Health Assessment #2

See pages 695 - 697 to identify the 9 areas of subjective data information. What subjective data should be collected for the male genitourinary exam? What are examples of questions you would ask in each of the 9 subjective information areas?

1. Frequency, urgency, and nocturia; urinating more than usual? Can't wait to pee? Awake because of need to pee? How often? Recent change? 2. Dysuria: any pain or burning with urinating? 3. Hesitancy and straining: any trouble starting urination? Need to strain to start/maintain pee? Change in force of stream? Dribbling? Do you still feel need to pee after? any past UTIs? 4. Urine color: is urine clear or discolored, cloudy, foul smelling, or bloody? 5. Past GU history: any trouble controlling urine? Pee upon laughing, sneezing, coughing, or bearing down? Any history of kidney disease, kidney stones, flank pain, UTI, or prostate trouble? 6. Penis: any changes? Pain? Lesions? Any discharge? Color? Odor? Discharge associated w/ pain or peeing? 7. Scrotum, self-care behaviors: any problems? Lumps or swelling on testes? Change is size of scrotum? Hernia? Dragging or heavy feeling in scrotum? 8. Sexual activity and contraceptive use: in relationship w/ sexual intercourse? Satisfactory sex? Any changes in ability to have erection? Using contraceptives? What kind? Satisfying? Number of sexual partners in last 6 months? Sexual preferences? 9. STI contact: any sexual contact w/ partners w/ STI? When? Did you get it? How did you treat it? Complications? Condoms being used? Questions or concerns about STDs?

Describe the structure and function of the 4 abdominal quadrants, including anatomy of internal organs and vascular structures and where these organs and structures are located in relation to your assessment. Abdomen • Extends from ____ to ____ • Bordered by ____ (3 things) • External Oblique ? check textbook • Internal Oblique ? • Transversus ? • Rectus Abdominus - palpable ? • Landmarks for abdomen: GI Anatomy • RUQ: what is included in each of these quadrants? • LUQ: • LLQ: • RLQ: • Midline: what is in the midline? also what is the midline • Small Intestine: which quadrant(s)? idea place each in the 4 quadrants/midline: Part of Descending Colon, Bladder (if distended), L ureter, Body of Pancreas, Part of Ascending and Transverse Colon, Gallbladder, Spleen, Liver, Small Intestine, Part of Transverse and Descending Colon, L Ovary and Tube, Head of Pancreas, Appendix, Aorta, R kidney, Uterus (if enlarged), R ureter, Liver, R Ovary and Tube, Stomach

Abdomen • Extends from diaphragm to pelvic brim • Bordered by vertebral column, ribs, and abdominal muscles • External Oblique • Internal Oblique • Transversus • Rectus Abdominus - palpable • Landmarks • Linea alba • Xiphoid • Costal margin • Umbilicus • MCL, MAL • Anterior superior...?illiac spine GI Anatomy • RUQ: Gallbladder, Liver, Head of Pancreas, Part of Ascending and Transverse Colon, R kidney • LUQ: Stomach, Spleen, Liver, Body of Pancreas, Part of Transverse and Descending Colon • LLQ: Part of Descending Colon, L Ovary and Tube, L ureter • RLQ: Appendix, R Ovary and Tube, R ureter • Midline: Aorta, Uterus (if enlarged), Bladder (if distended) • Small Intestine - all 4 quad

Anatomy: Review normal anatomy of the anus and rectum for your review on pages 721- 723. o anal canal: o internal is under involuntary control (autonomic NS); external sphincter is voluntary o intersphincteric groove: o anal columns/columns of Morgagni: o anal valve: o anal crypt: o rectum: o rectal ampulla: o valves of Houston: o peritoneum: o male prostate gland: o median sulcus: o seminal vesicles: o bulbourethral glands: o female: uterine cervix lies in front of ... and can be palpated through it o combined length of anal canal and rectum is ...; examination finger length is... o sigmoid colon:

Anatomy: Review normal anatomy of the anus and rectum for your review on pages 721- 723. o anal canal: outlet of GI tract; 3.8 cm long in adults; lined w/ modified skin merging with rectal mucosa at anorectal junction; surround by two concentric layers of muscles-sphincters o internal is under involuntary control (autonomic NS); external sphincter is voluntary o intersphincteric groove: separates internal and external sphincters and is palpable o anal columns/columns of Morgagni: folds of mucosa extending vertically down rectum and end in anorectal junction; non-palpable junction but is visible on proctoscopy; each anal column has artery and vein o anal valve: at end of each column; small crescent fold of mucous membrane o anal crypt: space above anal valve b/w the columns; small recess o rectum: 12 cm long; distal portion of large intestine; from sigmoid column at level of 3rd sacral vertebra and ends at anal canal o rectal ampulla: where rectum dilates and turns posteriorly o valves of Houston: 3 semilunar transverse folds in rectal interior; unclear function- may serve to hold feces at flatus passes; lowest is within reach of palpation usually on left side but can't be mistaken for intrarectal mass o peritoneum: covers upper two thirds of rectum; in the male: anterior part reflects down to within 7.5 cm of anal opening forming rectovesical pouch and then covers bladder; female: rectouterine pouch and extends down to within 5.5 cm of anal opening o male prostate gland: lies in front of anterior wall of rectum and 2 cm behind symphysis pubis; surrounds bladder neck and urethra and has 15-30 ducts that open into urethra; secretes thin, milky, alkaline fluid that helps sperm viability; bilobed structure with round or heart shape; 2.5 cm long, 4 cm in diameter o median sulcus: separates two lateral lobes; shallow groove o seminal vesicles: two; project above prostate; secrete fluid rich in fructose which nourishes sperm and contains prostaglandins o bulbourethral glands: two; aka Cowper glands; size of pea located inferior to prostate on either side of urethra; secrete clear, viscid mucus o female: uterine cervix lies in front of anterior rectal wall and can be palpated through it o combined length of anal canal and rectum is 16 cm in adults; examination finger length is 6-10 cm o sigmoid colon: S shaped; extends from iliac flexure of descending colon and ends at rectum; 40 cm long; can only exam through colonoscopy

Describe the components and purpose of the musculoskeletal system including the bones, muscle types, ligaments, tendons, cartilage, and joints. Include the definition and purpose of each component. • Bones: • Muscles: • Ligaments: • Tendons: • Cartilage: • Bursa: • Joints:

Bones: o Provide support o Protect tissues and organs Muscles: o Principle organ of movement o Three types of muscle: • Smooth:visceral, involuntary • Cardiac • Skeletal:striated, voluntary o Muscles are also grouped according to function: • EX: flexor, extensor, abductor, adductor o Muscles are attached at each end to bone, tendon, ligament, fascia Ligaments: o Connective tissue that join bones to one another o Add strength and stability, allow movement Tendons: o Strong, dense bands of connective tissue at ends of muscles. Attach muscles to periosteum. o Enable bones to move when skeletal muscles contract Cartilage: o Gel-like supporting tissue at ends of bones. o Protects/supports bones during weight bearing activities. Bursa: o Enclosed sac filled with synovial fluid; help muscles & tendons glide over bone. Joints: o Area where two surfaces of bone come together o Two types of joints: • Nonsynovial • May be immovable (EX: cranial sutures) -OR- • Slightly movable (EX: manubriosternal joint) • Synovial - freely movable joint filled with synovial fluid and covered with cartilage. EX: knee • Diarthrotic are the most common joint

What are the subjective data (for the breast and the axilla) areas to include when assessing the female breast? What emotionality may you observe when discussing assessment of the breasts?

