NUR314 Exam 3: Breasts and Regional Lymphatics, Male GU, Female GU

General health history: Preadolescents and adolescents (sexual growth, development, behavior): Permission statement Ubiquity approach

FIRST ASK QUESTIONS THAT SEEM APPROPRIATE FOR BOY'S AGE, BUT BE AWARE THAT NORMS VARY WIDELY​ WHEN YOU ARE IN DOUBT, IT IS BETTER TO ASK TOO MANY QUESTIONS THAN TO OMIT SOMETHING​ CHILDREN GET INFORMATION, OFTEN MISINFORMATION, FROM MEDIA, INTERNET, AND FROM PEERS AT EARLY AGES​ ASK DIRECT, MATTER-OF-FACT QUESTIONS; AVOID SOUNDING JUDGMENTAL​ START WITH A PERMISSION STATEMENT: "OFTEN BOYS YOUR AGE EXPERIENCE..."​ TRY THE UBIQUITY APPROACH: "WHEN DID YOU..." RATHER THAN "DO YOU..." ​

Male exam: inspection and palpation The scrotum

IF YOU FIND A MASS, NOTE:​ -TENDERNESS?​ -IS THE MASS DISTAL OR PROXIMAL TO TESTIS?​ -CAN YOU PLACE YOUR FINGERS OVER IT?​ -DOES IT REDUCE WHEN PERSON LIES DOWN?​ -CAN YOU AUSCULTATE BOWEL SOUNDS OVER IT?​ TRANSILLUMINATION​ -PERFORM THIS MANEUVER ONLY IF YOU NOTE SWELLING OR MASS ​ -DARKEN ROOM; SHINE FLASHLIGHT FROM BEHIND SCROTAL CONTENTS​ -NORMAL SCROTAL CONTENTS DO NOT TRANSILLUMINATE​

**on exam** Male exam: inspection and palpation of the penis NORMAL FINDINGS ABNORMAL: phimosis, paraphymosis, hypospadias, epispadias

INSPECT AND PALPATE​ -SKIN: WRINKLED, HAIRLESS, W/O LESIONS​ -GLANS: SMOOTH W/O LESIONS​ (ask the uncircumcised male to retract the foreskin: it should move easily​) --PHIMOSIS: Narrowed opening of prepuce so foreskin cannot be retracted --PARAPHIMOSIS​: Painful constriction of glans by retracted foreskin​ -URETHRAL MEATUS: CENTRALLY POSITIONED​ --HYPOSPADIAS: Ventral location of the meatus --EPISPADIAS​: Dorsal location of the meatus​ -PUBIC HAIR: AT BASE OF PENIS, CONSISTENT​ WITH AGE​ -URETHRAL DISCHARGE​ -SHAFT: SMOOTH, SEMIFIRM, NONTENDER​

Male exam: inspection and palpation of a hernia

INSPECT INGUINAL REGION FOR BULGE AS PERSON STANDS AND STRAINS DOWN; NORMALLY NONE IS PRESENT​ PALPATE INGUINAL CANAL​ FOR RIGHT SIDE: ASK MALE TO SHIFT HIS WEIGHT ONTO LEFT LEG​ PLACE YOUR RIGHT INDEX FINGER LOW ON RIGHT SCROTAL HALF ​ PALPATE UP LENGTH OF SPERMATIC CORD, INVAGINATING SCROTAL SKIN AS YOU GO, TO THE EXTERNAL INGUINAL RING​ IT FEELS LIKE A TRIANGULAR SLITLIKE OPENING, IF IT WILL ADMIT YOUR FINGER, GENTLY INSERT IT INTO CANAL AND ASK PERSON TO "BEAR DOWN;" ---NORMALLY YOU FEEL NO CHANGE​ ---REPEAT PROCEDURE ON THE LEFT SIDE​ -PALPATE FEMORAL AREA FOR A BULGE​ (NORMALLY YOU FEEL NONE​) ​ -PALPATE INGUINAL LYMPH NODES​ (TEACH TESTICULAR SELF-EXAMINATION​) ​

Inspection: Infants and children Routine exam is limited to _______

Infant: Place on exam table​ Toddler/preschooler: Place on parent's lap in frog-like position​ School-age: Place on exam table in frog-like position​ ​ A routine exam is limited to inspection of the EXTERNAL GENITALIA to determine that:​ -The structures are intact​ -The vagina is present​ -The hymen is patent​ ​

Scrotum

LOOSE PROTECTIVE SAC; CONTINUATION OF ABDOMINAL WALL​ AFTER ADOLESCENCE, SCROTAL SKIN DEEPLY PIGMENTED AND HAS LARGE SEBACEOUS FOLLICLES​ SCROTAL WALL CONSISTS OF THIN SKIN LYING IN FOLDS, OR RUGAE, AND UNDERLYING CREMASTER MUSCLE​ CREMASTER MUSCLE CONTROLS SIZE OF SCROTUM BY RESPONDING TO AMBIENT TEMPERATURE​ SEPTUM INSIDE SEPARATES SAC INTO HALVES; IN EACH IS A TESTIS, WHICH PRODUCES SPERM​ ​

Withdrawal from sexual activity (without disease)

LOSS OF SPOUSE​ DEPRESSION​ PREOCCUPATION WITH WORK​ MARITAL OR FAMILY CONFLICT​ SIDE EFFECTS OF MEDICATIONS​ HEAVY USE OF ALCOHOL​ LACK OF PRIVACY, LIVING WITH ADULT CHILDREN OR IN A NURSING HOME​ ECONOMIC OR EMOTIONAL STRESS​ POOR NUTRITION OR FATIGUE​

Aging adult male: sperm production, testosterone, pubic hair/penis, scrotum, testes

MALE DOES NOT EXPERIENCE A DEFINITE END TO FERTILITY AS FEMALE DOES​ AROUND AGE 40 YEARS, PRODUCTION OF SPERM BEGINS TO DECREASE, ALTHOUGH IT CONTINUES INTO 80S AND 90S​ TESTOSTERONE PRODUCTION DECLINES AFTER AGE 30 BUT CONTINUES VERY GRADUALLY SO RESULTING PHYSICAL CHANGES ARE NOT EVIDENT UNTIL LATER IN LIFE​: PUBIC HAIR DECREASES AND PENIS SIZE DECREASES​ DUE TO DECREASED TONE OF DARTOS MUSCLE, SCROTAL CONTENTS HANG LOWER, RUGAE DECREASE, AND SCROTUM BECOMES PENDULOUS​ TESTES DECREASE IN SIZE AND ARE LESS FIRM TO PALPATION​ INCREASED CONNECTIVE TISSUE IS PRESENT IN TUBULES, SO THESE BECOME THICKENED AND PRODUCE LESS SPERM​ ​

