Heath Assessment Test 3

Organs in the Left Lower Quadrant:

- Part of descending colon - Sigmoid colon - Left ovary and tube - Left ureter - Left spermatic cord

Iliopsoas Muscle Test

- Perform the iliopsoas muscle test when the acute abdominal pain of appendicitis is suspected. - With the person supine, lift the right leg straight up, flexing at the hip; then push down over the lower part of the right thigh as the person tries to hold the leg up. - When the test is negative, the person feels no change.

Documentation:

*Normal assessment documentation:* Abdomen is soft, non-distended (ND), non-tender(NT), no masses, bruits, or pulsations, + normative BS all quads.

Deep Palpation

- *deep palpation* using the technique described earlier but push down about 5 to 8 cm (2 to 3 inches). Moving clockwise, explore the entire abdomen - Used to determine enlarged organs or masses - If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ. Then note the following: 1. Location 2. Size 3. Shape 4. Consistency (soft, firm, hard) 5. Surface (smooth, nodular) 6. Mobility (including movement with respirations) 7. Pulsatility 8. Tenderness Mild tenderness normally is present when palpating the sigmoid colon. Any other tenderness should be investigated.

Questions to ask about axilla:

- Any tenderness or lumps in the underarms? - Any rashes in the underarms? - Ask the preadolescent if she has noticed breast development? - Ask if she has noticed others girls at school developing? - Ask the pregnant woman if she has had any tenderness or fullness in her breasts or a history of inverted nipples, is she planning on breastfeeding? - Ask the menopausal woman if she has noticed changes in her breasts

Organs in the Midline:

- Aorta - Uterus (if enlarged) - Bladder (if distended)

Rebound Tenderness (Blumberg Sign)

- Assess rebound tenderness when the person reports abdominal pain or when you elicit tenderness during palpation. - Choose a site away from the painful area. Hold your hand 90 degrees, or perpendicular, to the abdomen. Push down slowly and deeply; then lift up quickly. This makes structures that are indented by palpation rebound suddenly. - A normal, or negative, response is no pain on release of pressure. Perform this test at the end of the examination because it can cause severe pain and muscle rigidity. - Charted: negative rebound tenderness

Light and Deep Palpation:

- Begin with *light palpation.* - With the first four fingers close together, depress the skin about 1 cm - Make a gentle rotary motion, sliding the fingers and skin together. Then lift the fingers (do not drag them) and move clockwise to the next location around the abdomen. - The objective here is not to search for organs but to form an overall impression of the skin surface and superficial musculature. - Save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. - As you circle the abdomen, discriminate between voluntary muscle guarding and involuntary rigidity.

Palpation for Specific Organs - Liver

- Beginning in the RUQ - Place your left hand under the person's back parallel to the 11th and 12th ribs and lift up to support the abdominal contents. - Place your right hand on the RUQ, with fingers parallel to the midline. - Push deeply down and under the right costal margin. - Ask the person to breathe slowly. With every exhalation, move your palpating hand up 1 or 2 cm. It is normal to feel the edge of the liver bump your fingertips as the diaphragm pushes it down during inhalation. - It feels like a firm, regular ridge. - Often the liver is not palpable and you feel nothing firm.

Organs in the Right Lower Quadrant:

- Cecum - Appendix - Right ovary and tube - Right ureter - Right spermatic cord

Assess Urinary Function:

- Color should be pale yellow to amber - Should be clear - pH range 4.5-8 - Specific gravity

Percussion - Indirect

- Costovertebral Angle Tenderness - Indirect fist percussion causes the tissues to vibrate instead of producing a sound. - To assess the kidney place one hand over the 12th rib at the costovertebral angle on the back. - Thump that hand with the ulnar edge of your other fist. The person normally feels a thud but no pain. - If pain is felt it is usually indicative of kidney inflammation called + CVA tenderness.

