NSG 200 - TEST 5

Soft, fatty enlargement of breast tissue for males is seen in

obesity

The first procedure involves

obtaining a clean-catch, midstream urine specimen. After the client has voided, instruct her to undress. Provide adequate gowns and cover-up drapes to ensure privacy.

ATROPHIC VAGINITIS

occurs after menopause when estrogen production is low. The discharge produced may be blood-tinged and is usually minimal. The labia and vaginal mucosa appear atrophic. The vaginal mucosa is typically pale, dry, and contains areas of abrasion that bleed easily. Atrophic vaginitis causes itching, burning, dryness, and painful urination.

Referred pain

occurs at distant sites that are innervated at approximately the same levels as the disrupted abdominal organ. This type of pain travels, or refers, from the primary site and becomes highly localized at the distant site. The accompanying illustrations show common clinical patterns and referents of pain.

ECTOPIC PREGNANCY

occurs when a fertilized egg attaches to the fallopian tube and begins developing instead of continuing its journey to the uterus for development. A solid, mobile, tender, and unilateral adnexal mass may be palpated if tenderness allows. The cervix and uterus will be softened, and movement of these structures will cause pain.

Visceral pain

occurs when hollow abdominal organs—such as the intestines—become distended or contract forcefully, or when the capsules of solid organs such as the liver and spleen are stretched. Poorly defined or localized and intermittently timed, this type of pain is often characterized as dull, aching, burning, cramping, or colicky.

Parietal pain

occurs when the parietal peritoneum becomes inflamed, as in appendicitis or peritonitis. This type of pain tends to localize more to the source and is characterized as a more severe and steady pain.

UTERINE PROLAPSE

occurs when the uterus protrudes into the vagina. It is graded according to how far it protrudes into the vagina. In first-degree prolapse, the cervix is seen at the vaginal opening; in second-degree prolapse the uterus bulges outside of vaginal openings; in third-degree prolapse, the uterus bulges completely out of the vagina.

The older client is more susceptible to vaginal infection because

of atrophy of the vaginal mucosa associated with aging. Women with vaginal atrophy have a greater chance of chronic vaginal infections and urinary function problems. It can also make sexual intercourse painful

Copper/suspensory ligaments

run from the skin through the breast and attach to the deep fascia of the muscles of the anterior chest wall.

"Hyperactive" bowel sounds that are

rushing, tinkling, and high pitched may be abnormal indicating very rapid motility heard in early bowel obstruction, gastroenteritis, diarrhea, or with use of laxatives.

Hardness and irregularities may be from

scarring or cancer.

Hardness may indicate

scarring or cancer.

Discoloration of the foreskin may indicate

scarring or infection.

Excoriation and swelling may be from

scratching or self-treatment of the lesions. Evaluate all lesions and refer the client to a primary care provider for treatment.

solid viscera

organs that maintain their shape consistently: liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus.

paritel peritoneum

outer layer, lines the internal walls of the abdominopelvic cavity

gray or tan stool results from

the lack of bile pigment

Fibrocystic breast tissue that feels ropy, lumpy, or bumpy in texture is referred to as

"nodular" or "glandular" breast tissue.

Pica

a craving for or ingestion of nonnutritional substances such as dirt or clay, is seen in all socioeconomic classes and cultures. Pica can be a major concern if the craving interferes with proper nutrition during pregnancy.

An enlarged kidney may be due to

a cyst, tumor, or hydronephrosis. It can be differentiated from splenomegaly by its smooth rather than sharp edge, absence of a notch, and overlying tympany on percussion

A hernia

(protrusion of the bowel through the abdominal wall) is seen as a bulge in the abdominal wall. Diastasis recti appears as a bulge between a vertical midline separation of the abdominis rectus muscles. This condition is of little significance. An incisional hernia may occur when a defect develops in the abdominal muscles because of a surgical incision.

· The newborn's liver is palpable at

0.5 to 2.5 cm below the right costal margin, thereby occupying proportionately more space than at any other time after birth. In infants and small children, the liver is palpable at 1 to 2 cm below the right costal margin.

Palpating the breasts

1. Ask the client to lie down and to place overhead the arm on the same side as the breast being palpated. Place a small pillow or rolled towel under the breast being palpated. 2. Use the flat pads of three fingers to palpate the client's breasts (Figure A). 3. Palpate the breasts using one of three different patterns (Figures B, C, and D). Choose one that is most comfortable for you, but be consistent and thorough with the method chosen. 4. Be sure to palpate every square inch of the breast, from the nipple and areola to the periphery of the breast tissue and up into the tail of Spence. Vary the levels of pressure as you palpate. · Light—superficial · Medium—mid-level tissue · Firm—to the ribs 5. Use the bimanual technique (Figure E) if the client has large breasts. Support the breast with your nondominant hand and use your dominant hand to palpate.

Using a Speculum

1. Before using the speculum, choose the instrument that is the correct size for the client. Vaginal speculums come in two basic types: · Graves speculum—appropriate for most adult women and available in various lengths and widths. · Pederson speculum—appropriate for virgins and some postmenopausal women who have a narrow vaginal orifice. Speculums can be metal with a thumbscrew that is tightened to lock the blades in place or plastic with a clip that is locked to keep the blades in place. (Plastic speculums are shown in Fig. A.) 2. Encourage the client to take deep breaths and to maintain her feet in the stirrups with her knees resting in an open, relaxed fashion. 3. Place two fingers of your gloved nondominant hand against the posterior vaginal wall and wait for relaxation to occur. 4. Insert the fingers of your gloved nondominant hand about 2.5 cm into the vagina and spread them slightly while pushing down against the posterior vagina. 5. Lubricate the blades of the speculum with vaginal secretions from the client. Do not use commercial lubricants on the speculum. Lubricants are typically bacteriostatic and will alter vaginal pH and the cell specimens collected for cytologic, bacterial, and viral analysis. 6. Hold the speculum with two fingers around the blades and the thumb under the screw or lock. This is important for keeping the blades closed. Position the speculum so that the blades are vertical. 7. Insert the speculum between your fingers into the posterior portion of the vaginal orifice at a 45-degree angle downward. When the blades pass your fingers inside the vagina, rotate the closed speculum so that the blades are in a horizontal position (Fig. B). 8. Continue inserting the speculum until the base touches the fingertips inside the vagina. 9. Remove the fingers of your gloved nondominant hand from the client's posterior vagina. 10. Press handles together (Fig. C) to open blades and allow visualization of the cervix. 11.Secure the speculum in place by tightening the thumbscrew or locking the plastic clip

Obtaining an Ectocervical Specimen

1. Insert one end of plastic spatula (i.e., longer on the ends than in the middle) into the cervical os (Fig. B). 2. Press down and rotate the spatula, scraping the cervix and the transformation zone (squamocolumnar junction) in a full circle. 3. Withdraw the spatula. 4. Rinse the spatula in the preservative solution by swishing the spatula vigorously in the vial 10 times. 5. Discard the spatula.

Obtaining an Endocervical Specimen

1. Insert the endocervical brush into the cervical os. Use the endocervical brush to increase the number of cells obtained for analysis. 2. Rotate the brush one half-turn in one direction (Fig. C) very gently to minimize possible bleeding. 3. Withdraw the brush. 4. Rinse the brush in the preservative solution by rotating the device in the solution 10 times while pushing against the vial wall. Swirl the brush vigorously to further release material. 5. Discard the brush. 6. Tighten the cap on the solution. 7. Record client's name and date on the vial. 8. Send the vial to laboratory.

measuring abdominal girth

1. Measure abdominal girth at the same time of day, ideally in the morning just after voiding, or at a designated time for bedridden clients or those with indwelling catheters. 2. The ideal position for the client is standing; otherwise, the client should be in the supine position. The client's head may be slightly elevated (for orthopneic clients). The client should be in the same position for all measurements. 3. Use a disposable or easily cleaned tape measure. If a tape measure is not available, use a strip of cloth or gauze, then measure the gauze with a cloth tape measure or yardstick. 4. Place the tape measure behind the client and measure at the umbilicus. Use the umbilicus as a starting point when measuring abdominal girth, especially when distention is apparent. 5. Record the distance in designated units (inches or centimeters). 6. Take all future measurements from the same location. Marking the abdomen with a ballpoint pen can help you identify the measuring site. As a courtesy, the nurse needs to explain the purpose of the marking pen and ask the client not to wash the mark off until it is no longer needed.

Vaginal Specimen

1. Select appropriately sized speculum; warm speculum and test it on the patient's leg for comfortable temperature. 2. Insert speculum at a 45-degree angle, then rotate and open when completely inserted. 3. Obtain a specimen of vaginal fluid from the posterior fornix (see Fig. 27-2, p. 638). 4. On a single glass slide, place a drop of sodium chloride (NaCl) and a drop of potassium hydroxide (KOH) on separate ends of the slide. 5. Mix a small amount of vaginal fluid with each solution and apply coverslip (Association of Professors of Gynecology and Obstetrics [APGO], 2008).

A deviated umbilicus may be caused by

pressure from a mass, enlarged organs, hernia, fluid, or scar tissue.

Regular contractions before 37 completed weeks' gestation may suggest

preterm labor.

older client breasts

a decrease in the size and firmness of the breasts as she ages because of a decrease in estrogen levels. Glandular tissue decreases whereas fatty tissue increases. A well-fitting supportive bra can reduce breast discomfort related to sagging breasts.

Atrophy of the liver is indicated by

a decreased span.

Sphincter tightens, making further examination

unrealistic.

PARAPHIMOSIS

A foreskin that is left in a retracted position leads to venous congestion and edema of the foreskin.

Cullen sign:

A bluish or purple discoloration around the umbilicus (periumbilical ecchymosis) indicates intra-abdominal bleeding.

Distention

A generalized protuberant or distended abdomen may be due to obesity, air (gas), or fluid accumulation (Abnormal Findings 23-1). Distention below the umbilicus may be due to a full bladder, uterine enlargement, or an ovarian tumor or cyst. Distention of the upper abdomen may be seen with masses of the pancreas or gastric dilation.

CANCER OF THE CERVIX

A hardened ulcer is usually the first indication of cervical cancer, but it may not be visible on the ectocervix. In later stages, the lesion may develop into a large cauliflower-like growth. A Pap smear is essential for diagnosis.

CERVICAL POLYP

A polyp typically develops in the endocervical canal and may protrude visibly at the cervical os. It is soft, red, and rather fragile. Cervical polyps are benign.

The external os of a woman who is nulliparous (having borne no offspring) will appear as ??. The external os of a woman who has given birth will appear ??

a small, round depression on examination. slit-like due to dilation of the cervix.

gynecomastia

a smooth, firm, movable disc of glandular tissue, may be seen in one breast in males during puberty, usually temporary. However, it may also be seen in hormonal imbalances, drug abuse, cirrhosis, leukemia, and thyrotoxicosis. Irregularly shaped, hard nodules occur in breast cancer.

Poor sphincter tone may be the result of

a spinal cord injury, previous surgery, trauma, or a prolapsed rectum.

Black stool may indicate

upper gastrointestinal bleeding

The cervix functions to

allow the entrance of sperm into the uterus and to allow the passage of menstrual flow. It also secretes mucus and prevents the entrance of vaginal bacteria. During childbirth, the cervix stretches (dilates) to allow the passage of the fetus.

Breast Self-Examination

Ask the client who performs BSE to demonstrate how she does so, if she chooses to receive feedback on her technique and method. This should be offered as an option and the client's choice accepted. This offers the nurse an opportunity to teach BSE. Give clients printed instructions (Box 20-1).Client may request instructions on how to perform the examination or choose not to learn how to perform the examination. Either choice needs to be accepted by the examiner.

Blumberg's sign

Abdominal pain or tenderness experienced when examiner, tests for rebound tenderness by palpating deeply at 90 degrees into the abdomen one-halfway between the umbilicus and the anterior iliac crest (McBurney point) Peritoneal irritation

Genetic variation of breast cancer

About 5-10% of breast cancer cases are thought to be hereditary. BRCA1 and BRCA2 genes are the most common cause of hereditary breast cancer. In the United States, BRCA mutations are found most often in Jewish women of Ashkenazi (Eastern Europe) origin

Crabs

Absence or scarcity of pubic hair may be seen in clients receiving chemotherapy. Lice or nit (eggs) infestation at the base of the penis or pubic hair is known as pediculosis pubis. transmitted by sexual contact

Risk factors for prostate cancer

Age: rare in men under 40, rises rapidly after age 50 Race/ethnicity: highest for African American or Caribbean males of African origin; occurs less often in Asian, Hispanic/Latino men than in whites Geography: most common in North America, northwestern Europe, Australia, and on Caribbean islands; less common in Asia, Africa, Central America, and South America. Family history: having a father or brother with prostate cancer Certain gene changes Exposure to agent orange Excessive alcohol consumption Working on a farm, in a tire plant, with paint, with cadmium or firefighters exposed to toxic chemicals. Diet: unclear, but slightly higher risk for those who eat a diet high in red meat or high fat daily, and fewer vegetables. High calcium intake may be a factor. Note that prostate cancer is less common in people who do not eat meat (vegetarians). Low melatonin levels (sleeping with even small light source; shift work) (Florida Atlantic University, n.d.) Studies with unclear or ambivalent findings, or only slight risk suggested: Obesity has not been found to be a factor but obese men have a lower risk of getting the less dangerous form of the disease. Prostatitis STIs Vasectomy Smoking (more related to small increased risk of dying with prostate cancer vs. getting it)

· ENLARGED SPLEEN

An enlarged spleen (splenomegaly) is defined by an area of dullness exceeding 7 cm. When enlarged, the spleen progresses downward and toward the midline

· Anatomic changes of the musculoskeletal system during pregnancy result from fetal growth, hormonal influences, and maternal weight gain.

As the pregnancy progresses, uterine growth pulls the pelvis forward, which causes the spine to curve forward, creating a gradual lordosis (Fig. 29-3). The enlarging breasts cause the shoulders to droop forward. The pregnant client typically finds herself pulling her shoulders back and straightening her head and neck to accommodate for this weight. Progesterone and relaxin (nonsteroidal hormone) induce relaxation of the pelvic joints and ligaments. The symphysis pubis, sacroiliac and sacrococcygeal joints become more flexible during pregnancy. This flexibility allows the pelvic outlet diameter to increase slightly, which reduces the risk of trauma during childbirth. After the postpartum period, the pelvic diameter will generally remain larger than the size before childbirth.

TEST FOR CHOLECYSTITIS

Assess RUQ pain or tenderness, which may signal cholecystitis (inflammation of the gallbladder). Press your fingertips under the liver border at the right costal margin and ask the client to inhale deeply. EF: No increase in pain is present. AF: Accentuated sharp pain that causes the client to hold his or her breath (inspiratory arrest) is a positive Murphy sign and is associated with acute cholecystitis.

Tests for appendicitis/peritoneal irritation

Assess for rebound tenderness. If the client has abdominal pain or tenderness, test for rebound tenderness by palpating deeply at 90 degrees into the abdomen halfway between the umbilicus and the anterior iliac crest (McBurney point) Then suddenly release pressure. Listen and watch for the client's expression of pain. Ask the client to describe which hurt more—the pressing in or the releasing—and where on the abdomen the pain occurred. Ef: No rebound tenderness is present. AF: The client has rebound tenderness when the client perceives sharp, stabbing pain as the examiner releases pressure from the abdomen (Blumberg sign). It suggests peritoneal irritation (as from appendicitis). If the client feels pain at an area other than where you were assessing for rebound tenderness, consider that area as the source of the pain (see test for referred rebound tenderness, below). Test for referred rebound tenderness. Palpate deeply in the LLQ and quickly release pressure Ef: No rebound pain is elicited. AF: Pain in the RLQ during pressure in the LLQ is a positive Rovsing sign. It suggests acute appendicitis. Assess for psoas sign. Ask the client to lie on the left side. Hyperextend the client's right leg. EF: No abdominal pain is present. AF: Pain in the RLQ (psoas sign) is associated with irritation of the iliopsoas muscle due to appendicitis (an inflamed appendix). Assess for obturator sign. Support the client's right knee and ankle. Flex the hip and knee, and rotate the leg internally and externally EF: No abdominal pain is present. AF: Pain in the RLQ indicates irritation of the obturator muscle due to appendicitis or a perforated appendix. Perform hypersensitivity test. Stroke the abdomen with a sharp object (e.g., broken cotton tipped applicator or tongue blade) or grasp a fold of skin with your thumb and index finger and quickly let go. Do this several times along the abdominal wall. EF: The client feels no pain and no exaggerated sensation. AF: Pain or an exaggerated sensation felt in the RLQ is a positive skin hypersensitivity test and may indicate appendicitis.

· With fetal growth, the uterus continues to expand throughout the pregnancy.

At approximately 10 to 12 weeks' gestation, the uterus should be palpated at the top of the symphysis pubis. At 16 weeks' gestation, the top of the uterus, known as the fundus, should reach halfway between the symphysis pubis and the umbilicus. At 20 weeks' gestation, the fundus should be at the level of the umbilicus. For the rest of the pregnancy, the uterus grows approximately 1 cm/wk; the fundal height should equal the number of weeks pregnant (e.g., at 25 weeks' gestation, the fundal height should measure 25 cm). This formula is known as McDonald's rule. It can be calculated by taking the fundal height in centimeters and multiplying it by 8/7. With a full-term pregnancy, the fundus should reach the xiphoid process. The fundal height measurement may drop in the last few weeks of the pregnancy if the fetal head is engaged and descended in the maternal pelvis. This occurrence is known as lightening.

Screening for PUD

At present, there is no recommendation for screening for peptic ulcer disease (Carson-DeWitt, 2015). One possibility for the future is screening for H. pylori, but since many people have H. pylori with no disease whatsoever, this approach to screening may not be cost effective.

Auscultation abdomen

Auscultate for bowel sounds. Use the diaphragm of the stethoscope and make sure that it is warm before you place it on the client's abdomen. Apply light pressure or simply rest the stethoscope on a tender abdomen. Begin in the RLQ and proceed clockwise, covering all quadrants. Listen for at least 5 minutes before determining that no bowel sounds are present and that the bowels are silent. EF: A series of intermittent, soft clicks and gurgles are heard at a rate of 5-30 per minute. Hyperactive bowel sounds referred to as "borborygmus" may also be heard. These are the loud, prolonged gurgles characteristic of one's "stomach growling." Confirm bowel sounds in each quadrant. Listen for up to 5 minutes (minimum of 1 minute per quadrant) to confirm the absence of bowel sounds. Bowel sounds may be more active over the ileocecal valve in the RLQ. Note the intensity, pitch, and frequency of the sounds. Bowel sounds normally occur every 5-15 seconds. An easy way to remember is to equate one bowel sound to one breath sound. Auscultate for vascular sounds. Use the bell of the stethoscope to listen for bruits (low-pitched, murmur-like sound, pronounced BROO-ee) over the abdominal aorta and renal, iliac, and femoral arteries (Fig. 23-11). EF: Bruits are not normally heard over abdominal aorta or renal, iliac, or femoral arteries. However, bruits confined to systole may be normal in some clients depending on other differentiating factors. Listen for venous hum. Using the bell of the stethoscope, listen for a venous hum in the epigastric and umbilical areas. EF: Venous hum is not normally heard over the epigastric and umbilical areas. Auscultate for a friction rub over the liver and spleen. Listen over the right and left lower rib cage with the diaphragm of the stethoscope. EF: No friction rub over liver or spleen is present.

Teach clients the following lifestyle changes to reduce GERD

Avoid alcohol and tobacco intake. Assess foods that cause distress and avoid these foods. Avoid foods that cause you to swallow air, such as chewing gum, sucking hard candy, or drinking sodas (which contain air). Eat 5-6 small meals a day rather than 3 large ones. Eat slowly and chew food well. Do not lie down after eating. Remain upright for 2 hours Avoid late evening snacks. Avoid bending or stooping after you eat. Avoid lifting heavy objects. Avoid wearing tight clothes around waist, abdomen, or stomach. Lose weight if overweight. Raise head of bed 6-8 in. Try sleeping on left side. Take medicines exactly as prescribed. Tell any health care provider examining you that you have GERD. Keep a relaxed atmosphere when eating meals. Avoid the foods listed below, which increase reflux: Food that is very hot or very cold Fatty or fried foods Peppermint or spearmint, including flavoring Coffee, tea, and soft drinks that contain caffeine Spicy, highly seasoned foods Tomato-based dishes, such as spaghetti with sauce, chili, and pizza Citrus fruits and juices, especially in the morning Chocolate and sweets, if they cause symptoms

Client education on cervical cancer

Avoid risky sexual practices: do not have sex at an early age; do not have multiple partners; avoid high-risk sexual activities and partners who participate in these. Consult with a health care professional about having an HPV vaccination for boys and girls as early as 9 years old and up to 26 years old, but especially between 10 and 11 years of age (ACOG, 2015). Follow the USPSTF guidelines for routine Pap smears. If your mother took DES to prevent miscarriage, maintain a careful preventive screening schedule. Eat nutritious food and have routine care for illnesses that weaken your immune system. Talk to your partner about your expectations of sexual health before becoming intimate.

CONSIDERATIONS FOR PALPATING THE ABDOMEN

Avoid touching tender or painful areas until last, and reassure the client of your intentions. Perform light palpation before deep palpation to detect tenderness and superficial masses. Keep in mind that the normal abdomen may be tender, especially in the areas over the xiphoid process, liver, aorta, lower pole of the kidney, gas-filled cecum, sigmoid colon, and ovaries. Overcome ticklishness and minimize voluntary guarding by asking the client to perform self-palpation. Place your hands over the client's. After a while, let your fingers glide slowly onto the abdomen while still resting mostly on the client's fingers. The same can be done by using a warm stethoscope as a palpating instrument—again letting your fingers drift over the edge of the diaphragm—and palpate without promoting a ticklish response. Work with the client to promote relaxation and minimize voluntary guarding. Use the following techniques: Place a pillow under the client's knees. Ask the client to take slow, deep breaths through the mouth. Apply light pressure over the client's sternum with your left hand while palpating with the right. This encourages the client to relax the abdominal muscles during breathing against sternal resistance.

· FECES

Hard stools in the colon appear as a localized distention. Percussion over the area discloses dullness.

Teach prostate cancer clients

Behaviors found to lower risk of prostate cancer: Frequent ejaculation (Harvard Medical School, 2011) Eating a diet high in fruits and vegetables (at least 2½ cups of a variety of vegetables and fruits daily), staying physically active (exercise most days of the week), and maintaining a healthy weight (ACS, 2015b) Taking vitamin E and selenium (ambivalent study results) Possible preventive effect from medications for benign prostatic hypertrophy; aspirin (unclear results) Sleeping in a completely dark room Avoiding shift work that requires daytime sleep Drink green tea daily (Doheny, 2012). Observe for the following symptoms (which may or may not be present, but are likely in more advanced stages) and report any you experience to a health care provider (Mayo Clinic, 2015b): Trouble urinating Decreased force in the stream of urine Blood in the semen Swelling in the legs Bone pain Erectile dysfunction

Palpation of abdomen

Box 23-2 provides considerations for palpation. Light palpation is used to identify areas of tenderness and muscular resistance. Using the fingertips, begin palpation in a nontender quadrant, and compress to a depth of 1 cm in a dipping motion. Then gently lift the fingers and move to the next area (Fig. 23-19). For techniques to minimize the client's voluntary guarding (a tensing or rigidity of the abdominal muscles usually involving the entire abdomen), see Box 23-2. Keep in mind that the rectus abdominis muscle relaxes on expiration. EF: Abdomen is nontender and soft. There is no guarding. Deeply palpate all quadrants to delineate abdominal organs and detect subtle masses. Using the palmar surface of the fingers, compress to a maximum depth (5-6 cm). Perform bimanual palpation if you encounter resistance or to assess deeper structures EF: Normal (mild) tenderness is possible over the xiphoid, aorta, cecum, sigmoid colon, and ovaries with deep palpation. Figure 23-21 illustrates normally palpable structures in the abdomen. Palpate for masses. Note their location, size (cm), shape, consistency, demarcation, pulsatility, tenderness, and mobility. Do not confuse a mass with an organ or structure. EF: No palpable masses are present. Palpate the umbilicus and surrounding area for swellings, bulges, or masses. EF: Umbilicus and surrounding area are free of swellings, bulges, or masses. Palpate the aorta. Use your thumb and first finger or use two hands and palpate deeply in the epigastrium, slightly to the left of midline (Fig. 23-22). Assess the pulsation of the abdominal aorta. EF: The aorta is approximately 2.5-3.0 cm wide with a moderately strong and regular pulse. Possibly mild tenderness may be elicited. Palpate the liver. Note consistency and tenderness. To palpate bimanually, stand at the client's right side and place your left hand under the client's back at the level of the eleventh to twelfth ribs. Lay your right hand parallel to the right costal margin (your fingertips should point toward the client's head). Ask the client to inhale, then compress upward and inward with your fingers. Have the client exhale and hold your hand in place as the client inhales a second time. With deep inhalation the edge of the liver is more easily palpated. EF: The liver is usually not palpable, although it may be felt in some thin clients. If the lower edge is felt, it should be firm, smooth, and even. Mild tenderness may be normal. To palpate by hooking, stand to the right of the client's chest. Curl (hook) the fingers of both hands over the edge of the right costal margin. Ask the client to take a deep breath and gently but firmly pull inward and upward with your fingers Palpate the spleen. Stand at the client's right side, reach over the abdomen with your left arm, and place your hand under the posterior lower ribs. Pull up gently. Place your right hand below the left costal margin with the fingers pointing toward the client's head. Ask the client to inhale and press inward and upward as you provide support with your other hand EF: The spleen is seldom palpable at the left costal margin. Rarely, the tip is palpable in the presence of a low, flat diaphragm (e.g., chronic obstructive lung disease) or with deep diaphragmatic descent on inspiration. If the edge of the spleen can be palpated, it should be soft and nontender. Alternatively, asking the client to turn onto the right side may facilitate splenic palpation by moving the spleen downward and forward (Fig. 23-26). Document the size of the spleen in centimeters below the left costal margin. Also note consistency and tenderness. Palpate the kidneys. To palpate the right kidney, support the right posterior flank with your left hand and place your right hand in the RUQ just below the costal margin at the MCL. To capture the kidney, ask the client to inhale. Then compress your fingers deeply during peak inspiration. Ask the client to exhale and hold the breath briefly. Gradually release the pressure of your right hand. If you have captured the kidney, you will feel it slip beneath your fingers. To palpate the left kidney, reverse the procedure (Fig. 23-27). EF: The kidneys are usually not palpable. Sometimes the lower pole of the right kidney may be palpable by the capture method because of its lower position. If palpated, it should feel firm, smooth, and rounded. The kidney may or may not be slightly tender. Palpate the urinary bladder. Palpate for a distended bladder when the client's history or other findings warrant (e.g., dull percussion noted over the symphysis pubis). Begin at the symphysis pubis and move upward and outward to estimate bladder borders EF: An empty bladder is neither palpable nor tender

client education for colorectal cancer

Call your health care provider if you notice any of the following symptoms: black, tarry stools, blood during a bowel movement, change in bowel habits, or unexplained weight loss. Follow preventive screening schedules as recommended by the USPSTF (2016) if you are between 50 and 75 years of age. If you are of African American or Eastern European descent, or if you have a family history of colon cancer or colon polyps, or if you have a history of inflammatory bowel syndromes or a history of breast cancer or other cancer, inform your health care provider and follow recommended screening protocols. Avoid a diet high in red and processed meat, high fat, or low in fiber. Avoid smoking cigarettes and keep alcohol intake to a minimum.