Abnormal findings: Infections Yeast infection, clinical findings

Candida vaginitis a fungal (yeast) infection usually caused by Candida albicans.​ Clinical findings​ -Some women have asymptomatic infections.​ -Clients often experience vulvar pruritus associated with thick, cheesy, white vaginal discharge.​ -Vaginal soreness and external dysuria (caused by splash of urine on inflamed tissue) may occur.​ -Erythema and edema to labia and vulvar skin may be visible.​

Age-related variations: Lactating women When colostrum changes to milk, temp/texture, best treatment for nipple soreness

Colostrum changes to milk production around the 3rd postpartum day ■ Breasts may become engorged, appearing enlarged, reddened, and shiny and feeling warm and hard ■ Frequent nursing helps drain ducts and sinuses and stimulate milk production ■ Nipple soreness normal, appearing around twentieth nursing, lasting 24 to 48 hours, then disappearing ■ Nipples may look red and irritated; may even crack but will heal rapidly if kept dry and exposed to air; frequent nursing is the best treatment for nipple soreness

Penis

Composed of three cylindrical columns of erectile tissue (2 corpora cavernosa on dorsal side, corpus spongiosum ventrally) Glans: at distal end of shaft corpus spongiosum expands into cone of erectile tissue (corona: shoulder where glans join shaft) Urethra transverses corpus spongiosum and its meatus forms slit at tip of glans Foreskin or prepuce forms hood or flap over glans (often removed after birth by circumcision) Frenulum: fold of foreskin extending from urethral meatus ventrally

Common Problems and Conditions:​ Prolapse or Herniation​ Cystocele Rectocele

Cystocele: Protrusion of BLADDER against ANTERIOR wall of vagina.​ Clinical finding​ Woman may experience sensation of pressure, stress incontinence, occasional urgency, and feeling of incomplete emptying after voiding.​ Soft bulging mass of anterior vaginal wall is usually seen and felt as woman bears down.​ Rectocele: Hernia-type protrusion of RECTUM against POSTERIOR wall of vagina.​ Clinical finding​ Woman often complains of heavy feeling within vagina.​ Other symptoms include constipation, feeling of incomplete emptying of rectum after bowel movement, or feeling of something "falling out" in vagina.​ Bulging of posterior vagina is observed as woman bears down.​

Common Problems and Conditions: ​ Malignant Reproductive Conditions​ Endometrial Cancer Population most commonly seen in; cardinal symptom

The MOST COMMON gynecologic malignancy Occurs most often in postmenopausal women, especially those women taking estrogen.​ Clinical findings​ Cardinal symptom is abnormal uterine bleeding or spotting, although a watery vaginal discharge is frequently noted several weeks to months before bleeding.​

Subjective data: infants and children

ASK DIRECTLY TO PRESCHOOLER OR YOUNG SCHOOL-AGE CHILD: HAS ANYONE EVER TOUCHED YOUR PENIS OR IN BETWEEN YOUR LEGS AND YOU DID NOT WANT THEM TO? ​ TELL HIM THAT SOMETIMES THAT HAPPENS TO CHILDREN AND IT'S NOT OKAY ​ THEY SHOULD REMEMBER THAT THEY HAVE NOT BEEN BAD​ THEY SHOULD TRY TO TELL A BIG PERSON ABOUT IT​ ​

Surface Anatomy II Areola surrounds nipples; contains glands

- Montgomery's glands: contains small elevated sebaceous glands, called - Secrete protective lipid material during lactation. Areola: has smooth muscle fibers that cause nipple erection when stimulated. Nipple and areola = more darkly pigmented than rest of breast surface; color varies from pink to brown, depending on person's skin color and parity.

Assessment of breast: Surface Anatomy: location and structures Cooper's ligament

- On the anterior surface of the chest wall from ribs 2-6. The breast contains a tail called the tail of spence. This tail extends into the axilla. - Breasts lie anterior to pectoralis major and serratus anterior muscles. - Nipple is just below the center of the breast.

Additional history: Aging adult S/S, or questions, to ask pt regarding vaginal bleeding, atrophic vaginitis, weak pelvic muscles/uterine prolapse

-Additional vaginal bleeding after menopause needs follow up and referral -Atrophic vaginitis associated with: vaginal itching, discharge, pain with menopause -Weakened pelvic musculature and uterine prolapse: S/S of pressure in the genital area, loss of urine with cough or sneeze, back pain, or constipation​

Assessment of urinary function:

-COLOR​ -NOTE PH & SPECIFIC GRAVITY​ (4.5 TO 8.0​, 1.005-1.025​) SERUM ANALYSIS OF KIDNEY FUNCTION -CORRELATES WITH CR LEVEL WHICH IS RELATIVELY STABLE --(END PRODUCT OF MUSCLE METABOLISM)​ -BUN MEASURES UREA WHICH CAN VARY BASED ON SEVERAL FACTORS ​ --(END PRODUCT OF PROTEIN METABOLISM)​

Abnormal findings: the scrotum Epididymis and associated structure, reason for abnormality, clinical findings

-EPIDIDYMITIS IS INFLAMMATION OF EPIDIDYMIS --VAS DEFERENS USUALLY ASSOCIATED WITH STIs INVOLVING ---C. TRACHOMATOSA ---GONORRHEA CLINICAL FINDINGS​ CLASSIC: "DULL, UNILATERAL SCROTAL PAIN DEVELOPING OVER PERIOD OF HOURS OR DAYS.​" -SCROTUM BECOMES ERYTHEMATOUS AND EDEMATOUS. ​ -ASSOCIATED SYMPTOMS MAY INCLUDE FEVER AND DYSURIA -HYDROCELE MAY BE SEEN WITH TRANSILLUMINATION.​

Promoting a healthy lifestyle: testicular self-examination

-EVERY MALE AGED 13 YEARS TO ADULTHOOD​ -MALES WITH UNDESCENDED TESTES ARE AT GREATEST RISK​ -CAUCASIANS 4 TIMES MORE LIKELY TO CONTRACT TESTICULAR CANCER​ -NO EARLY SYMPTOMS​ -IF DETECTED EARLY, CURE RATE ALMOST 100%​