Auscultate Bowel Sounds and Vascular Sounds

- Depart from the usual examination sequence and auscultate the abdomen next. - This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. - Use the diaphragm end piece because bowel sounds are relatively high-pitched. - Hold the stethoscope lightly against the skin; pushing too hard may stimulate more bowel sounds. - Begin in the RLQ at the ileocecal valve area because bowel sounds normally are always present here

Palpate the Anus and Rectum:

- Drop lubricating jelly onto your gloved index finger. - Instruct the person that palpation is not painful but may feel like needing to move the bowels. - Ask the patient to take a deep breath and hold it. Place the pad of your index finger gently against the anal verge. You will feel the sphincter tighten and then relax. - As it relaxes ask the patient to exhale and flex the tip of your finger and slowly insert it into the anal canal in a direction toward the umbilicus. - Never approach the anus at right angles with your index finger extended. Such a jabbing motion does not promote sphincter relaxation and is painful.

Circumcision:

- Elective surgical procedure to remove the *foreskin* from the penis. - Often this decision is rooted in religious belief. - *Medical benefits*: reduced risk of acquiring HIV from heterosexual contact, as well as HSV and HPV. Circumcised males also have a decreased incidence of *UTI and Penile Cancer.* - Circumcision is recommended by the American Academy of Pediatrics. - Risks include pain, bleeding, swelling and urinary retention.

Inspection Positions - Rectum, Anus, and Prostate

- Examine the male in the left lateral decubitus or standing position. - Instruct the standing male to rest his elbows on the exam table and point his toes together; this relaxes the regional muscles, making it easier to spread the buttocks. - Place the female in the lithotomy position if examining genitalia as well; use the left lateral decubitus position for the rectal area alone.

General Tympany

- First percuss lightly in all four quadrants to determine the prevailing amount of tympany and dullness. Move clockwise. - Tympany should predominate because air in the intestines rises to the surface when the person is supine.

Inspection: Contour

- Flat - Scaphoid - Rounded - Protuberant

Percussion

- General Tympany - Dullness Liver and Spleen

Subjective Data - Questions to ask about your patient's obstetric history:

- Have you ever been pregnant? - How many times? - How many babies have you had? - Any miscarriage or abortion? - Describe each pregnancy's duration, complications, labor and delivery, baby's gender, birth weight and condition. - Do you believe you could be pregnant now? - What symptoms have you noticed?

Subjective Data - Questions to ask your patient about menopause (48-51):

- Have your periods slowed down or stopped? - Do you have any associated symptoms? (hot flashes, night sweats, numbness and tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness or itching) Are you treating it with anything? - Are you on hormone replacement therapy (HRT)? Any side effects? - How do you feel about going through menopause? - Do you have any pain with intercourse?

Female Genitourinary System: The Aging Woman

- Hormones decline rapidly with menopause, occurring around age 48-51. - Physical changes: Uterus shrinks, ovaries atrophy and become non palpable, sacral ligaments relax and pelvic musculature weakens causing the uterus to droop, the cervix shrinks, the vagina becomes shorter and narrower while the lining becomes thin, dry and more at risk for vaginitis, the mons, labia and clitoris become smaller and pubic hair becomes thin and sparse. - Sexual function is possible with good health and a willing partner.

Prostate

- In the male the prostate gland lies in front of the anterior wall of the rectum and *2 cm* behind the symphysis pubis. - It surrounds the bladder neck and urethra - It secretes a thin, milky alkaline fluid to enhance the viability of sperm. - It is round or heart shape measuring 2.5 cm long and 4 cm in diameter.

Male Genitourinary System:

- It is important to note where the inguinal and femoral canal are located, these are common sites for a *hernia.* - Lymphatics of the penis and scrotum drain into the *inguinal nodes*, the testes drain into the *abdominal* nodes, which are not accessible for palpation.

Organs in the Right Upper Quadrant:

- Liver - Gallbladder - Duodenum - Head of pancreas - Right kidney and adrenal - Hepatic flexure of colon - Part of ascending and transverse colon

If you palpate a lump during CBE, how do you chart it?