Breast: pain, lump, discharge, rash, swelling, trauma, history of breast disease, surgery or radiation, medications, patient-centered care/perform breast self-examination/last mammogram Axilla: tenderness/lump/swelling, rash Emotionality: breasts are regarded differently in different cultures. Ex: western culture, breasts are sexualized. Breasts may be crucial to a woman's self-concept and perception of femininity. Some women may be uncomfortable talking about their breasts. Another woman may talk wryly or discouragingly about the size or development of their breasts. Adolescents are acutely aware of their development in comparison to their peers. A woman who found a bump may have anxiety, fear, panic.

Read page 394 regarding preparation for the objective exam

Equipment needed: small pillow, ruler marked in centimeters, pamphlet or teaching aid for BSE. Begin with the woman setting up and facing you. You may use a short gown, open at the back, and lift it up to the woman's shoulders during inspection. During palpation when the woman in supine, cover one breast with the gown while examining the other. Be aware that many women are embarrassed to have their breasts examined; use a sensitive but matter-of-fact approach. After your examination, be prepared to teach the woman BSE.

2. Explain the different types of joint motion, and give an example of each. When muscles contract, they move a joint; skeletal muscles produce (7) basic types of joint movement (not a complete list). Flexion: Extension: Abduction: Adduction: Internal rotation: External rotation: Circumduction:

Flexion: Bending a limb at a joint. Extension: Straightening of a limb at a joint. Abduction: Movement of a limb away from midline Adduction: Movement of a limb toward central axis of body or beyond. Internal rotation: Turning of a body part inward toward the central axis. External rotation:Turning of a body part away from midline. Circumduction: Movement in a circular pattern. Muscles may also be grouped according to what type of movement they produce EX: extensor muscle, flexor muscle

Teaching Breast Self Exam: See pages 400 - 401 regarding teaching breast self-examination. What would you want to include in your teaching? - best time to perform BSE

Goal: woman should become familiar with their breasts so they know when something changes. Best time to perform BSE: right after menstrual period (day 4 to 7 of the cycle), when breasts are smallest and least congested. Instruct women who don't get their period to pick a day. Give the women a pamphlet to reinforce the steps. Tell her what to look for when inspecting her breasts. She can do this in the shower (soap/water help) or can be lying down supine. Have her practice in front of you, so you can ensure proper technique.

Describe objective data assessment for GI assessment, elements and sequence of the abdominal exam including inspection, auscultation, percussion, & palpation. What are the normal findings for the GI exam? What are some examples of abnormal findings? What are normal and abnormal vascular findings for the abdominal exam? Inspect abdomen for ... Auscultate abdomen over 4 quadrants for bowel sounds (listen in ___ areas/quad, approx. ___ seconds/area). Percuss abdomen over all 4 quadrants (percuss in ___ areas/quad) Palpate lightly over all 4 quadrants for tenderness, masses (palpate in ____ places/quad). • Why this order of assessment? Normal Findings: • Contour - • Symmetry - • Umbilicus - • Skin - • Pulsation or Movement- • Hair Distribution (lower abdomen/pubic area)- • Scars - • Pulsations - *look at contour pics on power point abnormal findings: Auscultation technique: • Place ___ of stethoscope LIGHTLY over abdomen. • Auscultate abdomen over 4 quadrants for bowel sounds (listen in ___ areas/quad, approx. ___ seconds/area). • BS produced by movement of air and fluid through stomach and large and small intestine. Occur 5 - 30/ minute. • Begin in which quadrant? BS normally always present here. • Normal Findings: regarding bowel sounds • Variations: regarding bowel sounds • VASCULAR SOUNDS o Listen for Bruits Over: 4 areas o Normal: regarding bruits. sidenote: (4-20% of healthy people have normal bruit from celiac artery) Percussion • General Percussion o Normal Findings: o Other Findings: • Liver Span o Start where? o Begin in area of ____ o Start abdomen - where? o Normal: o Abnormal: • Scratch Test o Alternative to percussion: Scratch Test if abdomen is _____. • CVA Tenderness o One hand over ___ rib at costovertebral angle on the back o Normal: o Pain occurs with _____ • Do NOT perform: PALPATION • Palpation done to: - Technique: • Normal Findings: • Do NOT need to perform: Common Sites of Referred Abdominal Pain:

Inspect abdomen for contour, lesions, scars. Auscultate abdomen over 4 quadrants for bowel sounds (listen in 3 areas/quad, approx. 20-30 seconds/area). Percuss abdomen over all 4 quadrants (percuss in 3 areas/quad) Palpate lightly over all 4 quadrants for tenderness, masses (palpate in 2-3 places/quad). • Why this order of assessment? Normal Findings: • Contour - Flat, Round • Symmetry - Symmetric Bilaterally • Umbilicus - Midline, Inverted • Skin - Smooth, Even, Homogeneous color, No lesions • Pulsation or Movement- pulsations over aorta • Hair Distribution (lower abdomen/pubic area)- diamond shape in M, inverted triangle in F • Scars - Note location • Pulsations - Aortic pulsations, peristalsis in epigastric area may be visible in thin people. *look at contour pics on power point abnormal findings: hernia, umbilicus, skin: striae, scars Auscultation technique: • Place diaphragm of stethoscope LIGHTLY over abdomen. • Auscultate abdomen over 4 quadrants for bowel sounds (listen in 3 areas/quad, approx. 20-30 seconds/area). • BS produced by movement of air and fluid through stomach and large and small intestine. Occur 5 - 30/ minute. • Begin in RLQ - BS normally always present here. • Normal Findings: Bowel Sounds active X 4 quadrants (BS X 4) • Variations: Absent, hypoactive, borborygmus ("stomach growling") • VASCULAR SOUNDS o Listen for Bruits Over: • Aorta • Renal Arteries • Iliac Arteries • Femoral Arteries o Normal: No bruits • (4-20% of healthy people have normal bruit from celiac artery) Percussion • General Percussion o Lightly in all four quadrants o Determine tympany & dullness o Normal Findings: Tympany predominates o Other Findings: • Dullness over distended bladder, adipose tissue, fluid, mass • Hyperresonance with gaseous distention • Liver Span o Measure height of liver o Start right midclavicular line o Begin in area of lung resonance o Mark spot changes to dull o Mark spot o Start abdomen - tympany o Mark spot changes to dull o Normal - 6-12 cm, R MCL o Abnormal: Hepatomegaly • Scratch Test o Alternative to percussion: Scratch Test if abdomen is tender, guarding present. • CVA Tenderness o One hand over 12th rib at costovertebral angle on the back o Thump o Normal: NO pain o Pain occurs with inflammation of kidney • Do NOT perform: o Fluid wave o Shifting dullness PALPATION • Palpation done to: • Assess size, location of organs, masses • Assess for tenderness, muscle guarding, rigidity Technique: • Depress 1 cm for light palpation (2-3 inches for deep palpation) using rotating motion while moving clockwise for the entire abdomen. • Bimanual technique for large abdomen (2 hands) • Normal Findings: o Light Palpation in 4 quadrants - no pain, no tenderness, no guarding o Deeper Palpation in 4 quadrants - no presence of tenderness, masses or organ enlargement o Liver, Spleen, Kidneys - non-palpable o Xiphoid process, liver edge, pulsatile aorta, full bladder- may be normally palpable. • Do NOT need to perform: o Liver palpation, 'hooking technique' o Palpation of the spleen o Palpation of the kidneys o Palpation of the aorta o Special procedures (pg. 560) Common Sites of Referred Abdominal Pain: esophagus, stomach, liver and gallbladder, pylorus, colon, left and right kidneys, ureter, perforated duodenal ulcer (diaphragmatic irritation), biliary colic, acute pancreatic and renal colic, uterine and rectal pain