Breast cancer is a leading cause of mortality and morbidity in

Canada. Breast screening may be less than optimal in Canadian women, especially in Iranian immigrant women residing in Toronto, who were found to have little knowledge of breast cancer and screening practices. It is essential that the nurse assess the client's knowledge regarding risks and recommended screenings

· Normal changes in the cervix, vagina, and vulva also occur during pregnancy.

Cervical softening (Goodell sign), bluish discoloration (Chadwick sign), and hypertrophy of the glands in the cervical canal all occur. With these glands secreting more mucus, there is an increase in vaginal discharge, which is acidic. The mucus collects in the cervix to form the mucous plug. This plug seals the endocervical canal and prevents bacteria from ascending into the uterus, thus preventing infection. The vaginal smooth muscle and connective tissue soften and expand to prepare for the passage of the fetus through the birth canal.

Dark bluish-pink striae are associated with

Cushing syndrome.

Inspection of preggo abdomen

Inspect the abdomen. For this part of the examination, ask the client to recline with a pillow under her head and her knees flexed. Note striae, scars, and the shape and size of the abdomen. EF: Striae and linea-nigra are normal. The size of the abdomen may indicate gestational age. The shape of the uterus may suggest fetal presentation and position in later pregnancy.

Milk cysts (sacs filled with milk) and infections (mastitis),.

may turn into an abscess and occur if breastfeeding or recently given birth

MALFORMATIONS FROM EXPOSURE TO DIETHYLSTILBESTROL (DES)

DES, a drug used more than 50 years ago to prevent spontaneous abortion and premature labor, was learned to be teratogenic (capable of causing malformations in the fetus). Women who were exposed to this drug as fetuses may have cervical abnormalities that may progress to cancer. Some abnormalities associated with maternal DES use include columnar epithelium that covers most or all of the ectocervix; columnar epithelium that extends onto the vaginal wall; a circular column of tissue that separates the cervix from the vaginal wall; transverse ridge; and enlarged upper ectocervical lip.

Fetal Heart

Determine the location, rate, and rhythm of the fetal heart. Auscultate the fetal heart rate in the woman's left lower abdominal quadrant when the fetal back is positioned on maternal left, vertex position (Fig. 29-17). In breech presentations, fetal heart rate is heard in the upper quadrant of the maternal abdomen. Other locations for auscultating fetal heart rate (when the fetal back is positioned differently) are illustrated in Box 29-1. EF: Fetal heart rate ranges from 120 to 160 beats/min. During the third trimester, the fetal heart rate should accelerate with fetal movement. AF: Inability to auscultate fetal heart tones with a fetal Doppler at 12 weeks may indicate a retroverted uterus, uncertain dates, fetal demise, or false pregnancy. Fetal heart rate decelerations could indicate poor placental perfusion.

ptyalism

Excessive salivation may occur in the first trimester.

Rectovaginal examination

Explain that you are going to perform a rectovaginal examination and explain its purpose. Forewarn the client that she may feel uncomfortable as if she wants to move her bowels but that she will not. Encourage her to relax. Change the glove on your dominant hand and lubricate your index and middle fingers with a water-soluble lubricant. Ask the client to bear down to promote relaxation of the sphincter and insert your index finger into the vaginal orifice and your middle finger into the rectum. While pushing down on the abdominal wall with your other hand, palpate the internal reproductive structures through the anterior rectal wall (Fig. 27-16). Pay particular attention to the area behind the cervix, the rectovaginal septum, the cul-de-sac, and the posterior uterine wall. Withdraw your vaginal finger and continue with the rectal examination. EF: The rectovaginal septum is normally smooth, thin, movable, and firm. The posterior uterine wall is normally smooth, firm, round, movable, and nontender.

male genitalia positions

Explain to the client that he will be asked to stand (if able) for most of the examination of the genitalia. The most frequently used position for inspection and palpation of the anus, rectum, and prostate is the left lateral position. This position allows adequate inspection and palpation of the anus, rectum, and prostate (in men) and is usually more comfortable for the client. The client's torso and legs can be draped during the examination, which helps to lessen the feeling of vulnerability. To help the client into this position, ask him to lie on the left side, with the buttocks as close to the edge of the examining table as possible, and to bend the right knee. However, some examiners find it easiest to perform the male anus, rectum, and prostate examination while the client stands and bends over the examining table with his hips flexed.

6 F's of abdominal distention

Fat (obesity), Fluid (Ascites), Flatulence (gas), Fetus (pregnancy), Feces, Fibroids and other masses

FEMALE GENITAL CUTTING (FGC)

Female genital cutting (FGC, also called female genital mutilation or female circumcision) includes piercing, cutting, removing, or sewing closed all or part of a woman's or a girl's external genitals (infibulation) for no medical reason (Womenshealth.gov, 2015). Approximately 513,000 women or girls have experienced or are at risk for experiencing this genital mutilation. Complications of pregnancy are rare, but complications of delivery include prolonged labor; excessive bleeding after the birth; higher risk for episiotomy; higher risk for cesarean section. Risks to the infant include low birth weight (less than 5 ½ lb); breathing problems; stillbirth; or early death after birth. The practice is culturally evident in many countries, especially those in northern and eastern Africa and the Middle East. In the United States, FGC is against the law, and it is a crime to perform FGC on a girl younger than 18 or to take or attempt to take a girl out of the United States for FGC. Girls and women who have experienced FGC are not at fault and have not broken any U.S. laws. Some women or their husbands ask for or demand reinfibulation after delivery when defibulation was necessary with the delivery. Ethical issues abound. Performing reinfibulation is discouraged, as there is no medical benefit, but if a patient insists upon the procedure and the provider is agreeable, a repair may legally be performed. The provider who agrees to do this is protected under the Federal Prohibition of Female Genital Mutilation Act of 1996, under which the initial mutilation is prohibited but not the repair (Lee & Strong, 2015).

Anus and Rectum

Inspect the anus and rectum. Note color, varicosities, lesions, tears, or discharge. EF: Mucosa should be pink and intact. No masses, varicosities, lesions, tears, or discharge present. Hemorrhoids or varicose veins may be present. Hemorrhoids usually get bigger and more uncomfortable during pregnancy. Bleeding and infection may occur. AF: Masses may indicate cancer.

Nonmodifiable risk factors for breast cancer

Gender: Females are 100 times more likely to develop breast cancer than males (estrogen and progesterone are implicated). Age: Risk increases with age, especially for invasive breast cancers. Genetics: About 5-10% of breast cancer cases are thought to be hereditary. BRCA1 and BRCA2 genes are the most common cause of hereditary breast cancer. In the United States, BRCA mutations are found most often in Jewish women of Ashkenazi (Eastern Europe) origin. Race/ethnicity: Caucasian women are at greater risk for diagnosis of breast cancer and Black women are at greater risk for dying of breast cancer in the United States. Family history (genetics and ethnicity): Even if father or brother has had breast cancer, risk is increased. Personal history of breast cancer (three- to fourfold risk of cancer in the same or other breast) Breast consistency: Denser breasts increase risk. Early menstruation (before 12 years of age) or later menopause (older than 55 years) Previous chest radiation (for therapy) before age 40 Diethylstilbestrol exposure (1940s and 1950s), used by women to avoid miscarriage, or in daughters of mothers who took this medication

Teach About the Risk Factors for Breast Cancer

Get intentional physical exercise for least 45-60 minutes per day for 5 or more days per week. Avoid alcohol intake of more than one alcoholic beverage per day (e.g., 6-oz glass of wine). Avoid excessive weight gain, especially as an adult and especially after menopause. Be aware of increased risk if client has no children or had first child after 30 years of age. Note breast consistency and be aware that denser breasts increase risk; women with denser breast tissue should work with their health care provider to establish a recommendation for screening patterns. Consider family history of breast cancer and note risk if genetic kin, including father and brothers, have had breast cancer. Night shift work and exposure to secondhand smoke may be linked to increased risk for breast cancer. Avoid even dim light source while sleeping at night (Yardell, 2014). Advise client to talk with health care provider after completing a formal breast cancer risk assessment such as the Gail Model.

Modifiable risk factors for breast cancer

Having no children or giving birth to first child after 30 years of age. Recent oral contraceptive use (risk declines to normal after 10 years of no use). Use of menopausal combined hormone replacement therapy (both estrogen and progesterone; risk is highest in first 2-3 years but long use increases risk; risk reduces to normal risk after 2-3 years without therapy). Estrogen-only therapy increases risk if used for 10 years or longer. No history of breast-feeding. Breast-feeding may have a protective effect due to reduced lifetime number of menstrual cycles. Alcohol consumption (increased risk with increased intake; especially drinking 2-5 drinks a day). Excess weight or obesity (due to increased fat tissue after menopause, increasing estrogen levels). Weight gain as adult female (studies not showing same for weight gain as child). Limited physical activity: increasing activity to include from 1.25 to 2.5 hours of brisk walking at least 5 days per week has been shown to decrease risk by 18% (ACS, 2016b). Even dim light at night while sleeping has been shown to speed the growth of human breast cancer tumors implanted into rats, and makes the tumors resistant to tamoxifen (Yardell, 2014). Unclear associations with breast cancer (under further study): Night work (such as nurses on night shift) Exposure to secondhand smoke Environmental chemicals with estrogen-like properties Diet and vitamin intake

Risk factors for cervical cancer

Human papilloma virus (HPV) infection Smoking Immunosuppression Chlamydia infection Diet low in fruits and vegetables Being overweight Intrauterine device use Having multiple full-term pregnancies Being younger than 17 at first full-term pregnancy Poverty Having a mother who took diethylstilbestrol (DES) while pregnant Family history of cervical cancer

CHILDREN AND ADOLESCENTS ABDOMEN

INSPECTION Inspect the shape of the abdomen. In children up to 4 years of age, the abdomen is prominent in standing and supine positions. After 4 years of age, the abdomen appears slightly prominent when standing, but flat when supine until puberty. A scaphoid (boat-shaped; i.e., sunken with prominent rib cage) abdomen may result from malnutrition or dehydration. Inspect umbilicus. Note color, discharge, evident herniation of the umbilicus. Umbilicus is pink, no discharge, odor, redness, or herniation. Inflammation, discharge, and redness of umbilicus suggest infection. Diastasis recti (separation of the abdominal muscles) is seen as midline protrusion from the xiphoid to the umbilicus or pubis symphysis. This condition is secondary to immature musculature of abdominal muscles and usually has little significance. As the muscles strengthen, the separation resolves on its own. A bulge at the umbilicus suggests an umbilical hernia, which may be seen in newborns; many disappear by the age of 1 year, and most by 4 or 5 years of age. Cultural Considerations Umbilical hernias are seen more frequently in African American children. AUSCULTATION Auscultate bowel sounds. Follow auscultation guidelines for adult clients provided in Chapter 23. Normal bowel sounds occur every 10-30 seconds. They sound like clicks, gurgles, or growls. Marked peristaltic waves almost always indicate a pathologic process such as pyloric stenosis. PALPATION Palpate for masses and tenderness. Palpate abdomen for softness or hardness. Clinical Tip To decrease ticklishness, have the child help by placing his or her hand under yours, using age-appropriate distraction techniques, and maintaining conversation focused on something other than the examination (Fig. 31-26). Abdomen is soft to palpation and without masses or tenderness. A rigid abdomen is almost always an emergent problem. Masses or tenderness warrants further investigation. Palpate liver. Palpate the liver the same as you would for adults (see Chapter 23). Liver is usually palpable 1-2 cm below the right costal margin in young children. An enlarged liver with a firm edge that is palpated more than 2 cm below the right costal margin usually indicates a pathologic process. Palpate spleen. Palpate the spleen the same as you would for adults. Spleen tip may be palpable during inspiration. Enlarged spleen is usually indicative of a pathologic process. Palpate kidneys. Palpate the kidneys the same as you would for adults. The tip of the right kidney may be palpable during inspiration. Enlarged kidneys are usually indicative of a pathologic process. Palpate bladder. Palpate the bladder the same as you would for adults. Bladder may be slightly palpable in small children. An enlarged bladder is usually due to urinary retention but may be due to a mass.

BREASTS FOR ELDERLY

INSPECTION AND PALPATION Inspect and palpate breast and axillae. When viewing axillae and contour of the breasts, assist a client with arthritis to raise the arms over the head. Do this gently and without force and only if it is not painful for the client. If the breasts are pendulous, assist the client to lean slightly so that the breasts hang away from the chest wall, enabling you to best observe symmetry and form. Clinical Tip A greater percentage of elderly women have had radical mastectomies. If so, inquiring about pain and swelling from lymphedema is important. The breasts of elderly women are often described as pendulous due to the atrophy of breast tissue and supporting tissues and the forward thrust of the client brought about by kyphosis. Decreases in fat composition and increase in fibrotic tissue may make the terminal ducts feel more fibrotic and palpable as linear, spoke-like strands. The nipples may turn in slightly and the areola and any hair surrounding it may nearly disappear. Pain upon palpation may indicate an infectious process or cancer. Breast tenderness, pain, or swelling may be side effects of hormone replacement therapy and an indication that a lower dosage is needed. Nipples that appear retracted and cannot be everted, or any retraction of only one nipple may indicate breast cancer. Male breast enlargement (gynecomastia) may result from a decrease in testosterone. Inspect skin under breasts. Skin intact without lesions or rashes. Macerated skin under the breasts may result from perspiration or fungal infection (usually seen in an immunocompromised client).

ANUS, RECTUM, AND PROSTATE ELDERLY

INSPECTION AND PALPATION Inspect the anus and rectum. The anus is darker than the surrounding skin. Bluish, grape-like lumps at the anus are indicators of hemorrhoids. Lesions, swelling, inflammation, and bleeding are abnormalities. If hemorrhoids account for discomfort, the degree to which bleeding, swelling, or inflammation interferes with bowel activity generally determines if treatment is warranted. Put on gloves to palpate the anus and rectum. Clinical Tip The left side-lying position with knees tucked up toward the chest is the preferred one for comfort. Pillows may be needed for positioning and client comfort. No masses, polyps, internal hemorrhoids, rectal prolapse, or fecal impaction palpated. Palpation of internal masses could indicate polyps, internal hemorrhoids, rectal prolapse, cancer, or fecal impaction. Obliteration of the median sulcus is felt with prostatic hyperplasia. Palpate the prostate in the male client. The prostate is normally soft or rubbery-firm and smooth, and the median sulcus is palpable. Some degree of enlargement (benign prostate hypertrophy [BPH]) almost always occurs by age 85, as does a decrease in amount and viscosity of seminal fluid. Sperm count may decrease by as much as 50%. Orgasm may be briefer and time to obtain an erection may increase. These changes alone, however, do not usually result in any loss of libido or satisfaction. A hard, asymmetrically enlarged, and nodular prostate is suggestive of malignancy (Swartz, 2014, p. 461). A tender and softer prostate is more common with prostatitis. Fever and painful urination are common with acute prostatitis. Obstructive symptoms are seen with both malignancy and infection of the prostate.

ANUS AND RECTUM CHILDREN AND ADOLESCENTS

INSPECTION AND PALPATION Inspect the anus. The anus should be inspected in children and adolescents. Perform quickly at the end of the genitalia examination to limit embarrassment in the older child and adolescent. Spread the buttocks with gloved hands, and note patency of anal opening, presence of any lesions and fissures, and condition and color of perianal skin. The anal opening should be visible, moist, and hairless. No hemorrhoids or lesions. Perianal skin should be smooth and free of lesions. Perianal skin tags may be noted. Imperforate anus (no anal opening) should be referred. Hemorrhoids are unusual in children and could be due to chronic constipation, but may be caused by sexual abuse or abdominal pressure from lesion. Bleeding and pain often indicate tears or fissures in the anus, which often cause constipation because of pain of passing stool. Pustules may indicate secondary infection of diaper rash. A dark ring around the anus may indicate heavy-metal poisoning. Lacerations, purulent discharge, or extreme apprehension during examination may indicate physical or sexual abuse. Palpate rectum. This internal examination is not routinely performed in children or adolescents. However, it should be performed if symptoms suggest a problem. The child should be in a supine position with the legs flexed. Provide reassurance throughout the examination. If the child is old enough, ask the child to bear down. This helps to relax the sphincter. Slowly insert a gloved, lubricated finger (the pinky finger may be used for comfort, but the index finger is more sensitive) into the anal opening, aiming the finger toward the umbilicus. Prostate gland is nonpalpable in young boys. Bimanual rectoabdominal examination in girls may reveal small midline mass (cervix). If other masses are palpated, they are considered abnormal; no other structures are palpable until adolescence.

VAGINITIS

In assessing female genitalia, the nurse may suspect vaginal infection from signs such as redness or lack of color, unusual discharge and secretions, reported itching, and other typical symptoms of the kinds of vaginitis discussed here.

CHILDREN AND ADOLESCENTS BREAST

Inspect and palpate breasts. Note shape, symmetry, color, tenderness, discharge, lesions, and masses. Breasts are flat and symmetric in prepubertal children. Obese children may appear to have breast tissue. Redness, edema, and tenderness indicate mastitis. Enlargement in adolescent boys suggests gynecomastia. Masses in the adolescent female breast usually indicate cysts or trauma. Assess stage of breast/sexual development of girl client. Teach breast self-examination to adolescents. See Tanner's sexual maturity rating in Table 31-1. Breast development before age 8 may indicate precocious puberty or thelarche. Lack of breast development after age 13 may indicate delayed puberty and/or a pathologic process.

NEWBORN

Inspect and palpate breasts. Note shape, symmetry, color, tenderness, discharge, lesions, and masses. Newborns may have enlarged and engorged breasts with a white liquid discharge resulting from the influence of maternal hormones (Fig. 30-20). This condition resolves spontaneously within days. A palpable mass of the breast is abnormal. The newborn or infant may have extra nipples noted on the chest or abdomen, called supernumerary nipples. Inspect the shape of the abdomen. In infants, the abdomen is prominent in supine position. A scaphoid (boat-shaped; i.e., sunken with prominent rib cage) abdomen may result from malnutrition or dehydration. Distended abdomen may indicate pyloric stenosis. Inspect umbilicus. Note color, discharge, evident herniation of the umbilicus. Umbilicus is pink, with no discharge, odor, redness, or herniation. Cord should demonstrate three vessels (two arteries and one vein). Remnant of cord should appear dried 24-48 hours after birth. Inflammation, discharge, and redness of umbilicus suggest infection. Diastasis recti (separation of the abdominal muscles) is seen as a midline protrusion from the xiphoid to the umbilicus or pubis symphysis. This condition is secondary to immature musculature of abdominal muscles and usually has little significance. As the muscles strengthen, the separation resolves on its own. A bulge at the umbilicus suggests an umbilical hernia (Fig. 30-22), which may be seen in newborns; many disappear by the age of 1 year. Cultural Considerations Umbilical hernias are seen more frequently in African American children. Abnormal insertion of cord, discolored cord, or two-vessel cord could indicate genetic abnormalities; however, these are also seen in newborns without abnormalities. FIGURE 30-22 Umbilical hernia. Auscultate bowel sounds. Follow auscultation guidelines for adult clients provided in Chapter 23. Normal bowel sounds occur every 10-30 seconds. They sound like clicks, gurgles, or growls. Marked peristaltic waves almost always indicate a pathologic process such as pyloric stenosis. Palpate for masses and tenderness. Palpate abdomen for softness or hardness. Abdomen is soft to palpation and without masses or tenderness. A rigid abdomen is almost always an emergent problem. Masses or tenderness warrants further investigation. Hirschsprung disease could also be considered, especially with a rigid abdomen. The most common finding is failure to have a bowel movement within 48 hours after birth. Palpate liver. Palpate the liver the same as you would for adults (see Chapter 23). Liver is usually palpable 1-2 cm below the right costal margin in young children. The liver is hard to palpate in the newborn. An enlarged liver with a firm edge that is palpated more than 2 cm below the right costal margin usually indicates a pathologic process. Palpate spleen. Palpate the spleen the same as you would for adults. Spleen tip may be palpable during inspiration. The spleen is difficult to palpate in the newborn. Enlarged spleen is usually indicative of a pathologic process. Palpate kidneys. Palpate the kidneys the same as you would for adults. The tip of the right kidney may be palpable during inspiration. Enlarged kidneys are usually indicative of a pathologic process. Palpate bladder. Palpate the bladder the same as you would for adults. Bladder may be slightly palpable in infants and small children. An enlarged bladder is usually due to urinary retention but may be due to a mass.

Inspection and Palpation of the axillae

Inspect and palpate the axillae. Ask the client to sit up. Inspect the axillary skin for rashes or infection. NF: No rash or infection noted. Hold the client's elbow with one hand, and use the three fingerpads of your other hand to palpate firmly the axillary lymph nodes. · First palpate high into the axillae, moving downward against the ribs to feel for the central nodes. Continue to move down the posterior axillae to feel for the posterior nodes. Use bimanual palpation to feel for the anterior axillary nodes. Finally palpate down the inner aspect of the upper arm. NF: No palpable nodes or one to two small (less than 1 cm), discrete, nontender, movable nodes in the central area.

Inspection and Palpation Preggo Breasts

Inspect and palpate the breasts and nipples for symmetry and color (Fig. 29-7). NF: Venous congestion is noted with prominence of veins. Montgomery tubercles are prominent. Breast size is increased and nodular. Breasts are more sensitive to touch. Colostrum is excreted, especially in the third trimester. Hyperpigmentation of nipples and areolae is evident

Inspection and Palpation of Male Breasts

Inspect and palpate the breasts, areolas, nipples, and axillae. Note any swelling, nodules, or ulceration. Palpate the flat disc of undeveloped breast tissue under the nipple. EF: No swelling, nodules, or ulceration should be detected. Soft

GENITALIA FOR ELDERLY

Inspect external genitalia. Assist the client into the lithotomy position. Inspect the urethral meatus and vaginal opening. Many atrophic changes begin in women at menopause. Pubic hair is usually sparse, and labia are flattened. Clitoris is decreased in size. The size of the ovaries, uterus, and cervix also decreases. Redness or swelling from the urethral meatus indicates a possible UTI. Clinical Tip Arthritis may make the lithotomy position particularly uncomfortable for the older woman, necessitating changes. If the client has breathing difficulties, elevating the head to a semi-Fowler position may help. Ask the client to cough while in the lithotomy position. Clinical Tip Incontinence is not a normal part of aging. If embarrassment or acceptance is preventing the client from acknowledging the problem, the genital examination may be a more acceptable time to introduce the topic. No leakage of urine occurs. Leakage of urine that occurs with coughing is a sign of stress incontinence and may be due to lax pelvic muscles from childbirth, surgery, obesity, cystocele, rectocele, or a prolapsed uterus. Clinical Tip In noncommunicative clients, an excoriated perineum may be the result of incontinence, which warrants further investigation. Test for prolapse. Ask the client to bear down while you observe the vaginal opening. No prolapse is evident. A protrusion into the vaginal opening may be a cystocele, rectocele, or uterine prolapse, which is a common sequelae of relaxed pelvic musculature in older women. Perform a pelvic examination. Put on disposable gloves and use a small speculum if the vaginal opening has narrowed with age. Use lubrication on the speculum and hand because natural lubrication is decreased. Vagina narrows and shortens. A loss of elastic tissue and vascularity in the vagina results in a thin, pale epithelium. Atrophic changes are intensified by infrequent intercourse. Loss of elasticity and reduced vaginal lubrication from diminishing levels of estrogen can cause dyspareunia (painful intercourse). Sexual desire and pleasure are not necessarily diminished by these structural changes, nor do women lose capacity for orgasm with age. Because the ovaries, uterus, and cervix shrink with age, the ovaries may not be palpable. Atrophic vaginitis symptoms can mimic malignancy, vulvar dystrophies, and infections (MacBride et al., 2010). Test pelvic muscle tone. Ask the woman to squeeze muscles while the examiner's finger is in the vagina. Assess perineal strength by turning fingers posterior to the perineum while the woman squeezes muscles in the vaginal area. The vaginal wall should constrict around the examiner's finger, and the perineum should feel smooth. If the client has a cystocele, the examiner's finger in the vagina will feel pressure from the anterior surface of the vagina. In clients with uterine prolapse, protrusion of the cervix is felt down through the vagina. A bulging of the posterior vaginal wall and part of the rectum may be felt with a rectocele. MALE Inspect the male genital area with the client in standing position if possible. The decline in testosterone brings about atrophic changes. Pubic hair is thinner. Scrotal skin is slightly darker than surrounding skin, and is smooth and flaccid in the older man. Penis and testicular size decrease, scrotum hangs lower. Scrotal edema may be present with portal vein obstruction or heart failure. Lesions on the penis may be a sign of infection. Associated symptoms of infection frequently include discharge, scrotal pain, and difficulty with urination. Observe and palpate for inguinal swelling or bulges suggestive of hernia in the same manner as for a younger male. No swelling or bulges are present. Masses or bulges are abnormal, and pain may be a sign of testicular torsion. A mass may be due to a hydrocele, spermatocele, or cancer. Auscultate the scrotum if a mass is detected; otherwise, palpate the right and left testicle using the thumb and first two fingers. No detectable sounds or masses are present. Bowel sounds heard over the scrotum may suggest an indirect inguinal hernia. Masses are abnormal, and the client should be referred to a specialist for follow-up examination.

CHILDREN AND ADOLESCENTS FEMALE GENITALIA

Inspect external genitalia. Note labia majora, labia minora, vaginal orifice, urinary meatus, and clitoris. Clinical Tip Have female children assist with genitalia examination by using their hands to spread the labia. This helps to decrease any stress and embarrassment. Labia majora and minora are pink and moist. Young girls have flattened majora, thin minora, small clitoris, and thin hymen. Starting at school age, the labia become fuller and the hymen thickens. This progresses until puberty, when the genitalia develop adult characteristics. No discharge from vagina or meatus; no redness or edema present normally. Partial or complete labia minora adhesions are sometimes seen in girls younger than 4 years of age. Referral is necessary to disintegrate the thin, membranous adhesion. An imperforate hymen (no central orifice) is sometimes seen and is not significant unless it persists until puberty and causes problems with menstruation. Discharge from vagina or urinary meatus, redness, edema, or lacerations may suggest abuse in the young child. However, infections or a foreign body in the vagina may cause these symptoms. Discharge in adolescents suggests STI, infection, or irritation. Inspect internal genitalia. An internal genitalia examination is not routinely performed in the child although it may be called for if infection, bleeding, a foreign body, disease, or sexual abuse is suspected. A pediatric specialist should perform the examination. An internal genital examination consisting of both the speculum and bimanual examinations is recommended for all sexually active adolescents. An internal examination may be indicated in the adolescent who has discharge or suspects an STI. The procedure is the same as for the adult. Time and care must be taken for adequate teaching and reassurance. See Chapter 27 for normal findings. See Chapter 27 for abnormal findings. Assess sexual development. Note pubic hair pattern. See Tanner's Sexual Maturity Ratings in Table 31-3 for normal findings. Growth of pubic hair in young girls (<8 years of age) suggests precocious puberty. Unusual pubic hair distribution in pubertal girls may indicate a disorder. For example, a male pattern of hair growth may suggest polycystic ovary disease.