Inspection and palpation: Adolescents When to perform a pelvic exam

-Examine her alone, without a parent present​ -Assure privacy & confidentiality​ -Perform a pelvic exam when the history suggests abnormal vaginal discharge, missed periods and a positive pregnancy test, or at 21 years of age ​ ​

**on test** Objective Data— Palpation Nurse Completing Breast Exam Oder of breast exam Lump; note...

-Lie down. Press the 3 middle fingers in a circular motion and use 3 levels of pressure. Follow an up and down pattern. -Sit up. Examine underarm with arm slightly raised. Note surface changes with hands pushed on hips and shoulder hunched. o Examine the unaffected breast first to learn a baseline of normal consistency for the patient. If a lump is present, note - Location - Size - Shape - Consistency - Mobility - Distinctness - Nipple retraction - Overlying skin - Tenderness - Lymphadenopathy

Abnormal findings: the scrotum and testicles Testicular cancer, most common age, clinical findings, significance of pain, exam findings

-MOST COMMON MALIGNANCY IN MEN AGES 20 TO 34. ​ CLINICAL FINDING​ -PAINLESS TESTICULAR MASS -USUALLY DISCOVERED BY CLIENT OR HIS SEXUAL PARTNER.​ WHEN PAIN IS INITIAL SYMPTOM, USUALLY AN INDICATION THAT MASS HAS CAUSED BLEEDING WITHIN TESTICLE OR HAS CAUSED TESTICULAR TORSION.​ ON EXAM, A HARD, IRREGULAR MASS IS FELT WITHIN TESTIS; IF MASS IS LARGE ENOUGH, DEFORMITY OF SCROTUM MAY BE OBSERVABLE.​

Aging woman: External vagina Physical structures, changes in sexual response cycle

-Mons pubis looks smaller because fat pad atrophies​ -Labia and clitoris gradually decrease in size​ -Pubic hair becomes thin and sparse​ -Changes in female sexual response cycle​ (dec. estrogen) --Reduced amount of vaginal secretion and lubrication during excitement​ --Shorter duration of orgasm; and rapid resolution​ --Changes DO NOT AFFECT sexual pleasure and function​ --Sexual desire and need for full sexual expression continue​ ​

Subjective data: Adult: -Frequency, urgency, and nocturia -Dysuria: Any pain or burning with urinating -Hesitancy & Straining -Urine Color/frequency -GU history (incontenence) -Penis -Scrotum, self-care behaviors -Sexual Activity and Contrtaceptive Use -STI contact/prevention

-Nocturia occurs with frequency and urgency in urinary tract disorders; other origins include cardiovascular, habitual, diuretic medication​ -Burning common with acute cystitis, prostatitis, and urethritis​ -Do you have any trouble starting urine stream? -Is usual urine clear (not discolored, cloudy, foul-smelling, or bloody); Average adult voids 5-6 times/day varying with fluid intake​ -True incontinence: loss of urine without warning. -Urgency incontinence: sudden loss, as in acute cystitis. -Sexual history may be used to determine client's risk for STIs. ​ -Occasionally a man notices a change in ability to have an erection when aroused. ​

Abnormal findings: male genital lesions II Urethritis, urethral discharge and dysuria

-PAINFUL BURNING URINATION​ --MEATUS EDGES ARE REDDENED, EVERTED, AND SWOLLEN; PURULENT URETHRAL DISCHARGE IS PRESENT; URINE CLOUDY WITH DISCHARGE AND MUCOUS SHREDS​ --CAUSE DETERMINED BY MICRORGANISM​ ---GONOCOCCAL URETHRITIS HAS THICK, PROFUSE, YELLOW OR GRAY-BROWN DISCHARGE​ ---NONSPECIFIC URETHRITIS (NSU) MAY HAVE SIMILAR DISCHARGE BUT OFTEN HAS SCANTY, MUCOID DISCHARGE ​ ---ABOUT 50% ARE CAUSED BY CHLAMYDIA INFECTION​

Male exam: inspection and palpation of the scrotum NORMAL FINDINGS (room temp, sebaceous cysts, testes, epididymis, spermatic cord)

-SIZE VARIES WITH AMBIENT ROOM TEMPERATURE. -ASYMMETRY IS NORMAL; LEFT SCROTAL HALF USUALLY LOWER THAN RIGHT​ -SEBACEOUS CYSTS: 1CM YELLOWISH NODULES, FIRM AND NONTENDER​ -TESTES: OVAL, FIRM, RUBBERY, SMOOTH, EQUAL BILATERALLY, FREELY MOVABLE AND SLIGHTLY TENDER TO MODERATE PRESSURE​ -EPIDIDYMIS: DISCRETE, SOFTER THAN THE TESTES, SMOOTH, AND NONTENDER​ -SPERMATIC CORD: SMOOTH, NONTENDER CORD​

Aging woman: Vagina Reasons (and consequence) for changes in structure, size, epithelium, secretions, pH

-Shorter, narrower, and less elastic (increased connective tissue​) -Vagina atrophies to one-half its former length and width​ (Without sexual activity) -Vaginal epithelium atrophies, becoming thinner, drier, and itchy​ --Results in a fragile mucosal surface that is at risk for BLEEDING and VAGINITIS​ -Decreased vaginal secretions leave vagina dry and at risk for irritation and pain with intercourse, dyspareunia​ -Vaginal pH becomes more alkaline, and a decreased glycogen content occurs from the decreased estrogen​

Pregnant woman: greatest change is in uterus- size Expansion, factors that stimulate growth, shape of uterus at 10-12 weeks, 20-24 weeks, hallmark symptom

-Uterus expands 500-1000 X versus its non-pregnant state -1st: Hormone stimulation, then because of increasing size of its contents ​ -2nd: Growth of uterus shows symptom of urinary frequency​ bc of pressure on bladder -10 to 12 weeks' gestation, uterus becomes GLOBULAR in shape; too large to stay in pelvis​ -20 to 24 weeks' gestation, uterus has OVAL shape ---It rises almost to the liver ---Displacing intestines superiorly and laterally​ -INCREASED URINE FREQUENCY​

HPV Teaching points Purpose of vaccine, HPV vaccine and cancer, role of PAP test, how to prevent HPV without vaccine, condoms