Inspection and Palpation of the Breast and Axillae: What are the normal inspection and palpation findings for the breast as noted on pages 394 - 400? What are the normal findings for inspection and palpation of the axillae? How does the nurse perform palpation of the breast? could write out headlines Acronym: BREAST

Inspect the Breast: - General appearance: note symmetry of size and shape. It's common to have one breast slightly larger than the other. Usually the left is slightly larger than the right. o Sudden increase in size of one breast, which signifies inflammation or new growth. - Skin: smooth, even color. Note any localized areas of redness, bulging, or dimpling. Note any lesions or focal vascular pattern (normal during pregnancy - pale linear striae, or stretch marks, often follow pregnancy). edema should not be present (edema would make the hair follicles look like "pig-skin or orange peel"). o Abnormal findings: hyperpigmentation, redness and heat with inflammation, unilateral dilated superficial veins in a non-pregnant woman, edema. - Lymphatic drainage areas: observe axillary and supraclavicular regions. Note any bulging, discoloration, or edema. - Nipple: nipples should be symmetrical. Usually protrude, although some are flat or inverted. They tend to stay in original condition. If a nipple recently becomes retracted, when it has been inverted since puberty, this is a bad sign. Normal nipple inversion may be unilateral or bilateral and usually can be pulled out (it's not fixed in place). Note any dry scaling, fissure or ulceration, and bleeding or other discharge. o A supernumerary nipple is a normal and common variation. An extra nipple along the embryonic "milk line" on the thorax or abdomen is a congenital finding. Usually it is 5-6cm below the breast near the midline and has no associated glandular tissue. It looks like a mole, although a close look reveals a tiny nipple and areola. It is not significant, merely distinguish it from a mole. o Abnormal findings: deviation in pointing, recent nipple retraction, discharge - especially in presence of a breast mass, supernumerary breast (additional glandular tissue) - Maneuvers to Screen for Retraction o Direct woman to change position while you check breast for skin retraction signs. First ask her to lift her arms slowly over her head. Both breasts should move up symmetrically. • Abnormal: retraction signs are caused by fibrosis in the breast tissue, usually caused by growing neoplasms. The fibrosis shortens with time, causing contrasting signs with the normally loose breast tissue. Note a lag in the movement of one breast. o Next ask her to push her hands onto her hips and push her two palms together. These moves contract the pectoralis major muscle. Both breasts should slightly lift. • Abnormal: note a dimpling or a pucker, which indicated skin retraction. o Ask women with large, pendulous breasts to lean forward while you support her forearms. Note symmetric free-movement of both breasts. • Abnormal: note fixation to chest wall, or skin retraction. - Inspect and Palpate the Axillae o Examine axilla while woman is sitting. Inspect skin, note any rash or infection. Lift woman's arm and support it yourself, so her muscles are loose and relaxed. Use your right hand to palpate the left axilla. Reach your fingers high into the axilla. Move them firmly down in 4 directions: (1) down chest wall in a line from the middle of the axilla, (2) along anterior border of axilla, (3) along posterior border, (4) along inner aspect of upper arm. Move woman's arm through range of motion to increase surface area you can reach. • Usually nodes are not palpable, although you may feel a small, soft, nontender node in the central group. Expect some tenderness when palpating high in the axilla. Note any enlarged and tender lymph nodes. • Abnormal: nodes enlarge with local infection of the breast, arm, or hand, and with breast cancer metastases. - Palpate the Breasts: o Help woman into a supine position. Tuck a small pad under the side to be palpated and raise her arm over her head. These maneuvers flatten the breast tissue and displace is medially. Any significant lumps then feel more distinct. For pendulous breasts, to distribute the tissue medially across chest wall, ask woman to rotate hips opposite to the side your palpating. o Use pads of your first 3 fingers and make gentle rotary motion on the breast. Vary your pressure so you are palpating light, medium, and deep tissue in each location. • Vertical strip pattern is best for finding a mass. • 2 other patters are common: from nipple palpating out to the periphery as if following spokes on a wheel and palpating in concentric circles out to the periphery. o For vertical strip pattern, start high in axilla and palpate down the mid-axillary line just lateral to the breast down to the bra line. Proceed medially in overlapping vertical lines ending at the sternal edge. Take care to palpate every square inch of the breast and examine the tail of Spence high into the axilla. o In nulliparous women (never given birth or been pregnant beyond 20 weeks), breast tissue feels firm, smooth, and elastic. After pregnancy, the tissue feels softer and looser. Premenstrual engorgement is normal when increasing progesterone. This consists of a slight enlargement, tenderness to palpate, and generalized nodularity; the lobes feel prominent and their margins more distinct. • Additionally, you may feel a firm, transverse ridge of compressed tissue in the lower quadrants. This is the "inframammary ridge", and it is especially noticeable in large breasts. Do not confuse with abnormal lump. • Breast implants: correctly placed implants are located behind the breast tissue. Therefore follow the same steps for CBE as shown for a woman w/o implants. • Abnormal: heat, redness, swelling in non-lactating and non-postpartum breasts indicate inflammation. o After palpating over 4 breast quadrants, palpate the nipple. Note any induration or sub-areolar mass. With your thumb and forefinger gently depress the nipple tissue into the well behind the areolar. The tissue should move inward easily. If woman reports spontaneous nipple discharge, press areolar inward with your index finger; repreat from a few different directions. If any discharge appears, note color/consistency. • Abnormal: discharge is abnormal, except in pregnancy and lactation. Note the number of discharge droplets and quadrant(s) producing them. Blot the discharge on a white gauze to ascertain its color. Test any abnormal discharge for presence of blood. o For woman with large, pendulous breasts, you may palpate by using a bimanual technique. Woman is in sitting position. Leaning forward. Support inferior part of the breast with one hand. Use other hand to palpate breast tissue against supporting hand. o If woman mentions a breast lump she found herself, examine the unaffected breast first to learn a baseline of normal consistency for this woman. If you do not feel the lump or mass, note the following characteristics: location, size, shape, consistency, moveable, distinctness, nipple, note the skin over the lump (is it erythematous/dimpled/retracted?), tenderness, or lymphadenopathy. • Look at details of all these on page 400 o Premenopausal women at midcycle often have tissue edema and mastalgia (pain) that makes it hard to detect a lesion. Ask for a follow up visit, if your findings are in question. o Women with healing or healed mastectomy need special consideration. They may be worried about cancer reoccurrence. Inspect and palpate normally. Be gentle around scar tissue. Should be no inflammation or infection. Lymphedema of upper arms is common sequela because of interruption of lymphatic drainage and removal of nodes. o Abnormal: acronym BREAST: Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, Tender breast.

Anatomy: Review normal anatomy of the Male Genitourinary System: Pages 691-692 - Male genital structures: o Penis: composed of... • At the distal end of the shaft, the corpus spongiosum expands into a cone of erectile tissue, the glans. The shoulder where the glans joins the shaft is the corona. - The urethra: ... It transverses..., and its meatus forms.... Over the glans, the skin folds in and back on itself, forming.... - frenulum: o Scrotum: - rugae: • cremaster muscle: • The scrotum is separated into 2 halves, which each have..., which produces.... • Tunica vaginalis: • Epididymis: • Vas deferens: • Spermatic cord: • lymphatics: • Inguinal • Inguinal canal: • Femoral canal: • where hernia potentially occurs?