NEWBORN FEMALE GENITALIA

Inspect external genitalia. Note labia majora, labia minora, vaginal orifice, urinary meatus, and clitoris. Labia majora and minora are pink and moist. Newborn's genitalia may appear prominent because of influence of maternal hormones. Bruises and swelling may be caused by breech vaginal delivery. Pseudomenstruation (blood-tinged discharge), smegma (cheesy white discharge) of the sebaceous gland. Reddish, orange, pink-tinged urine, or stains on diaper may also be normal due to uric acid crystals. Enlarged clitoris in newborn combined with fusion of the posterior labia majora suggests ambiguous genitalia. In girls, breast growth is stimulated by estrogen at the onset of puberty. Between 8 and 13 years of age, thelarche (breast development) may occur; breasts continue to develop in stages (Table 31-1). Breasts enlarge primarily as a result of fat deposits. However, the duct system also grows and branches, and masses of small cells develop at the duct endings. These masses are potential alveoli. Tenderness and asymmetric development are common, and anticipatory guidance and reassurance are needed. Gynecomastia, enlargement of breast tissue in boys, may be noted in some male adolescents. This is related to pubertal changes and is usually temporary. However, use of marijuana and anabolic steroids are two of several external causes of gynecomastia. The abdomen of small children is cylindrical, prominent in the standing position, and flat when supine. The abdomen of toddlers appears prominent and gives the child what is popularly called a pot-belly appearance. The contours of the abdomen change to adult shapes during adolescence. Peristaltic waves may be visible in thin children; they may also be indicative of a disease or disorder. The tip of the right kidney may be felt in young children, especially during inspiration. In small children, the liver is palpable at 1 to 2 cm below the right costal margin. The spleen may be palpable below the left costal margin at 1 to 2 cm. Often, in older children these structures are not palpable.

Inspection of inguinal area

Inspect for inguinal and femoral hernia. Inspect the inguinal and femoral areas for bulges. Ask the client to turn head and cough or to bear down as if having a bowel movement, and continue to inspect the areas. EF: The inguinal and femoral areas are normally free from bulges.

Internal Genitalia

Inspect internal genitalia (refer to gynecologic examination in textbook). Insert speculum into the vagina. Visualize the cervix, noting position and color. Obtain Pap smear and cultures if indicated. Withdraw speculum. EF: Cervix should look pink, smooth, and healthy. With pregnancy, the cervix may appear bluish (Chadwick sign). In multiparous women, the cervical opening has a slit-like appearance known as "fish mouth." A small amount of whitish vaginal discharge (leukorrhea) is normal. AF: Gonorrhea infection may present with thick, purulent vaginal discharge. A thick, white, cheesy discharge presents with a yeast infection. Grayish-white vaginal discharge, positive "whiff test" (fishy odor), and clue cells positive on microscopic wet prep (epithelial cells that have been invaded by disease-causing bacteria) are evidence of bacterial vaginosis. Perform pelvic examination. Put on gloves lubricated with water or KY jelly, gently insert fingers into the vagina, and palpate the cervix. Estimate the length of the cervix by palpating the lateral surface of the cervix from the cervical tip to the lateral fornix. EF: The cervix may be palpated in the posterior vaginal vault. It should be long, thick, and closed. Cervical length should be approximately 2.3-3 cm. Positive Hegar sign (softening of the lower uterine segment) should be present AF: An effaced opened cervix may indicate an incompetent cervix if gestation is not at term, or preterm labor Feel for uterus. While leaving the fingers in the vagina, place the other hand on the abdomen and gently press down toward the internal hand until you feel the uterus between the two hands. EF: The uterus should feel about the size of an orange at 10 weeks (palpable at the suprapubic bone) and about the size of a grapefruit at 12 weeks. AF: If uterine size is not consistent with dates, consider wrong dates, uterine fibroids, or multiple gestation. Palpate the left and right adnexa. EF: No masses should be palpable. Discomfort with examination is due to stretching of the round ligaments throughout the pregnancy. AF: Adnexal masses may indicate ectopic pregnancy

CHILDREN AND ADOLESCENTS MALE GENITALIA

Inspect penis and urinary meatus. Inspect the genitalia, observing size for age and any lesions. Clinical Tip Use distraction or teaching (such as testicular self-examination) when examining the genitalia in older children and adolescents to decrease embarrassment. Penis is normal size for age, and no lesions are seen. The foreskin is retractable in uncircumcised child. Urinary meatus is at the tip of the glans penis and has no discharge or redness. Penis may appear small in obese boys because of overlapping skin folds. An unretractable foreskin in a child older than 3 months suggests phimosis. Paraphimosis is indicated when the foreskin is tightened around the glans penis in a retracted position. Hypospadias, urinary meatus on the ventral surface of the glans, and epispadias, urinary meatus on the dorsal surface of the glans, are congenital disorders (see Abnormal Findings 26-1). Discharge, redness, or lacerations may indicate abuse in young children but may occur from infections or a foreign body. Discharge in adolescents may be due to STI, infection, or irritation. Inspect and palpate scrotum and testes. To rule out cryptorchidism, it is important to palpate for testes in the scrotum in young boys. Clinical Tip When palpating the testicles of a young boy, you must keep the cremasteric reflex in mind. This reflex pulls the testicles up into the inguinal canal and abdomen and is elicited in response to touch, cold, or emotional factors. Have young boys sit with knees flexed and abducted. This lessens the cremasteric reflex and enables you to examine the testicles. Scrotum is free of lesions. Testes are palpable in the scrotum, with the left testicle usually lower than the right. Testes are equal in size, smooth, mobile, and free of masses. If a testicle is missing from the scrotal sac but the scrotal sac appears well developed, suspect physiologic cryptorchidism. The testis has originally descended into the scrotum but has moved back up into the inguinal canal because of the cremasteric reflex and the small size of the testis. You should be able to milk the testis down into the scrotum from the inguinal canal. This normal condition subsides at puberty. Absent testicle(s) and atrophic scrotum suggest true cryptorchidism (undescended testicles; see Chapter 26). This suggests that the testicle(s) never descended. This condition occurs more frequently in preterm than term infants because testes descend at 8 months of gestation. It can lead to testicular atrophy and infertility, and increases the risk for testicular cancer. Hydroceles are common in infants. They are fluid-filled masses that can be transilluminated (see Abnormal Findings 26-2). They usually resolve spontaneously. A scrotal hernia is usually caused by an indirect inguinal hernia that has descended into the scrotum. It can usually be pushed back into the inguinal canal. This mass will not transilluminate. A painless nodule on the testis may indicate testicular cancer, which appears most frequently in males aged 15-34 years; therefore, testicular self-examination (TSE) should be taught to all boys 14 years old and older. Inspect and palpate inguinal area for hernias. Observe for any bulge in the inguinal area. Ask the child to bear down or try to lift something heavy to elicit a possible hernia. Using your pinky finger, palpate up the inguinal canal to the external inguinal ring if a hernia is suspected. No inguinal hernias are present. A bulge in the inguinal area or palpation of a mass in the inguinal canal suggests an inguinal hernia. Indirect inguinal hernias occur most frequently in children (see Chapter 26). Assess sexual development. Note public hair pattern, and size and development of penis and scrotum. See Tanner's Sexual Maturity Ratings in Table 31-2. Pubic hair growth, enlargement of the penis to adolescent or adult size, and enlarged testes in a boy less than 8 years of age suggest precocious puberty.

NEWBORN MALE GENITALIA

Inspect penis and urinary meatus. Inspect the genitalia, observing size for age and any lesions. Penis is normal size for age, and no lesions are seen. Diaper rash, however, is a common finding in infants (Fig. 30-23). The foreskin is retractable in uncircumcised child. Urinary meatus is at tip of glans penis and has no discharge or redness. Penis may appear small in large for gestational age (LGA) boys because of overlapping skin folds. For circumcised boys, the site is dry with minimal swelling and drainage. An unretractable foreskin in a child older than 3 months suggests phimosis. Paraphimosis is indicated when the foreskin is tightened around the glans penis in a retracted position. Hypospadias (urinary meatus on the ventral surface of glans) and epispadias (urinary meatus on dorsal surface of glans) are congenital disorders (see Chapter 26). Circumcision has become a topic of discussion due to increased anti-circumcision activism (Strobbe, 2014). Strobbe quotes findings and conclusions by the CDC and other researchers about circumcision: Circumcision is a personal decision often based on cultural or religious beliefs. Studies in Africa have suggested that circumcision may reduce the spread of HIV-AIDS; the benefits of circumcision have become even more clear over the last 10 years of studies in Africa. Acceptance of circumcision has swung widely in the United States from about 25% of males in 1900, to a high of 64.9% in 1981, and back down to about 58% in 2010. Stobbe lists the reasons for the CDC's conclusion, based on strong evidence, that male circumcision can: Cut a man's risk by 50-60% of becoming infected with HIV from an infected female partner Reduce the risk by 30% of becoming infected with genital herpes or human papilloma virus Lower the risk of UTI in infancy and of cancer of the penis in adulthood However, research evidence does not show that circumcision can stop the spread of AIDS to women or to a same sex partner. The final conclusion is that the decision to circumcise or not is personal, even in light of the evidence. When palpating the testicles in the infant, you must keep the cremasteric reflex in mind. This reflex pulls the testicles up into the inguinal canal and abdomen, and is elicited in response to touch, cold, or emotional factors. Scrotum is free of lesions. Testes are palpable in scrotum, with the left testicle usually lower than the right. Testes are equal in size, smooth, mobile, and free of masses. If a testicle is missing from the scrotal sac but the scrotal sac appears well developed, suspect physiologic cryptorchidism. The testis has originally descended into the scrotum but has moved back up into the inguinal canal because of the cremasteric reflex and the small size of the testis. You should be able to milk the testis down into the scrotum from the inguinal canal. This normal condition subsides at puberty. Absent testicle(s) and atrophic scrotum suggest true cryptorchidism (undescended testicles). This suggests that the testicle(s) never descended. This condition occurs more frequently in preterm than term infants because testes descend at 8 months of gestation. It can lead to testicular atrophy and infertility, and increases the risk for testicular cancer. Hydroceles are common in infants. They are a collection of fluid along the spermatic cord within the scrotum that can be transilluminated (see Chapter 26, Abnormal Findings 26-2). They usually resolve spontaneously. A scrotal hernia is usually caused by an indirect inguinal hernia that has descended into the scrotum. It can usually be pushed back into the inguinal canal. This mass will not transilluminate. Inspect and palpate inguinal area for hernias. Observe for any bulge in the inguinal area. Using your pinky finger, palpate up the inguinal canal to the external inguinal ring if a hernia is suspected. No inguinal hernias are present. A bulge in the inguinal area or palpation of a mass in the inguinal canal suggests an inguinal hernia. Indirect inguinal hernias occur most frequently in children (see Chapter 26).

Inspection of female breasts

Inspect size and symmetry. Have the client disrobe and sit with arms hanging freely (Fig. 20-6). Explain what you are observing to help ease client anxiety. NF: Breasts can be a variety of sizes and are somewhat round and pendulous. One breast may normally be larger than the other. Inspect color and texture. Be sure to note client's overall skin tone when inspecting the breast skin. Note any lesions. NF: Color varies depending on the client's skin tone. Texture is smooth, with no edema. Inspect superficial venous pattern. Observe visibility and pattern of breast veins. NF: Veins radiate either horizontally and toward the axilla (transverse) or vertically with a lateral flare (longitudinal). Veins are more prominent during pregnancy. Inspect the areolas. Note the color, size, shape, and texture of the areolas of both breasts. NF: Areolas vary from dark pink to dark brown, depending on the client's skin tones. They are round and may vary in size. Small Montgomery tubercles are present. Inspect the nipples. Note the size and direction of the nipples of both breasts. Also note any dryness, lesions, bleeding, or discharge. EF: Nipples are nearly equal bilaterally in size and are in the same location on each breast. Nipples are usually everted, but they may be inverted or flat. Supernumerary nipples (Fig. 20-7) may appear along the embryonic "milk line." · No discharge should be present. Inspect for retraction and dimpling. To inspect the breasts accurately for retraction and dimpling, ask the client to remain seated while performing several different maneuvers. Ask the client to raise her arms overhead (Fig. 20-8A); then press her hands against her hips (Fig. 20-8B). Next ask her to press her hands together (Fig. 20-8C). These actions contract the pectoral muscles. EF: The client's breasts should rise symmetrically, with no sign of dimpling or retraction. Finally, ask the client to lean forward from the waist (Fig. 20-9). The nurse should support the client by the hands or forearms. This is a good position to use in women who have large, pendulous breasts. EF: Breasts should hang freely and symmetrically.

Check stool

Inspect the stool. Withdraw your gloved finger. Inspect any fecal matter on your glove. Assess the color, and test the feces for occult blood. Provide the client with a towel to wipe the anorectal area. EF:Stool is normally semi-solid, brown, and free of blood.

Inspection and Palpation of Penis

Inspect the base of the penis and pubic hair. Sit on a stool with the client facing you and standing (Fig. 26-6). Ask the client to raise his gown or drape. Note pubic hair growth pattern and any excoriation, erythema, or infestation at the base of the penis and within the pubic hair. EF: Pubic hair is coarser than scalp hair. The normal pubic hair pattern in adults is hair covering the entire groin area, extending to the medial thighs and up the abdomen toward the umbilicus. The base of the penis and the pubic hair are free of excoriation, erythema, and infestation (Fig. 26-7). Inspect the skin of the shaft. Observe for rashes, lesions, or lumps. EF: The skin of the penis is wrinkled and hairless and is normally free of rashes, lesions, or lumps. Genital piercing is becoming more common, and nurses may see male clients with one or more piercings of the penis. Palpate the shaft. Palpate any abnormalities noted during inspection. Also note any hardened or tender areas. EF: The penis in a nonerect state is usually soft, flaccid, and nontender. Inspect the foreskin. Observe for color, location, and integrity of the foreskin in uncircumcised men. EF: The foreskin, which covers the glans in an uncircumcised male client, is intact and uniform in color with the penis. Inspect the glans. Observe for size, shape, and lesions or redness. EF: The glans size and shape vary, appearing rounded, broad, or even pointed. The surface of the glans is normally smooth, free of lesions and redness. If the client is not circumcised, ask him to retract his foreskin (if the client is unable to do so, the nurse may retract it) to allow observation of the glans. This may be painful. EF: The foreskin retracts easily. A small amount of whitish material, called smegma, normally accumulates under the foreskin. Note the location of the urinary meatus on the glans. EF: The urinary meatus is slit-like and normally found in the center of the glans. Palpate for urethral discharge. Gently squeeze the glans between your index finger and thumb EF: The urinary meatus is normally free of discharge.

External gentalia

Inspect the external genitalia. Note hair distribution, color of skin, varicosities, and scars. EF: Normal findings include enlarged labia and clitoris, parous relaxation of the introitus, and scars from an episiotomy or perineal lacerations (in multiparous women). AF: Labial varicosities, which can be painful. Evidence of female genital cutting Palpate Bartholin and Skene glands. EF: There should be no discomfort or discharge with examination. AF: Discomfort and discharge noted with palpation may indicate infection. Inspect vaginal opening for cystocele or rectocele. EF: No cystocele or rectocele. AF: Cystocele or rectocele may be more pronounced because of the muscle relaxation of pregnancy.

External Genitalia assessment

Inspect the mons pubis. Wash your hands and put on gloves. As you begin the examination, note the distribution of pubic hair. Also be alert for signs of infestation. NF: Pubic hair is distributed in an inverted triangular pattern and there are no signs of infestation. Some clients may have piercing of the genital area. Observe and palpate inguinal lymph nodes. NF: There should be no enlargement or swelling of the lymph nodes. Inspect the labia majora and perineum. Observe the labia majora and perineum for lesions, swelling, and excoriation. NF: The labia majora are equal in size and free of lesions, swelling, and excoriation. A healed tear or episiotomy scar may be visible on the perineum if the client has given birth. The perineum should be smooth. NF: Keep in mind the woman's childbearing status during inspection. For example, the labia of a woman who has not delivered offspring vaginally will meet in the middle. The labia of a woman who has delivered vaginally will not meet in the middle and may appear shriveled. Inspect the labia minora, clitoris, urethral meatus, and vaginal opening. Use your gloved hand to separate the labia majora and inspect for lesions, excoriation, swelling, and/or discharge NF: The labia minora appear symmetric, dark pink, and moist. The clitoris is a small mound of erectile tissue, sensitive to touch. The normal size of the clitoris varies. The urethral meatus is small and slit-like. The vaginal opening is positioned below the urethral meatus. Its size depends on sexual activity or vaginal delivery. A hymen may cover the vaginal opening partially or completely. Palpate Bartholin glands. If the client has labial swelling or a history of it, palpate Bartholin glands for swelling, tenderness, and discharge (Fig. 27-9). Place your index finger in the vaginal opening and your thumb on the labia majora. With a gentle pinching motion, palpate from the inferior portion of the posterior labia majora to the anterior portion. Repeat on the opposite side. NF: Bartholin glands are usually soft, nontender, and drainage free. Palpate the urethra. If the client reports urethral symptoms or urethritis, or if you suspect inflammation of Skene glands, insert your gloved index finger into the superior portion of the vagina and milk the urethra from the inside, pushing up and out NF: No drainage should be noted from the urethral meatus. The area is normally soft and nontender.

Inspection of Anus and Rectum

Inspect the perianal area. Spread the client's buttocks and inspect the anal opening and surrounding area (Fig. 26-14) for the following: · Lumps · Ulcers · Lesions · Rashes · Redness · Fissures · Thickening of the epithelium EF: The anal opening should appear hairless, moist, and tightly closed. The skin around the anal opening is coarser and more darkly pigmented. The surrounding perianal area should be free of redness, lumps, ulcers, lesions, and rashes. Ask the client to perform Valsalva's maneuver by straining or bearing down. Inspect the anal opening for any bulges or lesions. EF: No bulging or lesions appear. Inspect the sacrococcygeal area. Inspect this area for any signs of swelling, redness, dimpling, or hair. EF: Area is normally smooth, and free of redness and hair.

Internal Gentialia

Inspect the size of the vaginal opening and the angle of the vagina. Insert your gloved index finger into the vagina, noting the size of the opening and whether the lining of the vagina is thinning or feels dry. Then attempt to touch the cervix. This will help you establish the size of the speculum you need to use for the examination and the angle at which to insert it. Next, while maintaining tension, gently pull the labia majora outward. Note hymenal configuration and transections or injury. EF: The normal vaginal opening varies in size according to the client's age, sexual history, and whether she has given birth vaginally. The vagina is typically tilted posteriorly at a 45-degree angle and should feel moist. Inspect the vaginal musculature. Keep your index finger inserted in the client's vaginal opening. Ask the client to squeeze around your finger. EF: The client should be able to squeeze around the examiner's finger. Typically, the nulliparous woman can squeeze tighter than the multiparous woman. Use your middle and index fingers to separate the labia minora. Ask the client to bear down. EF: No bulging and no urinary discharge. Inspect the cervix. Follow the guidelines for using a speculum in Assessment Guide 27-1. With the speculum inserted in position to visualize the cervix, observe cervical color, size, and position. Also observe the surface and the appearance of the os. Look for discharge and lesions. EF: The surface of the cervix is normally smooth, pink, and even. Normally, it is midline in position and projects 1 to 3 cm into the vagina. In pregnant clients, the cervix appears blue (Chadwick sign). After inspecting the cervix, obtain specimens for the Pap smear and, if indicated, specimens for culture and sensitivity testing to identify possible STIs EF: Cervical secretions are normally clear or white and without unpleasant odor. Secretions may vary according to timing within the menstrual cycle. After inspecting the cervix, obtain specimens for the Pap smear and, if indicated, specimens for culture and sensitivity testing to identify possible STIs. Follow the procedure presented in Assessment Guide 27-2. Inspect the vagina. Unlock the speculum and slowly rotate and remove it. Inspect the vagina as you remove the speculum. Note the vaginal color, surface, consistency, and any discharge. If you are preparing a wet mount slide, use a cotton swab to collect the specimen of vaginal secretions from the anterior vaginal fornix or the lateral vaginal walls before you collect the specimens for the Pap or other test. Avoid the posterior fornix, which is contaminated with cervical secretions. Use part of the wet mount sample to test the pH of the vaginal secretions. EF: The vagina should appear pink, moist, smooth, and free of lesions and irritation. It should also be free of any colored or malodorous discharge.

Inspection of scotum

Inspect the size, shape, and position of the scrotum. Ask the client to hold his penis out of the way. Observe for swelling, lumps, or bulges. EF: The scrotum varies in size (according to temperature) and shape. The scrotal sac hangs below or at the level of the penis. The left side of the scrotal sac usually hangs lower than the right side. Inspect the scrotal skin. Observe color, integrity, and lesions or rashes. To perform an accurate inspection, you must spread out the scrotal folds (rugae) of skin (Fig. 26-9). Lift the scrotal sac to inspect the posterior skin. EF: Scrotal skin is thin and rugated, (crinkled) with little hair dispersion. Its color is slightly darker than that of the penis. Lesions and rashes are not normally present. However, sebaceous cysts (small, yellowish, firm, nontender, benign nodules) are a normal finding.

OVARIAN CANCER

Masses that are cancerous are usually solid, irregular, nontender, and fixed.

Steps for Abdomen assessment

Inspection, Auscultation, Percussion, and Palpation

in contrast, during the second half of pregnancy, tissue sensitivity to insulin progressively decreases, producing hyperglycemia and hyperinsulinemia.

Insulin resistance becomes maximal in the latter half of the pregnancy (and this is when gestational diabetes is more likely to occur)

A trusting relationship is key to a successful interview.

Keep in mind that serious or life-threatening problems may be present. Testicular cancer, for example, carries a high mortality rate, especially if not detected early. The information gathered during this portion of the health history interview provides a basis for teaching about important health screening issues such as testicular self-examination. It also is a good time to teach the client about risk factors related to diseases, such as HIV, colorectal or prostate cancer, and about ways to decrease those risk factors. Additionally, explore in some depth with a symptom analysis any symptoms that the client reports or hints about.

ABDOMEN FOR ELDERLY

MOTILITY Assess GI motility and auscultate bowel sounds. Review fiber intake and laxative use. Clinical Tip Risk of constipation is increased by diminished physical activity, decreased fluid intake, decreased fiber in diet, and by ingestion of certain medications, such as iron or narcotics. 5-30 bowel sounds/min are heard. A decrease in gastric emptying time occurs with aging and may cause early satiety. Intestinal motility is generally reduced from a general loss of muscle tone. Absence of bowel sounds and vomiting of undigested food is abnormal. Decreased motility is exacerbated by common pathologies such as Parkinson disease, stroke, and diabetes mellitus. Results in propensity for chronic constipation and diverticula. If diverticula become infected, emergency treatment may be required to prevent perforation and sepsis. Hiatal hernia that manifests by postprandial chest fullness, heartburn, or nausea. Determine absorption or retention problems in older adult clients receiving enteral feedings. Clinical Tip An abdominal radiograph, flat plate, should be taken to check for correct placement of newly inserted nasogastric tubes. Less than 100 mL residual is a normal finding for intermittent feedings. More than 100 mL residual measured before a scheduled feeding is a sign of insufficient absorption and excessive retention. Abdominal distention, diarrhea, fluid overload, aspiration pneumonia, or fluid/electrolyte imbalances may indicate excessive retention although mental status changes may be the first or only sign. Inspect and percuss the abdomen in the same manner as for younger adults. Clinical Tip The loss of abdominal musculature that occurs with aging may make it easier to palpate abdominal organs. Liver, pancreas, and kidneys normally decrease in size, but the decrease is not generally appreciable upon physical examination. Atrophy of intestinal villi is a common aging change. Anorexia, abdominal pain and distention, impaired protein digestion, and vitamin B12 malabsorption suggest inflammatory gastritis or a peptic ulcer. Abdominal distention, cramping, diarrhea, and increased flatus are signs of lactose intolerance, which may occur for the first time in old age. Bruits over aorta suggest an aneurysm. If present, do not palpate because this could rupture the aneurysm. Guarding upon palpation, rebound tenderness, or a friction rub (sounds like pieces of sandpaper rubbing together) often suggests peritonitis, which could be secondary to ruptured diverticuli, tumor, or infarct. Palpate the bladder. (Ask client to empty bladder before the examination.) If the bladder is palpable, percuss from symphysis pubis to umbilicus. If the client is incontinent, postvoid residual content may also need to be measured. Empty bladder is not palpable or percussible. Full bladder sounds dull. More than 100 mL drained from bladder is considered abnormal for a postvoid residual. A distended bladder with an associated small-volume urine loss may indicate overflow incontinence (see Box 32-4).

ADOLESCENT GENTITALIA

Male genitalia generally develop over a 2- to 5-year period, beginning from preadolescence to adulthood. In the adolescent male, enlargement of the testes is an early sign of puberty, occurring between the ages of 9.5 and 13.5 years. Pubic hair signifies the onset of puberty in boys. Pubic hair development and penile enlargement are concurrent with testicular growth (Table 31-2). Axillary hair development occurs late in puberty. It follows definitive penile and testicular enlargement in boys. Facial hair in boys also develops at this time. The onset of spontaneous nocturnal emission of seminal fluid is a sign of puberty similar to menarche in females. During puberty, the prostate gland grows rapidly to twice its prepubertal size under the influence of androgens. In female adolescents, puberty is the time that estrogen stimulates the development of the reproductive tract and secondary sex characteristics. The external genitalia increase in size and sensitivity, whereas the internal reproductive organs increase in weight and mass. Pubic hair begins growing early in puberty (2 to 6 months after thelarche) and follows a distinct pattern (Table 31-3). Axillary hair development precedes menarche (first menstrual period) in girls. Menarche takes place in the latter half of puberty after breast and pubic hair begin to develop. Menarche typically begins 2.5 years after the onset of puberty. The menstrual cycle is usually irregular during the first 2 years because of physiologic anovulation.