-Vaccine does not mean they can forget about routine pelvic examinations and Pap tests ​ -Vaccine will protect against major types of HPV that cause cervical cancer, but not all types​ -Pap tests detect cell changes in cervix before they turn into cancer, at an early, curable stage​ -Only other way to prevent HPV is to abstain from all sexual activity​ -Condoms may not protect against HPV because areas not covered by condom can be exposed to virus​

Abnormal findings: the scrotum and testicles Hydrocele, clinical findings, difference in findings with transillumination

ACCUMULATION OF FLUID IN SCROTUM.​ IN INFANTS, HYDROCELES OFTEN RESOLVE ON THEIR OWN (OCCASIONALLY SURGERY REQUIRED) IN ADULTS, CAUSE IS OFTEN UNKNOWN, MAY RESULT FROM INFECTION OR MALIGNANCY. ​ CLINICAL FINDINGS​ SCROTAL ENLARGEMENT IS MOST COMMON SYMPTOM.​ SCROTUM ENLARGED; EDEMA APPEARS ON ANTERIOR SURFACE OF THE TESTIS, MAY EXTEND TO SPERMATIC CORD ​ TRANSILLUMINATION INDICATED IF HYDROCELE SUSPECTED; LIGHT RED GLOW INDICATES PRESENCE OF FLUID; FAILURE TO GLOW SUGGESTS A MASS.​

Subjective data: Child

ANY URINARY TRACT INFECTIONS?​ (IF CHILD OLDER THAN 2 TO 2½ YEARS OF AGE) HAS TOILET TRAINING STARTED? HOW IS IT PROGRESSING?​ IF CHILD IS 5 YEARS OLD OR OLDER, DOES HE WET BED AT NIGHT? IS THIS A PROBLEM FOR CHILD OR FOR PARENTS? WHAT HAVE YOU DONE? HOW DOES THE CHILD FEEL ABOUT IT? ​ SCREEN FOR SEXUAL ABUSE​

General health history: Preadolescents and adolescents assessment question

ASSESS KNOWLEDGE OF AND FEELINGS: -REGARDING PUBESCENT CHANGES​ -- AROUND 12 TO 13, BOYS GROW AROUND PENIS AND SCROTUM -KNOWLEDGE/ MISINFORMATION REGARDING SEX​ --ASK AB BIRTH CONTROL, OR STIS ​ -ASSESS KNOWLEDGE OF TESTICULAR SELF-EXAM​ --HAS A NURSE OR DOCTOR EVER TAUGHT YOU HOW TO EXAMINE YOUR OWN TESTICLES TO MAKE SURE THEY ARE HEALTHY?​ -TEACH STI RISK REDUCTION​ --SEXUAL PARTNERS/DATING -SCREEN FOR SEXUAL ABUSE​

Subjective Data: Health history questions Preadolescent, pregnant female, menopausal woman

Additional history for preadolescent ■ Changes in breasts ■ Other changes Additional history for pregnant female ■ Enlargement of breasts ■ Plans to breastfeed Additional history for menopausal woman ■ Changes in breasts ■ Risk Factor Profile for Breast Cancer

Age-related variations: Pregnant women Striae, nipple changes, colostrum

Breasts increase in size, as do nipples ■ Delicate blue vascular pattern is visible over the breasts ■ Jagged linear stretch marks, or striae, may develop if breasts have large increase ■ Nipples become darker and more erectile ■ Areolae widen; grow darker; and contain small, scattered, elevated Montgomery's glands ■ On palpation, breasts feel more nodular, and thick yellow colostrum can be expressed after first trimester

Objective Data—Inspection and Palpation

Axillae—Inspect and Palpate ■ Skin ■ Palpation technique ■ Lymph nodes

Objective Data—Inspection

Breasts—Inspect ■ General appearance ■ Skin ■ Lymphatic drainage areas ■ Nipple (supernumerary nipple) ■ Maneuvers to screen for retraction

Objective Data—Palpation

Breasts—Palpate ■ Position ■ Palpation patterns ■ Expected findings ■ Nipple ■ Bimanual palpation The VERTICAL STRIP PATTERN is the best way to detect a breast mass Correctly placed breast implants are located behind the breast tissue. Follow the same steps

Culture and genetics: circumsicion and its effects on disease

CIRUMCISION DECIDED: DURING PREGNANCY OR IMMEDIATE NEONATAL PERIOD​ THERE ARE RELIGIOUS AND CULTURAL INDICATIONS FOR CIRCUMCISION, ALSO PREVENTION OF PHIMOSIS AND INFLAMMATION OF GLANS PENIS AND FORESKIN, DECREASING INCIDENCE OF CANCER OF PENIS, AND SLIGHTLY DECREASING INCIDENCE OF URINARY TRACT INFECTIONS IN INFANCY​ LOWERS RISK OF CERTAIN STIs, SPECIFICALLY SYPHILIS, CHANCROID, AND SOMEWHAT REDUCED RISK OF GENITAL HERPES​ SIGNIFICANTLY LOWERED RISK OF ACQUIRING GENITAL HPV INFECTION, PARTNERS HAVE A LOWER RISK OF CERVICAL CANCER​ A POTENTIAL REDUCTION IN ACQUISITION OF HIV IN CIRCUMCISED MEN​ ​

Preparing for the female exam Equipment, instructions, positioning, addressing psychological needs, how should you approach the genitalia

Before exam: prepare room, equipment, sheet or gown, warm temperature, and assistant, if needed.​ Ask client to empty bladder, undress, and put on gown.​ Assist into lithotomy position (knees in squatting position while supine)--feet in stirrups, and knees apart with adequate draping, buttocks at edge of exam table, arms at sides or across chest.​ Position sheet exposing only vulva for exam; fixing sheet so you can see woman's face as you proceed.​ ​ If uncomfortable or embarrassed, ask if she would like her head elevated so that she can see you better.​ Reassure her that you will tell her everything that you are going to do before you actually do it (if patient gets too uncomfortable, you will stop and reassess.) Remember to touch inner aspect of thigh before you touch external genitalia.​

Common Problems and Conditions: ​ Benign Reproductive Conditions​ Endometriosis

Benign progressive disease Characterized by presence and growth of UTERINE TISSUE OUTSIDE UTERUS Clinical findings​ Pelvic pain, dysmenorrhea (painful periods), and heavy or prolonged menstrual flow.​ Clinical exam findings: small, firm, nodular-like masses palpable along UTEROSACRAL ligaments and uterus may be tender; in many women a clinical exam will not detect abnormalities.​

