anterior axillary line: tympany
Palpation
normal findings: soft with no palpable masses, no tenderness or rigidity
bladder noted as a bulge in abdomen when filled with more than 500cc of urine
deep palpation may produce tenderness - liver, kidneys, spleen inguinal nodes generally not palpable
Auscultation
bowel motility - normal findings: audible in all quadrants
vascular sounds - normal findings
no vascular sounds over aorta or femoral arteries
renal artery bruits can be heard
Alterations
distention
ascites
paralytic ileus
borborygmus
guarding (muscles contract)
tenderness
pain
Geriatric alterations
increased fat deposits over abdominal area
muscle tone more lax
Female reproductive system
History: sexually transmitted disease, menstrual history, obstetrical history, contraception ( illustration )
Inspection
external genitalia - normal findings
hair distribution: variable; usually inverted triangle starting at symphysis pubis
skin of perineum smooth, clean, slightly darker than other skin
labia majora: may be closed or gaping
clitoris: about two cm in length and 0.5 cm in width
urethral orifice: intact, pink without irritation
vaginal orifice: ranges from thin, vertical slit to large orifice with moist tissue
anus: moist and hairless: skin more darkly pigmented
internal genitalia
cervix - normal findings: pink; midline; usually about two to three cm in diameter; smooth, firm, rounded or oval; odorless, creamy or clear secretions
Papanicolaou (Pap) Smear
vagina: pink throughout; clear or cloudy, odorless secretions; about ten to 15 cm in length
Palpation
ovaries may or may not be palpable; firm, slightly tender, oval, mobile; about four cm in diameter
uterus: mobile; rounded; palpable at level of pelvis
Skene's gland and Bartholin's gland - normal findings: nontender, no discharge
Geriatric alterations
labial folds flatten
skin paler, shiny
meatus usually more posterior
cervix decreases in size; may appear paler
scanty cervical discharge
vagina shortens with age
decreased vaginal secretions
uterus diminishes in size; may not be palpable
ovaries atrophy with age
Male reproductive system
History: sexual history, sexually transmitted disease, contraception, surgery, associated urinary problems ( illustration )
Inspection
external genitalia
hair distribution: varies; hair extends from base of penis over symphysis pubis; coarse and curly
penis shaft, corona, prepuce, glans
urethral meatus is slit like opening positioned on ventral surface, millimeters from tip of glans; opening should be glistening and pink
scrotum
skin more darkly pigmented; more wrinkled; usually loose
symmetry: left testicle is lower than right
size: changes with temperature
inguinal canal - normal finding: no bulging
Palpation
penis
foreskin should retract easily
small amount of thick white secretion between glans and foreskin is normal
testicle: ovoid; ranges from two - four cm in diameter, smooth and rubbery; nontender
inguinal canal
normal finding: inguinal lymph nodes not palpable
Geriatric alterations
increased bogginess of prostate
testes softer
Rectum and anus
inspection of perianal areas
skin: smooth and uninterrupted
anal tissues: normally moist and hairless
digital palpation
anal sphincter: note tone
rectal walls: smooth and even
prostate gland
palpate through anterior rectal wall
small walnut-sized, heart shaped structure
ranges from 2.5 to 4 cm in diameter
normal findings: firm, protrudes < one cm into rectum
alterations
femorrhoids ( illustration )
fissures
fistulas
polyps
pain
Musculoskeletal
History: participation in sports, risk factors for osteoporosis, impact of current problem on activities of daily living
Inspection
gait - normal findings: client walks with arms swinging freely at sides; coordinated and smooth; rhythmic with push off and swing through
posture and balance - normal findings
upright stance with parallel alignment of hips and shoulders
feet aligned; toes pointing straight ahead
convex curve to thoracic spine
concave curve to lumbar spine
can stand still without swaying or tilting
extremities
normal findings: bilateral symmetry in length, circumference, alignment, position and number of skin folds
Palpation
all muscles, bones, joints
normal findings: muscles firm, non-tender
Range of motion - normal findings: able to move joints through required range of motion
Abduction
Adduction
Dorsiflexion
Eversion
Extension
Flexion
Hyperextension
Inversion
Plantar flexion
Pronation
Supination
Muscle strength and symmetry - normal findings: arm on dominant side generally stronger
Alterations
kyphosis
lordosis
scoliosis
pain
Geriatric alterations
stance less upright with head and neck forward
lumbar curvature less pronounced
height decreased
gait slower to initiate and stop
less knee and ankle lifts
steps may be shorter and more rapid
may need to hold onto furniture as age increases
muscles atrophy with disuse
weaker grip
active range of motion may be slower and limited in one or more joints
joints appear larger than surrounding tissue; may be stiff
Neurological system
History
Mental status
Mini-Mental State Exam (MMSE)
Emotional status - normal findings: affect matches speech
Cranial nerve function ( illustration )
Level of consciousness (LOC) - normal findings
alert
responds appropriately to visual, auditory, tactile and painful stimuli
able to carry out simple commands
Glasgow Coma Scale
alterations in LOC
Sensory function - normal findings
visual: recognizes objects
auditory: identifies sounds
tactile: identifies objects through blind touch; perceives pain, hot and cold and vibration; two-point discrimination
olfactory: identifies familiar smells
Cerebellar function - position and balance
Speech and language - normal findings
smooth flowing speech
able to formulate words without difficulty
varied inflection
able to write letters and numbers to dictation
vocabulary appropriate to educational level
Intellectual - normal findings
memory: immediate recall and remote recall
oriented to person, place and time
able to abstract
demonstrates consistent insight and perception of self
Reflexes - assessment and grading
pediatric considerations
Geriatric alterations in neuro status
longer response time to sensory stimulation
may resist new ideas or change
thought patterns may become more concrete
kinesthesia diminishes
superficial and deep reflexes may be diminished or absent