Fundal height

Measure fundal height. Do this by placing one hand on each side of the abdomen and walk hands up the sides of the uterus until you feel the uterus curve; hands should meet. Take a tape measure and place the zero point on the symphysis pubis and measure to the top of the fundus EF: Uterine size should approximately equal the number of weeks of gestation (e.g., the uterus at 28 weeks' gestation should measure approximately 28 cm) (Fig. 29-12). Measurements may vary by about 2 cm and examiners' techniques may vary, but measurements should be about the same. AF: Measurements beyond 4 cm of gestational age need to be further evaluated. Measurements greater than expected may indicate a multiple gestation, polyhydramnios (excess of amniotic fluid), fetal anomalies, or macrosomia (great increase in size similar to obesity). Measurements smaller than expected may indicate intrauterine growth retardation.

Rovsing sign

Pain in the RLQ during pressure in the LLQ Acute appendicitis

Obturator sign

Pain in the RLQ when hip and knee are flexed and leg is rotated internally and externally Irritation of the obturator muscle due to appendicitis or a perforated appendix.

The Mayo Clinic (2014) and UMPC (2016) list factors that increase the chances of developing GERD:

Obesity Hiatal hernia Pregnancy Smoking (weakens esophageal sphincter) Dry mouth Asthma Diabetes Delayed stomach emptying Connective tissue disorders, such as scleroderma Alcohol consumption (weakens esophageal sphincter)

· FAT

Obesity accounts for most uniformly protuberant abdomens. The abdominal wall is thick, and tympany is the percussion tone elicited. The umbilicus usually appears sunken.

Inspection for Abdomen

Observe the coloration of the skin. EF: Abdominal skin may be paler than the general skin tone because this skin is so seldom exposed to the natural elements. Note the vascularity of the abdominal skin. EF: Scattered fine veins may be visible. Blood in the veins located above the umbilicus flows toward the head; blood in the veins located below the umbilicus flows toward the lower body. Note any striae (stretch marks) due to past stretching of the reticular skin layers due to fast or prolonged stretching. EF: New striae are pink or bluish in color; old striae are silvery, white, linear, and uneven stretch marks from past pregnancies or weight gain. Inspect for scars. Ask about the source of a scar, and use a centimeter ruler to measure the scar's length. Document the location by quadrant and reference lines, shape, length, and any specific characteristics (e.g., 3-cm vertical scar in RLQ 4 cm below the umbilicus and 5 cm left of the midline). With experience, many examiners can estimate the length of a scar visually without a ruler. EF: Pale, smooth, minimally raised old scars may be seen. Assess for lesions and rashes. EF: Abdomen is free of lesions or rashes. Flat or raised brown moles, however, are normal and may be apparent. Inspect the umbilicus. Note the color of the umbilical area. EF: Umbilical skin tones are similar to surrounding abdominal skin tones or even pinkish. Observe umbilical location. EF: Umbilicus is midline at lateral line. Assess contour of umbilicus. EF: It is recessed (inverted) or protruding no more than 0.5 cm, and is round or conical. Inspect abdominal contour. Sitting at the client's side, look across the abdomen at a level slightly higher than the client's abdomen (Fig. 23-9). Inspect the area between the lower ribs and pubic bone. Measure abdominal girth EF: Abdomen is flat, rounded, or scaphoid (usually seen in thin adults; Fig. 23-10). Abdomen should be evenly rounded. Assess abdominal symmetry. Look at the abdomen as the client lies in a relaxed supine position. EF: Abdomen is symmetric. Further assessment. To further assess the abdomen for herniation or diastasis recti or to differentiate a mass within the abdominal wall from one below it, ask the client to raise the head. EF: Abdomen does not bulge when client raises head. Inspect abdominal movement when the client breathes (respiratory movements). EF: Abdominal respiratory movement may be seen, especially in male clients. Observe aortic pulsations. Ultrasound has high sensitivity and specificity and is the preferred screening modality. Abdominal palpation has poor accuracy and is not recommended for screening EF: A slight pulsation of the abdominal aorta, which is visible in the epigastrium, extends full length in thin people. Observe for peristaltic waves. EF: Normally, peristaltic waves are not seen, although they may be visible in very thin people as slight ripples on the abdominal wall.

risk factors for colorectal cancer

Older age, especially after 50 African American or eastern European descent, especially Ashkenazi Jews Having cancer elsewhere in the body Having inflammatory bowel disease (either Crohn's or ulcerative colitis) Having a personal history of colorectal polyps or CRC Having a family history of colorectal polyps or CRC Having a personal history of breast cancer Having certain genetic syndromes: familial adenomatous polyposis (FAP) or hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome Having diabetes mellitus type 2 Risk factors that can be changed: Being obese Physical inactivity Diet high in red meat and processed meat; cooking meat at high temperature (frying, broiling, grilling) Diet low in vegetables, fruits, and whole grains Smoking Alcohol use of more than 2 drinks a day for men and 1 drink a day for women. Human papilloma virus (about 95% of anal cancers are caused by HPV) (WHO, 2015)

Significant cardiovascular changes occur during pregnancy.

One of the most dynamic changes is the increase in cardiac output and maternal blood volume by approximately 40% to 50%. Because the heart is required to pump much harder, it actually increases in size. Its position is rotated up and to the left approximately 1 to 1.5 cm. The heart rate may increase by 10 to 15 beats/min and systolic murmurs may be heard.

Red, scaly, crusty areas may appear in ??

Paget disease

Murphy sign

Pain elicited when pressure is applied under the liver border at the right costal margin and client inhales deeply. Inflammation of the gallbladder

Psoas sign

Pain in RLQ when leg is hyperextended Irritation of the iliopsoas muscle due to appendicitis (an inflamed appendix).

Palpation of inguinal area

Palpate for inguinal hernia and inguinal nodes. Ask the client to shift his weight to the left for palpation of the right inguinal canal and vice versa. Place your right index finger into the client's right scrotum and press upward, invaginating the loose folds of skin (Fig. 26-13). Palpate up the spermatic cord until you reach the triangular-shaped, slit-like opening of the external inguinal ring. Try to push your finger through the opening and, if possible, continue palpating up the inguinal canal. When your finger is in the canal or at the external inguinal ring, ask the client to bear down or cough. Feel for any bulges against your finger. Then, repeat the procedure on the opposite side. EF: Bulging or masses are not normally palpated. Palpate inguinal lymph nodes. If nodes are palpable, note size, consistency, mobility, or tenderness. EF: No enlargement or tenderness is normal. Palpate for femoral hernia. Palpate on the front of the thigh in the femoral canal area. Ask the client to bear down or cough. Feel for bulges. Repeat on the opposite thigh. EF: Bulges or masses are not normally palpated.

Wedge Palpation Technique

Palpate from center of breast in a radial fashion, returning to areola for each spoke

Palpation of Breasts

Palpate texture and elasticity EF: Palpation reveals smooth, firm, elastic tissue. Palpate for tenderness and temperature. EF: A generalized increase in nodularity and tenderness may be a normal finding associated with the menstrual cycle or hormonal medications. Breasts should be a normal body temperature. Palpate for masses. Note location, size in centimeters, shape, mobility, consistency, and tenderness. Also note the condition of the skin over the mass. EF: No masses should be palpated. However, a firm inframammary transverse ridge may normally be palpated at the lower base of the breasts. Palpate the nipples. Wear gloves to compress the nipple gently with your thumb and index finger (Fig. 20-10). Note any discharge. If spontaneous discharge occurs from the nipples, a specimen must be applied to a slide and the smear sent to the laboratory for cytologic evaluation. EF:The nipple may become erect and the areola may pucker in response to stimulation. A milky discharge is usually normal only during pregnancy and lactation. However, some women may normally have a clear discharge. Palpate mastectomy or lumpectomy site. If the client has had a mastectomy or lumpectomy, it is still important to perform a thorough examination. Palpate the scar and any remaining breast or axillary tissue for redness, lesions, lumps, swelling, or tenderness (Fig. 20-11). EF: Scar is whitish with no redness or swelling. No lesions, lumps, or tenderness noted.

Palpate abdomen for preggo women

Palpate the abdomen. Note organs and any masses. NF: The uterus is palpable beginning at 10-12 weeks' gestation. Palpate for fetal movement after 24 weeks. NF: Fetal movement should be felt by the mother by approximately 18-20 weeks. Palpate for uterine contractions (Fig. 29-9). Note intensity, duration, and frequency of contractions. NF: The uterus contracts and feels firm to the examiner. Palpate the abdomen. Notice the difference between the uterus at rest and during a contraction. NF: Intensity of contractions may be mild, moderate, or firm to palpation. Time the length of the contraction from the beginning to the end. Also note the frequency of the contractions, timing from the beginning of one contraction until the beginning of the next (Fig. 29-10). The frequency of contractions is timed from the start of one contraction to the start of the next contraction. This allows the nurse to see the pattern of occurrence. Timing from the end of one contraction to the beginning of another would tell the amount of time between the contractions but that would not allow the nurse to see the pattern of occurrence. NF: Contraction may last 40-60 seconds and occur every 5-6 minutes.

Palpation of anus and rectum

Palpate the anus. Inform the client that you are going to perform the internal examination at this point. Explain that it may feel like his bowels are going to move but that this will not happen. Lubricate your gloved index finger; ask the client to bear down. As the client bears down, place the pad of your index finger on the anal opening and apply slight pressure; this will cause relaxation of the sphincter. EF: Client's sphincter relaxes, permitting entry. When you feel the sphincter relax, insert your finger gently with the pad facing down (Fig. 26-15 and Fig. 26-16). EF: Examination finger enters anus. If the sphincter does not relax and the client reports severe pain, spread the gluteal folds with your hands in close approximation to the anus and attempt to visualize a lesion that may be causing the pain. If tension is maintained on the gluteal folds for 60 seconds, the anus will dilate normally. Ask the client to tighten the external sphincter; note the tone. EF: The client can normally close the sphincter around the gloved finger. Rotate finger to examine the muscular anal ring. Palpate for tenderness, nodules, and hardness. EF: The anus is normally smooth, nontender, and free of nodules and hardness. Palpate the rectum. Insert your finger further into the rectum as far as possible (Fig. 26-17). Next, turn your hand clockwise then counterclockwise. This allows palpation of as much rectal surface as possible. Note tenderness, irregularities, nodules, and hardness. EF: The rectal mucosa is normally soft, smooth, nontender, and free of nodules. Palpate the peritoneal cavity. This area may be palpated in men above the prostate gland in the area of the seminal vesicles on the anterior surface of the rectum. Note tenderness or nodules. EF: This area is normally smooth and nontender

Nonmodifiable risk factors for PUD

Presence of H. pylori in gastrointestinal tract Stress (findings differ on whether or not stress is a factor) Hypersecretory condition, in which the stomach produces too much acid A personal or family history of ulcers (suspected genetic link) Radiation treatments Zollinger-Ellison syndrome (rare condition of a tumor in the pancreas that releases a high level of an acid-producing hormone)

Palpation of scrotum

Palpate the scrotal contents. Palpate each testis and epididymis between your thumb and first two fingers (Fig. 26-11). Note size, shape, consistency, nodules, masses, and tenderness. EF: Testes are ovoid, approximately 3.5 to 5 cm long, 2.5 cm wide, and 2.5 cm deep, and equal bilaterally in size and shape. They are smooth, firm, rubbery, mobile, free of nodules, and rather tender to pressure. The epididymis is nontender, smooth, and softer than the testes. Palpate each spermatic cord and vas deferens from the epididymis to the inguinal ring. The spermatic cord will lie between your thumb and finger (Fig. 26-12). Note any nodules, swelling, or tenderness. EF: The spermatic cord and vas deferens should feel uniform on both sides. The cord is smooth, nontender, and rope-like. Assessment of scrotal mass found during examination. If an abnormal mass or swelling was noted during inspection and palpation of the scrotum, perform transillumination. Darken the room and shine a light from the back of the scrotum through the mass. Look for a red glow. EF: Normally scrotal contents do not transilluminate. If during inspection and palpation of the scrotal contents, you palpated a scrotal mass, ask the client to lie down. Note whether the mass disappears. If it remains, auscultate it for bowel sounds. Finally, gently palpate the mass and try to push it upward into the abdomen. EF: Normal findings are not expected.

Bimanual examination

Palpate the vaginal wall. Tell the client that you are going to do a manual examination and explain its purpose. Apply water-soluble lubricant to the gloved index and middle fingers of your dominant hand. Then stand and approach the client at the correct angle. Placing your nondominant hand on the client's lower abdomen, insert your index and middle fingers into the vaginal opening. Apply pressure to the posterior wall, and wait for the vaginal opening to relax before palpating the vaginal walls for texture and tenderness EF: The vaginal wall should feel smooth, and the client should not report any tenderness. Palpate the cervix. Advance your fingers until they touch the cervix and run fingers around the circumference. Palpate for: · Contour · Consistency · Mobility Tenderness EF: The cervix should feel firm and soft (like the tip of your nose). It is rounded, and can be moved somewhat from side to side without eliciting tenderness. Palpate the uterus. Move your fingers intravaginally into the opening above the cervix and gently press the hand resting on the abdomen downward, squeezing the uterus between the two hands (Fig. 27-14). Note uterine size, position, shape, and consistency. EF: The fundus, the large, upper end of the uterus, is normally round, firm, and smooth. In most women, it is at the level of the pubis; the cervix is aimed posteriorly (anteverted position). However, several other positions are considered normal Attempt to bounce the uterus between your two hands to assess mobility and tenderness. EF: The normal uterus moves freely and is not tender. Palpate the ovaries. Slide your intravaginal fingers toward the left ovary in the left lateral fornix and place your abdominal hand on the left lower abdominal quadrant. Press your abdominal hand toward your intravaginal fingers and attempt to palpate the ovary EF: Ovaries are approximately 3 × 2 × 1 cm (or the size of a walnut) and almond-shaped. Slide your intravaginal fingers to the right lateral fornix and attempt to palpate the right ovary. Note size, shape, consistency, mobility, and tenderness. Withdraw your intravaginal hand and inspect the glove for secretions. EF: Ovaries are firm, smooth, mobile, and somewhat tender on palpation. A clear, minimal amount of drainage appearing on the glove from the vagina is normal.

Pelvic cultures obtained with this examination include a

Pap smear and gonorrhea and chlamydia cultures. Explain that after the examination is complete, the client will go to the laboratory for initial prenatal blood tests including complete blood count, blood type and screen, Rh status, rubella titer, serologic test for syphilis, hepatitis B surface antigen, and sickle cell anemia screen (for clients of African ancestry). Universal screening for HIV is recommended.

Percussing abdomen

Percuss for tone. Lightly and systematically percuss all quadrants EF: Generalized tympany predominates over the abdomen because of air in the stomach and intestines. Dullness is heard over the liver and spleen. Dullness may also be elicited over a nonevacuated descending colon Percuss the span or height of the liver by determining its lower and upper borders. EF: The lower border of liver dullness is located at the costal margin to 1-2 cm below. To assess the lower border, begin in the RLQ at the mid-clavicular line (MCL) and percuss upward (Fig. 23-14). Note the change from tympany to dullness. Mark this point: It is the lower border of liver dullness. To assess the descent of the liver, ask the client to take a deep breath and hold; then repeat the procedure. Remind the client to exhale after percussing. EF: On deep inspiration, the lower border of liver dullness may descend from 1 to 4 cm below the costal margin. To assess the upper border, percuss over the upper right chest at the MCL and percuss downward, noting the change from lung resonance to liver dullness. Mark this point: It is the upper border of liver dullness. EF: The upper border of liver dullness is located between the left fifth and seventh intercostal spaces. Measure the distance between the two marks: this is the span of the liver EF: The normal liver span at the MCL is 6-12 cm (greater in men and taller clients, less in shorter clients). Repeat percussion of the liver at the midsternal line (MSL). EF: The normal liver span at the MSL is 4-8 cm. The scratch test is a technique that can be used to ascertain the location and size of the liver and spleen. This test can be particularly useful if the abdomen is tense (rigid or guarded), distended, obese, or too tender to palpate. (Gupta et al., 2013). To perform the scratch test, place the diaphragm of your stethoscope at the second to last intercostal space, MCL. (see Fig. 23-16). Use one finger to very lightly stroke the skin horizontally, starting at the umbilicus. Continue to stroke the skin, moving toward the lower costal margin. The sound will suddenly be transmitted through the stethoscope and increase in intensity. This indicates the lower border of the liver. EF: The normal liver span at the MSL is 4-8 cm. Percuss the spleen. Begin posterior to the left mid-axillary line (MAL), and percuss downward, noting the change from lung resonance to splenic dullness. EF: The spleen is an oval area of dullness approximately 7 cm wide near the left tenth rib and slightly posterior to the MAL. A second method for detecting splenic enlargement is to percuss the last left interspace at the anterior axillary line (AAL) while the client takes a deep breath EF: Normally, tympany (or resonance) is heard at the last left interspace. Perform blunt percussion on the liver and the kidneys. This is to assess for tenderness in difficult-to-palpate structures. Percuss the liver by placing your left hand flat against the lower right anterior rib cage. Use the ulnar side of your right fist to strike your left hand. EF: Normally, no tenderness is elicited. Perform blunt percussion on the kidneys at the costovertebral angles (CVA) over the twelfth rib EF: Normally, no tenderness or pain is elicited or reported by the client. The examiner senses only a dull thud.

· Constipation is a common problem during pregnancy.

Progesterone decreases intestinal motility, allowing more time for nutrients to be absorbed for the mother and fetus. This also increases the absorption time for water into the circulation, taking fluid from the large intestine and contributing to hardening of the stool and decreasing the frequency of bowel movements. Iron supplementation can also contribute to constipation for those women who take additional iron. As a result, hemorrhoids (varicose veins in the rectum) may develop because of the pressure on the venous structures from straining to have a bowel movement. Vascular congestion of the pelvis also contributes to hemorrhoid development.

PAGET DISEASE

Redness and flaking of the nipple may be seen early in Paget disease and then disappear. However, further assessment is needed as this does not mean the disease is gone. Tingling, itching, increased sensitivity, burning, discharge, and pain in the nipple are late signs of Paget disease. It may occur in both breasts, but is rare.

PEAU D'ORANGE

Resulting from edema, an orange peel appearance of the breast is associated with cancer.

Rashes, lesions, or lumps may indicate

STI or cancer

Lesions may indicate

STIs, cancer, or hemorrhoids.

Teach clients for hemorrhoids

See your health care provider if you have rectal bleeding, which can indicate other diseases such as rectal cancer. Seek emergency care if you experience large amounts of rectal bleeding, lightheadedness, dizziness, or faintness, or extreme pain. Avoid straining with bowel movements. Avoid standing or sitting for prolonged periods, especially sitting on the toilet. Attempt to have a bowel movement as soon as the feeling occurs. Avoid anal intercourse. Avoid rubbing or cleaning too hard around the anus, which may make symptoms, such as itching and irritation, worse. Eat a diet high in fiber, especially cereal fiber and whole grains (consider a fiber supplement if you experience constipation). Drink 6 to 8 glasses of water or nonalcoholic fluids per day. Get regular exercise (and exercise to lose weight if obese). Avoid long periods of sitting. If you have hemorrhoids: (Mayo Clinic, 2013a) · Use over-the-counter creams or soothing pads. · Soak your anal area in plain warm water 10 to 15 minutes 2 to 3 times a day. · Bathe (preferably) or shower daily to cleanse the skin around your anus gently with warm water. Soap is not necessary and may aggravate the problem. Gently dry the area with a hair dryer after bathing. · Do not use dry toilet paper. · Apply ice packs or cold compresses on your anus to relieve swelling. · If not contraindicated, an over-the-counter pain medication can be used.

Culture Specimens: Gonorrhea and Chlamydia

Specimens for gonorrhea or Chlamydia cultures are obtained if you suspect the client has these STIs. The exact procedures for gathering and preparing the specimens vary according to each laboratory's policy. General guidelines follow. 1. Insert a cotton-tipped applicator into the cervical os and rotate it in a full circle. 2. Leave the applicator in place for approximately 20 seconds to make sure it becomes saturated with specimen. 3. Withdraw the applicator. 4. For Neisseria gonorrhoeae cultures: Spread the specimen onto a special culture plate (Thayer-Martin) in a "Z" pattern while rotating the applicator, or put in a liquid medium for transport and send to the laboratory. 5. For Chlamydia trachomatis cultures: Immerse a special swab (provided with test medium) in a liquid medium and refrigerate the sample until it is transported to the laboratory.

Tanner's Sexual Maturity Rating: Male Genitalia and Pubic Hair

Stage 1 Genitalia: Prepubertal Pubic hair: Prepubertal—No pubic hair; fine vellus hair Stage 2 Genitalia: Initial enlargement of scrotum and testes with rugation and reddening of the scrotum Pubic hair: Sparse, long, straight, downy hair Stage 3 Genitalia: Elongation of the penis; testes and scrotum further enlarge Pubic hair: Darker, coarser, curly; sparse over entire pubis Stage 4 Genitalia: Increase in size and width of penis and the development of the glans; scrotum darkens Pubic hair: Dark, curly, and abundant in pubic area; no growth on thighs or up toward umbilicus Stage 5 Genitalia: Adult configuration Pubic hair: Adult pattern (growth up toward umbilicus may not be seen); growth continues until mid-20s

Tanner's Sexual Maturity Rating: Female Breast Development

Stage 1 Prepubertal: Elevation of nipple only Stage 2 Breast bud stage; elevation of breast and nipple as small mound, enlargement of areolar diameter Stage 3 Enlargement of the breasts and areola, with no separation of contours Stage 4 Projection of areola and nipple to form secondary mound above level of breast Stage 5 Adult configuration; projection of nipple only, areola receded into contour of breast

Tanner's Sexual Maturity Rating: Female Pubic Hair

Stage 1 Prepubertal: No pubic hair; fine vellus hair Stage 2 Sparse, long, straight, downy hair Stage 3 Darker, coarser, curly; sparse over mons pubis Stage 4 Dark, curly, and abundant on mons pubis; no growth on medial thighs Stage 5 Adult pattern of inverse triangle; growth on medial thighs

THE FIVE STEPS OF A BREAST SELF-EXAMINATION

Step 1: Look at your breasts in the mirror with your shoulders straight and your arms on your hips. Check size, shape, and color. Notice if they are evenly shaped with no distortion or swelling. · Notify your doctor if you notice: · Dimpling, puckering, or bulging of the skin · A nipple that has changed position or an inverted nipple (pushed inward instead of sticking out) · Redness, soreness, rash, or swelling Step 2: Raise your arms and determine if you see the same changes. Step 3: Look for any signs of fluid coming out of one or both nipples (e.g., watery, milky, yellow fluid, or blood). Step 4: Lie down with your right arm behind your head. Lying down spreads the breast tissue evenly over the chest wall, making it easier to feel. Use the three middle finger pads and move them in a circular motion covering the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage · Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. · Some women prefer to use an up-and-down approach by moving the fingers up and down vertically, in rows, as if mowing a lawn. Be sure to feel all the tissue from the front to the back of your breasts: for the skin and tissue just beneath, use light pressure; use medium pressure for tissue in the middle of your breasts; use firm pressure for the deep tissue in the back. When you have reached the deep tissue, you should be able to feel down to your ribcage. Step 5: Many women find it easiest to do this in the shower when the skin is wet and slippery. Cover the entire breast, using the same hand movements described in step 4.

Variable

Stomach cancer

Risk assessment for hemorrhoids

Straining at bowel movements Prolonged sitting on the toilet Obesity Pregnancy Anal intercourse Familial tendency Lack of erect posture Higher socioeconomic status Chronic diarrhea or constipation Colon cancer Liver disease Anything causing elevated anal resting pressure Spinal cord injury Loss of rectal muscle tone Rectal surgery Episiotomy Inflammatory bowel disease (ulcerative colitis, Crohn disease)

Tests for Ascites

Test for shifting dullness. If you suspect that the client has ascites because of a distended abdomen or bulging flanks, perform this special percussion technique. The client should remain supine. Percuss the flanks from the bed upward toward the umbilicus. Note the change from dullness to tympany and mark this point. Now help the client turn onto the side. Percuss the abdomen from the bed upward. Mark the level where dullness changes to tympany EF: The borders between tympany and dullness remain relatively constant throughout position changes. AF: When ascites is present and the client is supine, the fluid assumes a dependent position and produces a dull percussion tone around the flanks. Air rises to the top and tympany is percussed around the umbilicus. When the client turns onto one side and ascites is present, the fluid assumes a dependent position and air rises to the top. There is a marked increase in the height of the dullness. This test is not always reliable, thus definitive testing by ultrasound is necessary. Ascites often is a sign of severe liver disease due to portal hypertension (high pressure in the blood vessels of the liver and low albumin levels (Cesario et al., 2013). Perform the fluid wave test. A second special technique to detect ascites is the fluid wave test. The client should remain supine. You will need assistance with this test. Ask the client or an assistant to place the ulnar side of the hand and the lateral side of the forearm firmly along the midline of the abdomen. Firmly place the palmar surface of your fingers and hand against one side of the client's abdomen. Use your other hand to tap the opposite side of the abdominal wall EF: No fluid wave is transmitted. AF: Movement of a fluid wave against the resting hand suggests large amounts of fluid are present (ascites). Because this test is not completely reliable, definitive testing by ultrasound is needed.

Screening for cervical cancer

The U.S. Preventive Services Task Force (USPSTF, 2012; being updated with a date of 2018) recommends a variety of screening protocols based on age and a combination of cervical cancer and HPV screenings. Recommendations include: Screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years Screening with a combination of cytology and HPV testing every 5 years for women ages 30 to 65 years who want to lengthen the screening interval USPSTF recommends against screening for: Cervical cancer in women younger than age 21 years Cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer Cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer Cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years

Screening for HIV

The U.S. Preventive Services Task Force (USPSTF, 2015a) strongly recommends that clinicians screen for HIV in all adolescents and adults aged 15 to 65, and for younger adolescents or older adults at increased risk for HIV infection. The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.

Screening for colorectal cancer

The U.S. Preventive Services Task Force (USPSTF, 2016) recommends screening for CRC starting at age 50 years and continuing until age 75 (using fecal occult blood testing, sigmoidoscopy, or colonoscopy). The risks and benefits of the screening methods vary. The USPSTF recommends against routine screening for CRC in adults ages 76 to 85 years, except for individuals who have never been screened before and are likely to benefit (healthy enough to undergo treatment if CRC is detected, and who do not have comorbid conditions that would significantly limit life expectancy). The USPSTF recommends against any screening for adults over 85 years. The Task Force also concludes that the evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities for CRC. The ACS (2016a) recommends that starting at age 50, an individual at average risk for CRC be screened by one of the following: a flexible sigmoidoscopy every 5 years, a colonoscopy every 10 years (should be done if other tests are positive in any case), a double contrast barium enema every 5 years, or a CT colonography every 5 years. In addition other tests recommended are a guaiac-based fecal blood test every year, a fecal immunochemical (FIT) test every year, or a stool DNA every 3 years. A rectal examination is not recommended as a standalone test. More elaborate testing is recommended for those persons with a history or polyps or others at high risk.