Common Problems and Conditions: ​ Benign Reproductive Conditions​ Uterine fibroids

Benign uterine tumors - occur singularly or in multiples - range microscopic lesions to large tumors filling entire abdominal cavity Clinical findings​ Majority of women are asymptomatic. ​ Symptoms: Pelvic pressure and heaviness, urinary frequency, dysmenorrhea, pelvic or back pain, and abdominal enlargement

Palpation: Internal genitalia: bimanual Cervix (consistency, contour, mobility) Uterus (consistency, mobility) Adnexa

Bimanual Examination​ - Palpation technique​ Cervix ​ -Consistency: smooth and firm (tip of nose)​ -Contour: evenly rounded​ -Mobility: no pain when moved side to side​ Uterus: assess position of uterus​ -Firm and smooth​ -Freely movable and nontender​ Adnexa​ (Often, cannot be felt​) -Smooth, firm, almond-shaped, highly movable, nontender​

Infants and adolescents: Changing sex characteristics (birth, puberty, menarche)

Birth- external genitalia are engorged because of presence of maternal estrogen​ Puberty- estrogens stimulate growth of cells in the reproductive tract and development of secondary sex characteristics​ First signs of puberty are breast and pubic hair development, beginning between ages 8 and 10 ​ Menarche occurs during latter half of this sequence, just after peak of growth velocity​ Ovaries are now in pelvic cavity​ ​

Subjective Data: Health history questions

Breast - Pain - Lump - Discharge - Rash - Swelling - Trauma - History of breast disease - Surgery - Self-care behaviors ■ Breast self-examination ■ Last mammogram Axilla - Tenderness, lump, or swelling - Rash

Risk Profile for Breast Cancer ____ major cause of death from cancer in women; 5-year survival rate from past, present, and if it has spread

Breast cancer is second major cause of death from cancer in women. •Early detection and improved treatment have increased survival rates. - The 5-year survival rate for localized breast cancer has increased from 78% in 1940s to 98% today. - If cancer has spread regionally, survival rate is 84%.

Abnormal findings: the scrotum and testicles Spermatocele, clinical findings, characterization, transillumination (y/n)

CYSTIC MASS OCCURRING WITHIN EPIDIDYMIS OR SPERMATIC CORD FILLED WITH SPERM AND SEMINAL FLUID. ​ CLINICAL FINDINGS​ CONDITION USUALLY PAINLESS, BUT CHARACTERIZED BY SIGNIFICANT TESTICULAR EDEMA IN INVOLVED TESTICLE​ A SEPARATE MASS IS PALPATED WITHIN TESTIS ADJACENT TO EPIDIDYMIS OR SPERMATIC CORD.​ BECAUSE LESION IS A CYST, IT TRANSILLUMINATES.​

Abnormal findings: the scrotum and testicles Varicocele, cause, clinical findings, specificity of testicle

CAUSED BY ABNORMAL DILATION AND TORTUOSITY OF VEINS ALONG SPERMATIC CORD CAUSE IS OFTEN MULTIFACTORIAL; -DILATION MAY BE CAUSED BY DIFFERENCES IN VENOUS DRAINAGE BETWEEN RIGHT AND LEFT SIDES.​ CLINICAL FINDINGS​ -PULLING SENSATION -DULL ACHE -SCROTAL PAIN -VEINS ABOVE TESTIS TEND TO FEEL THICKENED; A PALPABLE MASS IS USUALLY DETECTED IN THE SCROTUM -90% OF VARICOCELES OCCUR ON LEFT SIDE.​

Sexual expression later in life:

CHRONOLOGIC AGE BY ITSELF SHOULD NOT MEAN A HALT IN SEXUAL ACTIVITY; PHYSICAL CHANGES NEED NOT INTERFERE WITH LIBIDO AND SEXUAL PLEASURE​ OLDER MALE IS CAPABLE OF SEXUAL FUNCTION AS LONG AS HE IS IN REASONABLY GOOD HEALTH AND HAS AN INTERESTED, WILLING PARTNER​ DANGER IS IN MALE MISINTERPRETING NORMAL AGE CHANGES AS A SEXUAL FAILURE; ONCE THIS IDEA OCCURS, IT MAY DEMORALIZE MAN AND PLACE UNDUE EMPHASIS ON PERFORMANCE RATHER THAN ON PLEASURE​

Aging woman: Menopause Age seen, preceding onset and S/S of decline ovary function, hormones that stop production, cells in the reproductive tract are dependent on ____

Female's hormonal environment decreases rapidly in contrast with slow decline in aging male​ Menopause: cessation of menses​ (normally 48-51 yrs old) --Wide variation of ages (35-60) exists​ Stage -Preceding 1 to 2 yrs: decline in ovarian function (irregular menses that gradually become farther apart and produce lighter flow​) -Ovaries stop producing progesterone and estrogen​ -Because cells in the reproductive tract are estrogen dependent, decreased estrogen levels during menopause bring dramatic physical changes​

External male genitalia:

External: penis and scrotum Internal: testes, epididymus and vas deferens Glandular/accessory to genital organs: prostate, seminal vesicles and bublbourethral glands

Abnormal findings: male genital lesions I HSV-1, HSV-2, syphyilitic chancre, HPV/warts, carcinoma

GENITAL HERPES, HSV-2 INFECTION​ SYPHILITIC CHANCRE​ GENITAL WARTS, HUMAN PAPILLOMAVIRUS (HPV)​ CARCINOMA​ -BEGINS AS RED, RAISED WARTY GROWTH OR AS AN ULCER, WITH WATERY DISCHARGE​ -AS IT GROWS, MAY NECROSE AND SLOUGH​ -USUALLY PAINLESS; ALMOST ALWAYS ON GLANS OR INNER LIP OF FORESKIN AND FOLLOWING CHRONIC INFLAMMATION; ENLARGED LYMPH NODES ARE COMMON​

Common Problems and Conditions: ​ Malignant Reproductive Conditions​ Ovarian Cancer

HIGHEST MORTALITY RATE of the gynecologic cancers because typically UNDETECTED Clinical findings ​ -Usually no symptoms until advanced stages of disease​ -Most common symptom is abdominal distention or fullness.​ -By time ovarian malignancies are palpable, disease is usually advanced.​

Syphilis Objective, secondary syphilis

O: begins as a small , solitary​ SILVER PAPULE that erodes to a round or oval, ​superficial ulcer with a yellowish serous ​ discharge. May go unnoticed; resolves ​spontaneously.​ Secondary syphilis follows: fever, lymphadenopathy, mucocutaneous red rash, sore throat. ​