- Location: using the breast as a clock face or cm from the nipple - Size: use cm, length x width x thickness - Shape: round, oval, irregular - Consistency: soft, firm, hard - Movable: is it fixed to the chest wall or freely movable - Distinctness: one single lump or many - Nipple: displaced or retracted - Skin over the lump: reddened, dimpled, retracted - Tenderness: present to palpation - Lymphadenopathy: any palpable lymph nodes

Lymphatics:

- Most lymph drains to the ipsilateral (same side) nodes. - Drainage flows from the central axillary nodes into the infraclavicular and supraclavicular nodes.

Murphy Sign

- Normally palpating the liver causes no pain. - In a person with inflammation of the gallbladder (cholecystitis), pain occurs. - Hold your fingers under the liver border. Ask the person to take a deep breath. A normal response is to complete the deep breath without pain.

Palpation for Specific Organs - Spleen

- Normally the spleen is not palpable and must be enlarged 3 times its normal size to be felt. - To search for it, reach your left hand over the abdomen and behind the left side at the 11th and 12th ribs. Lift up for support. - Place your right hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin. - Push your hand deeply down and under the left costal margin and ask the person to take a deep breath. - You should feel nothing firm.

Subjective Data - Other questions/subjects to discuss with female patients:

- OBGYN checkups - Any acute pelvic pain - Urinary symptoms - Unusual vaginal discharge - Past history of lesions or surgeries - Sexual activity - Contraceptive use - STI (Sexually Transmitted Infection) contact - Assess adolescent girls' understanding of development and sexual behavior

Questions to ask about the breast:

- Pain? (Mastalgia occurs with trauma, inflammation, infection, and benign breast disease.) - Lumps or thickening of the breast? - Discharge? (Galactorrhea) - Rash? - Swelling? - Trauma? - History of breast disease?

Culture of Female Genitourinary System:

- Pap (Papanicolaou) smears screen for cervical cancers and STIs - HPV vaccine is recommended for all girls 11-12 years old. - "Cutting" is a social custom of mutilating the external genitalia in girls, common in southern Asia, the Middle East and most of Africa. As families immigrated to America, the custom has followed, but is outlawed in the United States. (This procedure involves the removal , partial, or total, of the clitoris and is believed to inhibit sexual pleasure - outlawed in the US.)

Objective Data - Female Genitourinary System

- Position the patient in the *lithotomy* position with feet in stirrups and the buttocks at the edge of the exam table. (45˚) - Decrease anxiety and increase comfort. - *Reassure* the patient she can voice discomfort at any time. - Skin color is even, hair distribution is even, labia should be *symmetric and plump.* - No lesions should be present. - Urethral opening should be stellate or slit like. - Perineum is smooth, scars may be present if she has had a vaginal birth. - Assess the urethra; it should be contender with no discharge. - Assess the Bartholin glands; they should be soft. - Assess pelvic musculature; there should be no bulging vaginal walls or urinary incontinence.

Male Genitourinary System - Adolescents:

- Puberty onset is between *9-10* years old. - Tanner Stages describe development - Undescended testicles and familial cancer traits only account for < 10% of testicular cancer

Performing a pelvic exam

- Select a properly-sized speculum and lubricate with water-soluble jelly. - Insert with blades turned obliquely and turn once in position and open blades. - Cervix and Os should be pink and even in color, midline, and diameter of ~ 1 inch. - Os is small and round, shape will differ after childbirth. - Any secretions should be odorless and nonirritating. Color and consistency will differ throughout the menstrual cycle.

Inspection:

- Spread the buttocks wide apart with both gloved hands and observe the perianal region. - The anus normally looks moist and hairless, with coarse, folded skin that is more pigmented than the perianal skin. - The anal opening is tightly closed. - No lesions are present. - Instruct the person to hold the breath and bear down by performing a Valsalva maneuver. - No break in skin integrity or protrusion through the anal opening should be present. - Describe any abnormality in clock-face terms, with the 12 o'clock position as the anterior point toward the symphysis pubis and the 6 o'clock position toward the coccyx.