Male genital structures: penis, scrotum (externally), testis, epididymis, and vas deferens internally. o Penis: composed of 3 cylindric columns of erectile tissue: the two corpora cavernosa on the dorsal side and the corpus spongiosum ventrally. • At the distal end of the shaft, the corpus spongiosum expands into a cone of erectile tissue, the glans. The shoulder where the glans joins the shaft is the corona. The urethra is a conduit for both the gential and the urinary systems. It transverses the corpus spongiosum, and its meatus forms a split at the glans tip. Over the glans, the skin folds in and back on itself, forming a hood or flap. This is the foreskin or prepuce. Often it is surgically removed shortly after birth by circumcision. The frenulum is a fold of the foreskin extending from the urethral meatus ventrally. o Scrotum: loose, protective sac, which is a continuation of the abdominal wall. After adolescence, the scrotal skin is deeply pigmented and has large sebaceous follicles. The scrotal wall consists of thin skin lying in folds, or rugae, and the underlying cremaster muscle. • cremaster muscle controls the size of the scrotum by responding to ambient temperature. This is to keep the testes at 3 degrees Celsius below the abdominal temperature, which is best for producing sperm. When it's cold, the muscle contracts, raising sac and bringing the testes closer to the body to absorb heat necessary for sperm viability. When it's warmer, the muscle relaxes, the scrotum lowers, and skin looks smoother. • The scrotum is separated into 2 halves, which each have a testis, which produces sperm. It is suspended vertically by the spermatic cord. The left testis is lower than the right because the left spermatic cord is longer. • Tunica vaginalis: covers each testis by a double-layer membrane, which separates it from the scrotal wall. The 2 layers are lubricated by fluid so the testis can slide a little within the scrotum; this helps prevent injury. • Epididymis: caps the testis. markedly coiled duct system; main sperm storage; comma-shaped; curves over top and posterior surface of testis; can be anterior in 6-7% of males • Vas deferens: muscular duct continuous with epididymis; approximates with other blood vessels to form spermatic cord. • Spermatic cord: goes along posterior border of testis and runs through the tunnel of the inguinal canal into abdomen where the vas deferens goes back and down behind bladder where is joins duct of seminal vesicle to form ejaculatory duct which empties into urethra • lymphatics: of penis and scrotal surface drain into inguinal lymph nodes; those of testes drain into abdomen (these nodes not accessible during physical exam) • Inguinal area: groin; juncture of lower abdomen wall and thigh; diagonal borders of anterior super iliac spine and symphysis pubis; b/w these are inguinal ligament • Inguinal canal: superior to inguinal ligament; narrow tunnel passing obliquely b/w laters of ab muscle; 4-6 cm in adults; has openings of an internal ring 1-2 cm above midpoint of the ligament, and external ring above and lateral to pubis • Femoral canal: inferior to inguinal ligament; potential space 3 cm medial to and parallel with femoral artery • all of these spots can be where hernia potentially occurs

What are the normal findings for examination of the male breast? (See pages 401-402).

Normal findings: It should feel even, with no nodules. Palpate the axillary lymph nodes. Male breast has a flat disk of undeveloped breast tissue beneath the nipple. Gynecomastia is a benign growth of this breast tissue - should feel like a smooth, firm, moveable disk - it can be unilateral or bilateral and is temporary.

For women at average risk, what does the American Cancer Society (ACS) recommend regarding CBE (clinical breast examination) and BSE (breast self exam)?

Research has not shown a clear benefit of physical breast exams done by either a health professional or by yourself for breast cancer screening. There is very little evidence that these tests help find breast cancer early when women also get screening mammograms. Because of this, a regular clinical breast exam and breast self-exam are not recommended. Still, all women should be familiar with how their breasts normally look and feel and report any changes to a health care provider right away. *side note: (this is for mammograms - not BSE or CBE) American Cancer Society screenings recommendations for women at average breast cancer risk. These guidelines are for women at average risk for breast cancer. A woman at average risk doesn't have a personal history of breast cancer, a strong family history of breast cancer, or a genetic mutation known to increase risk of breast cancer (such as BRCA), and has not had chest radiation therapy before the age of 30. (See below for guidelines for women at higher than average risk.) - Women between 40 and 44 have the option to start screening with a mammogram every year. - Women 45 to 54 should get mammograms every year. - Women 55 and older can switch to a mammogram every other year, or they can choose to continue yearly mammograms. Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer. All women should understand what to expect when getting a mammogram for breast cancer screening - what the test can and cannot do. Also note that CBE, BSE and mammograms are "complementary screening tools." With good BSE, women are more likely to know their breasts, and any changes in the breast tissue. Mammograms are good screening tools to detect small lumps that cannot be palpated, but lumps between mammograms may become palpable by CBE and BSE. (Jarvis, pg. 392, 400 and ACS website).

Breast Cancer Screening and Risk Factors: Read the section on pages 389 - 390 on breast cancer. What is the American Cancer Society's recommendation on screening mammography? What are the lifestyle factors related to breast cancer risk mentioned in the text on page 390?

We all have certain tumor suppressor genes termed BRCA 1 and BRCA 2; women who inherit a mutation on one or both have a significantly increased risk of developing breast or ovarian cancer. White women have a higher incidence rate of breast cancer after age 45, while black women have a higher rate before age 45. Black women are more likely to die from breast cancer at any age, compared to white women. The American Cancer Society recommends beginning annual screening at 40 years of age. Lifestyle factors to increase risk of breast cancer include: alcohol consumption (even low levels of drinking raise your chances of getting breast cancer), low physical activity, eating a "alcohol/Western diet" (meat, French fries, appetizers, rice/pasta, potatoes, pizza, etc)

Preparation for Objective Assessment: See page 725 regarding preparation for the objective exam. What position should the male patient be placed for the rectal exam? What position should the female patient be placed for the rectal exam?

o male: examine in left lateral decubitus or standing position; instruct male to rest elbows on exam table and point toes together to relax regional muscles and makes it easier to spread butt o females: lithotomy position if examining genitalia as well; use left lateral decubitus position for rectal area alone

Inspection and palpation: Describe the normal inspection and palpation findings of the following structures: glans penis, urethral meatus, scrotum, testes, spermatic cord.

o Glans penis: smooth and without lesions; ask patient or you have to retract foreskin for uncircumcised pt. o Urethral meatus: positioned just above centrally o Upon compression of glands anteroposteriorly b/w thumb and forefinger- meatus edge should appear pink, smooth and without discharge; collect any discharge for examination o Shaft: b/w thumb and first two fingers; feels smooth, semi firm, and contender o Scrotum: have male hold penis out the way or you do it w/ back of hand; size can vary w/ room temp; asymmetry is normal with left usually lower than right; spread rugae out b/w fingers and lift sac to inspect posterior surface- should be no lesions except for sebaceous cysts (yellow 1 cm nodules, firm, nontender, and multiple usually) o Continue by palpating each scrotal half b/w thumb and first two fingers- contents should slide easily; testes feel oval, firm, rubbery, smooth, and equal bilaterally, freely movable, slightly tender to moderate pressure o Epididymis feels discrete, softer than testis, smooth, and nontender o Spermatic cord: palpate b/w thumb and forefinger along its length from epididymis up to external inguinal ring- feels smooth, nontender

What are the risk factors for prostate cancer?

o Increasing age o African-American and African-Jamaican ancestry o family history esp. first degree relative like dad or brother o some genetic factors (BRCA2 mutations) o diets high in red and processed meat, animal and saturated fats, and dairy products. Obesity may increase risk of aggressive PC (prostate cancer). o Men w/ PC more likely have advanced form if uninsured or Medicaid insured or men of racial/ethnic minority groups o More common in North America and northwestern Europe; 70% higher incidence for African American men than whites

Lymph Nodes: What are the normal findings when palpating the inguinal lymph nodes?

o Palpate horizontal chain along groin inferior to inguinal ligament and the vertical chain along upper inner thigh o Can be normal to palpate isolated node sometimes; feels small (<1 cm), soft, discrete, and movable