Common Problems and Conditions: ​ Benign Reproductive Conditions​ Ovarian Cysts

Ovarian cysts are benign cystic growths WITHIN OVARY - solitary, or multiple - unilateral, or bilateral Clinical findings​ Most are asymptomatic.​ Often include tenderness and dull sensation or feeling of heaviness in pelvis Exam findings include non-tender, fluctuant, mobile, and smooth mass on ovary.​ -If cyst ruptures, a sudden onset of abdominal pain occurs.​

Male exam: prepping

POSITION CLIENT EITHER STANDING OR LYING DOWN.​ - EVALUATE FOR HERNIA: CLIENT NEEDS TO STAND TO -APPREHENSION OF PT. DEALT W BY NURSE BY APPROACHING GENITALIA EXAM IN PROFESSIONAL, MATTER-OF-FACT WAY, PROJECTING CONFIDENCE THROUGHOUT EXAMINATION.

**on test** Male Breast: Principles and physical exam Other physical exam it is combined with

Principles: Examination of male breast can be abbreviated, but do not omit it. - Combine breast exam with that of anterior thorax. - Inspect chest wall, noting skin surface and any lumps or swelling. - Palpate nipple area for any lump or tissue enlargement; it should feel even, with no nodules. - Palpate axillary lymph nodes. Physical Exam: Male breast ■ Gynecomastia > Male breast tissue. May develop during puberty or later in life due to lowered levels of testosterone. Developmental care ■ Adolescent ■ Pregnant female ■ Lactating female ■ Aging female

Common Problems and conditions: Infections Cont'd PID What structures are involved, what infections predisposed PID, leading cause of ___________; Clinical findings (acute v chronic)

Pelvic inflammatory disease (PID)—women ​ Polymicrobial infection of upper reproductive tract affecting: -Endometrium -Fallopian tubes -Ovaries -Uterine wall -Broad ligaments​ PID a leading cause of infertility.​ Usually is caused by untreated gonococcal and Chlamydia infection​ Acute or Chronic; -Acute: very tender adnexal areas (ovaries and fallopian tubes) and pain is so severe client cannot tolerate bimanual pelvic exam.​ -Other symptoms include fever, chills and abnormal vaginal discharge.​ -Chronic PID associated with tender, irregular, and fixed adnexal areas.​

Common Problems and Conditions: ​ Benign Reproductive Conditions​ Premenstrual symptom (emotional, cognitive, physical symptoms)

Premenstrual syndrome: a group of recurrent symptoms associated with menstrual cycle​ Clinical findings​ Combination of symptoms during LAST HALF of menstrual cycle and diminishing as menstruation begins​ -Emotional symptoms: mood swings, depression or sadness, irritability, anxiety, restlessness, and anger. ​ -Cognitive symptoms: difficulty concentrating, confusion, forgetfulness, and being accident prone.​ -Physical symptoms: excessive energy or fatigue, nausea or changes in appetite, insomnia, back pain, headaches, general muscular pain, breast tenderness, and fluid retention.​

Inspection: External genitalia Skin color​ / Hair distribution​ Labia majora​ Any lesions​ Clitoris​ Labia minora​ Urethral opening​ Vaginal opening ​ Perineum​ Anus​

Pubic hair and skin - Inspect over mons pubis and inguinal area for distribution and surface characteristics.​ Labia majora, labia minora, and clitoris - Inspect and palpate for pigmentation and surface characteristics​ Urethral meatus, vaginal introitus, and perineum -Inspect for positioning and surface characteristics Inspect perianal area and anus for color and surface characteristics.​ ​

Abnormal findings: Urinary problems

RENAL CALCULI​ ACUTE URINARY RETENTION​ URETHRAL STRICTURE ​

**on test** Promoting a health lifestyle: HPV vaccine; PAP Smear Recommended for ________ Stains of HPV covered, ages pt should get vaccinated, amount of injections, why pt should get vaccinated

Recommended prior to becoming sexually active​ If sexually active or infected, still recommended ( 6 major strains covered)​ Ages 9 to 26 (beginning at age 11 or 12)​ Recommended and covered by insurance for males and females​ --Gardasil is only vaccine for males​ 3 separate injections over a 6 month period​ HPV is the most rapid growing STI​ PAP Smear Yearly exam once sexually active or 21 years old, whichever comes first​ ​ ​

Hepes Simplex S, O

S: Episodes of local pain, dysuria, fever​ O: Clusters of small, shallow vesicles with surrounding erythema; erupts on genital areas and inner thighs. Initial infection lasts 7 to 10 days. Virus remains dormant indefinitely. ​

Chlamydia: S, O

S: Minimal or no symptoms. May have urinary frequency, dysuria, vaginal discharge, postcoital bleeeding​ (bleeding after sex) O:May have yellow or green mucopurulent discharge , friable cervix, cervical motion tenderness​

HPV: Most common STI esp in adolescents S, O

S: Painless warty growths; may be unnoticed by woman​ Pink or flesh-colored, soft, pointed, moist warty papules. Cauliflower-like patch.​

Trichomoniasis S, O; in men; symptoms and menstruation

S: Pruritis, watery & often malodorous (foul-smelling) vaginal discharge. Symptoms worse during menstruation​ O: Vulva may be erythamatous. Vagina has a strawberry appearance. Frothy yellow-green foul-smelling discharge​ Men: DO NOT have s/s. Some men may have a temporary irritation inside the penis, mild discharge, or slight burning after voiding or ejaculating​

Peiculosis Pubis S, O

S: Severe perianal itching​ O: Excoriations and erythemateous areas. May see little dark spots, nits adherent to pubic hair near roots. ​

Gonnorhea S, O

S: Variable: Vaginal discharge, dysuria, abnormal uterine bleeding; 95% are asymptomatic ​ O: Often no signs are apparent. May have purulent vaginal discharge​

Adolescence and puberty

SIGNS OF PUBERTY ARE APPEARING EARLIER IN BOYS ACCORDING TO RESEARCH STUDIES AT AN AVERAGE AGE OF 9 YEARS IN AFRICAN AMERICANS & AGE 10 FOR CAUCASIANS & HISPANICS ​ FIRST SIGN IS ENLARGEMENT OF TESTES​ NEXT, PUBIC HAIR APPEARS, THEN PENIS SIZE INCREASES​ STAGES OF DEVELOPMENT ARE DOCUMENTED IN TANNER'S SEXUAL MATURITY RATINGS​