Organs in the Left Upper Quadrant:

- Stomach - Spleen - Left lobe of liver - Body of pancreas - Left kidney and adrenal - Splenic flexure of colon - Part of transverse and descending colon

Male Genitourinary System - Adults and Elderly Adults

- The older man does not experience an end to fertility as a woman does, but sperm production decreases around *40*. - As a man ages, pubic hair and penis size decreases, the scrotum hangs lower and the rugae decrease. - *Age* alone should not decrease sexual activity.

Benign Prostatic Hypertrophy (BPH)

- The prostate gland commonly starts to enlarge during the middle adult years, but this is not cancer. - This *benign prostatic hypertrophy (BPH)* is present in 1 of 10 males at the age of 40 years and grows larger with age. - The diagnosis of BPH indicates that the hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign adenomas (growth) - These gradually impede urine output because they obstruct the urethra.

Subjective Data: Questions to ask your patient:

- Urinating more often than usual? (Polyuria) - Do you feel as though you cannot wait to urinate? (Urgency) - Do you awaken during the night to urinate? (Nocturia) - Any pain or burning with urination? (Dysuria) - Have any trouble starting the urine stream? (Hesitancy) - Do you need to strain to maintain a urine stream? - Any history of UTI? - Urine Color? - Any difficulty controlling your urine? (Urge incontinence, Stress incontinence) Do you have any accidents when you sneeze or bear down? - Any history of bladder, kidney or prostate issues? - Any pain or lesions on the penis? - Any discharge from the penis? - Any lumps or swelling in the scrotum or testicles? (Hernia) - Are you in a sexual relationship? Is it satisfying for you and your partner? - Do you use contraceptives? Which method? - How many partners have you had in the last 6 months? - Have you or your partners had an STI?

Self-Breast Exam:

- Use same techniques used in the CBE, using a mirror to note any changes in shape or contour when moving arms. - Teach to perform on the same day of the month - Keep teaching simple, reinforce with a pamphlet - Even though it is no longer supported by the American Cancer Society, this is a good way for women to become familiar with their bodies so they can recognize a problem early on.

Subjective Data: Questions to ask about the patient's menstrual cycle

- When was your last menstrual period (LMP)? - How old were you when you had your first period? (Menarche) - How often? - How many days does it last? (28 days) - What is the usual amount of flow, how many pads or tampons do you use each day? - Do you have any clotting? - Do you have pain or cramps? - How do you treat it? - Does it interfere with daily activities?

- Perform the exam once a _________. - Perform in the ____________ to relax cremaster muscle. - Using __________________, feel each testicle, epididymis and spermatic cord. - Report any changes to a care provider.

- month. - warm shower - two fingers and the thumb

Abdominal Areas

- the abdominal wall is divided into four quadrants by a vertical and a horizontal line bisecting the umbilicus - *epigastric* for the area between the costal margins - *umbilical* for the area around the umbilicus, - *hypogastric or suprapubic* for the area above the pubic bone.

Percuss to assess:

- the relative density of abdominal contents - to locate organs - to screen for abnormal fluid or masses.

4 groups of nodes are present in the breast/axillary region:

1. *Central Axillary* - high in the axilla, over the ribs and serratus muscles (these drain the other three) 2. *Pectoral* - anterior along the lateral edge of the pectorals major muscle 3. *Subscapular* - posterior along the lateral edge of the scapula and deep in the axillary fold 4. *Lateral* - along the humerus bone, inside the upper arm

Assessment Data: Subjective Data (9)

1. Appetite 2. Dysphagia 3. Food Intolerance 4. Abdominal pain 5. Nausea/vomiting 6. Bowel habits 7. Past abdominal history 8. Medications 9. Nutritional assessment

Objective Data - Testicles and scrotum:

1. Asymmetry is normal, with left half usually lower than the right, but size should be very similar 2. Spread the rugae and be sure to inspect the posterior surface 3. Using your thumb and first two fingers, palpate scrotal contents, these should slide easily. 4. Testes feel oval, firm, rubbery, smooth, and freely mobile and slightly tender to moderate pressure. 5. The epididymis sits on top and slightly behind the testicle and is softer. 6. Palpate spermatic cord, should feel smooth and contender. 7. Inspect and palpate for hernia 8. Palpate for lymph nodes