Define the following terms: - Polyuria - oliguria - nocturia - dysuria - hematuria - urge continence - stress continence (page 695 - 696)

o Polyuria: excessive amount of pee o Oliguria: diminished amount of pee <400 mL/24 hours o Nocturia: frequency and urgency in UT disorders; other origins are CV, habitual, and diuretic meds o Dysuria: burning; common w/ acute cystitis, prostatitis, and urethritis o Hematuria: blood in urine o Urge continence: involuntary urine loss from overactive detrusor muscle in bladder o Stress continence: involuntary urine loss with physical strain, sneezing, or coughing caused by weakness in pelvic floor

Inspection of the anus: See page 726 regarding inspection of the perianal area. What re the normal inspection findings of the anus? o Spread buttocks wide apart with both gloved hands and observe perianal region o N= o Sacrococcygeal area (tailbone coccyx): normal findings o Have person hold breath and bear down by doing a Valsalva maneuver—>normal findings are...

o Spread buttocks wide apart with both gloved hands and observe perianal region o N= anus looking moist and hairless with coarse, folded skin that is more pigmented than perianal skin; anal opening is tightly closed; no lesions o Sacrococcygeal area: smooth and even upon inspection o Have person hold breath and bear down by doing a Valsalva maneuver—>no break in skin integrity or protrusion through the anal opening ; any abnormalities in clock face terms- 12 toward symphysis pubis and 6 toward coccyx

Define the following terms: dysmenorrhea, amenorrhea, menorrhagia. o dysmenorrhea: o amenorrhea: o menorrhagia:

o dysmenorrhea: pain during menstruation o amenorrhea: absent menses o menorrhagia: heavy menses

. Inspection: See page 746 regarding normal inspection findings for the external genitalia. What are the normal findings for inspection of the female genitalia including hair distribution, labia majora, labia minora, urethral opening, vaginal opening, perineum and anus? o external: o hair distribution o labia majora: o no lesions present expect for ... o separate labia majora to inspect ... o labia minora o urethral opening: o vaginal opening: o perineum: o anus:

o external: skin color is even, labia minora are a darker pink o hair distribution is usual female pattern of inverted triangle; can trail up abdomen towards umbilicus o labia majora: symmetric, plump, and well formed; in nulliparous women- can meet in midline; after vaginal delivery: gaping and slightly shriveled o no lesions present expect for occasional sebaceous cysts- yellowish, 1 cm nodules-firm, nontender and often multiple o separate labia majora to inspect clitoris o labia minora - dark pink and moist, usually symmetric o urethral opening: stellate or slit like and midline o vaginal opening: aka introitus; narrow vertical slip or larger opening o perineum: smooth; after birth: possible well heal episiotomy scar midline or mediolateral o anus: coarse skin of increased pigmentation

Preparation: What should the nurse's demeanor be when performing a male genitourinary exam? Should sexual practices or genitourinary history be discussed when performing the exam? What should the nurse do if the male patient has an erection? Equipment: What equipment is needed for the male genitourinary exam?

o male with undershorts down, appropriate draping; examiner sitting; male can supine initially to look at hernias o demeanor: confident and relaxed, unhurried yet businesslike o do not discuss GU history or sexual practices when performing exam; instead say I'm just checking for changes and you are normal and healthy o firm, deliberate touch, not soft and stroking o if erection does occur: explain that this is a normal physiologic response to touch, just as when the pupil constricts in response to bright light; then proceed with exam Gloves, occasionally glass slide for urethral specimen, materials for cytology, and flashlight

Subjective Data: What are the 11 areas of subjective data that should be collected for the female genitalia exam? (You do not need to know the additional history for infants and children, preadolescents and adolescents, aging adult.)

o menstrual history- flow, frequency, duration, associated symptoms, clotting o obstetric history (pregnancy) o menopause- periods slow or stopped, symptoms, hormone replacement therapy o patient centered care- how often do you get gynecologic checkups; last pap test o acute pelvic pain- pain in lower abdomen or pelvis[\ (PQRSTU) o urinary symptoms- any problems? blood? o vaginal discharge o past history- any problems in genital area? sores? lesions? treatment for them? any abdominal pain? any past surgery on uterus, ovaries, or vagina? o sexual activity o contraceptive use o sexually transmitted infection (STI) contact

What are the risk factors for testicular cancer?

o undescended testicle o family history of testicular cancer o HIV infection o carcinoma in situ of the testicle o having had testicular cancer before o being of certain race/ethnicity- white men are 4-5x higher risk than black or Asian American men; risk for American Indians fall in between Asians and whites; highest in US and Europe; lower in Africa or Asia o body size- taller men have higher risk (only some studies show this). Most studies have not found a link between testicular cancer and body weight. o cancer in other testicle o age: half of this cancer occurs in men 20-34 but can affect men of any age *Side note: prior injury or trauma to the testicles and reoccurring actions (such as horseback riding) do not appear to be related to the development of testicular cancer. Most studies have not found that strenuous physical activity increases testicular cancer risk.

Define the following terms: Dyschezia, melena, steatorrhea, fecal incontinence. o usual bowel routine, change in bowel habits, rectal bleeding, blood in stool, medications (laxatives, stool softeners, iron), rectal conditions (pruritus,hemorrhoids, fissure, fistula), family history, patient centered care (diet of high fiber foods, most recent examinations) o Dyschezia: o Melena: o Red blood in stool b/c of... o Clay color indicates... o steatorrhea: o fecal incontinence:

o usual bowel routine, change in bowel habits, rectal bleeding, blood in stool, medications (laxatives, stool softeners, iron), rectal conditions (pruritus,hemorrhoids, fissure, fistula), family history, patient centered care (diet of high fiber foods, most recent examinations) o Dyschezia: pain due to local condition (hemorrhoid, fissure) or constipation o Melena: black stools can be tarry b/c of occult blood from GI bleeding or non-tarry from indigestion or iron meds o Red blood in stool b/c of GI bleeding, or local bleeding around anus and with colon and rectal cancer o Clay color indicates absent bile pigment like with biliary cirrhosis, gallstones, alcoholic or viral hepatitis o steatorrhea: excessive fat in stool, from mal-absorption of fat as in celiac disease, cystic fibrosis, chronic pancreatitis, and Crohn's disease o fecal incontinence: leaking of solid or liquid stool involuntarily

Anatomy: Review normal anatomy of the external and internal female genitalia on pages 737 - 738. o vulva: o mons pubis: o after puberty: o labia minora: o clitoris: o vestibule: o urethral meatus: o paraurethral (skene) glands: o vaginal orifice: o hymen: o vestibular (Bartholin) glands: o internal genitalia o vagina: o cervix: o cervix epithelium: two distinct types o vagina and cervix covered with ...(type of skin) o inside os: endocervical canal is lined with ...type of skin o squamocolumnar junction: o anterior fornix/posterior fornix: o uterus: o fallopian tubes: o ovaries:

o vulva: external genitalia; or pudendum o mons pubis: round, firm pad of adipose tissue covering symphysis pubis; covered with hair in pattern of inverted triangle after puberty o after puberty: hair covers outer surfaces of labia; inner folds are smooth and moist and contain sebaceous follicles o labia minora: two smaller, darker folds of skin inside labia majora; joined anteriorly at clitoriswhere they form a hood or prepuce; joined posteriorly by a transverse fold (frenulum or fourchette) o clitoris: small, pea shaped erectile body (homologous with male penis); highly sensitive to tactile stimulation o vestibule: labial structures encircle this boat shaped space/cleft o urethral meatus: dimple 2.5 cm posterior to clitoris o paraurethral (skene) glands: surrounds urethral meatus; tiny and multiple; ducts aren't visible but open posterior to urethra at 5 and 7 o clock positions o vaginal orifice: posterior to meatus; thin median slit or large opening with irregular edges depending on membranous hymen o hymen: thin, circular or crescent shaped fold that may cover part of orifice or can be completely absent o vestibular (Bartholin) glands: two; on either side and posterior to orifice; secrete clear lubricating mucus during intercourse; ducts aren't visible but open in groove b/w labia minora and hymen o internal genitalia o vagina: flattened, tubular canal extending from orifice up and backward into pelvis; 9 cm long; b/w rectum posteriorly and the bladder and urethra anteriorly; walls are thick transverse folds (rugae) that allow vagina to dilate wildly during childbirth o cervix: at end of canal; projects into vagina; small and doughnut shape with small circular hole (os) for nulliparous female; os is larger and irregular after childbirth o cervix epithelium: two distinct types o vagina and cervix covered with smooth, pink, stratified squamous epithelium o inside os: endocervical canal is lined with columnar epithelium; red and tough o squamocolumnar junction: were the two tissues meet; not visible o anterior fornix/posterior fornix: continuous recess present around cervix; behind posterior fornix is a deep recess is formed by peritoneum; dips down b/w rectum and cervix to form rectouterine pouch or cul-de-sac of Douglas o uterus: pear shaped, thick walled, muscular organ; flattened anteroposterioly; 5.5-8 cm long; 3.5-4 cm wide; 2-2.5 cm thick; freely movable, not fixed, and usually tilts forward and superior to bladder o fallopian tubes: two; pliable, trumpet shaped tubes; 10 cm in length; from uterine funds laterally to brim of pelvis; curve posteriorly; fimbriated ends located near ovaries o ovaries: two; one on each side of uterus at level of anterior superior iliac spine; oval shaped, 3 cm long, 2 cm wide, and 1 cm thick; serves to develop ova (eggs) and female hormones

See page 745 - 746 regarding position for the female patient. How can you help the woman relax, decrease her anxiety and retain a sense of control during the exam?

o woman should be sitting initially; equal status position b/w you and pt. o for exam: lithotomy position with examiner on stool; help woman into lying/supine position with feet in stirrups and knees apart and butt at edge of exam table- ask woman to lift hips as you guide her into this position o woman can wear shoes or socks or place gloves over stirrups for warmth o arms at side or across chest not over head b/c of tightening of abdominal muscles o drape b/w woman's legs o elevate head to 45 degrees o help woman to be less anxious or more relaxed by: having her empty bladder, perineum isn't exposed to door, ask if she wants anyone present (have them at head of woman), elevate head and shoulders to semi sitting position, place stirrups so legs aren't abducted extremely far away; explain each exam step; tell her she can stop at any point; use gentle and firm touch with gradual movements; communicate through exam; and use techniques or educational or mirror pelvic exam so woman is active participant where she holds mirror to see everything you do

What is considered 'normal' vaginal discharge?.

small, clear or cloudy, and always nonirritating

T or F: For asymptomatic adolescents and adult males, the U.S. Preventative Health Services Task Force does not recommend routine screening (self-screening or clinical screening) for testicular cancer.

true

Anatomy: Review normal anatomy of the female breast and lymphatics on pages 385 - 387 • Breasts: lie anterior to... Between the ____ ribs, extending from the... to the .... - axillary tail of Spence • Nipple: • Areola: • Montgomery glands: what are they and their purpose Internal Female Anatomy: • Breast is composed of: • Glandular tissue: purpose as well • Suspensory ligaments (also called "Cooper ligaments - this is a bolded term too so know it): purpose • Adipose tissue: • Breast is divided into 4 quadrants by imaginary lines intersecting at the nipple. o In the upper, outer quadrant note the: o The upper outer quadrant is the site of most ... Lymphatics: • The breast has excessive lymphatic drainage. Most of the lymph (more than 75% drains into the ipsilateral {same side} axillary nodes). 4 groups of axillary nodes are present: o Central axillary nodes: o Pectoral (anterior): o Subscapular (posterior): o Lateral: • A smaller amount of lymphatic drainage does not take these channels but instead flows.... • During embryonic life ventral epidermal ridges, or "milk lines", are present and curve down from the axilla to the groin bilaterally. The breast develops along the ridge over the thorax and the rest of the ridge atrophies. Occasionally a supernumerary nipple persists and is visible somewhere along the track of the mammary ridge. At birth the only breast structures present are the lacteriferous ducts within the nipple. No alveoli have developed. Little change occurs until puberty.

• Breasts: lie anterior to the pectoralis major and serratus muscles. Between the 2nd and 6th ribs, extending from the side of the sternum to the midaxillary line. The superior lateral corner of breast tissue, called the axillary tail of Spence, projects up and laterally into the axilla. • Nipple: just below center of the breast. Rough, round, usually protrudent. Wrinkled/indented with tiny milk duct openings. • Areola: surrounds the nipple for a 1-2 cm radius. Has smooth muscle fibers that cause nipple erection when stimulated. • Montgomery glands: small elevated sebaceous glands in the areola. These secrete a protective lipid material during lactation. Internal Female Anatomy: • Breast is composed of: glandular tissue, fibrous tissue (including suspensory ligaments), adipose tissue. • Glandular tissue: contains 15-20 lobes radiating from the nipple, and these are composed of lobules. Within each lobule are clusters of alveoli that produce milk. Each lobe empties into a lactiferous duct. The 15-20 lactiferous duct form a collecting duct system converging toward the nipple. There the ducts form ampullae, or lactiferous sinuses, behind the nipple, which are reservoirs for storing milk. • Suspensory ligaments (also called "Cooper ligaments - this is a bolded term too so know it): fibrous connective tissue extending vertically from the skin surface to attach on chest wall muscles. These support the breast tissue. The lobes are embedded in adipose tissue. • Adipose tissue: layers of subcutaneous and retromammary fat actually provide most of the bulk of the breast. The relative proportion of glandular, fibrous, and fatty tissue varies, depending on age, cycle, pregnancy, lactation, and general nutritional state. • Breast is divided into 4 quadrants by imaginary lines intersecting at the nipple. o In the upper, outer quadrant note the Axillary tail of Spence (the cone-shaped breast tissue that projects up into the axilla) close to the pectoral group of axillary lymph nodes. o The upper outer quadrant is the site of most breast tumors. Lymphatics: • The breast has excessive lymphatic drainage. Most of the lymph (more than 75% drains into the ipsilateral {same side} axillary nodes). 4 groups of axillary nodes are present: o Central axillary nodes: high up in the middle of the axilla, over the ribs and serratus anterior muscle. These receive lymph from the other 3 groups of nodes. o Pectoral (anterior): along the lateral edge of the pectoralis major muscle, just inside the anterior axillary fold. o Subscapular (posterior): along the lateral edge of the scapula, deep in the posterior axillary fold. o Lateral: along the humerus, inside the upper arm. • A smaller amount of lymphatic drainage does not take these channels but instead flows directly up to the infraclavicular group, or deep into the chest, or into the abdomen, or directly across to the opposite breast. • During embryonic life ventral epidermal ridges, or "milk lines", are present and curve down from the axilla to the groin bilaterally. The breast develops along the ridge over the thorax and the rest of the ridge atrophies. Occasionally a supernumerary nipple persists and is visible somewhere along the track of the mammary ridge. At birth the only breast structures present are the lacteriferous ducts within the nipple. No alveoli have developed. Little change occurs until puberty.

