chapters 18-20

Sequence of the examination

1. Inspecting 2. Digital rectal examination 3. Testing stool for occult blood The anus and rectum are assessed at different times for the female and male assessment. ■ Female patient's rectum and anus are assessed after a gynecological assessment. ■ Male patient's rectum and anus are assessed after the male genital area assessment; the prostate gland is assessed at the same time. This assessment may be performed with the patient in the Sims' (side-lying) or lithotomy position, for women. Inspection is a noninvasive assessment that is done by the nurse.

Palpating axillary lymph nodes abnormal findings

ABNORMAL FINDINGS ■ Enlarged nodes may indicate infection or breast cancer metastasis.

patient education: Routine Gynecological Examinations

ACOG (2015) recommends that the first visit to the obstetrician-gynecologist for screening and the provision of preventive healthcare services and guidance take place between the ages of 13 and 15 years. ACOG (2015) continues to recommend routine pelvic examinations as part of an annual well-woman visit starting at age 21.

Patient education: breast self-examinations (female)

Breast cancer is the most commonly diagnosed cancer in women in the United States, and the second leading cause of death from cancer in American women. Breast cancer mortality can be effectively reduced through screening and awareness (ACOG, 2016). Teaching breast self-awareness and breast self-exam can save lives. Women should be alert to breast self awareness: knowing what is the normal look and feel of their breasts. Breast self-exam (BSE) is a step-by-step approach a woman can use to look at and feel her breasts (SusanGKomen.org, 2017). Nurses are on the front lines to spread the word and make a difference. Reinforce to each woman that most breast problems or changes are benign. Early detection of breast cancer can greatly improve a woman's chance to survive. In recent years, controversy exists about the value of BSE and whether it reduces mortality rates in women. Recommendations include: ■ The USPSTF (2016) recommends against teaching breast self-examination (BSE). ■ The National Breast Cancer Foundation (2016) recommends adult women of all ages to perform breast self-exams at least once a month. ■ The American Cancer Society (2015) does not recommend routine breast self-examination (BSE), neither do they recommend against routine BSE. A woman may choose to perform regular BSE or occasional BSE, or she may choose to not perform BSE at all. ■ Women should be told about benefits and limitations of BSE. They should report any new symptoms to their healthcare provider. It is essential that nurses feel comfortable with their own knowledge of BSE to share it with a patient. Nurses should: ■ assess the patient's understanding of breast self-awareness ■ assess the patient's understanding of breast self-exam ■ assess how and when the patient is doing BSE. Encourage women to conduct a BSE regularly so they know how their breasts look and feel. Since the vertical strip palpation method is preferred, show the patient a picture of this method and simulate on a breast model. Pamphlets are available from many organizations. Teaching Points for Breast Self-Examination ■ The best time to perform a BSE is 7 to 9 days after menses, when the breasts are least likely to be swollen or tender due to hormonal changes. ■ Pregnant women and menopausal women should identify a day each month to do BSE. The key is to remember to do the examination regularly. There are several positions in which a woman can perform BSE: ■ Standing in front of a mirror ■ Standing while taking a shower ■ Lying down on a flat surface such as a bed ■ Explain to the patient that lying down on a flat surface with a pillow under the side being examined helps to spread the breast tissue evenly over the chest wall.

four quadrants of the breast

Breasts extend from the second through sixth ribs and are divided into four quadrants (Fig. 18-1) including the tail of Spence; the tail of Spence is the lateral corner and axillary extension of the breast.

ROS for male health: Military history

Combat veterans experiencing traumatic events of the war are at higher risk for post-traumatic stress disorder (PTSD) (Gough & Robertson, 2010) or a new syndrome called post-deployment syndrome (PDS). These are illnesses of war that may have unexplained symptoms (Box 19-1, Box 19-2). The symptoms may be gradually present within months of returning home or may take years. These veterans may be at greater risk for substance abuse disorders or major depressive disorder. Symptoms of major depressive disorder may include: ■ anorexia ■ chronic fatigue ■ chronic aches and pains ■ insomnia ■ inability to work ■ loss of interest in activities, including sex ■ being persistently sad, anxious, or irritable ■ suicidal thoughts. When assessing veterans, it is important for nurses to remember that each war comes with its own set of health risks.

internal anatomy of the breast

Contains three types of tissue □ Fatty □ Fibrous: provides support to breasts □ Glandular: Contains 15 to 20 lobes per breast; each lobe has 20 to 40 lobules that contain milk-producing acini cells (Fig. 18-2) ■ Amount and size of the three types of tissue vary depending on the production of two female hormones, progesterone and estrogen. Female hormones, estrogen and progesterone, influence the development of the female breasts and reproductive system, high-pitched voice, and wide hips in women. Estrogen and progesterone are produced by the hypothalamus, anterior pituitary gland, and ovaries. ■ The internal mammary and lateral thoracic arteries provide the blood supply to the breasts.

Contraceptive History

Contraception can be categorized as hormonal or barrier methods that provide control over the timing and prevention of pregnancy, menstrual cycle and some hormonal conditions such as PMS. A contraceptive history should include current method, compliance with method, failure, or inability to use method appropriately and side effects. ■ What is your present contraceptive method? □ Birth control pills are a form of hormonal contraception preventing pregnancy. Varying birth control pills will include varying amounts of estrogen and progestin. □ Transdermal patch is a combined hormonal contraceptive containing both progestin and estrogen that is applied to the skin; hormones are released daily, resulting in a steady state of systemic hormones, resulting in ovulation suppression. □ Nuvaring is a hormonal bendable ring that is inserted into the vagina. Has a local effect of ovulation suppression and thickening of the uterus which protects against pregnancy. □ Diaphragm is a barrier method, dome-shaped cup that is inserted in the vagina to cover the cervix. Spermicide is often recommended to be applied inside the cup to allow for additional contraceptive protection. □ Intrauterine devices (IUDs) are small, "T" shaped devices that are placed into the uterus and are a long-acting, reversible method of birth control. IUDs prevent sperm from reaching or fertilizing an egg. IUDs also prevent a fertilized egg from attaching to the uterus and developing into a fetus. IUDs are either copper or plastic, have a local hormone that slowly releases progestin and may suppress ovulation. □ Female condom is a flexible pouch that is inserted into the vagina prior to intercourse; barrier contraceptive. □ Male condom is thin, flexible penile sheath made of synthetic or natural materials; barrier contraceptive. □ Spermicide acts as a barrier and inhibits sperm motility in the vagina and function. Surfactant designed to dissolve lipids in the sperm cell membrane, thus inactivating or killing the sperm. Spermicide is often used with other barrier methods to enhance the effectiveness of contraception. □ Rhythm method uses abstinence from sexual intercourse during the time of ovulation, and involves tracking changes in body temperature and cervical mucous. □ Posttubal ligation is a surgical procedure that blocks both fallopian tubes; permanent form of birth control. ■ Have there been any failure problems of this form of contraception in the past?

Diagnostics

Diagnostics of the breasts and internal reproductive organs aid in diagnoses of disease pathology. Some of the more commonly used diagnostics for women's health assessment are as follows: ■ Mammogram is one of the best screening tests to detect breast cancer; it is a film x-ray of the internal structures and tissues of the breasts. ■ Needle biopsy is the insertion of a needle directly into the suspicious breast tissue; the tissue sample then is assessed for cytological pathology. ■ Sonogram is a breast ultrasound that uses sound waves to take pictures of breast tissue; used to differentiate between solid and cystic masses and guides location for needle biopsy. ■ Papanicolaou test also known as Pap smear, is a screening test to detect abnormal cervical cells including cervical cancer; the cervical smear captures cell changes on the cervix that might become cervical cancer. ■ Human papillomavirus (HPV) test is recommended to be used along with the Pap test for screening women aged 30 years and older for the HPV infection which can put a woman at higher risk for cervical cancer (CDC, 2015b). ■ Vaginal specimens are obtained in women with vaginal discharge; the specimen identifies the organisms causing the symptoms; commonly collected for sexually transmitted infections (STIs) or vaginal drainage of unknown etiology.

patient education: testicular cancer

Do not press hard during the examination; if you feel pain or pressure, you are pressing too hard. Testicular assessment is easier to perform while in the shower or taking a warm bath, because the warmth will relax the scrotal area and the water will make it easier to smoothly move over the skin surface. The examination may also be performed after a shower or bath. 1. Feel each testicle with both hands by placing the index and middle fingers under the testicle with the thumbs placed on top. 2. Roll the testicle gently between the thumbs and fingers. 3. Feel for the epididymis, the soft, rope-like structure behind the testicle collects and carries sperm; palpate gently for any bumps. 4. If you find a lump on your testicle or any of the other signs of testicular cancer, see your healthcare provider as soon as possible for further evaluation.