Review Comfort Measures:

1. Bend the person's knees. 2. Keep your palpating hand low and parallel to the abdomen. Holding the hand high and pointing down would make anyone tense up 3. Teach the person to breathe slowly (in through the nose and out through the mouth). 4. Keep your own voice low and soothing. Conversation may relax the person. 5. Try "emotive imagery." For example, you might say, "Now I want you to imagine that you are dozing on the beach, with the sun warming your muscles and the sound of the waves lulling you to sleep. Let yourself relax." 6. With a very ticklish person, keep the person's hand under your own with your fingers curled over his or her fingers. Move both hands around as you palpate; people are not ticklish to themselves. 7. Alternatively perform palpation just after auscultation. Keep the stethoscope in place and curl your fingers around it, palpating as you pretend to auscultate. People do not perceive a stethoscope as a ticklish object. You can slide the stethoscope out when the person is used to being touched.

Assessment Sequence of the Abdomen

1. Inspection 2. Auscultation 3. Percussion 4. Palpation The reason auscultation precedes percussion and palpation of the abdomen - auscultation prevents distortion of bowel sounds that might occur after percussion and palpation.

Objective Data - Male Genitourinary System:

1. Position with appropriate draping to decrease discomfort, may be supine for most of the exam, but must stand to observe for *Hernia*. 2. *Reassure* the patient you are a medical professional performing a routine exam, he can express his discomfort at any time. 3. The skin in the penis is normally wrinkled, hairless, without lesions. Dorsal vein may be apparent. 4. Ask an uncircumcised male to retract the *foreskin*, it should move easily. 5. Urethral meatus should be central. 6. Pubic hair distribution should be consistent with age and without pests. 7. Compress the glans to check for discharge from the meatus. 8. The shaft should feel smooth and nontender.

If mass is palpated, be sure to note:

1. Tenderness 2. Position 3. Does it reduce when supine 4. Can you auscultate bowel sounds over it (Hernia)

Assessment Data: Subjective Data

1. Usual bowel routine 2. Change in bowel habits 3. Rectal bleeding, blood in the stool 4. Medications (laxatives, stool softeners, iron) 5. Rectal conditions (pruritus, hemorrhoids, fissure, fistula) 6. Family history 7. Patient-centered care (diet of high-fiber foods, most recent examinations)

Examination of Stool

Inspect any feces remaining on the glove. Normally the color is brown, and the consistency is soft. - *Jellylike mucus shreds mixed in stool* indicate inflammation. - *Bright red blood on stool surface* indicates rectal bleeding. - *Bright red blood mixed with feces* indicates possible colonic bleeding. - *Black tarry stool with distinct malodor* indicates upper GI bleeding with blood partially digested. - *Black stool:* Also occurs with ingesting iron or bismuth preparations. - *Gray, tan stool* - Absent bile pigment (e.g., obstructive jaundice). - *Pale yellow, greasy stool*: Increased *fat content (steatorrhea)*, as occurs with malabsorption syndrome. - *Occult bleeding* may indicate cancer of the colon, further testing is needed.

Inspection: Umbilicus

Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia - *Hernia* is a loop of bowel protruding through a weak spot in the abdominal muscles.

Palpation of Abdomen:

Palpate Surface and Deep Areas Perform palpation: - to judge the size, location, and consistency of certain organs - to screen for an abnormal mass or tenderness.

Inspection: Pulsation or Movement

Pulsations, Respiratory, waves of peristalsis.

Subjective Data:

Some patients may be very sensitive when talking about their breasts. - Our society has transformed breasts from a body part made to nourish our newborns into a part of the body that must be judged. - Reassure your patient that you are a medical professional performing an exam and to let her know she is free to voice discomfort at any time during the exam.

Stool Test

Test any stool on the glove for occult blood. - A negative response is normal. - If the stool is Hematest positive, it indicates occult blood. - There are two types of FITs: 1. liquid-based tests that store the stool sample in a hemoglobin stabilizing buffer, 2. dry-slide cards that are analyzed manually.