How would you prepare the patient for an abdominal exam (pg. 545 in Jarvis text)

• Empty Bladder, Urine Specimen if needed • Warm Room • Supine position with head on a pillow, knees bent or on pillow • Arms at sides or across chest • Warm stethoscope, Short fingernails • Painful areas last • Distraction

Clinical Pearls: Musculoskeletal • Many foot problems are caused by... • Check for hollows on either side of the knee; if they are absent... • Do not ___, ___, or ___ more than 90 degrees on patients with hip replacements; doing so may cause hip displacement. • Never force a joint to move! • Inspect the soles of your patient's shoes; how they wear is a good indicator of ___ • Shoulder pain may be from the shoulder itself, or it may be referred pain from an abdominal (gallbladder), cardiac or pleural condition. • Redness is the least common sign of... • About ____% of patient's with 'tennis elbow' (lateral epicondilytis) actually play tennis! • Males and females can expect a progressive decrease in height an average of ___ inches in ___ year span from age ___ to ___ • Between 12-15 years, boys grow an average of ___" and gain ___ lb. In weight. • Osteoarthritic pain usually is worse what time of day? and increases with ____. RA pain is worse what time of day? and lessens with ____. • Use the mnemonic RICE for basics of MS injuries: R= I= C= E=

• Many foot problems are caused by poorly fitting shoes. • Check for hollows on either side of the knee; if they are absent, fluid may be present. • Do not adduct, internally rotate, or flex more than 90 degrees on patients with hip replacements; doing so may cause hip displacement. • Never force a joint to move! • Inspect the soles of your patient's shoes; how they wear is a good indicator of gait problems. • Shoulder pain may be from the shoulder itself, or it may be referred pain from an abdominal (gallbladder), cardiac or pleural condition. • Redness is the least common sign of inflammation near a joint. • About 5% of patient's with 'tennis elbow' (lateral epicondilytis) actually play tennis! • Males and females can expect a progressive decrease in height an average of 2 inches in 50 year span from age 20 to age 70. • Between 12-15 years, boys grow an average of 8" and gain 40 lb. In weight. • Osteoarthritic pain usually is worse later in the day and increases with movement. RA pain is worse in the morning and lessens with movement. • Use the mnemonic RICE for basics of MS injuries: R= rest, I= ice for 72 hours (heat after 72 hours to enhance circulation), C= compression, E = elevation.

Describe the Testicular Self-Exam • More than half of testicular cancers are found in men ages: _____ • The symptoms of testicular cancer are: • Symptoms that shows cancer has spread: How should men perform a testicular exam? (The answer can be found in the answer to the question "Can testicular cancer be found early?" in the link above. Please also review TSE on page 704-705 of the Jarvis textbook.) o American Cancer Society recommendations: o Best time: o Process of testicular self exam: o TSE (Testicular Self-Examination):

• More than half of testicular cancers are found in men ages: 20 to 34. • The symptoms of testicular cancer are (several symptoms are listed on the website): painless lump on or in a testicle, swollen testicle without a lump, few tumors of testicles cause pain, heavy or aching feeling in lower belly or scrotum, breast growth or soreness, signs of early puberty in boys not men (deepening of voice, growth of facial and body hair at early age) • Symptoms that shows cancer has spread: low back pain, SOB, chest pain, cough,belly pain, headaches, or confusion Using the link below, answer the following questions: https://www.cancer.org/content/dam/CRC/PDF/Public/8845.00.pdf • How should men perform a testicular exam? (The answer can be found in the answer to the question "Can testicular cancer be found early?" in the link above. Please also review TSE on page 704-705 of the Jarvis textbook.) o American Cancer Society: no recommendations for regular testicular self exams b/c of lack of research; some say monthly after puberty o Best time: during or after bath/shower so scrotum skin is relaxed o Hold penis out of way and examine each testicle separately o Hold textile between thumbs and fingers w/ both hands and roll it gently between fingers o Look/feel for any hard lumps or nodules (smooth rounded masses) or any change in size, shape, or consistency of testicles o The coiled tube (epididymis) is normal that can be felt on upper or middle outer side of testis o Book: include teaching but emphasize getting familiar with your body rather than only looking for cancer o TSE (Testicular Self-Examination): T=timing- once a month; S=shower, warm water relaxes scrotal sac; E=examine, check for changes, report changes immediately

Describe specific techniques and findings for muscle assessment including muscle tone, muscle mass, and length of extremities. Specific Muscle Assessment (used if general assessment isn't normal) • Muscle Tone: define o Normal= • Muscle Mass: define o Measure at... o Difference of less than ___ is not considered significant; dominant muscle usually___ • Length of extremities: use when?

• Muscle Tone: The tension present in resting muscle or with slight resistance (use your judgment). o N = firm • Muscle Mass: The size of muscle is largely the function of use/disuse of the muscle. o Measure at max. circumference. Make sure the limbs are in the same position if doing repeated exams. o Difference of less than 1cm is not considered significant; dominant muscle usually greater. • Length of extremities: o Use if suspected asymmetry

Describe the subjective data assessment for health information specific to GI assessment

• Pain • Appetite • Dysphagia • Food Intolerance • Nausea • Vomiting • Bowel Movement • Past Abdominal History • Medications • Nutrition

Male Breast: Read the section on the male breast (pg. 389, 401-402). Define the following term: gynecomastia • Rudimentary structure consisting of a thin disk of undeveloped tissue underlying the nipple. The areolar is well developed, although the nipple is relatively very small. During adolescence it is common for the breast tissue to enlarge temporarily, producing gynecomastia. This condition is usually temporary. Gynecomastia may reappear in the aging male and may be the result of testosterone deficiency. • examination of the male breast can be abbreviated, but do not omit it. Combine the breast examination with that of the... explain how to do male breast exam o Normal findings: o Abnormal findings: o Gynecomastia:

• Rudimentary structure consisting of a thin disk of undeveloped tissue underlying the nipple. The areolar is well developed, although the nipple is relatively very small. During adolescence it is common for the breast tissue to enlarge temporarily, producing gynecomastia. This condition is usually temporary. Gynecomastia may reappear in the aging male and may be the result of testosterone deficiency. • examination of the male breast can be abbreviated, but do not omit it. Combine the breast examination with that of the anterior thorax. Inspect the chest wall, noting the skin surface and any lumps or swelling. Palpate the nipple area for any lump or tissue enlargement. o Normal findings: It should feel even, with no nodules. Palpate the axillary lymph nodes. o Abnormal findings: male breast cancer is rare, but usually presents with painless, firm, retroareolar lump. Also note less frequent signs: nipple discharge (clear or bloody), ulceration, retraction, axillary lymphadenopathy. Nipple discharge is rare but strongly associated with cancer; thus it demands detailed evaluation. • The normal male breast has a flat disk of undeveloped breast tissue beneath the nipple. o Gynecomastia: a benign growth of this breast tissue, making it distinguishable from the other tissues in the chest wall. It feels like a smooth, firm, movable disk. This occurs in about one half of adolescent boys at 13 or 14 years of age. It can be unilateral or bilateral and is temporary. This is normal, common, and temporary. Abnormal findings: gynecomastia also occurs with use of anabolic steroids, some medications, cirrhosis, and other disease states

3. Describe the elements of each portion of the general musculoskeletal exam including inspection, palpation, ROM and muscle strength, i.e. what is involved in the inspection of the joint? Palpation? ROM? Testing muscle strength? Include normal findings. • Subjective data first: • Preparation of environment: • Sequence of musculoskeletal exam: • General Inspection o Symmetry: o Involuntary Movements: Muscle fasiculations (define) o Gross Deformities o Swelling/Edema: Etiologies examples o Color: Ecchymosis (Define), and what else? o Posture o Gait o Normal findings for general inspection: • General Palpation o Perform general palpation of joint as well as palpation with active ROM o Assess for: o Range of Motion (ROM): Definition: • Two types of ROM: brieftly explain both • test ROM or muscle strength first? why? • how would you perform ROM in a screening? • Normal Findings for ROM: • If ROM limited, use... • Decreased ROM symptoms/signs • Increased ROM symptoms/signs Muscle Assessment Assess muscle groups for coordination, pain and resistance to opposing force. Examine muscles by having the muscle resist opposing force. - Assess muscle strength unilaterally or bilaterally? • Normal Findings: • With muscles in general: (pattern you use to compare muscles)