Screening for breast cancer

The USPSTF (2009) recommends biennial screening mammography for women aged 50-74 years. The decision to start regular biennial screening mammography before the age of 50 years should be an individual one and take client context into account, including the client's values regarding specific benefits and harms. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. The USPSTF recommends against teaching breast self-examination (BSE). The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 50 years or older. ACR (2015), along with the Society of Breast Imaging, supports starting mammograms at age 40 and recommends that women with significant risk factors for breast cancer begin screening at least by age 30, but not before age 25. The ACS supports offering the option of yearly mammograms at age 40-45, with annual mammograms from 45 to 54, and every 2 years for those women over 55 (ACS, 2016b). The ACS (2015b) has changed its guidelines regarding BSE and clinical breast examination. It states due to lack of evidence, regular clinical breast examinations and BSE are not recommended. However, BSE is an option for women starting in their 20s, due to the fact that research has shown that BSE plays a small role in finding breast cancer. Because studies show that dense breast tissue is six times more likely to develop cancer, and dense tissue makes it harder to detect breast cancer on mammograms, Breastcancer.org (2016) recommends that women with dense breast tissue consult with their health care provider to determine the best screening methods.

Screening for GERD

The USPSTF does not address screening for GERD. Other organizations have modified their recommendations regarding the common use of endoscopy to evaluate GERD symptoms. The American College of Physicians (2013) has modified its recommendation, suggesting that upper endoscopy be limited to the following: clients who have other symptoms, such as dysphagia, bleeding, anemia, weight loss, or recurrent vomiting; clients with a history of esophageal stricture who have recurrent dysphagia symptoms; and those with severe erosive esophagitis who have completed a 2-month course of PPI therapy, to assess healing and rule out Barrett esophagus.

In the upper end of the vagina, the cervix dips down and forms

a circular recess that gives rise to areas known as the anterior and posterior fornices. The cervix (or neck of the uterus) separates the upper end of the vagina from the isthmus of the uterus. The junction of the isthmus and the cervix forms the internal os; the junction of the cervix and the vagina forms the external os or ectocervix. The "os" refers to the opening in the center of the cervix.

BACTERIAL VAGINOSIS

The cause of bacterial vaginosis is unknown (possibly anaerobic bacteria), but it is thought to be sexually transmitted. The discharge is thin and gray-white, has a positive amine (fishy smell), and coats the vaginal walls and ectocervix. The labia and vaginal walls usually appear normal and pH is greater than 4.5 (5.5-6.0).

CYANOSIS OF THE CERVIX

The cervix normally appears bluish in the client who is in her first trimester of pregnancy. However, if the client is not pregnant, a bluish color to the cervix indicates venous congestion or a diminished oxygen supply to the tissues.

GENITAL HERPES SIMPLEX

The initial outbreak of herpes may have many small, painful ulcers with erythematous base. Recurrent herpes lesions are usually not as extensive.

Papanicolaou (Pap) Smear

The new standard of care for the Pap smear is liquid-based technology. The traditional Pap smear is estimated to be 80% accurate in detection of low- and high-grade lesions of the cervix. The thin prep, or liquid-based, technology has improved accuracy of findings by about 54%. The specimen for the Pap smear is obtained in the same way, using a wooden spatula, cotton swab, or brush; but the specimen is placed in the preservative solution rather than on a slide (Lab Tests Online, 2012). This solution may be used to test for human papilloma virus (HPV) and to determine HPV type.

NORMAL ENLARGEMENT: PREGNANCY

The only uterine enlargement that is normal results from pregnancy and fetal growth. In such cases, the isthmus feels soft (Hegar sign) on palpation, and the fundus and isthmus are compressible at between 10 and 12 weeks of pregnancy.

The vaginal wall comprises four layers.

The outer layer is composed of pink squamous epithelium and connective tissue. It is under the direct influence of the hormone estrogen and contains many mucus-producing cells. This outer layer of epithelium lies in transverse folds called rugae. These transverse folds allow the vagina to expand during intercourse; they also facilitate vaginal delivery of a fetus. The second layer is the submucosal layer. It contains the blood vessels, nerves, and lymphatic channels. The third layer is composed of smooth muscle, and the fourth layer consists of connective tissue and the vascular network. The normal vaginal environment is acidic (pH of 3.8-4.2). This environment is maintained because the vaginal flora is composed of Döderlein bacilli, and the bacilli act on glycogen to produce lactic acid. This acidic environment helps to prevent vaginal infection.

· Relaxin contributes to changing the client's gait during pregnancy.

The pregnant woman's gait is often described as "waddling." Gait changes are also attributed to weight gain in the uterus, fetus, and breasts. At approximately 24 weeks' gestation, the woman's center of gravity and stance change, causing her to lean back slightly to balance herself. Backaches are common during pregnancy. Along with these changes, the woman may also see an increase in shoe size, especially in width.

Obtaining an Ectocervical and Endocervical Specimen

The procedure for gathering endocervical and ectocervical specimens is performed on nonpregnant clients. This combined procedure uses a special cytobroom to collect both endocervical and ectocervical cells. 1. Insert the cytobroom into the cervical os (Fig. A). 2. Rotate the cytobroom in a full circle five times, collecting cell specimens from the squamocolumnar junction and the cervical surface. 3. Withdraw the cytobroom. 4. Swish the broom in the preservative solution by pushing the broom into the bottom of the vial 10 times, forcing the bristles apart. Swirl the broom vigorously to further release material. 5. Discard the cytobroom. 6. Tighten the cap on the preservative. This solution is sent to the laboratory.

Palpation of prostate gland

The prostate can be palpated on the anterior surface of the rectum by turning the hand fully counterclockwise so that the pad of your index finger faces toward the client's umbilicus Tell the client that he may feel an urge to urinate but that he will not. Move the pad of your index finger over the prostate gland, trying to feel the sulcus between the lateral lobes. Note the size, shape, and consistency of the prostate, and identify any nodules or tenderness. EF: The prostate is normally nontender and rubbery. It has two lateral lobes that are divided by a median sulcus. The lobes are normally smooth, 2.5 cm long, and heart-shaped.

Lipomas are

a collection of fatty tissue that may also appear as a lump.

Spermatic cord

The testes are suspended in the scrotum by a ??. The ?? contains blood vessels, lymphatic vessels, nerves, and the vas deferens (or ductus deferens), which transports spermatozoa away from the testis. The spermatic cord on the left side is usually longer; thus the left testis hangs lower than the right testis.

Tail of spence

The upper outer quadrant, which extends into the axillary area. Most breast tumors occur in this quadrant

Other changes that occur during pregnancy include dependent edema and varicosities.

Two thirds of all pregnant women have swelling of the lower extremities in the third trimester. Swelling is usually noted late in the day after standing for long periods. Fluid retention is caused by the increased hormones of pregnancy, increased hydrophilicity of the intracellular connective tissue, and increased venous pressure in the lower extremities. As the expanding uterus applies pressure on the femoral venous area, femoral venous pressure increases. This uterine pressure restricts venous blood flow return, causing stagnation of the blood in the lower extremities and resulting in dependent edema. Varicose veins in the lower extremities, vulva, and rectum are also common during pregnancy. Pregnant women are also more prone to development of thrombophlebitis because of the hypercoagulable state of pregnancy. Women who are placed on bedrest during pregnancy are at a very high risk for development of thrombophlebitis.

Inside the labia majora are the thinner skin folds of the labia minora.

These folds join anteriorly at the clitoris and form a prepuce or hood; posteriorly the two folds join to form the frenulum. Compared with the labia majora, the labia minora are hairless and usually darker pink. They contain numerous sebaceous glands that promote lubrication and maintain a moist environment in the vaginal area. The clitoris is located at the anterior end of the labia minora. It is a small, cylindrical mass of erectile tissue and nerves with three parts: the glans, the corpus, and the crura. The glans is the visible rounded portion of the clitoris. The corpus is the body, and the crura are two bands of fibrous tissue that attach the clitoris to the pelvic bone. The clitoris is similar to the male penis and contains many blood vessels that become engorged during sexual arousal.

WHERE TO AUSCULTATE FETAL HEART RATE

These illustrations represent the best locations for auscultating the fetal heart rate: Left occiput anterior (LOA), right occiput anterior (ROA), left occiput posterior (LOP), right occiput posterior (ROP), left sacrum anterior (LSA), and right sacrum posterior (RSP).

During pregnancy, the abdominal muscles stretch as the uterus enlarges.

These muscles, known as the rectus abdominis muscles, may stretch to the point that permanent separation occurs. This condition is known as diastasis recti abdominis. Four paired ligaments (broad ligaments, uterosacral ligaments, cardinal ligaments, round ligaments) support the uterus and keep it in position in the pelvic cavity (Fig. 29-2). As the uterus enlarges, the client may complain of lower pelvic discomfort, which quite commonly results from stretching the ligaments, especially the round ligaments.

CERVICAL EROSION

This condition differs from cervical eversion in that normal tissue around the external os is inflamed and eroded, appearing reddened and rough. Erosion usually occurs with mucopurulent cervical discharge.

MUCOPURULENT CERVICITIS

This condition produces a mucopurulent yellowish discharge from the external os. It usually indicates infection with Chlamydia or gonorrhea. However, these STIs may also occur with no visible signs, although the discharge may change the cervical pH (3.8-4.2).

BILATERAL TRANSVERSE LACERATION

This drawing illustrates a type of healed laceration that may be seen in a woman who has given birth vaginally.

STELLATE LACERATION

This drawing illustrates a type of healed laceration that may be seen in a woman who has given birth vaginally.

CANDIDAL VAGINITIS (MONILIASIS)

This infection is caused by the overgrowth of yeast in the vagina. It causes a thick, white, cheesy discharge. The labia may be inflamed and swollen. The vaginal mucosa may be reddened and typically contains patches of the discharge. This infection causes intense itching and discomfort.

CERVICAL EVERSION

This is a normal finding in many women and usually occurs after vaginal birth or when the woman takes oral contraceptives. The columnar epithelium from within the endocervical canal is everted and appears as a deep red, rough ring around the cervical os, surrounded by the normal pink color of the cervix.

MIDPOSITION

This is a normal variation. The cervix is pointed slightly more anteriorly (compared with the anteverted position), and the body of the uterus is positioned more posteriorly than the anteverted position, midway between the bladder and the rectum. It may be difficult to palpate the body through the abdominal and rectal walls with the uterus in this position.

ANTEVERTED

This is the most typical position of the uterus. The cervix is pointed posteriorly, and the body of the uterus is at the level of the pubis over the bladder.

TRICHOMONAS VAGINITIS (TRICHOMONIASIS)

This type of vaginal infection is caused by a protozoan organism and is usually sexually transmitted. The discharge is typically yellow-green, frothy, and foul smelling. The labia may appear swollen and red, and the vaginal walls may be red, rough, and covered with small red spots (or petechiae). This infection causes itching and urinary frequency in the client. Upon testing, the pH of vaginal secretion will be greater than 4.5 (usually 7.0 or more). If a sample of vaginal secretions is stirred into a potassium hydroxide solution (KOH prep), a foul odor (typically known as a "+" amine) may be noted.

screening for prostate cancer

U.S. Preventive Services Task Force Recommendation Statement (USPSTF, 2015b) has concluded that the benefits do not outweigh the risks when routine screening is done for prostate cancer. Therefore, currently the USPSTF recommends against routine screening with a prostate-specific antigen (PSA) test for men in the United States. The National Cancer Institute (2015) notes that the PSA test to detect prostate cancer is nonspecific, as the PSA level may be elevated in benign prostate hypertrophy or with infection or inflammation of the prostate. If a prostate biopsy is done and is negative, then an additional test (this one of urine) may be done for the PCA3 gene for prostate cancer. The effectiveness of combining PSA level and digital rectal examination (DRE) is being studied. The American Association of Family Physicians (AAFP, 2015) provides a comparison of several organizations' recommendations for prostate screening: AAFP: Do not routinely screen for prostate cancer using a PSA test or DRE. American College of Preventive Medicine: Do not routinely perform PSA-based screening for prostate cancer. American Geriatric Society: Do not screen for prostate cancer (with the PSA test) without considering life expectancy and the risks of testing, overdiagnosis, and overtreatment. American Society for Clinical Oncology: Do not perform PSA testing for prostate cancer in men with no symptoms of the disease when they are expected to live for less than 10 years. American Urological Society: Offer PSA screening for prostate cancer only after engaging in shared decision making. In summary, the PSA is available but is unreliable, and men between 50 and 70 years of age who are expected to live at least 10 years should have the risks and benefits of screening explained to them by their health care provider. The Canadian Task Force on Preventive Health Care (2014) recommends not using the PSA test to screen for prostate cancer. Cancer Research UK (2014) reports that there is no prostate cancer screening program in the United Kingdom. This is due to the unreliability of the PSA and other screening methods.

Risks for HIV

Unprotected sex (especially male-on-male anal intercourse) Presence of another STI Use of intravenous drugs, especially sharing needles Being an uncircumcised male Being the fetus of an HIV-positive mother Mother-infant transmission during pregnancy or delivery Exchange of blood or body fluids through blood transfusions, needle sticks, breast-feeding by HIV-infected mother, body piercing with nonsterilized instruments

Modifiable risk factors of PUD

Use of NSAIDs or bisphosphonates (Actonel, Fosamax, etc.) Smoking or chewing tobacco

Teach HIV clients

Use precautions to decrease transfer of body fluids: Avoid unprotected sex (use a new condom every time you have sex) or practice sexual abstinence (CDC, 2013) Avoid having multiple sex partners. Avoid anal sex. Avoid intravenous drug use. Avoid mixing sex and alcohol or drugs. If you take medications requiring needle use, use a new, sterile needle each time. Consider circumcision, if uncircumcised and lifestyle is risky. Follow guidelines for handling body secretions, objects that touch bodily secretions, or contaminated items. Openly discuss HIV risk behavior history with partner and use above precautions. If you already have HIV/AIDS: Eat healthy, well-rounded diet. Avoid food and drink that may easily transmit foodborne illness (e.g., raw eggs, unpasteurized dairy products, raw seafood, undercooked meat (cook well done). Get immunizations against other illnesses if allowed by physician. Be aware that companion animals may harbor parasites that can cause infections. Tell your sex partner right away if you are HIV positive. If pregnant, seek medical care right away. Seek support from support group to deal with your emotions. Obtain and stay on antiretroviral protocol, if available.

Fetal Position

Using Leopold maneuvers, palpate the fundus, lateral aspects of the abdomen, and the lower pelvic area. Leopold maneuvers assist in determining the fetal lie (where the fetus is lying in relation to the mother's back), presentation (the presenting part of the fetus into the maternal pelvis), size, and position (the fetal presentation in relation to the maternal pelvis). For the first maneuver, face the client's head. Place your hands on the fundal area, expecting to palpate a soft, irregular mass in the upper quadrant of the maternal abdomen (Fig. 29-13). For the second maneuver, move your hands to the lateral sides of the abdomen (Fig. 29-14). For the third maneuver, move your hands down to the lower pelvic area and palpate the area just above the symphysis pubis to determine the presenting part. Grasp the presenting part with the thumb and third finger (Fig. 29-15). For the fourth maneuver, face the client's feet, place your hands on the abdomen, and point your fingers toward the mother's feet. Then try to move your hands toward each other while applying downward pressure (Fig. 29-16). EF: A longitudinal lie, in which the fetal spine axis is parallel to the maternal spine axis, is the expected finding. The presentation may be cephalic, breech, or shoulder. The size of the fetus may be estimated by measuring fundal height and by palpation. Fetal positions include right occiput anterior (ROA), left occiput posterior (LOP), left sacrum anterior (LSA), and so on. (Refer to a textbook on obstetrics for further detail.) The soft mass is the fetal buttocks. The fetal head feels round and hard. On one side of the abdomen, you will palpate round nodules; these are the fists and feet of the fetus. Kicking and movement are expected to be felt. The other side of the abdomen feels smooth; this is the fetus's back. The unengaged head is round, firm, and ballotable, whereas the buttocks are soft and irregular. If the hands move together easily, the fetal head has not descended into the maternal pelvic inlet. If the hands do not move together and stop to resistance met, the fetal head is engaged into the pelvic inlet. AF: Oblique or transverse lie needs to be noted. If vaginal delivery is expected, external version can be performed to rotate the fetus to the longitudinal lie. Breech or shoulder presentations can complicate delivery if it is expected to be vaginal. Soft, presenting part at the symphysis pubis indicates breech presentation.

The epididymis is

a comma-shaped, coiled, tubular structure that curves up over the upper and posterior surface of the testis. It is within the epididymis that the spermatozoa mature.

UNILATERAL TRANSVERSE LACERATION

Vaginal birth may cause trauma to the cervix and produce tears or lacerations. Therefore, healed lacerations may be seen as a normal variation. This drawing illustrates a unilateral transverse laceration.

Teach client PUD

Wash hands frequently with soap and water. Eat foods that have been cooked completely. Use all recommended cautions when taking pain relievers, such as taking as low a dose over as short a length of time as possible; take pain medications with food; avoid drinking alcohol while on pain medications. Avoid excessive alcohol intake (more than one drink per day for women and two drinks per day for males). Avoid or stop smoking and chewing tobacco. If medications are ordered by your primary health care provider, follow the directions carefully and report if there are continuing symptoms, symptoms worsen, or more serious symptoms occur (such as severe pain, vomiting with bleeding, tarry stools).

client education for breast cancer

Women and men can have breast cancer; both should note any changes in breast size, shape, or tissue consistency and report to health care provider. Inform clients of different screening recommendations and advise them to talk with their health care provider to determine the best screening protocol for them

Zika virus

Zika virus was first identified in Uganda in 1947 in monkeys, and in humans in 1952 in both Uganda and Tanzania (WHO, 2016). The virus has been known to circulate in Africa, Asia, the Pacific, and the Americas. In response to the recent epidemic of Zika virus infections in the Americas, by February of 2016 the CDC (2016) activated the highest level of its Emergency Operations Center and the WHO (2016) declared a Public Health Emergency of International Concern. The urgent response to the Zika virus is due to the number of cases reported, especially in Brazil and northern parts of South America, and to increased reports of birth defects (microcephaly) and Guillain-Barré syndrome in areas affected by Zika. Prior to February of 2016, there were cases in the United States, but only in persons who had travelled to Zika-infested areas and not from person-to-person transmission. However, as the disease has spread up through Central America and cases have been identified in Florida, U.S. citizens have been put on alert. The CDC (2016) explains that the Zika virus is transmitted to people primarily through the bite of an infected Aedes species mosquito (A. aegypti and A. albopictus). These are the same mosquitoes that spread the dengue and chikungunya viruses. These mosquitoes typically lay eggs in standing water, such as buckets, dishes, bowls, and flower pots. They are aggressive daytime biters, but can bite at night as well. The mosquitoes become infected by biting an infected person and then spread the disease by biting another person. The virus has been shown to spread through sexual contact and blood transfusions as well. It was believed that there is no transmission of the virus via breast-feeding. However, there is evidence that the virus is transmitted across the placental barrier to the unborn infant, as it has been found in the amniotic fluid in studies of fetuses with microcephaly in mothers infected with the virus (Calvet et al., 2016). People with the Zika virus usually have symptoms that can include mild fever, skin rashes, conjunctivitis, muscle and joint pain, malaise, or headache (WHO, 2016). These symptoms normally last for 2 to 7 days. There is no specific treatment or vaccine currently available. HEALTHY PEOPLE 2020 GOAL Overview Healthy People 2020 includes the topic area of Immunization and Infectious Diseases. Goal The goal for this topic is general and states: "Increase immunization rates and reduce preventable infectious diseases" (Healthy People 2020, 2016). Objectives Unfortunately, Healthy People 2020 has not yet added objectives for prevention of Zika virus infections. SCREENING The CDC (2016) has updated guidelines that include a new recommendation to offer serologic testing to asymptomatic pregnant women (women who do not report clinical illness consistent with Zika virus disease) who have traveled to areas with ongoing transmission of Zika virus. Testing can be offered between 2 and 12 weeks after pregnant women return from travel to areas with ongoing Zika virus transmission. The updated guidelines also include recommendations for health care providers caring for women who reside in areas with ongoing transmission of Zika virus, including recommendations for screening, testing; and management of pregnant women and recommendations for counseling women of reproductive age (15-44 years). RISK ASSESSMENT Because Zika virus infection is preventable, knowing risks and practicing risk-reducing behaviors will help to stem the epidemic of this infection. Risks include: Being bitten by mosquitoes that carry Zika virus (which also spread dengue and chikungunya infections) Development of microcephaly in fetuses of pregnant women who have Zika virus CLIENT EDUCATION Teach Clients (CDC, 2016) When traveling to countries where Zika virus or other viruses spread by mosquitoes are found, remember that they bite mostly in daytime but also at night, and take the following steps: Wear long-sleeved shirts and long pants. Stay in places with air conditioning or that use window and door screens to keep mosquitoes outside. Sleep under a mosquito bed net if you are overseas or outside and are not able to protect yourself from mosquito bites. Use Environmental Protection Agency (EPA)-registered insect repellents. When used as directed, EPA-registered insect repellents are proven safe and effective, even for pregnant and breast-feeding women. · Always follow the product label instructions · Reapply insect repellent as directed. · Do not spray repellent on the skin under clothing. · If you are also using sunscreen, apply sunscreen before applying insect repellent. If you have a baby or child: · Do not use insect repellent on babies younger than 2 months of age. · Dress your child in clothing that covers arms and legs, or · Cover crib, stroller, and baby carrier with mosquito netting. · Do not apply insect repellent onto a child's hands, eyes, mouth, and cut or irritated skin. · Adults: Spray insect repellent onto your hands and then apply to a child's face. Treat clothing and gear with permethrin or purchase permethrin-treated items. · Treated clothing remains protective after multiple washings. See product information to learn how long the protection will last. · If treating items yourself, follow the product instructions carefully. · Do NOT use permethrin products directly on skin. They are intended to treat clothing. If you have Zika, protect others from getting sick During the first week of infection, Zika virus can be found in the blood and passed from an infected person to another mosquito through mosquito bites. An infected mosquito can then spread the virus to other people. To help prevent others from getting sick, avoid mosquito bites during the first week of illness. Prevent mosquitos from hatching in the environment Take care to empty standing water from all sources such as flower pots, bowls, buckets, or other areas of standing water.

CYSTOCELE

a bulging in the anterior vaginal wall caused by thickening of the pelvic musculature. As a result, the bladder, covered by vaginal mucosa, prolapses into the vagina.

RECTOCELE

a bulging in the posterior vaginal wall caused by weakening of the pelvic musculature. Part of the rectum covered by the vaginal mucosa protrudes into the vagina.

A peritoneal protrusion into the rectum, called a rectal shelf may indicate ??. Tenderness may indicate ??

a cancerous lesion or peritoneal metastasis peritoneal inflammation.

PERIANAL ABSCESS

a cavity of pus, caused by infection in the skin around the anal opening. It causes throbbing pain and is red, swollen, hard, and tender.

GERD

a digestive disease that occurs when stomach acid or contents flow back into the esophagus. The backwash (reflux) irritates the lining of the esophagus, and, if left untreated, over time chronic esophageal irritation can lead to serious complications. These complications include narrowing of the esophagus (esophageal stricture), esophageal ulcer, or Barrett esophagus, a condition involving precancerous changes in the esophagus (Mayo Clinic, 2014). When both acid reflux and heartburn occur at least twice a week, or interfere with daily life, it is recommended that a person see a healthcare provider, as permanent damage to the esophagus can result. Symptoms of GERD include hoarseness, laryngitis, chronic dry cough, asthma or worsening of asthma symptoms, feeling as if there is a lump in the throat, sudden increase in saliva, bad breath (halitosis), earaches, and/or chest pain or discomfort (seek emergency care for chest pain)

AIDS

a disease caused by the human immunodeficiency virus (HIV)

urinary bladder

a distensible muscular sac located behind the pubic bone in the midline of the abdomen, functions as a temporary receptacle for urine. A bladder filled with urine may be palpated in the abdomen above the symphysis pubis.

The vas deferens is

a firm, muscular tube that is continuous with the lower portion of the epididymis (see Fig. 26-1). It travels up within the spermatic cord through the inguinal canal into the abdominal cavity. At this point, it separates from the spermatic cord and curves behind the bladder. It joins with the duct of the seminal vesicle (this will be further discussed in the section on structure and function of the prostate) and forms the ejaculatory duct. Finally, the ejaculatory duct empties into the urethra within the prostate gland.

· Older adult clients are especially at risk for potential complications with diarrhea—such as fluid volume deficit, dehydration, and electrolyte and acid-base imbalances—because they have

a higher fat-to-lean muscle ratio.

Hepatomegaly,

a liver span that exceeds normal limits (enlarged), is characteristic of liver tumors, cirrhosis, abscess, and vascular engorgement.

During embryonic development, BREASTS

a milk line or ridge extends from each axilla to the groin area. It gradually atrophies and disappears as the person grows and develops. However, in some clients, supernumerary nipples or other breast tissue may appear along this "milk line"

gallbladder

a muscular sac approximately 10 cm long, functions primarily to concentrate and store the bile needed to digest fat. It is located near the posterior surface of the liver lateral to the MCL. It is not normally palpated because it is difficult to distinguish between the gallbladder and the liver.

RETROVERTED UTERUS

a normal variation that consists of the cervix and body of the uterus tilting backward. The uterine wall may not be palpable through the abdominal wall or the rectal wall in moderate retroversion. However, if the uterus is prominently retroverted, the wall may be felt through the posterior fornix or the rectal wall.

RETROFLEXED UTERUS

a normal variation that consists of the uterine body being flexed posteriorly in relation to the cervix. The position of the cervix remains normal. The body of the uterus may be felt through the posterior fornix or the rectal wall.

ANTEFLEXED

a normal variation that consists of the uterine body flexed anteriorly in relation to the cervix. The position of the cervix remains normal.

The ovaries are

a pair of small, oval-shaped organs, each of which is situated on a lateral aspect of the pelvic cavity. Each is approximately 3 cm long, 2 cm wide, and 1 cm deep. The ovaries are connected to the uterus by the ovarian ligament. The ovary functions to develop and release ova and to produce hormones such as estrogen, progesterone, and testosterone. The ovum travels from the ovary to the uterus through the fallopian tubes. These 8- to 12-cm long tubes begin near the ovaries and enter the uterus just beneath the fundus. The end of the tube near the ovary has fringe-like extensions called fimbriae. The ovaries, fallopian tubes, and supporting ovarian ligaments are referred to as the adnexa (Latin for appendages).

A painful mass that is hardened and reddened suggests

a perianal abscess

With the dynamic increase in maternal blood volume,

a physiologic anemia (pseudoanemia) commonly develops. This anemia results primarily from the disproportionate increase in blood volume compared with the increased red blood cell (RBC) production. Plasma volume increases 40% to 50% and RBC volume increases 18% to 30% by 30 to 34 weeks' gestation.