Inspection: Symmetry

The abdomen should be symmetrical bilaterally. Note any localized bulging, visible mass, or asymmetric shape.

Inspection: Skin

The surface is smooth and even, with homogeneous color. Rash? Scars?

Involuntary Rigidity

a constant, board-like hardness of the muscles. It is a protective mechanism accompanying acute inflammation of the peritoneum. It may be unilateral, and the same area usually becomes painful when the person increases intra-abdominal pressure by attempting a sit-up.

Endocervical specimen

a cytobrush is inserted into the os and twisted, this may produce some scant bleeding and momentary discomfort. Do this last!

Inspection: Hernia

a loop of bowel protruding through a weak spot in the abdominal muscles

Cervical scrape:

a spatula is rotated around the surface of the cervix. - If discharge is concerning, collect a sample using a cotton swab for a "wet prep" slide analysis.

Dyspepsia

abdominal discomfort describes as burning, bloating, gassiness (indigestion, heartburn)

Dysphagia

difficulty swallowing medications and food

Kidney Inflammation

complaining of a sharp pain along the costovertebral angles. - +CVA tenderness

Testicular cancer is rare, but occurs most frequently between 15-35 year olds and has a strong association to _______________. - When detected early, there is almost a 100% cure rate.

cryptorchidism (undescended testicle)

Hepatomegaly

enlarged liver

Ascites

indicates the presence of fluid in the peritonium

Anal Canal

outlet of the gastrointestinal (GI) tract. - It is lined with modified skin (having no hair or sebaceous glands) that merges with rectal mucosa at the anorectal junction. - surrounded by two concentric layers of muscle, the sphincters.

Voluntary guarding

occurs when the person is cold, tense, or ticklish. It is bilateral, and you will feel the muscles relax slightly during exhalation. Use the relaxation measures to try to eliminate this type of guarding, or it will interfere with deep palpation.

Gastrointestinal bleeding

results in a black, tarry stool if high GI bleed.

Encourage _________ in every male patient from adolescents through adults

self-care

Rectum

the distal portion of the large intestine, it extends from the sigmoid colon.

The external sphincter surrounds

the internal sphincter it is under voluntary control.

Except for the passing of feces and gas,

the sphincters keep the anal canal tightly closed.

Umbilical hernia

umbilicus is enlarged and everted.

The internal sphincter is

under involuntary control by the autonomic nervous system.

Objective Data: Palpation

• Have the patient in a sitting position, with you supporting her arm so her muscles are relaxed. • Use your right hand to palpate her left axilla and left hand to palpate her right axilla, moving firmly down the *midaxillary* line, anteriorly, posteriorly, and the upper arm. Moving the arm using passive range of motion will increase the surface area available for palpation. • Lymph nodes should be *nontender and nonpalpable* Sometimes contender nodes can be felt in the central group, note any tenderness or palpable nodes.

Breast Cancer:

• *BRCA 1 and BRCA 2* are two tumor suppressing genes, mutation of these genes leaves affected women especially vulnerable to breast cancer. A familial trend is often seen. • *Caucasian* women have a higher risk of breast cancer after the age of 45. • *African American* women have a higher risk of breast cancer before the age of 45 and are more likely to die from the disease at every age. • Long-term use of combined hormone therapy was proven to increase the risk of breast cancer in post-menopausal women, so hormone replacement therapy is no longer as popular as between 1992-2005. • American Cancer Society recommends screening mammograms beginning at *age 40.*

The Aging Woman: Breast, Axillae, and Lymphatics

• After menopause, decreased levels of *estrogen and progesterone* causes glandular tissue to atrophy and be replaced by fibrous connective tissue. • Breast size and elasticity is reduced, so breasts sag, this is emphasized by kyphosis in some women. • The reduction in volume and elasticity makes nodules more prominent. What may have been there all along may now be palpable. • Axillary hair thins and loses pigmentation.