Risks of vaginal douching

Douching is not recommended because this washing depletes the vagina of normal healthy bacteria and mucus, increasing the risk of vaginal, uterine, ovarian, and fallopian tube infections has been a common practice for various cultural backgrounds. African-American women douche more often than women of other races. In some parts of the world, douching is a routine cleansing method, while other women douche after menstruation, sexual relations, or to prevent infection

Patient Education: Testicular cancer

For men over the age of 14, a monthly self-examination of the testicles is an effective way of becoming familiar with this area of the body and thus enabling the detection of testicular cancer at an early and very curable stage Males should be taught how to check their testicles for lumps; if one is found, it should be assessed by their healthcare provider. The best time to check the testicles is after a warm shower or bath

Patient education: Hepatitis

Hepatitis viruses are the most common cause of hepatitis in the world, but other infections and autoimmune diseases, toxic substances (e.g., alcohol, certain drugs), contaminated food and water, infected blood, semen, and other body fluids can also cause hepatitis (WHO, 2015). There are five hepatitis viruses, A, B, C, D, and E. Patients should be educated about the causes and availability and benefits of vaccinations.

Scrotum

Located at the base of the penis; covered with loose and wrinkled skin called rugae. ■ The scrotum contains the following: a testicle on each side, epididymis, and parts of the spermatic cord. ■ Cutaneous, fibromuscular sac containing the testes and lower parts of the spermatic cord has sebaceous glands, sweat glands, and nerve endings ■ The scrotum acts as a climate control system, allowing the testicles to be slightly away from the rest of the body and keeping them slightly cooler than normal body temperature for optimal sperm development

Patient education: Menopause

Menopause is a normal part of life, and women need to have accurate information about what to expect. Women who have the knowledge about this period of their life will know what to expect and understand related menopausal symptoms. Encourage women to: ■ stay healthy and maintain a healthy weight ■ exercise at least 150 minutes per week; weight-bearing exercises such as running and using weights are highly recommended ■ eat a diet rich in calcium and vitamin D ■ limit alcohol intake ■ stop smoking ■ discuss with the nurse or healthcare provider symptoms of concern. ■ Women who smoke seem to go through menopause 1½ to 2 years earlier than women who do not smoke.

Palpating axillary lymph nodes normal findings

NORMAL FINDINGS ■ No swelling, tenderness, or lumps

normal vs abnormal findings occult blood test

NORMAL FINDINGS ■ Window remains brown in color ■ Negative for occult blood ABNORMAL FINDINGS ■ Window turns a bluish hue ■ Positive for occult blood

premenstural Symptoms

Nausea Vomiting Tender breasts Fatigue Bloating Gastrointestinal symptoms (e.g., constipation, heartburn, or diarrhea) Insomnia Irritability Mood swings

Patient Education: male breast cancer

No screening guidelines exist for men in the general population (Block & Muradali, 2013). Male breast cancer is usually found in men 60 to 70 years of age (NIH, 2017). Screening is only recommended for men with a strong family history, genetic predisposition for, or strong family history of breast cancer or the history and physical assessment results suggest breast cancer (ACS, 2014). Recommendations include: ■ Semiannual clinical breast examination (starting at age 35) ■ Baseline mammography (at age 40) with further annual mammography if increased breast density is seen on a baseline mammogram ■ Men should be taught about breast self-awareness and how to do breast self-examination

Skin changes ROS women's reproductive health

Note the specific location, type (i.e. rash, redness, dimpling), texture, and any discomfort.

Patient education: mammograms

Nurses need to educate women about the importance of having screening mammograms. The American Cancer Society (ACS, 2016) recommends the current guidelines for women at average risk for breast cancer to have a mammogram: ■ Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so. ■ Women age 45 to 54 should get mammograms every year. ■ Women 55 and older should switch to mammograms every 2 years, or can continue yearly screening. ■ Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer. ■ All women should be familiar with the known benefits, limitations, and potential harms linked to breast cancer screening. The U.S. Preventive Services Task Force (2016) recommends: ■ Biennial screening mammography for women aged 50 to 74 years. ■ Women 40 to 49 years: The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years.

inspecting the anus

Purpose: To assess for abnormalities of the anus 1. Explain the technique to the patient. 2. Put on gloves. 3. Have the patient lie on his or her left side with the right knee slightly bent. 4. Gently spread the buttocks to expose the anus and perianal area (Fig. 20-3). 5. Assess the anus and the perianal area for: □ redness □ inflammation □ lesions or lumps □ wounds or excoriation □ hemorrhoids, fissures. 6. Remove and discard gloves. 7. Assist patient to sitting position. 8. Document your findings.

Performing a Digital Rectal Examination

Purpose: To assess for abnormalities of the rectum and prostate (in males) steps 1. Explain the technique to the patient. 2. Assist your patient to the preferred position. 3. Put on gloves. 4. Apply a moderate to large amount of the water-soluble lubricant to your index finger of your dominant hand. 5. Gently touch the anus with your index finger and ask the patient to bear down on your finger as you gently insert your index finger into the lower rectum; assess the rectal sphincter muscle tone (Fig. 20-5). 6. Male patient only: Move your index finger so that it is positioned anteriorly pointing toward the umbilicus, and palpate the posterior surface of the prostate gland; assess the prostate gland for: □ size □ shape □ smoothness □ lumps □ tenderness. 7. Using the pad of your index finger, gently palpate the inside of entire rectum assessing for tenderness, lumps, or masses. 8. If needed, a stool smear for occult blood may be taken to assess for hidden blood in the stool (see Technique 20-3). 9. After assessing the rectum and prostate (in the male), gently remove your index finger. 10. Remove and discard your glove. 11. Assist the patient to a comfortable position. 12. Document your findings.

Palpating axillary lymph nodes

Purpose: To assess for enlarged lymph nodes ASSESSMENT STEPS 1. Explain the technique to the patient. 2. Position the patient in a sitting position with her arms down by her sides. 3. Using the three finger pads of your dominant hand, gently palpate the cervical nodes (on the neck), supraclavicular nodes (above the collarbone), and infraclavicular nodes (behind the collarbone) bilaterally using firm circular motions. (See Chapter 15.) 4. Put on gloves. 5. Ask the patient to slightly hold up her right arm. Using the three finger pads of your dominant hand, palpate deeply the following right axillary lymphatic regions using firm circular motions on the skin (Fig. 18-21A). Palpate the four axillary areas and assess for (Fig. 18-21B): □ texture of breast tissue (soft or hard) □ enlarged lymph nodes • singularity or multiple node • size of node(s) • mobility of nodes (fixed or matted) • tenderness or nontender ■ Lymph nodes are better felt with gentle palpation; it is normal to feel soft and nontender nodes. 7. Repeat step 5 on the left side. 8. Document your findings. ■ If the patient is in a sitting position, support her arm while palpating the axilla nodes.

Inspecting the Female External Genitalia

Purpose: To assess for inflammation, lumps, lesions, or abnormalities. ASSESSMENT STEPS 1. Explain the technique to the patient. 2. Show and demonstrate the instruments that will be used for the procedure and offer the use of a mirror to explain findings. 3. Prepare all slides and specimen container for use with patient's name and date. 4. Fully drape the patient and assist the patient to be in the lithotomy position; assist the patient to place her feet in the stirrups; ask the patient if she is comfortable. 5. Offer the patient a mirror to also observe the examination. 6. Position stool and light source so that good visualization can occur. 7. Make sure the patient is able to voice any concerns or discomfort; let the patient be able to see you during the examination so that you can make eye contact with the patient; this helps to alleviate fear and anxiety. 8. Perform hand hygiene and put on gloves. 9. Talk to the patient as you are performing the steps of the assessment. 10. Inspect the skin color of the labia majora and minora. 11. Inspect the following external genitalia for redness, swelling, or lesions: □ Mons pubis □ Labia majora □ Labia minora □ Perineum for hair distribution 12. Using your dominant gloved hand, gently separate the labia majora to inspect the urethral meatus for developmental abnormalities, discharge, lesions, warts, and abscess (Fig. 18-24). 13. Inspect the clitoris and vestibule for size, color, presence of lesions, and discoloration or masses. 14. Inspect the perineum of swelling, ulcers, condylomata (warts), or changes in colors. 15. Inspect urethral meatus for position. 16. Inspect the vaginal orifice for discharge, protrusion of the walls, and condition of the hymen. 17. Inspect the perineum and anus for color and shape. 18. Remove and discard gloves. 19. Document your findings.