Intraductal papilloma is

a small growth inside a milk duct of the breast, often near the areola. It is harmless and occurs in women ages 35-50.

The scrotum is

a thin-walled sac that is suspended below the pubic bone, posterior to the penis. This darkly pigmented structure contains sweat and sebaceous glands and consists of folds of skin (rugae) and the cremaster muscle. The scrotum functions as a protective covering for the testes, epididymis, and vas deferens and helps to maintain the cooler-than-body temperature necessary for production of sperm (less than 37°C). The scrotum can maintain temperature control because the cremaster muscle is sensitive to changes in temperature. The muscle contracts when too cold, raising the scrotum and testes upward toward the body for warmth (cremasteric reflex). This accounts for the wrinkled appearance of the scrotal skin. When the temperature is warm, the muscle relaxes, lowering the scrotum and testes away from the heat of the body. When the cremaster muscle relaxes, the scrotal skin appears smooth.

colon or large intestine

a wider diameter than the small intestine (approximately 6.0 cm) and is approximately 1.4 m long. It originates in the RLQ, where it attaches to the small intestine at the ileocecal valve. The colon is composed of three major sections: ascending, transverse, and descending. The ascending colon extends up along the right side of the abdomen. At the junction of the liver in the RUQ, it flexes at a right angle and becomes the transverse colon. The transverse colon runs across the upper abdomen. In the LUQ near the spleen, the colon forms another right angle then extends downward along the left side of the abdomen as the descending colon. At this point, it curves in toward the midline to form the sigmoid colon in the LLQ. The sigmoid colon is often felt as a firm structure on palpation, whereas the cecum and ascending colon may feel softer. The transverse and descending colon may also be felt on palpation.

Western culture tends to emphasize the importance of

a woman's reproductive ability, thereby entwining self-esteem and body image with the female sex role. Anxiety, embarrassment, and fear may affect the client's ability to discuss problems and ask questions. Because some problems can be serious or even life-threatening, it is important to establish a trusting relationship with the client because the information gathered during the subjective examination may suggest a problem or point to the possibility of a problem developing. Cancer of the cervix, for example, is associated with a high mortality rate. However, related risk factors are highly modifiable and cure rates are high in disease that is discovered early.

The scrotum enlarges and ED increases in frequency with

age

Sensitivity to pain may diminish with ??. Therefore, assess older adult clients carefully for acute abdominal conditions.

aging

Vigorous, wide, exaggerated pulsations may be seen with

abdominal aortic aneurysm.

An everted umbilicus is seen with

abdominal distention

Colored, malodorous, or irritating discharge is ??; a specimen should be obtained for culture.

abnormal

Large amounts of colorful, frothy, or malodorous secretions are abnormal. Ovaries that are palpable 3 to 5 years after menopause are also

abnormal.

Masses, thickened structures, immobility, and tenderness are

abnormal.

Asymmetric labia may indicate

abscess

Tenderness and swelling may indicate

acute orchitis, torsion of the spermatic cord, a strangulated hernia, or epididymitis

A swollen, tender prostate may indicate

acute prostatitis.

· Older adult clients may experience a decline in appetite from various factors such as

altered metabolism, decreased taste sensation, decreased mobility, and, possibly, depression. If appetite declines, the client's risk for nutritional imbalance increases.

A small opening in the skin that surrounds the anal opening may be

an anorectal fistula

Splenomegaly is characterized by

an area of dullness greater than 7 cm wide. The enlargement may result from traumatic injury, portal hypertension, and mononucleosis.

An enlarged area of dullness is heard over Abnormal dullness is heard over If you suspect ascites, perform the shifting dullness and fluid wave tests. These special techniques are described later.

an enlarged liver or spleen. a distended bladder, large masses, or ascites.

A varicocele is

an enlargement of the veins within the scrotum, which may cause low sperm production and decreased sperm quality, which can cause infertility.

Enlarged or tender lymph nodes may indicate

an inflammatory process or infection of the penis or scrotum.

Thickening of the epithelium suggests repeated trauma from

anal intercourse.

a nonmenopausal woman, a pale cervix may indicate

anemia.

Tightened sphincter tone may indicate

anxiety, scarring, or inflammation.

Braxton Hick contractions are irregular contractions that may occur

anytime during the pregnancy and do not cause cervical dilation or changes in the cervix.

A wide, bounding pulse may be felt with an abdominal ??. A prominent, laterally pulsating mass above the umbilicus with an accompanying audible bruit strongly suggests an ??

aortic aneurysm

The enlarging uterus also

applies pressure and displaces the small intestine. This pressure, along with the secretion of progesterone, decreases gastric motility. Gastric tone is decreased and the smooth muscles relax, decreasing emptying time of the stomach. Constipation results from these physiologic events. Heartburn, which may also result, may also be related to decreased gastrointestinal motility and displacement of the stomach. This causes reflux of stomach acid into the esophagus. Progesterone secretion also relaxes the smooth muscles of the gallbladder; as a result, gallstone formation may occur because of the prolonged emptying time of the gallbladder.

The prostate gland is

approximately 2.5 to 4 cm in diameter, surrounding the neck of the bladder and urethra; it lies between these structures and the rectum in male clients. The prostate gland consists of two lobes separated by a shallow groove called the median sulcus (Fig. 26-4). It secretes a thin, milky substance that promotes sperm motility and neutralizes female acidic vaginal secretions. This chestnut- or heart-shaped organ can be palpated through the anterior wall of the rectum.

abdominal organs are supplied with

arterial blood by the abdominal aorta and its major branches (Fig. 23-6). Pulsations of the aorta are frequently visible and palpable midline in the upper abdomen. The aorta branches into the right and left iliac arteries just below the umbilicus. Pulsations of the right and left iliac arteries may be felt in the RLQ and LLQ.

Pale, taut skin may be seen with

ascites (significant abdominal swelling indicating fluid accumulation in the abdominal cavity).

Contractions lasting too long or occurring too frequently cause

fetal distress

The abdomen of infants is

cylindrical. Peristaltic waves may be visible in infants up to 3 months of age and may be indicative of a disease or disorder such as pyloric stenosis

Bulging of the anterior wall may indicate a

cystocele

Any type of spontaneous discharge should be referred for

cytologic study and further evaluation.

Bulge or mass palpated as client

bears down or coughs.

Circular Palpation Technique

begin at outermost edge and spiral inward toward nipple

vertical strip palpation technique

begin at top of breast and go downward then upward working your way over the entire breast

Abdominal cavity

begins with the stomach. It is a distensible, flask-like organ located in the LUQ just below the diaphragm and between the liver and spleen. The stomach is not usually palpable. The stomach's main function is to store, churn, and digest food.

OVARIAN CYST

benign masses on the ovary. They are usually smooth, mobile, round, compressible, and nontender.

An enlarged smooth, firm, slightly elastic prostate that may not have a median sulcus suggests

benign prostatic hypertrophy (BPH).

Benign breast disease consists of

bilateral, multiple, firm, regular, rubbery, mobile nodules with well-demarcated borders.

Purple discoloration at the flanks (Grey-Turner sign) indicates

bleeding within the abdominal wall, possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis.

A bruit with both systolic and diastolic components occurs when

blood flow in an artery is turbulent or obstructed. This may indicate an aneurysm or renal arterial stenosis (RAS). When blood flows through a narrow vessel, it makes a whooshing sound, called a bruit. However, the absence of this sound does not exclude the possibility of RAS.

Nipple discharge may be

bloody (possibly from a papilloma in the duct); greenish (often from a draining breast cyst); or clear (more likely associated with cancer unless from both nipples) (Johns Hopkins Medicine, n.d.).

Grey-Turner sign:

bluish of purplish discoloration on the abdominal flanks.

More than half of women have ?? at some time. The term "fibrocystic breast disease" is no longer used and is referred to as "fibrocystic breasts" or "fibrocystic breast changes

fibrocystic breast changes

Abdomen

bordered superiorly by the costal margins, inferiorly by the symphysis pubis and inguinal canals, and laterally by the flanks. It is important to understand the anatomic divisions known as the abdominal quadrants, the abdominal wall muscles, and the internal anatomy of the abdominal cavity in order to perform an adequate assessment of the abdomen.

Bloody discharge of the nipple and retraction of the skin could indicate

breast cancer.

Internally the scrotal sac is divided into two portions

by a septum, each portion containing one testis (testicle; see Fig. 26-1). The testes are a pair of ovoid-shaped organs, similar to the ovaries in the woman, that are approximately 3.7 to 5 cm long, 2.5 cm wide, and 2.5 cm deep. Each testis is covered by a serous membrane called the tunica vaginalis, which separates the testis from the scrotal wall. The tunica vaginalis is double layered and lubricated to protect the testes from injury. The function of the testes is to produce spermatozoa and the male sex hormone testosterone.

Spleen

filter the blood of cellular debris, to digest microorganisms, and to return the breakdown products to the liver.

A hard area on the prostate or hard, fixed, irregular nodules on the prostate suggest

cancer

Painless nodules may indicate

cancer

A hard, immobile cervix may indicate ??. Pain with movement of the cervix (cervical motion tenderness, CMT) may indicate ??

cancer infection (Chandelier sign)

Blood detected in the stool may indicate

cancer of the rectum or colon.

Peau d'orange skin, associated with ??, may be first seen in the areola.

carcinoma

Dilated surface arterioles and capillaries with a

central star (spider angioma) may be seen with liver disease or portal hypertension.

Dilated veins may be seen with

cirrhosis of the liver, obstruction of the inferior vena cava, portal hypertension, or ascites.

The amount of glandular, fibrous, and fatty tissue varies according to various factors including the

client's age, body build, nutritional status, hormonal cycle, and whether she is pregnant or lactating.

hollow viscera

consist of structures that change shape depending on their contents. These include the stomach, gallbladder, small intestine, colon, and bladder.

Axillary lymph nodes

consist of the anterior (pectoral), posterior (subscapular), lateral (brachial), and central (mid-axillary) nodes (Fig. 20-5). The anterior nodes drain the anterior chest wall and breasts. The posterior chest wall and part of the arms are drained by the posterior nodes.

Grandular tissue

constitutes the functional part of the breast, allowing for milk production arranged in 15 to 20 lobes that radiate in a circular fashion from the nipple. Each lobe contains several lobules in which the secreting alveoli (acini cells) are embedded in grape-like clusters.

Absence of a testis suggests

cryptorchidism (an undescended testicle).

In a nonpregnant woman, a bluish cervix may indicate

cyanosis

"Hypoactive" bowel sounds indicate

diminished bowel motility. Common causes include paralytic ileus following abdominal surgery, inflammation of the peritoneum, or late bowel obstruction. May also occur in pneumonia.

As women age, their estrogen production

decreases, causing atrophy of the vaginal mucosa. These women may experience dyspareunia and may need to use lubrication to increase comfort during intercourse. Women experiencing surgical menopause, symptoms of which occur more abruptly, may also benefit from lubrication.

Menarche (beginning of menstruation) tends to begin earlier in women living in

developed countries and later in women who live in undeveloped countries.

Epispadias is

displacement of the urinary meatus to the dorsal surface of the penis

Hypospadias is

displacement of the urinary meatus to the ventral surface of the penis.

After the client has changed, enter the room with a chaperone and assist the client into the

dorsal lithotomy position. This is a supine position with the feet in stirrups. Position the client's hips toward the bottom of the examination table so that the feet can rest comfortably in the stirrups. Ask the client not to put her hands over her head because this tightens the abdominal muscles. She should relax her arms at her sides. If possible, elevate the client's head and shoulders. This allows the nurse to maintain eye contact with the client during the examination and enables the client to see what the nurse is doing. Another technique is to offer the client a mirror so that she can view the examination (Fig. 27-4). This is a good way to teach normal anatomy and to get the client more involved and interested in maintaining or improving her genital health.

Tell the client before she comes in for the examination (at least 4 to 5 days ahead of time) not to ??, which is never recommended (Office on Women's Health, U.S. Department of Health and Human Services [USDHHS], 2015). Inform her not to use vaginal creams, jellies, medicines, or spermicidal foams for 2 to 3 days before a gynecologic examination, all of which can interfere with cervical cells. Also inform client not to have sex within 24 hours of the examination, as it can cause tissue inflammation (Johns Hopkins Medicine, n.d.).

douche

Lymph nodes

drain lymph from the breasts to filter out microorganisms and return water and protein to the blood.

lateral lymph nodes

drain most of the arms, and the central nodes receive drainage from the anterior, posterior, and lateral lymph nodes. A small proportion of the lymph also flows into the infraclavicular or supraclavicular lymph nodes or deeper into nodes within the chest or abdomen.

Linear stretch marks on breasts may be seen

during and after pregnancy or with significant weight gain or loss.

Lifelong poverty and lower educational level are associated with

earlier menopause across the world

Ask the client to empty the bladder before beginning the examination to

eliminate bladder distention and interference with an accurate examination.

A liver in a lower position than normal may be caused by

emphysema, whereas a liver in a higher position than normal may be caused by an abdominal mass, ascites, or a paralyzed diaphragm. A liver in a lower or higher position should have a normal span, but an enlarged liver may be higher, lower, or both (Abnormal Findings 23-3).

Abdominal contents and structure/purpose

enclosed externally by the abdominal wall musculature, which includes three layers of muscle extending from the back, around the flanks, to the front. The outermost layer is the external abdominal oblique, the middle layer is the internal abdominal oblique, and the innermost layer is the transverse abdominis (Fig. 23-3). Connective tissue from these muscles extends forward to encase a vertical muscle of the anterior abdominal wall called the rectus abdominis. The fibers and connective tissue extensions of these muscles (aponeuroses) diverge in a characteristic plywood-like pattern (several thin layers arranged at right angles to each other), which provides strength to the abdominal wall. The joining of these muscle fibers and aponeuroses at the midline of the abdomen forms a white line called the linea alba, which extends vertically from the xiphoid process of the sternum to the symphysis pubis. The abdominal wall muscles protect the internal organs and allow normal compression during functional activities such as coughing, sneezing, urination, defecation, and childbirth.

Breast Self-Awareness

encourages women to be mindful of what their breasts normally look and feel like so they can inform their health care providers if they detect any changes

A palpable spleen suggests ?? (up to three times the normal size), which may result from infections, trauma, mononucleosis, chronic blood disorders, and cancers. The splenic notch may be felt, which is an indication of splenic enlargement. Splenic enlargement may not always be pathologic. Caution: To avoid traumatizing and possibly rupturing the organ, be gentle when palpating an enlarged spleen.

enlargement

Prostatic hyperplasia,

enlargement of the prostate gland, has become increasingly common in men over age 40.

Examination finger cannot

enter the anus.

Within the anus are the two sphincters that normally hold the anal canal closed

except when passing gas and feces. The external sphincter is composed of skeletal muscle and is under voluntary control. The internal sphincter is composed of smooth muscle and is under involuntary control by the autonomic nervous system. Dividing the two sphincters is the palpable intersphincteric groove. The anal canal proceeds upward toward the umbilicus. Just above the internal sphincter is the anorectal junction, the dividing point of the anal canal and the rectum. The rectum is lined with folds of mucosa, known as the columns of Morgagni. The anorectal junction is not palpable, but may be visualized during internal examination. The folds contain a network of arteries, veins, and visceral nerves. Between the columns are recessed areas known as anal crypts; there are 8 to 12 anal crypts and 5 to 8 papillae. If the veins in these folds undergo chronic pressure, they may become engorged with blood, forming hemorrhoids

An enlarged scrotal sac may result from

fluid (hydrocele), blood (hematocele), bowel (hernia), or tumor (cancer).

Chancres (red, oval ulcerations) ?? are sometimes detected on the glans.

from syphilis, genital warts, and pimple-like lesions from herpes

Redness and excoriation may be from scratching an area infected by

fungi or pinworms.

Accentuated tympany or hyperresonance is heard over a

gaseous distended abdomen.

Within the abdominal cavity are structures of several different body systems:

gastrointestinal, reproductive (female), lymphatic, and urinary.

Female breasts consist of three types of tissue

glandular, fibrous, and fatty (adipose)

A yellow discharge is usually associated with ??. A clear or white discharge is usually associated with ??. Any discharge should be cultured.

gonorrhea urethritis

The older client's breasts may feel more

granular, and the inframammary ridge may be more easily palpated as it thickens.

Ticklish and warm hands

has trouble lying still and relaxing during the hands-on parts of the examination. Try to combat this using a controlled, hands-on technique and by placing the client's hand under your own for a few moments at the beginning of palpation. Finally, warm hands are essential for the abdominal examination. Cold hands cause the client to tense the abdominal muscles. Rubbing them together or holding them under warm water just before the hands-on examination may be helpful.

The nipple and areola typically

have darker pigment than the surrounding breast. Their color ranges from dark pink to dark brown, depending on the person's skin color. The amount of pigmentation increases with pregnancy, then decreases after lactation. It does not, however, entirely return to its original coloration.

Clients from some cultures (e.g., Islam) may insist on

having a female nurse for both the nursing history and physical assessment of the female genitalia, anus, and rectum.

Tenderness may indicate

hemorrhoids, fistula, or fissure.

Bulges that appear at the external inguinal ring or at the femoral canal when the client bears down may signal a

hernia

A bulge or mass may indicate a

hernia.

A soft center of the umbilicus can be a potential for

herniation.

Lesions may be from an infectious disease, such as

herpes or syphilis

During pregnancy, integumentary system changes occur primarily because of

hormonal influences. Many of these skin, hair, and nail changes fade or completely resolve after the end of the gestation. As the pregnancy progresses, the breasts and abdomen enlarge and striae gravidarum, or stretch marks—pinkish-red streaks with slight depressions in the skin—begin to appear over the abdomen, breasts, thighs, and buttocks. These marks usually fade to a white or silvery color, but they typically never completely resolve after the pregnancy. Hyperpigmentation also results from hormonal influences (e.g., estrogen, progesterone, and melanocyte-stimulating hormone). It is most noted on the abdomen (linea nigra, a dark line extending from the umbilicus to the mons pubis) and face (chloasma, a darkening of the skin on the face, known as the facial "mask of pregnancy"). When not pregnant, women taking oral contraceptives may also experience chloasma because of the hormones in the medication. Other skin changes during pregnancy include darkening of the areolae and nipples, axillae, umbilicus, and perineum. Scars and moles may also darken from the influence of melanocyte-stimulating hormone. Vascular changes, such as spider nevi (tiny red angiomas occurring on the face, neck, chest, arms, and legs), may occur because of elevated estrogen levels. Palmar erythema (a pinkish color on the palms of the hands) may also be noted. Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a skin disorder seen during the third trimester of pregnancy, characterized by erythematous papules, plaques, and urticarial lesions. The rash begins on the abdomen and may soon spread to the thighs, buttocks, and arms. The intense itching and rash usually resolve within weeks of delivery. Acne vulgaris is an unpredictable response during pregnancy. Acne may worsen or improve. It consists of erythema, pustules, comedones, and/or cysts that appear on the face, back, neck, or chest. The activity of the eccrine sweat glands and the excretion rate of sebum onto the skin increase in normal pregnancy, whereas the activity of the apocrine sweat glands appears to decrease. The changes that occur in the endocrine system help to maintain optimal maternal and fetal health. Estrogen is primarily responsible for the changes that occur to the pituitary, thyroid, parathyroid, and adrenal glands. The increased production of hormones—especially triiodothyronine (T3) and thyroxine (T4)—increases the basal metabolic rate, cardiac output, vasodilation, heart rate, and heat intolerance. The basal metabolic rate increases up to 30% in a term pregnancy. Growth of hair and nails also tends to increase during pregnancy. Some women note excessive oiliness or dryness of the scalp and a softening and thinning of the nails by the 6th week of gestation. Pregnancy hormones increase the growing phases of the hair follicle and decrease the resting phase of the hair follicle. During the postpartum period, hormone withdrawal increases the resting phase of the hair follicle and transient hair loss is noticed, commonly peaking at 3 to 4 months postpartum. This loss is normally resolved within 9 months to 1 year of delivery.

A cyst suggests

hydrocele of the spermatic cord.

Swellings or masses that contain serous fluid

hydrocele, spermatocele—light up with a red glow.

Always ask a patient who complains of lumps or swelling in the breast

if the lump changes during the menstrual cycle. Women who have fibrocystic breasts will often have lumpy areas in the breast that increase in size in the two weeks prior to the menstrual period. They then decrease in size during menstruation and for the first 2 weeks after menstruation.

Cervical cancer

in the uterine cervix, the narrow neck at the lower part of the uterus, connecting the uterus to the vagina (ACS, 2017a). Approximately 8 out of 10 cervical cancers originate in surface cells lining the cervix (squamous cell carcinomas). This is a slow developing cancer and it is preceded by a precancerous stage of dysplasia, which is easily diagnosed with a Pap smear test. Dysplasia is 100% treatable. When dysplastic cells become cancerous (malignant), the first detectable stage is carcinoma in situ (CIS)—a noninvasive cervical cancer. As cancer cells multiply, some may invade the lining of the cervix, spread to nearby tissue, and enter the bloodstream or lymphatic system. When this happens, it can spread to other parts of the body. According to the CDC (2015), cervical cancer used to be the leading cause of cancer death for women in the United States. However, in the past 40 years, the number of cases of cervical cancer and the number of deaths from cervical cancer have decreased significantly. This decline largely is the result of many women getting regular Pap tests, which can find cervical precancer before it turns into cancer. ACS, 2017a notes that the incidence of cervical cancer in the United States has decreased by more than 50% in the past 30 years because of widespread screening with cervical cytology, including the Pap test (Pap smear). New technologies, including HPV testing, continue to evolve, as do guidelines for managing abnormal results. The WHO (2016a) reports that cervical cancer rates are highest in high-income countries (as are the rates for all cancers). The lowest cervical cancer rates are found in Eastern Mediterranean countries. However, an unusually high rate of cervical cancer was found in the African region where income levels tend to be low. The WHO (2015) notes that virtually all cases of cervical cancer are caused by human papillomavirus (HPV), and just two types of HPV, 16 and 18, are responsible for 70% of all cases. HPV is acquired through intercourse with an infected partner.

Venous hums are rare. However, an accentuated venous hum heard in the epigastric or umbilical areas suggests

increased collateral circulation between the portal and systemic venous systems, as in cirrhosis of the liver.

NEWBORN · Bladder capacity

increases with age; the bladder is considered an abdominal organ in infants because it is located between the symphysis pubis and the umbilicus (higher than in adults).

The spleen feels soft with a rounded edge when it is enlarged from ??. It feels firm with a sharp edge when it is enlarged from ??.

infecction chronic disease

Redness and inflammation of the scar area may indicate ?. Any lesions, lumps, or tenderness should be referred for further evaluation.

infection

Enlarged (greater than 1 cm) lymph nodes may indicate

infection of the hand or arm.

A beaded or thickened cord indicates

infection or cysts.

Drainage around piercings indicates

infection.

A recent increase in the size of one breast may indicate

inflammation or an abnormal growth.

Tenderness elicited over the liver may be associated with

inflammation or infection (e.g., hepatitis or cholecystitis).

However, pain may also occur with a malignant tumor. Therefore, refer the client for further evaluation. Heat in the breasts of women who have not just given birth or who are not lactating indicates

inflammation.

Redness is associated with breast

inflammation.

Running diagonally between these two landmarks, just above and parallel with the inguinal ligament, is the

inguinal canal. The inguinal canal is a tube-like structure (4 to 5 cm or 1.5 to 2 in long in an adult) through which the vas deferens travels as it passes through the lower abdomen.

When assessing the male genitalia, the nurse needs to be familiar with structures of the

inguinal or groin area because hernias (protrusion of loops of bowel through weak areas of the musculature) are common in this location (Fig. 26-2). The inguinal area is contained between the anterior superior iliac spine laterally and the symphysis pubis medially.

Peristaltic waves are increased and progress in a ripple-like fashion from the LUQ to the RLQ with

intestinal obstruction (especially small intestine). In addition, abdominal distention typically is present with intestinal wall obstruction.

HIV

is transmitted from person to person in a variety of ways: via exchange of body fluids, usually through sexual transmission, but also through contact with infected blood (e.g., blood transfusions, infected needles); by mother to child during pregnancy, childbirth, or breastfeeding; by intravenous drug users; and by other mechanisms of body fluid transfer. The highest incidence of HIV in the United States still occurs in MSM, followed by intravenous drug users. HIV damages the immune system by destroying CD4 white blood cells (helper T cells) and prevents the body from defending itself against other organisms, allowing development of opportunistic infections such as tuberculosis, cancer, and pneumonia (National Institutes of Health (NIH), 2017). The time from infection with HIV to development of AIDS (acquired immunodeficiency disease syndrome) may be years. At present, there is no cure for AIDS, but medications help to suppress the virus in most people who have access to these very expensive treatments. Although the incidence of AIDS has been reduced by use of this medication in some nations, the organization AVERT (Averting HIV and AIDS) (2015) noted that the populations of many countries in Africa, Asia, and the country of Haiti in the Americas are still being decimated by the disease. Primary or acute HIV infection may last a few weeks and have symptoms (noticeable or mild, even unnoticed) of fever, muscle aches and joint pain, rash, headache, sore throat, swollen lymph glands (mainly on the neck, and a first sign of infection), diarrhea, weight loss, oral yeast infection (thrush), and/or shingles (herpes zoster). With chronic HIV infection, no further symptoms other than those revealed through blood work are noted. Without treatment, HIV will progress to AIDS in about 10 years, and the immune system is severely damaged, allowing opportunistic infections. Once HIV infection progresses to AIDS, in about 10 years, additional symptoms are: soaking night sweats; recurring fevers; chronic diarrhea; persistent white spots or unusual lesions on tongue or in mouth; persistent unexplained fatigue; weight loss; and skin rashes or bumps (Mayo Clinic, 2015a). These symptoms may be indicative of a number of illnesses. During this phase, the viral load is particularly high, which accounts for the ease of transmission during this early stage. Swollen lymph nodes may persist and over time other symptoms may appear, such as fatigue, weight loss, and shortness of breath. Definitive diagnosis that HIV infection has progressed to AIDS is confirmed by a CD4 count under 200 cells/mm3 (AIDS.gov, 2015). Opportunistic infections (OIs) are signs of a declining immune system. Most life-threatening OIs occur when the CD4 count is below 200 cells/mm3. OIs are the most common cause of death for people with HIV/AIDS. A CD4 of between 500 and 200 cells/mm3 tends to allow for Candida albicans (thrush) and Kaposi sarcoma. A CD4 between 200 and 100 cells/mm3 tends to allow for Pneumocystis jirovecii pneumonia, histoplasmosis, coccidioidomycosis, and progressive multifocal leukoencephalopathy (PML). A CD4 count below 100 cells/mm3 allows for toxoplasmosis, cryptosporidiosis, cytomegalovirus, and other infections. AIDS.gov (2013) noted that tuberculosis is the leading cause of death for people living with HIV worldwide. It is important to note that HIV is a preventable disease. Effective HIV prevention interventions have been proven to reduce HIV transmission. People who get tested for HIV and learn that they are infected can make significant behavior changes to improve their health and reduce the risk of transmitting HIV to their sex or drug-using partners.

