NCLEX RN GUIDE                                                                                   the best of NCLEX

Health Promotion and Maintenance Part 4

              1. Breasts

                1. Inspection (performed with client in lying, sitting, or standing position)

                  1. size: vary from convex to pendulous

                  2. symmetry (the left breast is commonly larger than the other)

                  3. skin: color, venous pattern, possibly a few hairs around areola

                  4. alterations

                    1. retraction

                    2. dimpling

                    3. lesions

                    4. edema

                    5. inflammation

                    6. alterations with pregnancy and lactation

                      • enlargement of breasts

                      • soreness of nipples during lactation

                      • possible striae

                  5. nipple and areola

                    1. size

                    2. color: ranges from pink to brown

                    3. shape

                      • areola: round or oval

                      • nipples: everted

                    4. symmetry: normally symmetrical

                    5. direction: normally nipples point in same direction

                    6. alterations

                      • discharge

                      • inverted nipples

                      • bleeding

                1. Palpation - breast

                  1. lymph nodes - normal findings: not palpable

                  2. breast tissue

                    1. client in supine position with hand placed behind neck

                    2. methods of examining breast tissue

                      • clockwise or counterclockwise circling breast from nipple outward

                      • back and forth with fingers moving up and down each breast

                    3. consistency:

                      • varies widely from person to person

                      • normal findings: dense, firm and elastic

                    4. alteration - fibrocystic disease of the breast

                    5. geriatric alterations

                      • relaxed breasts

                      • may appear elongated or pendulous

                      • decrease in glandular tissue

              1. Abdomen

                1. History

                  1. pain, bowel habits, dietary problems, weight change, difficulty swallowing, flatulence, belching, heartburn, nausea, vomiting, cramping

                  2. 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

                2. Inspection

                  1. landmarks

                    1. xiphoid process: marks upper boundary of abdomen

                    2. symphysis pubis: marks lower boundary

                    3. abdomen divided into four quadrants: RUQ, RLQ, LUQ, LLQ (illustration )

                  2. normal findings

                    1. skin texture and color should be consistent with rest of body

                    2. stria may be present

                    3. umbilicus is normally flat or concave midway between xiphoid and symphysis pubis

                    4. abdomen may be flat, concave or convex; all three are normal if there is symmetry

                    5. you may note peristalsis movement or aortic pulse

                    6. voiding: steady, straight stream with no pain or post void dribble


          1. Percussion

            1. normal findings: tympany over stomach and intestines; dullness over liver, spleen, pancreas, kidneys and distended (>150cc) bladder

            2. liver border

              1. usually noted in the 5th, 6th or 7th intercostal space

              2. distance between upper and lower borders should range between six to 12 cm at right midclavicular line

            3. spleen

              1. left posterior midaxillary line: dullness at sixth to tenth rib

              2. left intercostal space in anterior axillary line: tympany

          2. Palpation

            1. normal findings: soft with no palpable masses, no tenderness or rigidity

            2. bladder noted as a bulge in abdomen when filled with more than 500cc of urine

            3. deep palpation may produce tenderness - liver, kidneys, spleen inguinal nodes generally not palpable

          1. Auscultation

            1. bowel motility - normal findings: audible in all quadrants

            2. vascular sounds - normal findings

              1. no vascular sounds over aorta or femoral arteries

              2. renal artery bruits can be heard

          2. Alterations

            1. distention

            2. ascites

            3. paralytic ileus

            4. borborygmus

            5. guarding (muscles contract)

            6. tenderness

            7. pain

          3. Geriatric alterations

            1. increased fat deposits over abdominal area

            2. muscle tone more lax

        1. Female reproductive system

          1. History: sexually transmitted disease, menstrual history, obstetrical history, contraception (illustration )

          2. Inspection

            1. external genitalia - normal findings

              1. hair distribution: variable; usually inverted triangle starting at symphysis pubis

              2. skin of perineum smooth, clean, slightly darker than other skin

              3. labia majora: may be closed or gaping

              4. clitoris: about two cm in length and 0.5 cm in width

              5. urethral orifice: intact, pink without irritation

              6. vaginal orifice: ranges from thin, vertical slit to large orifice with moist tissue

              7. anus: moist and hairless: skin more darkly pigmented

            2. internal genitalia

              1. cervix - normal findings: pink; midline; usually about two to three cm in diameter; smooth, firm, rounded or oval; odorless, creamy or clear secretions

              2. Papanicolaou (Pap) Smear

              3. vagina: pink throughout; clear or cloudy, odorless secretions; about ten to 15 cm in length

          1. Palpation

            1. ovaries may or may not be palpable; firm, slightly tender, oval, mobile; about four cm in diameter