Palpating female breasts

Purpose: To assess for lumps, density of breast tissue, or breast masses Nurses need to be aware that breast tissue is not evenly distributed. There are several different techniques to assess for lumps. It is important that the nurse has a systematic search pattern to thoroughly assess each breast, the tail of Spence, and axillary lymph nodes. ■ Circular pattern for palpation starts by palpating the areola first and moving in a circular motion from the areola to the outer perimeter of the breast (Fig. 18-16A). ■ Radial spoke pattern for palpation, also known as the wedge pattern, divides the breast into wedges; starts at the periphery of the breast and palpates toward the nipple (Fig. 18-16B). ■ Vertical strip pattern for palpation starts at the sternum palpating up and down in straight lines toward the outer perimeter of the breast, ending up in the axillary area (Fig. 18-16C). **If there are any signs of drainage or ulceration, gloves should be worn during palpation.** **Several methods have been utilized for clinical breast examination. There is a need to develop a standardized method to improve clinician performance. The vertical strip is the recommended method. The vertical strip method is superior for ensuring that all breast tissue is examined, because it is better for the examiner to track which areas have been examined, and the entire nipple-areolar complex is included** 1. Explain the technique to the patient. 2. Assist or ask the patient to assume the supine position on the examination table. 3. Ask the patient to take her right arm out of the gown sleeve and raise it above her head, keeping the left breast covered **You can place a pillow under the side being assessed to help spread breast tissue.** **The bimanual technique for breast palpation is better to use for a woman with large pendulous breasts ** 4. Standing on the patient's right side, using the three finger pads of your dominant hand (Fig. 18-19), palpate the right breast and corresponding axillary area using both light and deep firm circular motions following one of the three methods assessing for: □ Tissue density □ Lumps: If a lump, mass, or increased tissue density is palpated, note: • shape (round, oval, irregular) • consistency (hard, soft, gel-like) • location (use a clock face to identify location, i.e., 1 o'clock) • size (measured in centimeters) • moveable or fixed • tenderness. □ Tenderness or nontender **Raising the arm permits greater distribution of the breast tissue, allowing for you to examine the breast more evenly.** **It is critical to assess all the tissue areas, nipple, and areola so that you do not miss any abnormalities.** 5. Assist the patient to put her right hand back in the gown sleeve. 6. Repeat steps 3 through 5 on the left side. **Wear gloves if any past medical history of nipple drainage or reports of nipple drainage** 7. Gently palpate the nipple and compress the nipple and areola between your thumb and index finger to assess for any discharge (Fig. 18-20). If discharge is present, assess the: □ amount □ color □ odor □ consistency. 8. Document your findings.

Inspecting and Palpating the Male Breasts

Purpose: To assess for lumps, nipple discharge or abnormalities 1. Explain the technique to the patient. 2. With the patient lying in the supine position, inspect the male breasts for (Fig. 19-5A): □ symmetry □ color □ contour (dimpling or retraction) □ edema □ lesions □ ulcerations □ texture of skin. 3. Inspect the areola for: □ shape □ color. 4. Inspect the nipples for: □ size □ position □ shape □ discharge □ scaling or crusting. 5. Ask the patient to raise his arms over his head and inspect the lateral aspect of the breasts toward the mid-axillary line for skin changes **The most common presentation of male breast cancer is a painless, palpable, subareolar lump or mass** □ Palpate any lump or mass and note: • Shape • Size • Consistency (hard, soft, or rubbery) • Mobility (mobile or immobile) • Location (document by using clock method) 7. Put on gloves and palpate each areola area. 8. Gently palpate and press each side of the nipple at the base noting any discharge; if discharge is present, assess (Fig. 19-7): □ color □ consistency □ odor. 9. Remove and discard gloves. 10. Document your findings.

Inspecting the External Genitalia

Purpose: To assess the external male genitalia for lesions, edema, and masses 1. Explain to the patient that this technique requires two positions: lying supine and standing up. 2. Ask the patient to lie on the examination table in the supine position. 3. Put on gloves. 4. Drape the patient so that only the genital area being examined is exposed. 5. Inspect the skin of the male genitalia assessing for (Fig. 19-9): □ color □ lesions □ drainage □ edema □ hair distribution. 6. Assess the following structures: □ Penis: assess the ventral, lateral, and dorsal sides. □ Prepuce: note whether the patient is circumcised or not; if uncircumcised ask the patient to retract the foreskin. □ Urethral meatus: note the location of the urethral opening (Fig. 19-11). □ Pubic hair: assess pattern of hair distribution. □ Skin: assess for irritation, erythema, or pubic lice (also known as Phthirus pubis), more commonly known as crabs, derive their name from the crab-shaped insects that sometimes take up residence in the pubic hair; itching is the most common symptom reported 8. Ask the patient to turn on his side with his upper leg slightly bent, and gently spread the buttocks apart to inspect the anus. 9. Maintaining the patient's dignity, ask the patient to stand. Ask the patient to hold his penis up for this next part of the assessment 10. Assess the groin area for inguinal bulging; if suspected, ask the patient to cough for better visualization of any suspected bulging. 11. Remove and discard gloves. 12. Document your findings.

Obtaining a Urethral Culture

Purpose: To identify the organism causing the infection For accurate results, the patient should not have urinated for at least 1 hour prior to obtaining the culture. Read the institutional procedure prior to obtaining the culture. 1. Gather your supplies. 2. Explain the technique to the patient. 3. Put on gloves. 4. Open up the culturette tube and remove the swab (Fig. 19-16). 5. Maintaining sterility of the swab tip, hold the shaft of the penis and gently insert the tip of the swab about 2 to 4 cm into the urethra. 6. Gently turn the swab clockwise for 2 to 3 seconds, maintaining contact with the mucosal surfaces. 7. Slowly withdraw the swab and insert into culturette tube and medium. 8. Break off the end of the swab at the score line. 9. Turn and recap tightly; document or attach preprinted label with the patient's name, date, and source of culture. 10. Remove and discard gloves. 11. Send specimen to the laboratory.

Patient education: Human Papillomavirus

The HPV is a group of more than 150 related viruses that can cause infection and genital warts and lead to cancer, especially cervical cancer. There are some HPV strains that do not cause symptoms. HPV is the most common sexually transmitted virus in the United States. Vaccination against HPV is the best method for preventing HPV-related diseases, including cervical cancers and genital warts. The current recommendation is for all females (and males) ages 9 to 26 to receive the HPV vaccine. Vaccination over the age of 26 is less effective in reducing HPV-related diseases and therefore not recommended.

Gynecological history ROS

The five main types of cancer affecting a woman's reproductive organs are: cervical, ovarian, uterine, vaginal, and vulvar. As a group, they are referred to as gynecologic cancers Ask the patient: ■ Did you ever have gynecological symptoms (past and present)? □ Vaginal bleeding or itching □ Genital sores □ Abdominal or pelvic pain □ Bloating □ Painful urination □ Pain or bleeding with intercourse ■ Have you had gynecological surgeries or procedures (biopsy, laparoscopy, hysterectomy)? ■ Have you experienced problems getting pregnant? □ Infertility is a disease defined by the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination (Practice Committee of the American Society for Reproductive Medicine, 2013). ■ Do you have any vaginal discharge? If so, ask about the following: □ Onset, duration, frequency, volume, and odor of discharge. □ Characteristics (color, scant, profuse, thick, thin, frothy, malodorous) and any relation to menstrual cycle. • Normal vaginal discharge is clear; may turn white or yellow when exposed to the air; no odor, pain, or itching, and color and amount of drainage may change during the menstrual cycle. • Abnormal vaginal discharge may be related to infections and have a distinctive color, odor, and associated symptoms. ■ Have you ever had vaginal infections or STIs? Lesions? ■ What is the date of your last pelvic examination and Pap smear? ■ Do you use external products such as douches? □ If so, frequency, method, type of solutions, reasons, and time you douched?

patient education: Cervical cancer screening

The latest recommendations from ACS (2015b) for cervical cancer screenings are as follows: ■ All women should begin cervical cancer screening at age 21. ■ Women aged 21 to 29, should have a Pap test every 3 years. HPV testing should not be used for screening in this age group. (It may be used as part of follow-up for an abnormal Pap test.) ■ Women between the ages of 30 and 65 should have both a Pap test and an HPV test every 5 years. This is the preferred approach, but it is also all right to have a Pap test alone every 3 years. ■ Women over age 65 who have had regular screenings with normal results should not be screened for cervical cancer. Women who have been diagnosed with cervical pre-cancer should continue to be screened for at least 20 years.

nipple

The nipples are protuberant and round; located at the center of the areola and breast; may be flat or inverted. They are a highly sensitive area that contains milk glands, nerve endings, and smooth muscle fibers that contract and become erect based on temperature, stimulation, or lactation.