In many people, the liver extends

just below the right costal margin, where it may be palpated. If palpable, the liver has a soft consistency. The liver functions as an accessory digestive organ and has a variety of metabolic and regulatory functions as well, including glucose storage, formation of blood plasma proteins and clotting factors, urea synthesis, cholesterol production, bile formation, destruction of red blood cells, storage of iron and vitamins, and detoxification.

When interviewing clients—especially females—about the breasts,

keep in mind that this topic may evoke a wide spectrum of emotions from the client. Explore your own feelings regarding body image, fear of breast cancer, and the influence of the breasts on self-esteem. Western culture emphasizes the breasts for femininity and beauty as well as lactation. Fear, anxiety, or embarrassment may influence the client's ability to discuss the condition of the breasts and breast self-examination (BSE, if done) or breast self-awareness. Men with gynecomastia or cancer of the breast may be embarrassed to have what they consider a "female condition." The following questions provide guidance in conducting the interview.

Tenderness or sharp pain elicited over the CVA suggests

kidney infection (pyelonephritis), renal calculi, or hydronephrosis.

Liver

largest solid organ in the body. It is located below the diaphragm in the RUQ of the abdomen. It is composed of four lobes that fill most of the RUQ and extend to the left midclavicular line (MCL).

Ascites usually results from

liver failure or liver disease.

Kidneys

located high and deep under the diaphragm. These glandular, bean-shaped organs measuring approximately 10 × 5 × 2.5 cm are considered posterior organs and approximate with the level of the T12 to L3 vertebrae. The tops of both kidneys are protected by the posterior rib cage. Kidney tenderness is best assessed at the costovertebral angle (Fig. 23-5). The right kidney is positioned slightly lower because of the position of the liver. Therefore, in some thin clients, the bottom portion of the right kidney may be palpated anteriorly. The primary function of the kidneys is filtration and elimination of metabolic waste products. However, the kidneys also play a role in blood pressure control and maintenance of water, salt, and electrolyte balances. In addition, they function as endocrine glands by secreting hormones.

Nipple

located in the center of the breast, contains the tiny openings of the lactiferous ducts through which milk passes.

Pancreas

located mostly behind the stomach deep in the upper abdomen, is normally not palpable. It is a long gland extending across the abdomen from the RUQ to the LUQ. The pancreas has two functions: it is an endocrine gland and an accessory organ of digestion. The spleen is approximately 7 cm wide and is located above the left kidney just below the diaphragm at the level of the ninth, tenth, and eleventh ribs. It is posterior to the left mid-axillary line (MAL) and posterior and lateral to the stomach. This soft, flat structure is normally not palpable. In some healthy clients, the lower tip can be felt below the left costal margin.

A prominent venous pattern may occur as a result of increased circulation due to a ??. An asymmetric venous pattern may be due to ??.

malignancy

A recently retracted nipple that was previously everted suggests

malignancy

Dark, velvety pigmentation of the axillae (acanthosis nigricans) may indicate an underlying

malignancy.

Large nodes that are hard and fixed to the skin may indicate an underlying

malignancy.

Dimpling or retraction is usually caused by a ??. As the muscle contracts, it draws the breast tissue and skin with it, causing dimpling or retraction.

malignant tumor that has fibrous strands attached to the breast tissue and the fascia of the muscles

Restricted movement of breast or retraction of the skin or nipple indicates fibrosis and fixation of the underlying tissues. This is usually due to an underlying

malignant tumor.

Thickening of the tissues may occur with an underlying

malignant tumor.

Although rare, men can have breast cancer, which may not be caught until the late stages, because

many in society are unaware of its occurrence in men

Localized redness, pain, and warmth could indicate

mastitis.

UTERINE CANCER (CANCER OF THE ENDOMETRIUM)

may be enlarged with a malignant mass. Irregular bleeding, bleeding between periods, or postmenopausal bleeding may be the first sign of a problem.

Some causes may include: ??. The risk increases if the client smokes, has not had a vaginal birth, or rarely has sexual activity, which increases blood flow to tissues

menopause, breast feeding, surgical removal of the ovaries, and radiation or chemotherapy treatments for cancer or as a side effect of breast cancer hormone treatment

Pain and fullness occurs just before

menses.

Painful, tender breasts may be indicative of fibrocystic breasts, especially right before

menstruation

A pigskin-like or orange-peel (peau d'orange) appearance results from edema, which is seen in ??. The edema is caused by blocked lymphatic drainage.

metastatic breast disease

Palpation of a hard nodule in or around the umbilicus may indicate

metastatic nodes from an occult gastrointestinal cancer.

Urinary incontinence may develop in older women from

muscle weakness or loss of urethral elasticity.

An enlarged uterus above the level of the pubis is abnormal; an irregular shape suggests abnormalities such as

myomas (fibroid tumors) or endometriosis.

The male breasts have

no functional capability.

Women's removal of or trimming of pubic hair has become

normal. This practice varies with age, and razor shaving was by far the most popular removal method, with fewer than 5% of women engaging in waxing, electrolysis, or laser hair removal

Breasts

paired mammary glands that lie over the muscles of the anterior chest wall, anterior to the pectoralis major and serratus anterior muscles. Depending on their size and shape, the breasts extend vertically from the second to the sixth rib and horizontally from the sternum to the mid-axillary line

A foreskin that, once retracted, cannot be returned to cover the glans is called

paraphimosis.

· Meconium

passed during the first 24 hours of life, signifying anal patency. Stools are passed by reflex, and anal sphincter control is not reached until 1.5 to 2 years of age after the nerves supplying the area have become fully myelinated. Meconium not passed within 24 hours of birth could signify a problem. In boys, the prostate gland is underdeveloped and not palpable.

It is itchy, painful, and bleeds when the client

passes stool.

The uterus is a

pear-shaped muscular organ that has two components: the corpus, or body, and the cervix, or neck (discussed previously). The corpus of the uterus is divided into the fundus (upper portion), the body (central portion), and the isthmus (narrow lower portion). The uterus is usually situated in a forward position above the bladder at approximately a 45-degree angle to the vagina when standing (anteverted and anteflexed positions; see Fig. 27-2). The normal-sized uterus is approximately 7.5 cm long, 5 cm wide, and 2.5 cm thick. The uterus is movable.

· Before conception, the uterus is a small,

pear-shaped organ that weighs approximately 44 g. Its cavity can hold approximately 10 mL of fluid. Pregnancy changes this organ, giving it the capacity to weigh approximately 1,000 g and potentially hold approximately 5 L of amniotic fluid. This dynamic change is mainly due to the hypertrophy of pre-existing myometrial cells and the hyperplasia of new cells. Estrogen and the growing fetus are primarily responsible for this growth. Once conception occurs, the uterus prepares itself for the pregnancy: ovulation ceases, the uterine endometrium thickens, and the number and size of uterine blood vessels increase.

The older client often has more ??? breasts.

pendulous, less firm, and saggy

A digital rectal exam (DRE) may also be

performed as part of the examination. Detecting problems with the anus and rectum is the primary objective of this examination. This is important because some conditions, such as cancerous tumors, may be asymptomatic. Early detection of a problem is one way to promote early treatment and a more positive outcome. Use this time (especially if the examination is a well examination) to integrate teaching about ways to reduce risk factors for diseases and disorders of the anus and rectum.

Diminished abdominal respiration or change to thoracic breathing in male clients may reflect

peritoneal irritation.

Involuntary reflex guarding is serious and reflects

peritoneal irritation. The abdomen is rigid and the rectus muscle fails to relax with palpation when the client exhales. It can involve all or part of the abdomen but is usually seen on the side (i.e., right vs. left rather than upper or lower) because of nerve tract patterns. Right-sided guarding may be due to cholecystitis.

Absent bowel sounds may be associated with

peritonitis or paralytic ileus. High-pitched tinkling and rushes of high-pitched sounds with abdominal cramping usually indicate obstruction.

A tight foreskin that cannot be retracted is called

phimosis.

Older clients and others who no longer menstruate and who decide to continue with BSE may find it helpful to

pick a set day of the month for BSE, a date they will remember each month such as the day of the month they were born.

Hemorrhoids

piles, are swollen and inflamed veins in the lower rectum and anus (Mayo Clinic, 2013a). They may be located inside the rectum (internal hemorrhoids) or under the skin around the anus (external hemorrhoids). Causes for hemorrhoids include straining during a bowel movement, pregnancy, sitting for long periods on the toilet, chronic constipation or diarrhea, obesity, anal intercourse, low fiber diet, and other conditions that increased pressure on the veins due to intra-abdominal pressure. Symptoms of hemorrhoids include painless bleeding during bowel movements; itching or irritation, pain, discomfort, or swelling in the anal region; lump near the anus, which may be sensitive or painful; and leakage of feces. Although hemorrhoids are usually uncomplicated, they may be pushed out of the anus and protrude, or they may become prolapsed outside the anus, or become thrombosed or strangulated, which occurs when the blood supply to an internal hemorrhoid is cut off. This causes extreme pain and may lead to gangrene. Anemia is the other potential consequence of hemorrhoids if the rectal bleeding is substantial.

A reddened, swollen, or dimpled area covered by a small tuft of hair located midline on the lower sacrum suggests a

pilonidal cyst

The upper border of liver dullness may be difficult to estimate if obscured by

pleural fluid of lung consolidation.

Nodules may indicate

polyps or cancer.

Cervical lesions may result from

polyps, cancer, or infection.

Common causes of nipple discharge in addition to

pregnancy, include lactation, hypothyroidism, pituitary adenoma, oral contraceptives, antihypertensives, and tranquilizers

Carbohydrate metabolism is also altered during

pregnancy. Glucose use increases, leading to decreased maternal glucose levels. The rise in serum levels of estrogen, progesterone, and other hormones stimulates beta-cell hypertrophy and hyperplasia, and insulin secretion increases. Glycogen is stored and gluconeogenesis is reduced. In addition, the mother's body tissues develop an increased sensitivity to insulin, thus decreasing the mother's need. As a result, maternal hypoglycemia leads to hypoinsulinemia and increased rates of ketosis. Some well-controlled insulin-dependent diabetic clients have frequent episodes of hypoglycemia in the first trimester. This buildup of insulin ensures an adequate supply of glucose, because the glucose is preferentially shunted to the fetus.

Regular contractions prior to 37 weeks' gestation suggest

premature labor.

Inverted nipples

problematic for breast-feeding. Inverted nipples should be identified in the beginning of the third trimester. Breast shields can be inserted in the bra to train the nipple to turn outward.

As plasma blood volume increases, the blood vessels must accommodate for this volume:

progesterone acts on the vessels to make them relax and dilate. Clients often complain of feeling dizzy and lightheaded beginning with the second trimester. These effects peak at approximately 32 to 34 weeks. As the pregnancy progresses, the arterial blood pressure stabilizes and symptoms begin to resolve. Prepregnancy values return in the third trimester.

Cervical enlargement or projection into the vagina more than 3 cm may be from

prolapse or tumor, and further evaluation is needed.

· The umbilical cord is

prominent in the newborn and contains two arteries and one vein. The umbilicus consists of two parts: the amniotic portion and the cutaneous portion. The amniotic portion is covered with a gel-like substance and dries up and falls off within 2 weeks of birth. The cutaneous portion is covered with skin and draws back to become flush with the abdominal wall.

Fibrous tissue

provides support for the glandular tissue largely by way of bands called Cooper ligaments (suspensory ligaments).

Bulges of red mucous membrane may indicate a.. Hemorrhoids or an anal fissure may also be seen.

rectal prolapse

Bulging of the posterior wall may indicate a

rectocele

If the client has epididymitis, passive elevation of the testes may

relieve the scrotal pain (Prehn sign).

colon function

secrete large amounts of alkaline mucus to lubricate the intestine and neutralize acids formed by the intestinal bacteria. Water is also absorbed through the large intestine, leaving waste products to be eliminated in stool.

Located on either side of and above the prostate gland are the

seminal vesicles. These are rabbit-ear-shaped structures that produce the ejaculate that nourishes and protects sperm. They are not normally palpable. The Cowper's (or bulbourethral) glands are mucus-producing, pea-sized organs located posterior to the prostate gland. These glands surround and empty into the urethra. They are not normally palpable either.

Absent or decreased ability to squeeze the examiner's finger indicates decreased muscle tone. Decreased tone may decrease

sexual satisfaction.

If the client has breast implants,

she should check her breasts regularly, paying extra attention to how breasts look and feel. The implants have a different texture than original breast tissue. In 90% of breast cancer cases, the woman finds the breast lump herself and learning to recognize changes with the implants is one of the best ways to detect cancer if it develops

testicular self-examination (TSE)

should be performed once a month; it is neither difficult nor time consuming. A convenient time is often after a warm bath or shower when the scrotum is more relaxed. Stand in front of a mirror and check for scrotal swelling. Use both hands to palpate the testis; the normal testicle is smooth and uniform in consistency. With the index and middle fingers under the testis and the thumb on top, roll the testis gently in a horizontal plane between the thumb and fingers (A). Feel for any evidence of a small lump or abnormality. Follow the same procedure and palpate upward along the testis (B). Locate the epididymis (C), a cord-like structure on the top and back of the testicle that stores and transports sperm. Repeat the examination for the other testis. It is normal to find that one testis is larger than the other. If you find any evidence of a small, pea-like lump, consult your physician. It may be due to an infection or a tumor growth.

Decreased or absent bowel sounds

signify the absence of bowel motility, which constitutes an emergency requiring immediate referral.

A previously thrombosed hemorrhoid appears as a

skin tag that protrudes from the anus.

NABOTHIAN (RETENTION) CYSTS

small (less than 1 cm), yellow, translucent nodules on the cervical surface. Normal odorless and nonirritating secretions may be present on pink, healthy tissue. (Irritating secretions would appear on reddened tissue.) The viscosity of these secretions ranges from thin to thick; their appearance ranges from clear to cloudy, depending on the phase of the menstrual cycle. may occur when the everted columnar epithelium spontaneously transforms into squamous epithelium, a process called squamous metaplasia. Occasionally the tissue blocks endocervical glands and cysts develop.

The older client may have ?? nipples that are less erectile on stimulation.

smaller, flatter

Skin of breasts

smooth and varies in color depending on the client's skin tones

The cervix is composed of

smooth muscle, muscle fibers, and connective tissue. Two types of epithelium cover the external os or ectocervix—pink squamous epithelium (which lines the vaginal walls) and red, rough-looking columnar epithelium (which lines the endocervical canal). The columnar epithelium may be visible around the os. The point where the two types of epithelium meet is called the squamocolumnar junction. The squamocolumnar junction migrates toward the cervical os with maturation or with increased estrogen levels. This migration creates an area known as the transformational zone. The transformational zone is important: 1. 90% of the neoplasms of the lower genital tract originate in this area. 2. This is the area from which cells are obtained for cervical cytology or the Papanicolaou smear (Pap test).

These structures are typically referred to as the abdominal viscera and can be divided into two types:

solid viscera and hollow viscera

yellow stool suggests

steatorrhea (increased fat content).

If urine leaks out, the client may have

stress incontinence.

Areola

surrounds the nipple (generally 1- to 2-cm radius) and contains elevated sebaceous glands (Montgomery glands) that secrete a protective lipid substance during lactation. HAIR FOLLICLES SURROUND THIS Smooth muscle fibers in the areola cause the nipple to become more erectile during stimulation.

Redness and inflammation may be seen with infection of the

sweat gland.

A thrombosed external hemorrhoid appears

swollen.

Chancres (red, oval ulcerations) from

syphilis and genital warts are sometimes detected under the foreskin

When the client arrives, ask her to urinate before the examination so

that she does not experience bladder discomfort. If a clean-catch urine specimen is needed, provide a container and vaginal wipes. When the client is in the examining room, ask her to remove her underwear and bra and to put on a gown with the opening in the back. If she is also having a breast examination at this time, suggest that she leave the opening in the front—a sheet can be used for draping. Tell her that she can leave her socks on if desired because the stirrups on the examination table are metal and may be cool. Leave the room while the client changes.

· A flat pillow may be placed under the client's head for comfort. Slightly flex the client's legs by placing a pillow or rolled blanket under the client's knees to help relax

the abdominal muscles. Drape the client with sheets so that the abdomen is visible from the lower rib cage to the pubic area.

· Older adult clients are prone to UTIs because

the activity of protective bacteria in the urinary tract declines with age.

Mammary ducts

the alveoli converge into a single lactiferous duct that leaves each lobe and conveys milk to the nipple. The slight enlargement in each duct before it reaches the nipple is called the lactiferous sinus. The milk can be stored in the lactiferous sinus (or ampullae) until stimulated to be released from the nipple.

A swollen skin tag on the anal margin may indicate a fissure in

the anal canal

In the abdomen, the expanding uterus exerts pressure on

the bladder, kidney, and ureters (especially on the right side), predisposing the client to kidney infection. Urinary frequency is a common complaint in the first and third trimesters. The applied pressure on the kidneys and ureters causes decreased flow and stagnation of the urine. As a result, physiologic hydronephrosis and hydroureter occur. During the second trimester, bladder pressure subsides and urinary

For purposes of describing the location of assessment findings,

the breasts are divided into four quadrants by drawing horizontal and vertical imaginary lines that intersect at the nipple.

Excoriation may result from

the client scratching or self-treating a perineal irritation.

The external inguinal ring is

the exterior opening of the inguinal canal, which can be palpated above and lateral to the symphysis pubis. It feels triangular and slit-like. The internal inguinal ring is the internal opening of the inguinal canal. It is located 1 to 2 cm above the midpoint of the inguinal ligament and cannot be palpated. The femoral canal is another potential spot for a hernia. The femoral canal is located posterior to the inguinal canal and medial to and running parallel with the femoral artery and vein.

The anal canal is

the final segment of the digestive system. It begins at the anal sphincter and ends at the anorectal junction (also known as the pectinate line, mucocutaneous junction, or dentate line). It measures from 2.5 to 4 cm long. It is lined with skin that contains no hair or sebaceous glands but does contain many somatic sensory nerves, making it susceptible to painful stimuli. The anal opening (or anal verge) can be distinguished from the perianal skin by its hairless, moist appearance. The anal verge extends interiorly, overlying the external anal sphincter.

Phimosis

the foreskin cannot be retracted over the penis tip.

A mass within the abdominal wall is more prominent when

the head is raised, whereas a mass below the abdominal wall is obscured

visceral peritoneum

the inner layer of the peritoneum that surrounds the organs of the abdominal cavity

Friction rubs are rare. If heard, they have a high-pitched, rough, grating sound produced when

the large surface area of the liver or spleen rubs the peritoneum. They are heard in association with respiration. A friction rub heard over the lower right costal area is associated with hepatic abscess or metastases. A rub heard at the anterior axillary line in the lower left costal area is associated with splenic infarction, abscess, infection, or tumor.

Small intestine

the longest portion of the digestive tract (approximately 7.0 m long) but is named for its small diameter (approximately 2.5 cm). Two major functions of the small intestine are digestion and absorption of nutrients through millions of mucosal projections lining its walls. The small intestine, which lies coiled in all four quadrants of the abdomen, is not normally palpated.

The rectum is

the lowest portion of the large intestine and is approximately 12 cm long, extending from the end of the sigmoid colon to the anorectal junction. It enlarges above the anorectal junction and proceeds in a posterior direction toward the hollow of the sacrum and coccyx, forming the rectal ampulla. The anal canal and rectum are at approximately right angles to each other. The inside of the rectum contains three inward foldings called the valves of Houston. The function of the valves of Houston is unclear. The lowest valve may be felt, usually on the client's left side.

The penis is

the male reproductive organ. Attached to the pubic arch by ligaments, the penis is freely movable. The shaft of the penis is composed of three cylindrical masses of vascular erectile tissue that are bound together by fibrous tissue—two corpora cavernosa on the dorsal side and the corpus spongiosum on the ventral side. The corpus spongiosum extends distally to form the acorn-shaped glans. The base of the glans, or corona, is somewhat larger as compared with the shaft of the penis. If the man has not been circumcised, a hood-like fold of skin called the foreskin or prepuce covers the glans. In the center of the corpus spongiosum is the urethra, which travels through the shaft and opens as a slit at the tip of the glans as the urethral meatus. A fold of foreskin that extends ventrally from the urethral meatus is called the frenulum. The penis has a role in both reproduction and urination.

The vas deferens provides

the passage for transporting sperm from the testes to the urethra for ejaculation. Along the way, secretions from the vas deferens, seminal vesicles, prostate gland, and Cowper's (or bulbourethral) glands mix with the sperm and form semen.

The external genitalia consist of

the penis and the scrotum

Bowel sounds auscultated over the mass indicate

the presence of bowel and thus a scrotal hernia. Bowel sounds will not be heard over a hydrocele. If you cannot push the mass into the abdomen, suspect an incarcerated hernia. A hernia is strangulated when its blood supply is cut off. The client typically complains of extreme tenderness and nausea. If you suspect that the client has a strangulated hernia, refer the client immediately to the physician and prepare him for surgery.

For the purposes of examination, the abdomen can be described as having four quadrants

the right upper quadrant (RUQ), right lower quadrant (RLQ), left lower quadrant (LLQ), and left upper quadrant (LUQ) as seen in Figure 23-1. The quadrants are determined by an imaginary vertical line (midline) extending from the tip of the sternum (xiphoid) through the umbilicus to the symphysis pubis. This line is bisected perpendicularly by the lateral line, which runs through the umbilicus across the abdomen. Familiarization with the organs and structures in each quadrant is essential to accurate data collection, interpretation, and documentation of findings. Another method divides the abdomen into nine regions (Fig. 23-2). Three of these regions are still commonly used to describe abdominal findings: epigastric, umbilical, and hypogastric or suprapubic

Prostate cancer

the second most common cancer (after nonmelanoma skin cancer) and one of the leading causes of cancer death in men in the United States (lung cancer is first). The incidence and mortality trends of prostate cancer in the United States declined between 2002 and 2011. Prostate cancer is slow-growing and can be readily treated if found early. There is no sure way to prevent prostate cancer, but diet and lifestyle behaviors are thought to help with prevention. A common problem in almost all men as they grow older is an enlarged prostate (benign prostatic hyperplasia, or BPH). Some symptoms of BPH and prostate cancer are the same. Having BPH does not raise your risk of prostate cancer.

Colorectal cancer

the third most common cancer diagnosis in the United States (ACS, 2017b). The ACS estimates that there will be 95,520 new cases of colon cancer and 39,910 cases of rectal cancer in the United States in 2017. The lifetime risk for CRC is 1 in 21 men and 1 in 23 women. CRC is also the third leading cause of cancer-related death in the United States when men and women are considered separately and the second leading cause of death when men and women are considered together. CRC originates in the large intestine or rectum as opposed to other cancers that may affect the colon, such as, for example, lymphoma, sarcoma, or melanoma (ACS, 2017b). Most CRCs begin as a polyp on the inner lining of the colon or rectum. Some types of polyps, but not all, can change to cancer over the course of several years. Another type of precancer, dysplasia, is an area in a polyp or in the lining of the colon or rectum where the cells look abnormal, but not like true cancer cells. Because cancer found early is readily treatable, early diagnosis is essential before the cancer has spread to deeper tissues.

The endometrium, the myometrium, and the peritoneum are

the three layers of the uterine wall. The endometrium is the inner mucosal layer. The endometrium is composed of epithelium, connective tissue, and a vascular network. Estrogen and progesterone influence the thickness of this tissue. Uterine glands contained within the endometrium secrete an alkaline substance that keeps the uterine cavity moist. A portion of the endometrium sheds during menses and childbirth. The myometrium is the middle layer of the uterus. It is composed of three layers of smooth muscle fibers that surround blood vessels. This layer functions to expel the products of conception. The peritoneum is the outer uterine layer that covers the uterus and separates it from the abdominal cavity. The peritoneum forms anterior and posterior pouches around the uterus. The posterior pouch is called the recto-uterine pouch or the cul-de-sac of Douglas.

Within the anus are

the two sphincters that normally hold the anal canal closed except when passing gas and feces. The external sphincter is composed of skeletal muscle and is under voluntary control. The internal sphincter is composed of smooth muscle and is under involuntary control by the autonomic nervous system. Dividing the two sphincters is the palpable intersphincteric groove. The anal canal proceeds upward toward the umbilicus. Just above the internal sphincter is the anorectal junction, the dividing point of the anal canal and the rectum. The rectum is lined with folds of mucosa, known as the columns of Morgagni. The anorectal junction is not palpable, but may be visualized during internal examination. The folds contain a network of arteries, veins, and visceral nerves. Between the columns are recessed areas known as anal crypts; there are 8 to 12 anal crypts and 5 to 8 papillae. If the veins in these folds undergo chronic pressure, they may become engorged with blood, forming hemorrhoids

The peritoneum lines

the upper two thirds of the anterior rectum and dips down enough so that it may be palpated where it forms the rectovesical pouch in men and the rectouterine pouch in women.

ENDOMETRIOSIS

the uterus is fixed and tender. Growths of endometrial tissue are usually present throughout the pelvic area and may be felt as firm, nodular masses. Pelvic pain and irregular bleeding are common.

The internal genital structures function as the female reproductive organs (Fig. 27-2). They include

the vagina, the cervix, the uterus, the fallopian tubes, and the ovaries. The vagina, a muscular, tubular organ, extends up and slightly back toward the rectum from the vaginal orifice (external opening) to the cervix. It lies between the rectum posteriorly and the urethra and bladder anteriorly, and is approximately 10 cm long. The vagina performs many functions. It allows the passage of menstrual flow, receives the penis during sexual intercourse, and serves as the lower portion of the birth canal during delivery.

The skin folds of the labia majora and labia minora form a boat-shaped area (or fossa) called

the vestibule. The vestibule contains several openings. Located between the clitoris and the vaginal orifice is the urethral meatus. The openings of Skene glands are located on either side of the urethral opening and are usually not visible. Skene glands secrete mucus that lubricates and maintains a moist vaginal environment. These small glands are often referred to as the lesser vestibular glands. Below the urethral meatus is the vaginal orifice. This is the external opening of the vagina and has either a slit-like or irregular circular structure, depending on the configuration of a hymen. The hymen is a fold of membranous tissue that covers part of the vagina. On either side of and slightly posterior to the vaginal orifice (between the vaginal orifice and the labia minora) are the openings to Bartholin glands. These glands secrete mucus, which lubricates the area during sexual intercourse. These small glands, which are not visible to the naked eye, are often referred to as the greater vestibular glands.

If one's breast is bruised from an injury,

there will be a blood collection that appears as a lump, which goes away in days or weeks, or the blood may have to be drained by a health care provider.