Subjective data: Health history

Same as in for male with the exception of: -LMP/age of onset/characterists -OB history -Menopause -Self care (last PAP; Hep A/B, HPV) -Screen for sexual abuse in children

Abnormal Findings: STI

Sexually transmitted infections​ Chlamydia​ Gonorrhea​ Syphilis​ Trichomonas​ Herpes genitalis​ Human papillomavirus (genital warts, condylomata acuminatum)​ Pediculosis pubis (crabs, pubic lice)​

Pregnant woman: Anatomical changes, etiology of changes (4-6 weeks, 8-12 weeks, 6-8 weeks), Goodell's sign, Chadwick's sign, Hegar's sign

Shortly after first missed menstrual period, genitalia show signs of the growing fetus​ Changes occur because of increased vascularity and edema of cervix and hypertrophy and hyperplasia of cervical glands​ -Goodell's sign Cervix softens at 4 to 6 weeks of gestation -Hegar's sign Isthmus of uterus softens at 6 to 8 weeks of gestation​ -Chadwick's sign Vaginal mucosa and cervix look cyanotic at 8 to 12 weeks of gestation​

Skin Retraction What is it in relation to tissue?

Skin retraction over the breast is assessed by asking the patient to bring their hands above their head. In doing so the nurse should observe breast tissue elevating above the head. Skin retraction is an abnormal finding and may suggest fibrosis in the breast tissue caused by growth of neoplasm Have pt raise hands above head (to look for retraction). Have patient put hands on hips. Third, ask pt to put palms together and push. The purpose is to contract pectorals and push breast tissue off of pecs.

Inspection: Internal Another name for internal inspection, color, position, size; Os; nabothian cysts, secretions

Speculum examination​ Cervix and os ​ -Color: pink & even​ -Position; midline​ -Size: 2.5 cm (1 inch)​ -Os: small and round in nulli-​ parous women​ -Surface: smooth​ -Any Nabothian cysts: benign ​ growths commonly seen after ​ childbirth​ -Cervical secretions: change ​ -Depending on day of menstrual ​ cycle- should always be odorless and nonirritating​

**on exam** Testicular self-examination T.S.E.

T: TIMING, ONCE A MONTH​ S: SHOWER, WARM WATER RELAXES SCROTAL SAC​ E: EXAMINE, CHECK FOR CHANGES, REPORT CHANGES IMMEDIATELY​ HOLD THE SCROTUM IN THE PALM OF THE HAND AND GENTLY FEEL EACH TESTICLE USING THE THUMB AND FIRST TWO FINGERS. TESTICLE IS EGG-SHAPED AND MOVABLE. FEELS RUBBERY WITH A SMOOTH SURFACE. EPIDIDYMIS IS ON TOP AND BEHIND THE TESTICLE AND FEELS SOFTER.​ ​

Abnormal findings: the scrotum and testicles Testicular torsion, clinical findings, hallmark, etiology

TESTICULAR TORSION IS CAUSED BY TWISTING OF TESTICLE AND SPERMATIC CORD, CUTTING OFF BLOOD SUPPLY; CONSIDERED A SURGICAL EMERGENCY.​ CLINICAL FINDINGS​ -HALLMARK: HISTORY OF SUDDEN ONSET OF SEVERE PAIN AND SCROTAL SWELLING.​ -TESTICLE BECOMES VERY TENDER, AND SCROTUM BECOMES EDEMATOUS AND OFTEN SLIGHTLY DISCOLORED. ​ --NOT ASSOCIATED WITH PHYSICAL ACTIVITY OR TRAUMA​

Internal anatomy of structures: testes, tunica vaginalis, sperm, epididymis, vans deferens, spermatic cord, lymphatics, inguinal area (groin) and its openings (internal/external ring, femoral canal)

Testes: Have a solid oval shape, suspended vertically by spermatic cord. Left testis is lower because left spermatic cord is longer. Tunica vaginalis: double-layered membrane covers each testis and separates it from scrotal wall. Layers are lubricated by fluid so that testis can slide within scrotum which helps prevent injury​ Sperm & Spermatic Cord: Transported along series of ducts​ Epididymis: markedly coiled duct system and main storage site of sperm; comma-shaped structure, curved over top and posterior surface of testis​ Vas deferens: a muscular duct continuous with lower part of epididymis and with other vessels (arteries and veins, lymphatics, nerves) that forms spermatic cord​ Spermatic Cord: Ascends along posterior border of testis and runs through tunnel of inguinal canal into abdomen. Here, vas deferens continues back and down behind bladder, where it joins duct of seminal vesicle to form ejaculatory duct, which empties into urethra​ Lymphatics: Lymphatics of penis and scrotal surface drain into inguinal lymph nodes. Lymphatics of testes drain into abdomen. Abdominal lymph nodes are not accessible to clinical examination,​ Inguinal Area or Groin: Inguinal canal is 4 to 6 cm long in adult​ Openings are:​ Internal ring: 1 to 2 cm above midpoint of inguinal ligament​ External ring: above and lateral to pubis​ Femoral canal is inferior to inguinal ligament​ Potential space located 3 cm medial to and parallel with femoral artery​ You can use artery as landmark to find this space​ ​ ​ ​

Pregnant woman: greatest change is in uterus- birth Purpose of mucous plug, "bloody show", increased acidity purpose and consequence

The mucus plug- Clot of thick, tenacious mucus forms in spaces of cervical canal --Protects fetus from infection​ "Bloody show"​- Sign of labor, mucus plug dislodges when labor BEGINS at end of term Increased acidity occurs by action of Lactobacillus acidophilus, which changes glycogen into lactic acid​ Acidic pH keeps pathogenic bacteria from multiplying in vagina, but increases in glycogen increase risk of candidiasis (yeast infection) during pregnancy​

Rectovaginal examination I: Assesses __________ Feels like __________ Instructions for pt, procedure

Use this technique to assess -Rectovaginal septum -Posterior uterine wall -Cul-de-sac -Rectum​ Change gloves to avoid spreading any possible infection; lubricate first two fingers​ Instruct woman this may feel uncomfortable and will mimic feeling of moving her bowels​ Ask her to bear down as you insert your index finger into vagina and your middle finger gently into rectum​

Common Problems and Conditions: ​ Malignant Reproductive Conditions​ Cervical Cancer Most common cause, most common symptom, lesion surface