Menopause and ROS for Menopause

The permanent cessation of menstrual activity normally occurs in women in the United States between the ages of 45 and 55, with the mean age of 51 ■ Perimenopause may occur several years prior to menopause; the hormones, estrogen and progesterone, fluctuate causing some woman to experience symptoms of menopause (Box 18-1). ■ Menopause occurs when the woman has no menstrual activity for a period of 12 months (Venes, 2013); estrogen and progesterone levels decrease contributing to menopausal symptoms. ■ Postmenopause is the period of time after menopause when menopausal symptoms start to diminish; women have a greater risk of osteoporosis, cardiovascular disease, and urinary incontinence. Symptoms: Dry skin Hair thinning/loss Hot flashes Mood changes Insomnia Irregular menstrual periods Irritability Sweating/night sweats Vaginal dryness Weight gain ROS questions ■ At what age, did you start menopause? Do you experience any menopausal symptoms (see Box 18-1)? ■ Do you take any medications or over-the-counter (OTC) medications to help relieve symptoms? □ Estrogen and progesterone hormone replacement therapy may be prescribed by the healthcare provider. □ Nonprescription remedies such as soy, black cohosh, and vitamin E are available at local pharmacies and health food stores. ■ Has menopause affected your quality of life? □ Hormonal changes at menopause as well as other physiological, psychological, sociocultural, interpersonal, and lifestyle factors contribute to midlife sexual problems (Shifren & Gass, 2014). □ Depression, anxiety, and decreased sense of well-being are common psychological symptoms that may affect daily living. ■ Do you have any spotting or bleeding? □ Bleeding during menopause could be a sign of a serious problem and needs to be reported to the healthcare provider.

Rectum

The rectum's primary function is to store processed fecal material. Fecal material accumulates in the rectum triggering the sensory nerves to tell the brain it is time to have a bowel movement Rectum is the lower part of the sigmoid colon, the large intestine; average length is approximately 12 to 14 cm in an adult (Mahadevan, 2014). The rectum is made up of transverse folds that propel waste materials into the anal canal; it contains arteries, veins, and visceral nerves; the main rectal artery is the superior rectal artery, and the main vein is the superior rectal vein Perirectal fat lines the entire length of the rectal walls; rectal lymph nodes are located in these walls

Inspection of female breasts

To assess the breasts for size, shape, color, and abnormalities A patient who has had a mastectomy or breast augmentation requires the same full assessment (Fig. 18-7). Inspect the breasts in four different positions: ■ Seated with the arms hanging by each side ■ Seated with the arms placed over the head ■ Seated with the hands on the hips ■ Standing and leaning forward Steps 1. Explain the technique to the patient and tell her to let you know if she is uncomfortable in any position during the assessment. 2. Ask the patient to sit up with both arms at her side. 3. Assist the patient to lower the gown to her waist. 4. Inspect the breasts for: □ symmetry □ size of breasts. **If you notice that one breast is larger than the other, ask the patient if this is normal for the patient; if not normal, this may be indicative of an abnormal growth.** 5. 5. Inspect the skin for: □ color □ contour (dimpling or retraction) □ edema □ lesions □ ulcerations □ texture of skin □ vascularity □ venous patterns. 6. Inspect the areola for: □ shape □ color □ hair □ visible lumps 7. Inspect the nipples for: □ size □ position □ shape □ discharge □ crusting □ presence of accessory nipples **A supernumerary nipple is an accessory or additional nipple and is a common congenital malformation; most commonly located on the embryonic milk line** □ eversion or inversion of nipples **Ask the patient if the everted or inverted nipple is normal for her or new. An inverted nipple can be manually pulled out. A retracted nipple caused by breast cancer cannot be pulled out.** 8. Inspect breast for signs of retraction, such as (Fig. 18-11): □ dimpling □ puckering □ furrows (a groove in the skin). 9. Ask the patient to raise her arms over her head and inspect the lower aspect of the breasts for (Fig. 18-12): □ symmetry □ skin changes □ nipple deviations. 10. Inspect the axilla for: □ hair distribution □ skin texture □ protrusion of lumps or masses. 11. Ask the patient to press her hands against her hips contracting the pectoral muscles and inspect again for (Fig. 18-13): □ symmetry □ skin changes □ retraction areas □ nipple deviations. 12. Ask the patient to stand and bend forward and inspect from the front (Fig. 18-14A) and laterally (Fig. 18-14B) for: □ symmetry □ skin changes □ nipple deviations. 13. Document your findings.

ROS Menstrual History

What age did you start to menstruate? □ Menstruation can begin as early as age 8 and as late as age 14. □ The first menstrual period is called menarche. ■ What date did your last menstrual period begin? Is your menstruation cycle regular or irregular? Do you miss cycles? If so, how often? Every woman of childbearing age who has a complaint of irregular or absent menstrual cycles should be tested for pregnancy. □ A regular menstrual cycle occurs about 24 to 38 days and lasts up to 7 days. The cycle is from day one of bleeding to day one of the next cycle of bleeding. □ Menstrual cycles that are longer than 38 days or shorter than 24 days are abnormal (ACOG, 2017) □ Amenorrhea • Primary amenorrhea is defined in women who are age 15 years and older and have not had a menstrual cycle. • Secondary amenorrhea is the absence of a menstrual cycle for more than three months in girls or women who previously had regular menstrual cycles or for six months in girls or women who had irregular menses (Welt & Barbieri, 2017). □ Metrorraghia ■ What is the usual number of days of bleeding? □ The average number of days of bleeding is about 3 to 7 days. ■ What absorbent products do you use? ■ How would you describe the amount of flow? Do you experience lighter or heavier vaginal bleeding during menstruation? Ask about the onset of any changes in bleeding, amount, duration, and frequency. □ The total amount of blood loss may be less than 80 mL for the whole menstrual period; this amount may vary in different women and from period to period in the same woman. □ Heavy menstrual flow is defined as blood loss greater than or equal to 80 mL per menstrual cycle (Beebeejaun & Varma, 2013); bleeding usually lasts seven or more days. □ Heavy menstrual bleeding is a subjective report; and women vary in their perceptions of what is acceptable blood loss and when they should seek help. □ Menorrhagia □ Oligomenorrhea ■ Do you have menstrual cramps? If so, how bad? What medication do you take for the cramps? □ Primary dysmenorrhea

Patient education: Clinical Breast Examinations

a clinical breast exam every year for women aged 19 or older. Expert opinion suggests that the value of clinical breast examination and the ideal time to start such examinations is influenced by the patient's age and known risk factors for breast cancer.

Urethral specimens

are obtained in men with penile discharge; the specimen identifies the organisms causing the symptoms; commonly collected for sexually transmitted diseases such as gonorrhea or chlamydia.

Oligomenorrhea

decreased or light menses

ROME III

diagnostic criteria for functional constipation 1. Must include two or more of the following: -Straining during at least 25 percent of defecations -Lumpy or hard stools in at least 25 percent of defecations -Sensation of incomplete evacuation for at least 25 percent of defecations -Sensation of anorectal obstruction/blockage for at least 25 percent of defecations -Manual maneuvers to facilitate at least 25 percent of defecations (e.g., digital evacuation, support of the pelvic floor) -Fewer than three defecations per week 2. Loose stools are rarely present without the use of laxatives 3. Insufficient criteria for irritable bowel syndrome

Menorrhagia

excessive or prolonged duration of menses; may pass many clots with menstrual flow

Primary dysmenorrhea

is defined as menstrual pain occurring with ovulatory menstrual cycles; it is accompanied by a range of systemic symptoms such as lower abdominal pain that may radiate to the lower back or legs, headache, nausea, vomiting, diarrhea, irritability, fatigue, and depression **Dysmenorrhea is diagnosed when the pain is so severe as to limit normal activities, or require medical attention.**

Amenorrhea

is the absence of menses.

patient education: Prostate cancer

men should make an informed decision after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. ■ A yearly screening be offered to all men over 50 who have a life expectancy of at least 10 years. ■ For African-American men, or men with an affected first-degree family member, yearly screening is recommended beginning at age 45. ■ For men who have multiple first-degree relatives affected with prostate cancer at an early age, a baseline screen is advocated at age 40. There are many experts who believe all men should initiate screening at age 40.