· Near-term gestation, the uterine wall begins

thinning out to approximately 5 mm or less. Fetal parts are easily palpated on the external abdomen in the term pregnancy. Braxton Hicks contractions (painless, irregular contractions of the uterus) may occur sporadically in the third trimester. These contractions are normal as long as no cervical change is noted.

Fatty tissue

third component of the breast. The glandular tissue is embedded in the fatty tissue. This subcutaneous and retromammary fat provides most of the substance to the breast, determining the size and shape of the breasts. The functional capability of the breast is not related to size but rather to the glandular tissue present.

The external genitalia include

those structures that can be readily identified through inspection (Fig. 27-1). The area is sometimes referred to as the vulva or pudendum and extends from the mons pubis to the anal opening. The mons pubis is the fat pad located over the symphysis pubis. The normal adult mons pubis is covered with pubic hair in a triangular pattern. It functions to absorb force and to protect the symphysis pubis during coitus (sexual intercourse). The labia majora are two folds of skin that extend posteriorly and inferiorly from the mons pubis to the perineum. The skin folds are composed of adipose tissue, sebaceous glands, and sweat glands. The outer surface of the labia majora is covered with pubic hair in the adult, whereas the inner surface is pink, smooth, and moist.

The female breast is an accessory reproductive organ with two functions:

to produce and store milk that provides nourishment for newborns and to aid in sexual stimulation.

In children, any loss of hymenal tissue between the 3 o'clock position and the 9 o'clock position indicates

trauma (penetration by digits, penis or foreign objects).

Keloids (excess scar tissue) result from

trauma or surgery and are more common in African Americans and Asians

Severe tenderness or pain may be related to

trauma, peritonitis, infection, tumors, or enlarged or diseased organs.

A mass detected in any quadrant may be due to a

tumor, cyst, abscess, enlarged organ, aneurysm, or adhesions.

Swellings or masses that are solid or filled with blood—

tumor, hernias, or varicocele—do not light up with a red glow.

UTERINE FIBROIDS (MYOMAS)

tumors are common and benign. They are irregular, firm nodules that are continuous with the uterine surface. They may occur as one or many and may grow quite large. The uterus will be irregularly enlarged, firm, and mobile.

PELVIC INFLAMMATORY DISEASE (PID)

typically caused by infection of the fallopian tubes (salpingitis) or fallopian tubes and ovaries (salpingo-oophoritis) with an STI (i.e., gonorrhea, Chlamydia). It causes extremely tender and painful bilateral adnexal masses (positive Chandelier sign).

Peptic Ulcer Disease (PUD)

ulcers, or open sores, that form in the lining of the esophagus, stomach, or small intestine when acid eats away the protective mucous covering and erodes the underlying lining of these organs. (If the ulcer is in the stomach, it is known as a gastric ulcer.) A disruption of the acid and mucous balance, with increasing acid or decreasing mucous, can result in ulcer formation. Often the bacterium Helicobacter pylori (H. pylori) is active in causing the ulcer. Although usually present in the mucus, on occasion the H. pylori disrupt the mucous lining and inflame the organ lining. How H. pylori is acquired is not well understood; it may be spread from person to person, or through food or water. Other causes of peptic ulcer disease are associated with some medications, especially those treating pain (other than acetaminophen) and anti-inflammatory medications used over a long period of time, such as those for osteoarthritis. Ulcers can be quite painful and can bleed. However, some people experience no pain until the ulcer is quite advanced. If peptic ulcers are left untreated, they can result in internal bleeding, infection, and scar tissue. Symptoms vary widely. Often there is abdominal pain, which can be felt anywhere between the sternum and navel, can cause a burning sensation that often wakes the client in the night, and is worse on an empty stomach (often temporarily relieved with acid-reducing medications or some foods). Ulcers also cause a feeling of fullness that leads to reduced fluid and food intake, hunger, an empty feeling 1-3 hours after a meal, or mild nausea. Symptoms may come and go over days or weeks. Other symptoms may include chest pain, fatigue, weight loss, black or tarry stools, and vomiting, which may be bloody. According to Anand (2015), the prevalence of uncomplicated peptic ulcer disease has been declining in the United States over the last 30-40 years, but the rate of complicated cases remains unchanged (thought to be due to high aspirin intake by older people). The annual U.S. rate for peptic ulcer disease is approximately 4.5 million people, with about 10% of the U.S. population having had a duodenal ulcer at some time. The gender distribution has shifted from more males to being more equally distributed between males and females, with lower rates in young males and higher rates in older females. International rates vary with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and the presence of H. pylori.

An enlarged, everted umbilicus suggests

umbilical hernia

Malignant masses or tumors are most often found in the?? of the breast. These masses generally are hard, immobile, and fixed to surrounding skin and soft tissue, with poorly defined or irregular margins

upper outer quadrant

Drainage from the urethra indicates possible ??. Any discharge should be cultured. Urethritis may occur with infection with Neisseria gonorrhoeae or Chlamydia trachomatis.

urethritis

Fibroadenomas are

usually 1-5 cm, round or oval, mobile, firm, solid, elastic, nontender, single or multiple benign masses found in one or both breasts.

If the cervix or uterus protrudes down, the client may have

uterine prolapse

A condition in which the vagina becomes thinner and dryer is ??. This occurs when the body lacks estrogen.

vaginal atrophy.

Enlarged inguinal nodes may indicate a

vaginal infection or may be the result of irritation from hair removal.

Reddened areas, lesions, and colored, malodorous discharge are abnormal and may indicate ??. Altered pH may indicate infection.

vaginal infections, STIs, or cancer

Palpable, tortuous veins suggest

varicocele

Neuromuscular- or consciousness-impaired clients are at risk for lung aspiration with

vomiting.

The male and female breasts are similar until puberty,

when female breast tissue enlarges in response to the hormones estrogen and progesterone, which are released from the ovaries.

NEWBORN Ventral epidermal ridges (milk lines),

which run from the axilla to the medial thigh, are present during gestation. True breasts develop along the thoracic ridge; the other breasts along the milk line atrophy. Occasionally a supernumerary nipple persists along the ridge track. At birth, lactiferous ducts are present in the nipple but there are no alveoli. Although the newborn's breasts may be temporarily enlarged from the effects of maternal estrogen, they are usually flat and remain so until puberty

MASTECTOMY

· (A) Radical mastectomy (B) Modified radical mastectomy.

· CANCER OF THE PROSTATE

· A hard area on the prostate or hard, fixed, irregular nodules on the prostate suggest cancer. The median sulcus may not be palpable.

· FIBROIDS AND OTHER MASSES

· A large ovarian cyst or fibroid tumor appears as generalized distention in the lower abdomen. The mass displaces bowel, thus the percussion tone over the distended area is dullness, with tympany at the periphery. The umbilicus may be everted.

· LIVER LOWER THAN NORMAL

· A liver in a lower position than normal with a normal span may be caused by emphysema because the diaphragm is low.

· LIVER HIGHER THAN NORMAL

· A liver that is in a higher position than normal span may be caused by an abdominal mass, ascites, or a paralyzed diaphragm.

SCROTAL HERNIA

· A loop of bowel protrudes into the scrotum to create what is known as an indirect inguinal hernia. · Hernia appears as swelling in the scrotum. · Palpable as a soft mass and fingers cannot get above the mass.

· AORTIC ANEURYSM

· A prominent, laterally pulsating mass above the umbilicus strongly suggests an aortic aneurysm. It is accompanied by a bruit and a wide, bounding pulse.

· RECTAL CANCER

· A rectal carcinoma is usually asymptomatic until it is quite advanced. Thus, routine rectal palpation is essential. A cancer of the rectum may feel like a firm nodule, an ulcerated nodule with rolled edges, or, as it grows, a large, irregularly shaped, fixed, hard nodule.

RETRACTED NIPPLE

· A retracted nipple suggests malignancy.

VARICOCELE

· Abnormal dilation of veins in the spermatic cord. · Client may complain of discomfort and testicular heaviness. · Tortuous veins are palpable and feel like a soft, irregular mass or "a bag of worms," which collapses when the client is supine. · Infertility may be associated with this condition.

Equipment for pregnancy equipment

· Adequate room lighting · Ophthalmoscope · Otoscope · Stethoscope · Sphygmomanometer · Speculum · Light for pelvic examination · Tape measure · Fetal Doppler ultrasound device · Disposable gloves · Lubricant · Slides · KOH (potassium hydroxide) · Normal saline solution · Thin prep Pap smear test

BENIGN BREAST DISEASE

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

· ENLARGED NODULAR LIVER

· An enlarged firm, hard, nodular liver suggests cancer. Other causes may be late cirrhosis or syphilis.

· ENLARGED KIDNEY

· An enlarged kidney may be due to a cyst, tumor, or hydronephrosis. It may be differentiated from an enlarged spleen by its smooth rather than sharp edge, the absence of a notch, and tympany on percussion.

· ENLARGED LIVER

· An enlarged liver (hepatomegaly) is defined as a span greater than 12 cm at the midclavicular line (MCL) and greater than 8 cm at the midsternal line (MSL). An enlarged nontender liver suggests cirrhosis. An enlarged tender liver suggests congestive heart failure, acute hepatitis, or abscess.

· EPIGASTRIC HERNIA

· An epigastric hernia occurs when the bowel protrudes through a weakness in the linea alba. The small bulge appears midline between the xiphoid process and the umbilicus. It may be discovered only on palpation.

· ENLARGED GALLBLADDER

· An extremely tender, enlarged gallbladder suggests acute cholecystitis. A positive finding is Murphy sign (sharp pain that causes the client to hold the breath).

· INCISIONAL HERNIA

· An incisional hernia occurs when the bowel protrudes through a defect or weakness resulting from a surgical incision. It appears as a bulge near a surgical scar on the abdomen.

· UMBILICAL HERNIA

· An umbilical hernia results from the bowel protruding through a weakness in the umbilical ring. This condition occurs more frequently in infants, but also occurs in adults.

CANCER OF THE GLANS PENIS

· Appears as hardened nodule or ulcer on the glans. · Painless. · Occurs primarily in uncircumcised men.

Dull, Aching

· Appendicitis · Acute hepatitis · Biliary colic · Cholecystitis · Cystitis · Dyspepsia · Glomerulonephritis · Incarcerated or strangulated hernia · Irritable bowel syndrome · Hepatocellular cancer · Pancreatitis · Pancreatic cancer · Perforated gastric or duodenal ulcer · Peritonitis · Peptic ulcer disease · Prostatitis

Right Lower Quadrant (RLQ)

· Appendix · Ascending colon · Cecum · Right kidney (lower pole) · Right ovary and tube · Right ureter · Right spermatic cord

Right Upper Quadrant (RUQ)

· Ascending and transverse colon · Duodenum · Gallbladder · Hepatic flexure of colon · Liver · Pancreas (head) · Pylorus (the small bowel—or ileum—traverses all quadrants) · Right adrenal gland · Right kidney (upper pole) · Right ureter

Focused Specialty Assessment for abdomen

· Auscultate for vascular sounds (venous hum and/or friction rub). · Percuss size of liver (perform scratch test if needed). · Percuss size of spleen. · Perform blunt percussion of liver and kidneys. · Deeply palpate four abdominal quadrants for organs and masses. · Palpate aorta. · Palpate liver. · Palpate spleen. · Palpate kidneys. · Palpate urinary bladder. · Palpate for shifting, dullness. · Perform fluid wave test. · Assess for rebound tenderness. · Test for referred rebound tenderness. · Assess for psoas sign. · Assess for obturator sign. · Perform hypersensitivity test. · Test for cholecystitis.

Pressure

· Benign prostatic hypertrophy · Prostate cancer · Prostatitis · Urinary retention

Midline

· Bladder · Uterus · Prostate gland

DIRECT INGUINAL HERNIA

· Bowel herniates from behind and through the external inguinal ring. It rarely travels down into the scrotum. · This type of hernia is less common than an indirect hernia. · It occurs mostly in adult men older than age 40.

INDIRECT INGUINAL HERNIA

· Bowel herniates through internal inguinal ring and remains in the inguinal canal or travels down into the scrotum (scrotal hernia). · This is the most common type of hernia. · It may occur in adults but is more frequent in children.

FEMORAL HERNIA

· Bowel herniates through the femoral ring and canal. It never travels into the scrotum, and the inguinal canal is empty. · This is the least common type of hernia. · It occurs mostly in women.

Groups with breast cancer

· Breast cancer incidence reported by the Centers for Disease Control and Prevention (CDC, 2015) shows converging rates for Caucasians and blacks, with lower rates for Hispanics and the lowest rates for Asians. Breast cancer deaths, however, are significantly higher for blacks, with Caucasians lower and Asians and Hispanics at the lowest rates. · Black women were found to have various perceptions about the risks of breast cancer related to existing knowledge, stigmatization, as well as spiritual and religious beliefs, which can decrease their engagement in breast cancer screening

Equipment for breast exam

· Centimeter ruler · Small pillow · Gloves · Client handout for BSE · Slide for specimen

HERPES PROGENITALIS

· Clusters of pimple-like, clear vesicles that erupt and become ulcers. · Painful. · Initial lesions of this STI—typically caused by HSV-1 or HSV-2—disappear, and the infection remains dormant for varying periods of time. Recurrences can be frequent or minimally episodic.

HYDROCELE

· Collection of serous fluid in the scrotum, outside the testes within the tunica vaginalis. · Appears as swelling in the scrotum and is usually painless. · Usually the examiner can get fingers above this mass during palpation. · Will transilluminate (if there is blood in the scrotum, it will not transilluminate and is called a "hematocele").

Colicky

· Colon cancer

· DIASTASIS RECTI

· Diastasis recti occurs when the bowel protrudes through a separation between the two rectus abdominis muscles. It appears as a midline ridge. The bulge may appear only when the client raises the head or coughs. The condition is of little significance.

DIMPLING

· Dimpling suggests malignancy.

Burning, Gnawing

· Dyspepsia · Peptic ulcer disease · Cramping ("crampy") · Acute mechanical obstruction · Appendicitis · Colitis · Diverticulitis · Gastroesophageal reflux disease (GERD)

CRYPTORCHIDISM

· Failure of one or both testicles to descend into scrotum. · Scrotum appears undeveloped and testis cannot be palpated. · Causes increased risk of testicular cancer.

· ASCITIC FLUID

· Fluid in the abdomen causes generalized protuberance, bulging flanks, and an everted umbilicus. Percussion reveals dullness over fluid (bottom of abdomen and flanks) and tympany over intestines (top of abdomen).

EXTERNAL HEMORRHOID

· Hemorrhoids are usually painless papules caused by varicose veins. They can be internal or external (above or below the anorectal junction). This external hemorrhoid has become thrombosed—it contains clotted blood, is very painful and swollen, and itches and bleeds with bowel movements.

· RECTAL SHELF

· If cancer metastasizes to the peritoneal cavity, it may be felt as a nodular, hard, shelf-like structure that protrudes onto the anterior surface of the rectum in the area of the seminal vesicles in men and in the area of the rectouterine pouch in women.

EPIDIDYMITIS

· Infection of the epididymis. · Client usually complains of sudden pain. · Scrotum appears enlarged, reddened, and swollen; tender epididymis is palpated. · Usually associated with prostatitis or bacterial infection.

ORCHITIS

· Inflammation of the testes, associated frequently with mumps. · Client complains of pain, heaviness, and fever. · Scrotum appears enlarged and reddened. · Swollen, tender testis is palpated. The examiner may have difficulty differentiating between testis and epididymis.

TESTICULAR TUMOR

· Initially a small, firm, nontender nodule on the testis. · As the tumor grows, the scrotum appears enlarged and the client complains of a heavy feeling. · When palpated, the testis feels enlarged and smooth—tumor replaces testis. · Will not transilluminate.

SYPHILITIC CHANCRE

· Initially a small, silvery-white papule that develops a red, oval ulceration. · Painless. · A sign of primary syphilis (a sexually transmitted infection [STI]) that spontaneously regresses. · May be misdiagnosed as herpes. first appear on the perianal area as silvery white papules that become superficial red ulcers. first appear on the perianal area as silvery white papules that become superficial red ulcers. Syphilitic chancres are painless. They are sexually transmitted and usually develop at the site of initial contact with the infecting organism

General routine screening for breast exam

· Inspect size and symmetry, color and texture. · Inspect superficial venous pattern. · Inspect the areolas and nipples. · Inspect the breasts for retraction or dimpling. · Palpate texture and elasticity. · Palpate for tenderness and temperature. · Ask the client who performs BSE to demonstrate how she does so, if she chooses to receive feedback on her technique and method.

General routine screening for female

· Inspect the mons pubis, labia majora, and perineum. · Inspect the labia minora, clitoris, urethral meatus, and vaginal opening. · Inspect the perianal area and sacrococcygeal area.

General routine screening for male gentalia

· Inspect the penis, pubic hair, and scrotum. · Inspect the inguinal and femoral areas. · Inspect the perianal area. · Inspect the anus and rectum. · Inspect stool.

Left Upper Quadrant (LUQ)

· Left adrenal gland · Left kidney (upper pole) · Left ureter · Pancreas (body and tail) · Spleen · Splenic flexure of colon · Stomach · Transverse descending colon

Left Lower Quadrant (LLQ)

· Left kidney (lower pole) · Left ovary and tube · Left ureter · Left spermatic cord · Descending and sigmoid colon

General routine screening abdomen

· Observe the coloration, vascularization, scars, rashes, and lesions of the abdominal skin. · Observe umbilicus. · Observe abdominal contour and symmetry. · Observe for aortic pulsations and peristaltic waves. · Auscultate bowel sounds. · Percuss tones over four quadrants of abdomen. · Lightly palpate four quadrants of abdomen.

Remember these key points during the examination:

· Obtain an accurate and complete prenatal history. · Understand and recognize cardiovascular changes of pregnancy. · Recognize skin changes. · Identify common complaints of pregnancy and explain what causes them. · Correctly measure growth of uterus during pregnancy. · Demonstrate the four Leopold maneuvers and explain their significance.

Most neurologic changes that occur during pregnancy are discomforting to the client. Common neurologic complaints include:

· Pain or tingling feeling in the thigh: Caused by pressure on the lateral femoral cutaneous nerve · Carpal tunnel syndrome: Pressure on the median nerve below the carpal ligament of the wrist causes a tingling sensation in the hand. Because fluid retention occurs during pregnancy, swollen tissues compress the median nerve in the wrist and produce the tingling sensations. Pain can be reproduced by performing Tinel sign and Phalen test. Up and down movement of the wrist aggravates this condition. · Leg cramps: Caused by inadequate calcium intake. · Dizziness and lightheadedness: In early pregnancy, the client may experience dizziness because of blood pressure slightly decreasing as a result of vasodilation and decreased vascular resistance. In later pregnancy, the client in the supine position may experience dizziness caused by the heavy uterus compressing the vena cava and aorta. This compression reduces cardiac return, cardiac output, and blood pressure. This is known as supine hypotensive syndrome.

focused specialty assessment for female

· Palpate Bartholin glands and urethra. · Inspect the size of the vaginal opening and the angle of the vagina. · Inspect the vaginal musculature. · Inspect the cervix, vagina, and vaginal walls. · Palpate the vaginal wall, cervix, uterus, and ovaries. · Palpate the rectum and rectal sphincter. · Perform the rectovaginal examination. · Palpate the cervix through the anterior rectal wall.

Focused Specialty Assessment for breast exam

· Palpate the nipples for discharge. · Palpate the breasts for masses. · Palpate mastectomy or lumpectomy site. · Inspect and palpate the axillae.

focused specialty assessment for male genitalia

· Palpate the pubic hair, penis, and scrotum. · Palpate for urethral discharge, spermatic cord and vas deferens from the epididymis to the inguinal ring. · Transilluminate the scrotum. · Palpate for inguinal and femoral hernia. · Palpate for inguinal lymph nodes. · Palpate the anus and rectum

· PREGNANCY (NORMAL FINDING)

· Pregnancy is included here so that the examiner may differentiate it from abnormal findings. · It causes a generalized protuberant abdomen, protuberant umbilicus, a fetal heart beat that can be heard on auscultation, percussible tympany over the intestines, and dullness over the uterus.

Hirsutism of the face, abdomen, and back may also be experienced during the second and third trimesters of pregnancy. Hormonal changes (androgens) cause this hair growth, which may improve after delivery.

· Pregnant women may report a decrease in hearing, a sense of fullness in the ears, or earaches because of the increased vascularity of the tympanic membrane and blockage of the eustachian tubes. · Some women may note changes in their gums during pregnancy. Gingival bleeding when brushing teeth and hypertrophy are common. Occasionally epulis develop, which are small, irritating nodules of the gums. These nodules usually resolve on their own. Occasionally, the lesion may need to be surgically excised if the nodule bleeds excessively. · Vocal changes may be noted due to edema of the larynx. Nasal "stuffiness" and epistaxis are also common during pregnancy because of estrogen-induced edema and vascular congestion of the nasal mucosa and sinuses. · As the pregnancy progresses, progesterone influences relaxation of the ligaments and joints. This relaxation allows the rib cage to flare, thus increasing the anteroposterior and transverse diameters. This accommodation is necessary as the pregnancy progresses and the enlarging uterus pushes up on the diaphragm. The client's respiratory pattern changes from abdominal to costal. Shortness of breath is a common complaint during the last trimester. The client may be more aware of her breathing pattern and of deep respirations and more frequent sighing. Oxygen requirements increase during pregnancy because of the additional cellular growth of the body and the fetus. Pulmonary requirements increase, with the tidal volume increasing by 30% to 40%. All of these changes are normal and are to be expected during the last trimester.

MASTITIS

· Reddened, painful area on breast warm to palpation.

RETRACTED BREAST TISSUE

· Retracted breast tissue suggests malignancy.

GENITAL WARTS

· Single or multiple, moist, fleshy papules. · Painless. · STI caused by the human papillomavirus. human papilloma virus (HPV), are moist, fleshy lesions on the labia and within the vestibule. They are painless and believed to be sexually transmitted.

SMALL TESTES

· Small (less than 3.5 cm long), soft testes indicate atrophy. Atrophy may result from cirrhosis, hypopituitarism, estrogen administration, extended illness, or the disorder may occur after orchitis. · Small (less than 2 cm long), firm testes may indicate Klinefelter syndrome.

Equipment for abdomen

· Small pillow or rolled blanket · Centimeter ruler · Stethoscope (warm the diaphragm and bell) · Marking pen

SPERMATOCELE

· Sperm-filled cystic mass located on epididymis. · Palpable as small and nontender, and movable above the testis. · This mass will appear on transillumination.

Sharp, knifelike

· Splenic abscess · Splenic rupture · Renal colic · Renal tumor · Ureteral colic · Vascular liver tumor

Equipment for male genitalia

· Stool · Gown · Disposable non-latex gloves · Flashlight (for possible transillumination) · Stethoscope (for possible auscultation) · Water soluble lubricant · Specimen card

Equipment for vaginal exam

· Stool · Light · Vaginal speculum · Water-soluble lubricant · Large swabs for vaginal examination · Specimen container · Gloves (nonsterile) · Bifid spatula · Endocervical broom · pH paper · Feminine napkins · Hand-held mirror

· FLATUS

· The abdomen distended with gas may appear as a generalized protuberance (as shown), or it may appear more localized. Tympany is the percussion tone over the area.

Preparing client for breast exam

· The actual hands-on physical examination of the breast may create client anxiety. The client may be embarrassed about exposing his or her breasts and may be anxious about what the assessment will reveal. Explain in detail what is happening throughout the assessment and answer any questions the client might have. In addition, provide the client with as much privacy as possible during the examination. · Prepare for the breast examination by having the client sit in an upright position. Explain that it will be necessary to expose both breasts to compare for symmetry during inspection. One breast may be draped while the other breast is palpated. Be sensitive to the fact that many women may feel embarrassed to have their breasts examined. · The breasts are first inspected in the sitting position while the client is asked to hold arms in different positions. The breasts are then palpated while the client assumes a supine position. · The final part of the examination involves teaching clients how to perform BSE and asking them to demonstrate what they have learned. If the client states that she or he already knows how to perform BSE, then ask the client to demonstrate how this is done.

· BENIGN PROSTATIC HYPERTROPHY

· The prostate is enlarged, smooth, firm, and slightly elastic. The median sulcus may not be palpable. It is common in men older than 50 years.

· ACUTE PROSTATITIS

· The prostate is swollen, tender, firm, and warm to the touch. Prostatitis is caused by a bacterial infection.

EPISPADIAS

· The urethral meatus is located on the top of the glans (dorsal side); occurs rarely. · This condition is a congenital defect.

CANCEROUS TUMORS

· These are irregular, firm, hard, not defined masses that may be fixed or mobile. They are not usually tender and usually occur after age 50.

FIBROADENOMAS

· These lesions are lobular, ovoid, or round. They are firm, well defined, seldom tender, and usually singular and mobile. They occur more commonly between puberty and menopause.

· RECTAL POLYPS

· These soft structures are rather common and occur in varying sizes and numbers. There are two types: pedunculated (on a stalk) and sessile (on the mucosal surface).

· ANAL FISSURE

· These splits in the tissue of the anal canal are caused by trauma. A swollen skin tag ("sentinel tag") is often present below the fissure on the anal margin. They cause intense pain, itching, and bleeding.

· PILONIDAL CYST

· This congenital disorder is characterized by a small dimple or cyst/sinus that contains hair. It is located midline in the sacrococcygeal area and has a palpable sinus tract.

· ANORECTAL FISTULA

· This is evidenced by a small, round opening in the skin that surrounds the anal opening. It suggests an inflammatory tract from the anus or rectum out to the skin. A previous abscess may have preceded the fistula. · With an anoscope inserted in the anal canal, an anal fissure can be seen in the posterior midline of the squamous epithelium of the anal canal. A sentinel skin tag can be seen on the distal end of the fissure on the anal verge.

· RECTAL PROLAPSE

· This occurs when the mucosa of the rectum protrudes out through the anal opening. It may involve only the mucosa or the mucosa and the rectal wall. It appears as a red, doughnut-like mass with radiating folds.

Soon after conception, the surge of estrogen and progesterone begins, causing notable changes in the mammary glands (Fig. 29-1). Breast changes noted by many women include:

· Tingling sensations and tenderness · Enlargement of breast and nipple · Hyperpigmentation of areola and nipple · Enlargement of Montgomery tubercles · Prominence of superficial veins · Development of striae · Expression of colostrum in the second and third trimesters

HYPOSPADIAS

· Urethral meatus is located underneath the glans (ventral side). · This condition is a congenital defect. · A groove extends from the meatus to the normal location of the urethral meatus.

TORSION OF SPERMATIC CORD

· Very painful condition caused by twisting of spermatic cord. · Scrotum appears enlarged and reddened. · Palpation reveals thickened cord and swollen, tender testis that may be higher in scrotum than normal. · This condition requires immediate referral for surgery because circulation is obstructed.

Pregnant uterus

· may be palpated above the level of the symphysis pubis in the midline. The ovaries are located in the RLQ and LLQ, and are normally palpated only during a bimanual examination of the internal genitalia