Usually caused by HPV infection.​ Clinical findings ​ Most common symptom is abnormal vaginal bleeding between normal menstrual periods, after intercourse, or bleeding that is heavier or lasts longer than normal.​ On examination a lesion may be visible; lesion usually has a hard granular surface that bleeds easily and has irregular borders.​

Common Problems and Conditions:​ Prolapse or Herniation​ Uterine Prolapse- condition it's associated with; 1st, 2nd, 3rd degree;

Uterine prolapse: associated with RETROVERTED UTERUS that descends into vagina -1st degree prolapse: cervix remains within vagina; ​ -2nd degree prolapse cervix is in introitus -3rd degree prolapse, cervix and vagina drop outside introitus.​ Clinical finding​ -Primary symptoms include a feeling of heaviness, fullness, or sensation of "falling out" in perineal area -Cervix is visualized LOW within vagina, at vaginal opening, or protruding from opening.​ ​

Aging woman: Uterus/ovarian changes Size, appearance, consequences of musculature changes

Uterus -Shrinks in size because of decreased myometrium​ -Atrophy to 1 to 2 cm (not palpable after menopause)​ -Ovulation still may occur sporadically after menopause​ -Uterus droops as sacral ligaments relax and pelvic musculature weakens​ --Sometimes protrudes, or prolapses, into vagina​ -Cervix shrinks, looks paler, thick, glistening epithelium​

Inspection: Obtain cervical smears and cultures​ Tests performed, Data to include for the ​laboratory​ ​

Vaginal pool​ Cervical scrape​ Endocervical specimen​ Data to include for the laboratory: date of specimen, woman's DOB, LMP, Any hormone medications, if pregnant EDC, known infections, prior surgery or radiation, prior abnormal cytology, abnormal findings on physical exam

Female GU System: Internal female genital structures

Vagina​ Cervix​ Squamocolumnar ​ junction​ Anterior fornix ​ Posterior fornix​ Rectouterine pouch, or cul-de-sac of Douglas​ Uterus​ Fallopian tubes ​

Female GU System: External female genital structures

Vulva, or pudendum​ Mons pubis​ Labia majora​ Labia minora​ Frenulum or fourchette​ Clitoris​ Vestibule​ Urethral meatus​ Skene's glands​ Vaginal orifice​ Hymen​ Bartholin's glands​

Rectovaginal examination II: Findings of rectovaginal septum, uterine wall, fundus; Stool on glove

While pushing with abdominal hand, repeat steps of bimanual examination​ Keep intravaginal finger on cervix so intrarectal finger does not mistake cervix for a mass​ Rectovaginal septum should feel smooth, thin, firm, and pliable​ Uterine wall and fundus feel firm and smooth​ Rotate intrarectal finger to check rectal wall and anal sphincter tone​ Check your gloved finger as you withdraw; test any adherent stool for occult blood​ Give woman tissues to wipe area; help her to sit up​

Age-related variations: Older adults Atrophy, post-menopausal

■ Atrophic changes to female breasts begins by age 40 years and continues through menopause. ■ As glandular tissue atrophies, breast tissue is replaced with fat and connective tissue. ■ Postmenopausal women should continue to have regular breast examinations because of increased risk of breast cancer with age.

Age-related variations: Infants and Children Size at infancy; "witch's milk"

■ Breast assessment among infants and children only requires inspection. ■ Neonates of both genders may have slightly enlarged breast secondary to mother's estrogen. ■ Maternal hormones are also responsible for a small watery whitish discharge referred to as "witch's milk" seen in small percent of newborns during first few weeks of life.

Age-related variations: Adolescents Menarche, reasons for gynecomastia

■ Breast development, MENARCHE, begins in preadolescence and continues through adolescence. ■ Girls are often sensitive about having breasts exposed for examination; must take time to reassure patient and ensure privacy. ■ Boys may experience an unexpected enlargement of breasts (gynecomastia) as result of obesity or body change transition during early puberty.

**on exam** Breast Examination: Abnormal findings

■ Dimpling A dimple or skin tag is a compression in the skin. This may be the result of fibrosis associated with cancer. Fibrosis causes the suspensory ligaments to pull the skin taught. ■ Fixation-Asymmetry Fixation is when the breast tissue is less mobile, fixed in position, distorted or asymmetrical with elevation of the arm. ■ Edema (peau d'orange)-Lymph obstruction Peau d'Orange is obstruction of a lymphatic structure leading to edema of the breast tissue. As a result the breast appears swollen with a pig skin, orange peel texture. ■ Deviation in nipple pointing ■ Nipple retraction A nipple retraction is when the nipple is pulled inward into the chest cavity. The nipple appears flatter and broader. This is often the result of fibrosis of the duct system. It may also occur because of benign ectasia of the ducts. ■ Benign breast disease (formerly fibrocystic breast disease) A fibrotic cyst is a benign cystic structure that has well defined/ well delineated borders. It can be painless to very painful. It may change size and shape with menstrual cycle. ■ Cancer-Nontender Mass Most breast cancer is invasive and metastatic. It will begin in the lobules and ducts and travel into the tissue. It may be accompanied by dimpling, rash, deviation of nipples, nipple discharge. There may be crusting or erosion of the nipple. Lymph nodes may be palpable in the axilla. ■ Fibroadenoma-Benign Tumor Fibroadenoma is a non-cancerous mass in the breast that is typically detected in late adolescence. It is a solitary, non-tender mass that is firm, rubbery and elastic. - A women recovering from a mastectomy should not have any inflammation or infection. --Lymphedema of the upper arms is a common sequela because of interruptions of lymphatic drainage or removal of nodes. Should not have any: Sudden increase in size of one breast signifies inflammation or a new growth. Hyperpigmentation: redness and heat with inflammation. Unilateral dilated superficial veins in a non-pregnant women Edema During the maneuvers to screen for retraction, note any lag in the movement of one breast. Enlarged or tender lymph nodes Dimpling or a pucker Note any fixation to chest wall or skin retraction Deviation in the nipple pointing

**on exam** Teach breast self examination

■ Schedule for self-exam ■ Correct technique ■ Return demonstration -after menstrual period (4-7 days) -breast are smallest/least congested -Pregnant/menopausal pick familiar date - Pt inspects in front of mirror -at home done in shower water/soap assist in palpation -emphasize, monthly exams, familiarizes with own breast, absence of lumps, report unusual findings