Prostate biopsy

procedure removes a sample of body tissue for examination under a microscope; a core needle biopsy is the main method used to diagnose prostate cancer; it is usually done by an urologist, a surgeon who treats cancers of the genital and urinary tract, which includes the prostate gland

menstral cycle

reproductive years begin at puberty or menarche (usually occurs around age 12) and ends with menopause (around age 50). period of puberty lasts 3-5 years and is influenced by a variety of factors, including heredity, ethnicity, health, nutritional status, childhood infections, and environmental exposures During the reproductive years the body undergoes complex hormonal and physiological changes in preparation for conception. The four hormones involved in the menstrual cycles include follicle-stimulating hormone (FSH), estrogen, luteinizing hormone (LH), and progesterone. The menstrual cycle is comprised of two major phases: the follicular phase and the luteal phase. The follicular phase begins on the first day of menses and ends on the day before the luteinizing hormone surges and can last between 14-21 days. During this phase an egg in the ovary is getting mature to be released from the ovary and the lining of the uterus thickens and becomes ready for a fertilized egg (conception). The luteal phase begins with ovulation, an egg is released from the ovary and ends at the onset of the next menses and lasts 13 to 15 days. Ovulation occurs in the middle of the menstrual cycle and occurs when an ovary releases a matured egg. The egg will travel down the fallopian tube and if semen is present then fertilization occurs. If fertilization does not occur, the body undergoes cyclic hormonal changes known as the menstrual cycle whereby the thickened part of the endometrium lining that was preparing for the implantation of the fertilized egg of the uterus is shed. Cervical mucus changes during the menstrual cycle; most often the cervix produces a whitish discharge that maintains the flora and pH of the vagina and closer to ovulation the cervix produces clear sticky mucous that facilitates semen to navigate through the cervix and towards the released egg. The changes in the hormones throughout the menstrual cycle can also bring about changes in mood, breast tenderness, fluid retention, cramping, weight gain, diarrhea, and constipation.

Prostate-specific antigen (PSA)

test is a blood test that measures the amount of PSA, a protein secreted by prostate epithelial cells; used as a biological marker for prostate cancer

Metrorraghia

uterine bleeding at irregular intervals most often associated with dysfunctional ovaries

cultural awareness and Female reproductive health

• Certain cultures only allow same-sex healthcare providers, and women may ask for their husbands or significant others to be present during the assessment. It is essential to respect all cultural considerations. • There are some cultures, such as the Hispanic culture, in which it is believed to be inappropriate to touch the breasts. Please take a patient's culture into consideration and ask permission to examine or expose the breasts. • Breast cancer in African-American women and in women of ethnic groups living in countries of low socioeconomic status, is virtually unknown; breast cancer incidence is rapidly increasing in underdeveloped countries. • The human papillomavirus (HPV) is the most common cause of cervical cancer. The number of new cervical cancer cases has been declining steadily over the past decades. Incidence rates have declined over most of the past several decades in both Caucasian and African-American women. • In 2013, Hispanic women had the highest rate of getting cervical cancer, followed by black, white, American Indian/Alaska Native, and Asian/Pacific Islander women. Black women were more likely to die of cervical cancer than any other group. For women in many countries in Africa, Asia, and Latin America, cervical cancer is often detected late, when there is little hope for successful treatment

Risk factors for breast cancer

• Family history of one or more first-degree relatives • Inherited mutations in the BRCA1 and BRCA2 genes • Advancing age • Obesity in advancing age • Moderate levels of alcohol • Combined hormonal therapy of estrogen and progesterone • Physical inactivity • Increased breast tissue density • Long menstrual period (periods that start early and/or end later in life) • Oral contraceptives • Never having children • Having a child after age 30

Warning signs of breast cancer

• Lump • Thickening or dense tissue felt inside the breast or underarm area • Swelling, warmth, inflammation, or color changes • Change in the size or shape of the breast • Dimpling or puckering of the skin • Itchy, scaly sore or rash on or around the nipple • Retraction of the nipple or other parts of the breast • Nipple discharge • Pain in an area of the breast

Risk factors for ovarian cancer

• Personal or family history of breast, ovarian, or colon cancer • BRCA1 and BRCA2 gene mutation • Increasing age • Obesity • Nulliparity • Undesired infertility • Start of menstruating before age 12 • Menopause after age 50 • Menopausal hormone replacement therapy

normal findings for inspecting the anus

■ Anus is tightly closed. ■ Skin is moist and darkly pigmented; hair may be present. ■ No redness, inflammation, lesions, lumps, wounds, hemorrhoids, or fissures.

abnormal findings for female breast inspection

■ Asymmetrical breast or one abnormally large breast may indicate an abnormal growth. ■ Erythema and signs of inflammation may indicate an infection. ■ Mastitis is redness and inflammation of the breast tissue often occurring in the postpartum period when breastfeeding. ■ Signs of breast tissue retraction, lumps, or dimpling may indicate an abnormal growth or be a sign of breast cancer. ■ Unilateral venous pattern may indicate increased blood flow related to a malignancy. ■ Peau d 'orange is pitting, dimpling, or swelling seen in inflamed skin that overlies inflammatory carcinoma of the breast

normal findings Inspecting and Palpating the Male Breasts

■ Breasts are symmetric. ■ Skin has even color. ■ There are no lesions, dimpling, or puckering. ■ There are no lumps or masses. ■ Axillary area has no lumps or masses. ■ Areola is smooth, has uniform color, and is without skin changes. ■ Nipple is everted, skin intact, and without drainage.

Normal findings for female breast inspection

■ Breasts are symmetrical; size varies per individual. ■ Color of skin is uniform; no dimpling, retractions, edema, or lesions; texture smooth. ■ Areola is round or oval, uniform color, Montgomery tubercles present. ■ Nipples are centered, round, without discharge or crusting; color varies from pink to dark brown; everted or it may be normal for one or both nipples to be inverted. ■ Venous patterns are the same in both breasts. ■ Striae are stretch marks related to aging or pregnancy. ■ Supernumerary nipple is an additional nipple somewhere along the mammary line, which runs from underneath the axilla down toward the groin. The extra nipple can be small, having the appearance of a mole, and can also have mammary glands and produce milk during the lactation period. They are considered normal.

penis

■ Composed of three parts (Fig. 19-2): □ The root (radix) is attached to the abdominal wall and to the perineum. □ The body, or shaft, is the middle portion; contains vascular erectile tissue; during an erection, the vascular tissue becomes engorged. □ Glans penis is the cone-shaped head of the penis; the foreskin (prepuce) is loose skin that covers the glans penis; if a patient is circumcised, the foreskin is surgically removed (Fig. 19-3); this tip of the penis has nerve endings and is very sensitive; involved in sexual arousal. ■ Urethral meatus is at the tip of the glans penis. ■ Circumcision is one of the oldest and most controversial surgical procedures. Circumcision is performed for a variety of religious and cultural reasons. Male circumcision reduces the risk that a man will acquire HIV from a HIV-positive female partner, and also lowers the risk of other sexually transmitted infections (STIs), penile cancer, and urinary tract infections

Vas Deferens

■ Connects the testes with the urethra ■ Stores and transports sperm through the epididymis ■ Muscle contractions propel sperm into the ejaculatory duct and out through the urethra.

Pelvic Pain ROS

■ Do you experience any lower abdominal or pelvic pain? □ Use the OPQRST or OLDCARTS mnemonic. □ Ask about the patterns of pain in relation to menstruation and physical or sexual activity, associating factors (nausea and vomiting), and alleviating factors.