Auscultation - Vascular Sounds

• As you listen to the abdomen, note the presence of any vascular sounds or bruits. • Using firmer pressure, check over the aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension. • Usually no sound is present.

The Adolescent: Breast, Axillae, and Lymphatics

• At puberty, estrogen stimulates breast changes and they enlarge with fat deposition. The ductal system develops. • Onset of breast development is usually between *8-10*, but childhood obesity may lead to early onset. • Asymmetry of growth and tenderness is common • Tanner stages describe the phases of development through adolescence. • After development is complete, the breast size may fluctuate during the menstrual cycle. Breasts are usually smallest on the 4th -7th days of the cycle.

The Pregnant Woman: Breast, Axillae, and Lymphatics

• Breast tenderness is a common EARLY sign of pregnancy. (4-8 weeks) • Ductal system expands and true secretory alveoli develop, causing the breasts to enlarge and feel more nodular. • Nipples grow larger, darken in color and become more erect. This usually persists after lactation is complete. • Veins become prominent. • Colostrum may be present after the first trimester (yellow, thick liquid). • Milk production begins 1-3 days after delivery. (More white in color).

NG Placement

• For safe practice, one assessment for which you should NOT use auscultation of the abdomen is for the correct placement of nasogastric feeding tubes. • Despite evidence showing that auscultation of an air bolus is not adequate to determine placement in stomach or lung, you may see some nurses still practicing this method. • Current evidence mandates confirming initial placement by chest x-ray and continuing assessment by testing the pH of stomach aspirates (stomach pH is 1.0 to 3.0, whereas intestinal pH is 6.0 to 9.0).29 • Visualizing gastric aspirates can be helpful in distinguishing gastric (grassy green or colorless) versus intestinal (yellow, bile stained, clear or cloudy) placement but is not helpful in determining respiratory placement

Objective Data: Inspection

• General appearance- note size, shape and symmetry (it is normal to be slightly asymmetrical, usually Left is larger than Right breast) • Skin smooth and even in color, *striae* may be present • *Axillary and supraclavicular* regions should not have bulges, edema or discolorations • Nipples should be placed symmetrically, some may be inverted but can be pulled out • Screen for retraction - Have patient hold her arms over her head, place her hands on her hips, place palms together and flex and lean forward. Observe in each position and during transitions for puckers, dimpling, or fixation.

The Male Breast Exam:

• It is easy to forget this exam, but males can develop breast cancer as well! • Due to lack of tissue, enlarged axillary nodes are an early sign that is easily missed. • Use the same technique as a CBE • Be able to identify gynecomastia, provide reassurance to adolescent males.

Auscultation - Bowel Sounds

• Note the character and frequency of bowel sounds. They originate from the movement of air and fluid through the stomach and large and small intestine. • Bowel sounds are high-pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute. • Do not bother to count bowel sounds. Judge if they are present or are hypoactive or hyperactive. • One type of hyperactive bowel sounds is fairly common: hyper peristalsis, when you feel your "stomach growling," termed borborygmus. • A perfectly "silent abdomen" is uncommon; you must listen for 5 minutes by your watch before deciding if bowel sounds are completely absent.

Clinical Breast Exam:

• Place the patient in a supine position with a small pad tucked under her chest. • Using the pads of the first three fingers, use a small rotating motion to palpate all breast tissue, some methods often used are the vertical strip pattern, spiral pattern or wedge pattern. • Tissue changes texture after childbirth and lactation. • Palpate the nipple by squeezing gently, noting any discharge. • Pendulous breasts can be palpated with a bimanual approach with the patient leaning forward. • Mastalgia and tissue edema common in the middle of the menstrual cycle may make the CBE difficult. • Special considerations: breast implants, mastectomies and lymphedema.

The Male Breast

• Rudimentary structure • It is common in adolescence for the tissue to enlarge temporarily, causing *Gynecomastia.* • Gynecomastia is usually temporary, increased assurance is needed for the adolescent male, whose body image is very important. • Can be caused by some medications, disease processes and decreased testosterone in the aging male.