            2. uterus: mobile; rounded; palpable at level of pelvis

            3. Skene's gland and Bartholin's gland - normal findings: nontender, no discharge

          2. Geriatric alterations

            1. labial folds flatten

            2. skin paler, shiny

            3. meatus usually more posterior

            4. cervix decreases in size; may appear paler

            5. scanty cervical discharge

            6. vagina shortens with age

            7. decreased vaginal secretions

            8. uterus diminishes in size; may not be palpable

            9. ovaries atrophy with age

        1. Male reproductive system

          1. History: sexual history, sexually transmitted disease, contraception, surgery, associated urinary problems
            illustration )

          2. Inspection

            1. external genitalia

            2. hair distribution: varies; hair extends from base of penis over symphysis pubis; coarse and curly

            3. penis shaft, corona, prepuce, glans

            4. urethral meatus is slit like opening positioned on ventral surface, millimeters from tip of glans; opening should be glistening and pink

            5. scrotum

              1. skin more darkly pigmented; more wrinkled; usually loose

              2. symmetry: left testicle is lower than right

              3. size: changes with temperature

            6. inguinal canal - normal finding: no bulging

          3. Palpation

            1. penis

              1. foreskin should retract easily

              2. small amount of thick white secretion between glans and foreskin is normal

              3. testicle: ovoid; ranges from two - four cm in diameter, smooth and rubbery; nontender

            2. inguinal canal

              1. normal finding: inguinal lymph nodes not palpable

          1. Geriatric alterations

            1. increased bogginess of prostate

            2. testes softer

          2. Rectum and anus

            1. inspection of perianal areas

              1. skin: smooth and uninterrupted

              2. anal tissues: normally moist and hairless

            2. digital palpation

              1. anal sphincter: note tone

              2. rectal walls: smooth and even

              3. 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

            3. alterations

              1. femorrhoids (illustration )

              2. fissures

              3. fistulas

              4. polyps

              5. pain

    1. Musculoskeletal
      1. History: participation in sports, risk factors for osteoporosis, impact of current problem on activities of daily living

      2. Inspection

        1. gait - normal findings: client walks with arms swinging freely at sides; coordinated and smooth; rhythmic with push off and swing through

        2. posture and balance - normal findings

          1. upright stance with parallel alignment of hips and shoulders

          2. feet aligned; toes pointing straight ahead

          3. convex curve to thoracic spine

          4. concave curve to lumbar spine

          5. can stand still without swaying or tilting

        3. extremities

          1. normal findings: bilateral symmetry in length, circumference, alignment, position and number of skin folds

      3. Palpation

        1. all muscles, bones, joints

        2. normal findings: muscles firm, non-tender

      1. Range of motion - normal findings: able to move joints through required range of motion

        1. Abduction

        2. Adduction

        3. Dorsiflexion

        4. Eversion

        5. Extension

        6. Flexion

        7. Hyperextension

        8. Inversion

        9. Plantar flexion

        10. Pronation

        11. Supination

      2. Muscle strength and symmetry - normal findings: arm on dominant side generally stronger

      3. Alterations

        1. kyphosis

        2. lordosis

        3. scoliosis

        4. pain

      4. Geriatric alterations

        1. stance less upright with head and neck forward

        2. lumbar curvature less pronounced

        3. height decreased

        4. gait slower to initiate and stop

        5. less knee and ankle lifts

        6. steps may be shorter and more rapid

        7. may need to hold onto furniture as age increases

        8. muscles atrophy with disuse

        9. weaker grip

        10. active range of motion may be slower and limited in one or more joints

        11. joints appear larger than surrounding tissue; may be stiff

    1. Neurological system

      1. History

      2. Mental status

        1. Mini-Mental State Exam (MMSE)

      3. Emotional status - normal findings: affect matches speech

      4. Cranial nerve function   (illustration )

      5. Level of consciousness (LOC) - normal findings

        1. alert

        2. responds appropriately to visual, auditory, tactile and painful stimuli

        3. able to carry out simple commands

        4. Glasgow Coma Scale

        5. alterations in LOC 

      1. Sensory function - normal findings  

        1. visual: recognizes objects

        2. auditory: identifies sounds

        3. tactile: identifies objects through blind touch; perceives pain, hot and cold and vibration; two-point discrimination

        4. olfactory: identifies familiar smells

      2. Cerebellar function - position and balance  

      3. Speech and language - normal findings

        1. smooth flowing speech

        2. able to formulate words without difficulty

        3. varied inflection

        4. able to write letters and numbers to dictation

        5. vocabulary appropriate to educational level

      4. Intellectual - normal findings

        1. memory: immediate recall and remote recall

        2. oriented to person, place and time

        3. able to abstract

        4. demonstrates consistent insight and perception of self

      5. Reflexes - assessment  and grading

        1. pediatric considerations

      6. Geriatric alterations in neuro status

        1. longer response time to sensory stimulation

        2. may resist new ideas or change

        3. thought patterns may become more concrete

        4. kinesthesia diminishes

        5. superficial and deep reflexes may be diminished or absent