Abnormal Vaginal bleeding

■ Do you experience spotting or bleeding in between your menstrual cycle? □ Midcycle spotting or bleeding can occur during ovulation. □ Pelvic inflammatory disease and infection of the uterus, fallopian tubes, or ovaries may cause bleeding. □ Polycystic ovarian syndrome (PCOS) is an endocrine disorder in women of reproductive age that can cause irregular menstrual cycles; other PCOS symptoms may include unwanted hair growth on the face, chest, and back (hirsutism), weight gain, oily skin, and infertility. □ Bleeding after sexual intercourse may be related to friction of the cervical mucosa.

family and medical history with women's reproductive history

■ Do you have a family history of breast disease? □ Roughly 5 percent of breast cancers are due to an inherited mutation in BRCA1 or BRCA2; women with such mutations have a significantly increased risk of breast or ovarian cancer, often at an early age ■ Have you had any previous breast disease? □ Fibrocystic breast disease is benign painless lumps or thickening of tissue that are felt in a woman's breast; often associated with hormonal changes during a woman's menstrual cycle. □ Breast cysts are fluid-filled lumps in the breast; may or may not be painful. □ Fibroadenomas are solid, round, rubbery lumps filled with fibrous and glandular tissues; these lumps move easily when pushed; more common in younger women. ■ Have you had any type of breast surgeries? □ Mastectomy is the surgical removal of one or both breasts. □ Breast reduction surgery removes breast tissue and skin to reduce the size of the breasts. □ Breast augmentation is a surgical procedure to increase the size of one or both breasts

ROS for male health:Past medical and/or surgical history

■ Do you have a past medical or surgical history of conditions related to the kidneys, bladder, rectum, or the genital area? □ STIs are caused by bacteria and viruses; the six most common in men are: 1. Gonorrhea is caused by gram-negative diplococcus Neisseria gonorrhoeae causing inflammation of the urethra, prostate, rectum, and/or pharynx in men; most common symptom in men is a yellow mucopurulent penile discharge. 2. Chlamydia is an STI caused by a bacterium Chlamydia trachomatis; most common symptom in men is penile discharge and dysuria, pain with urination. ■ One in four men with chlamydia has no symptoms; chlamydia is the most common STI. 3. Genital herpes is an STI caused by herpes simplex viruses type 1 (HSV-1) or type 2 (HSV-2); painful fluid-filled blisters or vesicles form anywhere on the male genitalia or rectum. 4. Human papillomavirus (HPV) is an STI caused by the human papillomavirus; there are over 40 different types of HPV that are sexually transmitted (CDC, 2014); men may not have symptoms; some may cause genital warts. 5. Human immunodeficiency virus (HIV) is an STI viral infection caused by a retrovirus causing general flu-like symptoms in the early stages; the virus destroys the cells of the immune system and progresses and causes the acquired immunodeficiency syndrome (AIDS). 6. Syphilis is an STI caused by the spirochete Treponema pallidum; syphilis progresses through four different stages; the initial symptom is a sore called a "chancre"

ROS for male health: Family history

■ Do you have any family history of the following cancers? □ Bladder: bladder cancer is the fourth most common cancer in men; the most common signs or symptoms include blood in the urine (hematuria), dysuria, and frequency of urination. □ Breast: male breast cancer is uncommon in men under the age of 35, but men do get breast cancer; men have breast tissue and low levels of the estrogen hormone: breast cancer is about 100 times less common among men than among women (ACS, 2016a). □ Kidney: kidney cancer is found about twice as often in men as in women; Caucasian men have double the risk of African-American men (Simon, 2011). Men are more likely to be smokers and are more likely to be exposed to cancer-causing chemicals at work, which may account for some of the difference (ACS, 2016b). The most common symptom is painless hematuria (blood in the urine). □ Penis: penile cancer is rare in North America and Europe; accounts for less than 1% percent of cancers in men living in the United States; more common in men living in parts of Asia, Africa, and South America (ACA, 2016c). The most common symptom is a change in the color or texture of the skin on the penis. □ Prostate: prostate cancer is one of the most common cancers among men (after skin cancer). Signs and symptoms include: • difficulty or frequency urinating • hematuria • impotence (inability to have an erection) • early prostate cancer may have no symptoms. □ Testicular: testicular cancer can develop in one or both testicles or scrotum. This cancer is more common in young and middle aged men; the average age at time of diagnosis is 33; Caucasian men have the highest risk. Worldwide, the risk of developing this disease is highest among men living in the United States and Europe and lowest among men living in Africa or Asia (ACS, 2016d). Signs and symptoms include: • painless lump • swelling • pain.

ROS for male health: urinary symptoms

■ Do you have difficulty starting the stream of urination? ■ Do you experience hesitancy of urination? ■ Do you feel that you do not completely empty your bladder (urinary retention)? ■ Do you experience frequency of urination? □ Benign prostatic hypertrophy (BPH) is a nonmalignant enlargement of the prostate gland as part of the aging process; BPH occurs only in men; approximately 8 percent of men aged 31 to 40 have BPH. In men over age 80, more than 80 percent have BPH

ROS for male health: health promotion

■ Do you perform testicular self-examinations? If so, how often? □ Most testicular cancers are found by the patient either unintentionally, through self-examination, or routine physical examination. □ The ACS recommends a testicular examination by a doctor as part of a routine cancer-related checkup; ACS does not have a recommendation about regular testicular self-examinations for all men (ACS, 2015a). □ The most common symptom of testicular cancer is a painless testicular mass. □ Young men may have the "Superman complex" where they feel nothing can hurt them and they do not need to go see a doctor (Cancer Survivor, Carl Olsen, 2012); men may also take the "it'll never happen to me" approach (Martinez, 2014). ■ TIP Testicular cancer is rare but the most common cancer in men younger than age 35. ■ Have you had prostate cancer screening? □ Many states have laws assuring that private health insurers cover procedures to detect prostate cancer, including the prostate-specific antigen (PSA) test and the digital rectal examination (DRE). Some of these states also assure that public employee benefit health plans provide coverage for prostate cancer screening procedures. Most state laws assure annual coverage for men ages 50 and over and for high-risk men, ages 40 and over

ROS for male health: pain

■ Do you wear protective equipment when playing sports? □ Protection of the male genitalia during sports is important to prevent permanent damage or impotence.

ROS for male health: safety

■ Do you wear protective equipment when playing sports? □ Protection of the male genitalia during sports is important to prevent permanent damage or impotence.

Prostate Gland

■ Doughnut-shaped gland about the size of a walnut located between the bladder and the rectum ■ Contains 15 to 20 branched, tubular glands which form lobules ■ Secretes a viscid, alkaline fluid, which aids in sperm motility and in neutralizing the acidity of the vagina, thus enhancing fertilization

lympahtic system

■ Each breast has lymphatic vessels and nodes that lie directly below the surface of the skin. ■ The lymphatic circulation moves toward the upper outer quadrant of each breast and toward the axillary nodes. ■ Breast infection or disease may cause enlargement of the lymph node(s). **if a woman has breast cancer, the axillary lymph nodes are one of the first places the cancer may spread (metastasize)**

Male breast

■ Extend from the second through sixth anterior ribs with the sternum as the medial border and the mid-axillary line being the endpoint laterally (Fig. 19-1) ■ Consist of fibrous, glandular, and fatty tissue ■ The male hormone, testosterone, inhibits the development and growth of breast tissue in males. ■ Average diameter of a male areola is 1 inch.

ROS for male health: penile lesions or discharge

■ Have you developed any sores or lesions on your penis? □ Lesions or sores may be indicative of a bacterial or viral infection. □ Have you had any discharge from your penis? When did it start? Ask about the: • color of discharge • amount of discharge • consistency of discharge • odor of discharge □ A symptom of some STIs is penile discharge: • Gonorrhea: yellow, white, green • Chlamydia: a white or cloudy discharge from penis and rectum • Urethritis: clear and white

Breast Examinations ROS

■ Have you had a clinical breast examination (CBE)? If so, when? □ The CBE is an examination of your breasts by a health professional such as a doctor, nurse practitioner, nurse, or physician assistant. The healthcare provider carefully palpates your breasts and underarms for any changes or abnormalities (such as a lump). This examination is performed in the supine position and sitting up. **recommended that healthcare providers have special training in CBE to identify abnormal from normal findings. Trained and experienced healthcare providers can find breast abnormalities that a woman might not have felt herself and can detect lumps as small as a pea ** ■ Do you perform breast self-examination (BSE)? □ BSE is palpating your own breasts for lumps or changes in the shape and size of the breasts (Box 18-3). □ Risk factors for breast cancer are related to lifestyle, environment, and genetic factors (Box 18-4). ■ Have you had a mammogram? If so, when? ■ Do you have any breast concerns, such as: □ Lumps □ Pain in one or both breasts • Mastalgia is breast pain that usually is correlated to a woman's menstrual cycle. □ Tenderness; if so, is it during a specific time of the month? • Hormonal changes can cause breast tenderness. □ Nipple discharge: both abnormal and normal nipple discharge can be clear, yellow, white, or green in color; blood nipple discharge is never normal. □ Physiologic nipple discharge is usually bilateral; mainly caused by repeated manipulation, pregnancy, or medications. □ Pathologic nipple discharge is usually unilateral, spontaneous, and persistent Always have the patient identify the timing and location of the breast concern. Assess whether there is a pattern that correlates with her menstrual cycle and if the discharge is: ■ unilateral or bilateral ■ color ■ amount ■ frequency ■ consistency ■ relationship to menstruation ■ associated factors and symptoms. **Ask the healthcare provider if a sample of the nipple discharge should be sent out for analysis.**

ROS for male health: scrotum

■ Have you had any swelling or enlargement of the scrotum? □ The scrotum may become swollen, filled with fluid, or enlarged; this may be caused by inflammation of internal structures, masses, and medical conditions such as congestive heart failure. □ Hydrocele is an accumulation of fluid around the testes (Fig. 19-4). □ Epididymitis is swelling and inflammation of the epididymis (Fig. 19-4); may be related to a STI.

abnormal findings findings for Inspecting the Female External Genitalia

■ Labia majora and labia minora are bruised, swollen, inflamed, have lesions or lumps, a rash, or warts. ■ No pubic hair or sparse pubic hair may be related to aging, endocrine disease, nutritional deficiencies, or genetic factors. ■ Pediculosis pubis is the presence of lice or nits. ■ Urethra is swollen, red, or inflamed; discharge is present. ■ Urethra caruncle is benign fleshy outgrowths at the urethral meatus; most common lesion of the female urethra, occurring primarily in postmenopausal women (Rickley, 2012). ■ Fungal infections, candidiasis, or yeast infections commonly occur in the groin areas and external genitalia. ■ Perineum is with a tear, redness, or fissure; if present, episiotomy is red and inflamed. ■ Hemorrhoids are venous protrusions of dilated veins; may be inflamed, red, and swollen.

Normal findings for Inspecting the Female External Genitalia

■ Labia majora and labia minora are uniform color, symmetrical, wrinkled skin; may have nontender, yellow, sebaceous cysts that are less than 1cm in diameter. ■ Skin over mons pubis is smooth with even hair distribution. ■ Pubic hair is evenly distributed and shaped like an inverse triangle; no lice or nits. ■ Clitoris is approximately 1.5 to 2.0 cm long. ■ Urethra is a slit-like opening; midline; no swelling, redness, or discharge. ■ Bartholin's glands are at 4 and 8 o'clock; no redness or inflammation. ■ Skene's glands are at 1 and 11 o'clock; no redness or inflammation. ■ Perineum is smooth and skin color is uniform; if present, episiotomy scar is healed without inflammation. ■ Anus is dark brown; puckering of skin; no swelling, inflammation, or protrusions.

Seminal Vesicles

■ Located behind the bladder and prostrate; approximately 5 cm long ■ Transport sperm from the testes to the seminal vesicles ■ Add fluid to semen during ejaculation

Epididymis

■ Located on top and behind each testis ■ Collection area for mature sperm

Axillary changes ROS

■ Location ■ Note any lumps or tenderness ■ Date discovered ■ Changes in size or tenderness ■ Relationship to menstruation ■ Associated factors and symptoms

abnormal findings Inspecting and Palpating the Male Breasts

■ Lump or mass is palpated. ■ Gynecomastia is enlarged or overdeveloped fibroglandular breast tissue; term comes from the Greek words gyne meaning "woman" and mastos meaning "breast"; may be related to decreased testosterone levels in the aging male or a medication side effect; frequently associated with devastating social and emotional trauma ■ Breast cancer may present as a hard painless lump, erythema of the skin, scaling of the nipple, or nipple discharge

normal findings palpating female breasts

■ No tenderness, lumps, or increased tissue density ■ No nipple discharge ■ Firmness in the lower curve of each breast is normal. ■ Nipple discharge is normally seen in a pregnant woman and one who is breastfeeding an infant.

ROS for male health: Sexual health, partners

■ Partners □ Are you in a relationship? □ Are you satisfied with your sex life? □ Do you have sexual relationships with women, men, or both? • Heterosexual is a person who has sexual orientation to a person of the opposite sex. • Homosexual is a person who has sexual orientation to a person of the same sex. • Bisexual is a person who has sexual orientation both to a person of the same and also of the opposite sex. • Transgender is a gender identity disorder (GID) and is used to describe someone who was assigned female or male at birth, but later realizes that label does not accurately reflect who the person feels he or she is inside. □ Do you have several partners?

Urethra

■ Passageway for urine to flow ■ Transports semen during sexual intercourse

ROS for male health: Sexual health, past STIs

■ Past STIs □ Do you have a past history of STIs? If so, were you treated and when? □ Do you have any concerns about having HIV?

abnormal findings for inspecting the anus

■ Patulous anus: open and distended ■ Redness, inflammation, lesions, wounds, or hemorrhoids ■ Rectal prolapse: rectum partially or fully intussuscepts and comes out through anus

normal findings for Inspecting the External Genitalia

■ Penis: Caucasians: pink to light brown; African Americans: light to dark brown; smooth, no hair; dorsal vein is visible; no lesions; no discharge ■ Prepuce: circumcised foreskin is smooth and pink; uncircumcised foreskin easily retracts; smegma may or may not be present. ■ Urethra meatus: pink, smooth, located at the center of the glans ■ Pubic hair: at the base of the penis the hair distribution is in a triangular pattern consistent with age; coarse hair; no nits or lice. ■ Scrotum: skin is a darker pigmentation; wrinkled surface, thin skin; left testis may hang lower than the right testis. ■ Epidermoid cysts: sebaceous cysts that are yellow or white papules, nontender cutaneous lesions (Fig. 19-14) ■ Inguinal area: skin is smooth, free from lumps or bumps, no signs of a hernia ■ Anus: darker color skin, wrinkled around the orifice, no hemorrhoids

abnormal findings for Inspecting the External Genitalia

■ Penis: skin has lesions or sores. Lesions indicative of common STIs include □ Syphilis chancre lesion is a painless, firm, round, and open sore that forms during the primary stage of syphilis; commonly appears on the penis or anorectal area. □ Condyloma acuminatum (genital warts) are soft, small, cauliflower-shaped growths on the skin; caused by HPV. □ Herpes lesions typically develop on the penis; the painful lesions are vesicular small red bumps that change in appearance to blisters and ulcers as they progress through the four stages. □ Chancroid lesion is a bacterial STI; painful open sore covered with gray or yellow gray material; has irregular borders □ Tinea cruris, also known as "jock itch," is a fungal infection of the groin presenting as a bright red rash. □ Penile cancer appears as a lump, ulcerative lesion, or redness and irritation of the skin; may or may not have drainage. ■ Prepuce □ Phimosis is a stenosis of the preputial orifice so that the foreskin cannot be pushed back over the glans penis ; may be a complication after recurrent infections; if it obstructs urinary flow, a circumcision may be needed. □ Paraphimosis is an uncircumcised penis that may be covered with foreskin that once retracted, now cannot be returned to its original position; area becomes swollen; this requires immediate medical attention. □ Balanitis is inflammation of the skin covering the glans penis (Venes, 2013). ■ Pubic hair: hair distribution is not consistent with age. Skin and pubic hair are infested with lice; when the hair is infested, the surrounding skin is inflamed secondary to scratching. ■ Urethra: opening has discharge; the opening to the urethra is not centrally located on the tip of the glans. □ Epispadias: the urethral opening is located dorsally on the penis. □ Hypospadias: urethral opening is located ventrally on the penis. ■ Anus □ Hemorrhoids are swollen veins protruding from the anus. □ Rectal bleeding □ Protrusion of rectal mucosa related to rectal prolapse ■ Scrotum □ Skin is swollen and stretched causing a decrease in the rugae; presence of scrotal swelling can be from several causes including edema, heart failure, renal failure, local inflammatory or infectious process. □ Presence of any lesions on the scrotum is considered an abnormal finding. □ Empty scrotal sac or scrotal sac with small testes ■ Inguinal area □ Inguinal hernia is a weakening in the abdominal cavity wall with a protrusion of abdominal contents; any activity or medical problem that increases pressure on the abdominal wall tissue

ROS for male health: Sexual health, protection

■ Protection □ What types of precautions or protection do you use during sexual activity? • Latex condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of HIV and reduce the risk of other sexually transmitted diseases (STDs). Condom use may reduce the risk for genital HPV infection and HPV-associated diseases such as genital warts and cervical cancer in women (CDC, 2015a). □ Have you had the hepatitis A or B immunizations? • Men who have sex with other men are at higher risk for contracting hepatitis A, hepatitis B, and although uncommon, hepatitis C

abnormal findings Performing a Digital Rectal Examination

■ Rectum has a mass or nodule. ■ Internal hemorrhoids, mass, or fissure is present. ■ Prostate gland is enlarged, hard, or with nodules ■ Benign prostatic hyperplasia is an enlargement of the prostate gland that occurs with advancing age; the exact cause is unknown, but declining testosterone and increasing estrogen levels are thought to cause enlargement of the prostate gland; does not increase risk for prostate cancer.

normal findings when Performing a Digital Rectal Examination

■ Rectum is without masses or hemorrhoids. ■ Male patient: Prostate gland has two smooth lobes within normal size, no hard nodules; nontender

Testes (Testicles)

■ Right and left testes (testicles); each are oval shaped and feel soft and rubbery. ■ Primary male reproductive organs responsible for sperm and testosterone production ■ Spermatogenesis is the process of mature sperm development through cell divisions to produce spermatozoa. ■ Left testis (testicle) lies lower than the right testis because the left spermatic cord is longer.

patient education: STI's

■ Routine HIV screening for teens and adults between 15 and 65 years of age; younger adolescents and older adults who are at increased risk should also be screened. ■ Advise protection through use of condoms: □ Latex condoms, when used consistently and correctly, are highly effective in preventing and reducing the sexual transmission of HIV, the virus that causes AIDS, and other STIs (CDC, 2015a). □ In addition, consistent and correct use of latex condoms reduces the risk of other STIs, including diseases transmitted by genital secretions, and to a lesser degree, genital ulcer diseases.

Spermatic Cord

■ Suspends the testis in the scrotum ■ Left cord is slightly longer than the right. ■ Contains the vas deferens, testicular artery and veins

abnormal findings palpating female breasts

■ Tenderness or pain may indicate infection or inflammation. ■ Lumps or masses may be benign or cancerous and need further evaluation by the healthcare provider. ■ Nipple discharge may need to be sent for diagnostic assessment especially if there is bloody discharge or milky discharge outside the postpartum or non-lactation period. ■ Paget's disease, a type of breast cancer, may occur in the areola area; the areola is bumpy, persistently itchy, red, or scaly; patient may complain of tingling sensation. ■ If nipple discharge is present notify the healthcare provider; a sample is usually collected for cytology.

Patient education: sexually transmitted infections

■ The CDC (2015f) recommends that all sexually active women age 25 and younger be regularly screened for chlamydia and gonorrhea. Women over age 26 should be screened for chlamydia and gonorrhea annually if they have multiple sexual partners or if their partner has multiple sexual contacts. ■ CDC (2015g) encourages HIV testing, at least once, as a routine part of medical care if the patient is an adolescent or adult between the ages of 13 and 64. □ Educate patients on prevention of STIs. □ Limit activity to one mutually monogamous uninfected partner. □ Encourage use of condom or other barrier devices with oral, vaginal, and anal sexual activity. □ Avoid sexual activity with multiple partners or with individuals with multiple partners. ■ Avoid sexual activity with partners who use intravenous (IV) drugs. ■ Have HIV test if you have had unprotect sex in the past or have used IV drugs or have intercourse with someone who is HIV positive, or they use IV drugs.

anus

■ The length of the anal canal is 4 to 5 cm in length in an adult located in the perineum. ■ Anus is the terminal endpoint of the gastrointestinal tract and large intestine; lined with mucous-secreting anal glands and membranes arranged in longitudinal and curved folds ■ These glands help to lubricate the anal canal to make it easier for feces to move through the canal and out of the body. ■ The internal anal sphincter is composed of smooth, involuntary, ring-like muscle and supplied by parasympathetic nerve fibers; contributes to 60 to 75 percent of the anal resting tone (Mahadevan, 2014); relaxes in response to pressure from gas or fecal material. ■ The external anal sphincter is composed of striated, voluntary, ring-like muscle and can be contracted voluntarily. ■ The anorectal ring is the demarcation of the anal canal and the rectum. ■ The dentate line is located at the junction of the rectum and the anus; mucus-secreting cells change to squamous cells. ■ The perianal skin is composed of squamous cells and has hair, sweat, and sebaceous glands.

Internal reproductive organs of female

■ Vagina is a hollow, muscular, expandable canal measuring about 2 to 4 inches in length; extends from the external genitalia to the cervix (Fig. 18-5). Normal bacteria flora maintains the pH of the vagina between 4 and 5, thereby reducing infectious bacteria growth. ■ Uterus is a hollow muscular organ shaped like a pear; lies between the bladder and the rectum; during pregnancy the fetus grows and develops within the uterus. It is made of two segments; fundus, located at the top, and isthmus which is the lower portion of the uterus. The position of the uterus can be anteverted, retroverted, or midline. ■ Cervix is part of the lower uterus and is a canal that is made up of columnar epithelium that secretes mucous and is located inside the vagina. The opening of the cervix is called the external os and is located in the vagina. ■ Fallopian tubes are tube-like structures measuring 10-12 cm that initiate from the left and right sides of the fundus; the end of each tube branches out close to each ovary; use ciliary and muscular waves to move a mature egg toward the uterus. ■ Ovaries are almond-shaped organs, they measure approximately 3-4 cm in length, 2 cm in width, and 1-2 cm thickness, and located on each side of the uterus; produce the female hormones of estrogen and progesterone and contain female eggs.

external Genitalia of female

■ Vulva is the external genitalia organ that consists of the following □ Mons pubis is a round, fleshy elevation composed of subcutaneous fatty tissue over the pubic bone that becomes covered with pubic hair during puberty. □ Labia majora and minora are cutaneous folds made up of skin and adipose tissue. □ Clitoris is part of the vulva that contains nerve fibers; sensitive and enlarges during sexual stimulation. ■ Skene's glands are located on the anterior wall of the vagina; related to female ejaculation. ■ Bartholin's glands are two pea-sized glands located near the beginning of the vagina; produce clear mucus that lubricates the area during sex. ■ Urethra is a hollow tube that is a passageway for urine to exit the body. ■ Perineum is the area between the vagina and rectum.

ROS rectum

■ What is your normal bowel movement pattern? Have you noticed any change in the size and diameter of your stools? Are you constipated? Do you have any diarrhea? □ Constipation is when bowel movements are: • too hard or too small • become less frequent (less than 3 times per week) • difficulty having a bowel movement • a sense that bowels are not completely emptied □ Diarrhea is liquid stool; there are many causes including side effects of medications, viruses, food intolerances, and illness. □ Change in size and diameter of stools may indicate a partial obstruction or mass in the intestines. ■ Do you have any rectal bleeding? If so, what is the color of the blood? □ Rectal bleeding (hematochezia) can present as bright red blood or cause the stool to have a black, tarry appearance. The color of blood can give clues to where the bleeding is occurring: • Bright red blood usually indicates bleeding low in the colon or rectum. • Dark red or maroon blood usually indicates bleeding higher in the colon or the small bowel. • Melena is black, tarry feces caused by digestion of blood in the gastrointestinal tract; commonly seen with gastrointestinal bleeding (Venes, 2013, p. 1483). ■ Some causes of rectal bleeding are as follows: □ An anal fissure is a tear in the opening of the anus that can cause pain, itching, and bleeding; the most common cause is constipation (Sugarman & Sugarman, 2014). □ Hemorrhoids are swollen, dilated veins that protrude from the lower rectum or anus; symptoms may include bleeding, irritation, and itching; hemorrhoids may be caused by increased rectal pressure such as chronic straining related to constipation. There are two locations of hemorrhoids • Internal hemorrhoids are located inside the rectum. • External hemorrhoids protrude to the outside of the anus. □ Polyps are abnormal outgrowths of tissue in the lining of the colon; polyps may be precancerous. □ Inflammation of the gastrointestinal tract may cause rectal bleeding and need further evaluation. ■ Do you have any itching or pain in your anus? Any abnormal drainage? □ Eighty percent of anal cancers are squamous cell in nature and arise in the anal canal, where the mucosa is made up of squamous cell epithelium; symptoms include anal pain, irritation, itching, and bleeding (Coakes & White, 2013). □ An anal fistula will drain pus and abnormal fluid from the anus. An anal fistula may increase the risk of developing anal cancer

ROS for male health:medcations

■ What prescriptive, herbal, and over-the-counter medications are you currently taking? □ Medications have side effects; certain medications can contribute to sexual dysfunction or impotence; testosterone, a steroid hormone, may be given to men with low testosterone levels.

ROS for male health: Sexual health, erectile dysfunction

□ Are you able to achieve or maintain an erection? □ How long have these symptoms been present? Did they begin gradually or suddenly? • ED is when a man has trouble getting or keeping an erection. • ED becomes more common as men get older. • ED is not a natural part of aging. • Risk factors for ED include side effects of some medications. • ED is strongly linked to a number of other common diseases in men, such as diabetes, heart disease, high blood pressure, high cholesterol, vascular disease, neurologic conditions, chronic liver or kidney disease

ROS for male health: Sexual health, practices

□ What types of sexual practices do you engage in? • Types of sexual practice include: • oral sex • penile-vaginal sex • penile-rectal sex