• Subjective data first: examples on PP • Preparation of environment: wear clothes that allow adequate exam, support each joint at rest so muscles are at rest and joint can be accurately assessed. Use head-to-toe, side-to-side approach. If injury or discomfort, examine this area last, unaffected first. • Sequence of musculoskeletal exam: inspection, palpation, range of motion, muscle strength. • General Inspection o Symmetry: • General body alignment • Hypertrophy or atrophy of muscle • Joint involvement: • Rheumatoid arthritis (RA) typically involves several joints, symmetrical • Osteoarthritis typically involves one or two joints, asymmetrical o Involuntary Movements: • Muscle fasiculations - twitching or involuntary movement of muscle fibers o Gross Deformities • Examples: • Flexion contractures due to muscle shortening • Heberdon & Bouchard nodes • Sub - Q nodules • Bowlegs (genu varum) • Knock - knees (genu valgum) • Hypertrophy/atrophy of muscle • Ankylosis - stiffness or fixation of joint o Swelling/Edema • May be difficult to detect or readily visible • Etiologies: fluid in joint (effusion), thickening of synovial lining, inflammation, bony enlargement o Color: • Ecchymosis due to injury • Redness due to inflammation (least common sign of inflammation near a joint) o Posture • Does pt. favor one side or a particular joint more than another? • Note from front and behind pt., relationship of upper & lower extremities o Gait • Note ease of movement, ability to change position o Normal findings for general inspection: • Joints & muscles symmetrical • No fasiculations • No deformities or masses • No swelling, edema • Posture upright • Gait smooth & even • General Palpation o Perform general palpation of joint as well as palpation with active ROM o Assess for: • Pain/tenderness due to injury, inflammation, etc. • Swelling: May be evident only with palpation • Temperature: Increased warmth due to inflammation • Masses: Nodules • Crepitation: Cracking or grating sound due to irregularities on articulating joint surfaces • Significant only when associated with other S/S • Normal Findings : No pain or tenderness, no swelling, no masses or crepitation o Range of Motion (ROM) • Definition: Degree of movement of a joint. Diarthrotic joints are the only joint with one or more ROM. • Two types of ROM: • Active: When pt. moves joint • Passive: When you move the joint • ROM varies among individuals and decreases with age. • Test ROM before muscle strength - more marked contraction with muscle strength testing may cause pain and skew ROM results. • With screening exam (and in lab) perform only active ROM. If limited, perform passive. • Normal Findings for ROM: • Full, active ROM without pain. • When palpating, may normally feel crepitations • Active ROM should be about the same as passive. • Passive greater than active associated with muscle weakness or joint instability. Also seen with tendonitis, bursitis. • If ROM limited, use goniometer and record ROM from angle or starting position to maximal ROM reached during movement. • EX: from 20 degrees to 50 degrees • Decreased ROM: • Pain • Inflammation of tissues around joint • Ankylosis • Foreign body • Fluid due to swelling • Increased ROM: • Hypermobility may be benign or assoc. with ligament/fracture Muscle Assessment Assess muscle groups for coordination, pain and resistance to opposing force. Examine muscles by having the muscle resist opposing force. - Place pt. in position that allows movement through ROM. - Apply resistance to muscle, grade muscle contractions according to your judgement of client response. - Assess muscle strength bilaterally • Normal Findings: - Coordinated, painless - Greater in dominant arm & leg - May use scale to grade 0 - 5 (p. 590): - 0 = No contraction of muscle - 5 = Full ROM against gravity with full resistance - May also use descriptive terms: paralysis, severe weakness, moderate weakness • With muscles in general: Compare side to side, at rest and with contraction using general inspection & palpation guidelines (swelling, temperature change, change in shape, pain/tenderness, symmetry, contour)

For each specific joint, describe the landmarks, expected ROM and muscle strength findings. Include any unique characteristics for the joint. Tempromandibular Joint o Inspect & palpate... o ROM: how? normal findings? o Muscle Strength: how? Sternoclavicular Joint o Inspect & palpate... o ROM: how? o Muscle strength: how? Cervical Spine Joint o Inspect & palpate: how? o Note cervical spine joint (C1 & skull), spinous process, trapezius & paravertebral, sternocleidomastoid muscles. Palpate muscles for symmetry. o ROM: how? o Muscle Strength: how Shoulder Joint o Landmarks: o Inspect & palpate... • Look for equality of shoulder height (ant. & post.),contour and shape of shoulder. o ROM: o Muscle Strength: Elbow Joint o Landmarks: o Inspect & palpate... o ROM: o Muscle strength: Wrists/Hands/Fingers o Landmarks: o RA - freq. affects (but not limited to) PIP & MCP and wrist o OA - freq. affects (but not limited to) DIP, PIP o Inspect & palpate see guidelines slides 11 - 15. o ROM: o Muscle Strength: • For wrist: • For fingers: • Hand abnormalities: Hip Joint o Landmarks: o Inspect & palpate o ROM: o Muscle strength: Knee Joint • Landmarks: • Inspect & palpate • ROM: Ankles/feet • Landmarks: • Inspect & palpate: • ROM: • Look at abnormalities on powerpoint!!!! Spine • Landmarks: • Inspection: Normal Findings, Normal aging changes: • Palpation: Normal findings • ROM: • Muscle strength

• Tempromandibular Joint o Inspect & palpate using appropriate guidelines slides 11 - 15. Remember to perform general palpation of all joints/muscles and palpation with active ROM o ROM: • Open & close mouth. • N = 3-6 cm between upper & lower incisors with mouth open. • Project lower jaw • N = 1-2cm deviation of lower lip • Move jaw side to side • N = 1-2 cm from midline of lower lip deviation o Muscle Strength: • Bite down while palpating masseter muscle • Clench teeth while applying downward pressure on chin. • Sternoclavicular Joint o Inspect & palpate using appropriate guidelines slides 11 - 15. o ROM: Shrug shoulders o Muscle strength: • Not assessed • Cervical Spine Joint o Inspect & palpate using appropriate guidelines slides 11 - 15. • Assess ant. & post for deformity and unusual posture, note alignment of head. o Note cervical spine joint (C1 & skull), spinous process, trapezius & paravertebral, sternocleidomastoid muscles. Palpate muscles for symmetry. o ROM: • Flexion - chin to chest • Hyperextension - head back • Lateral bending - ear to shoulder • Rotation - turn head side to side o Muscle Strength: • Rotation, bending against resistance • Flexion, hyperextension against resistance • Shoulder Joint o Landmarks: Clavicle, acromium process of scapula, greater tubercule of humerus, coracoid process of scapula, acromioclavicular joint, glenoid fossa of scapula, glenohumeral joint. o Inspect & palpate using appropriate guidelines slides 11 - 15. • Look for equality of shoulder height (ant. & post.),contour and shape of shoulder. o ROM: • Forward flexion • Hyperextension • Internal rotation • External rotation • Abduction, adduction o Muscle Strength: • Deltoid: abduction against resistance • Biceps: flexion against resistance • Triceps: extension against resistance • Trapezius: shrug shoulders against resistance • Elbow Joint o Landmarks: medial & lateral epicondyles of humerus, olecranon process of ulna o Inspect & palpate using appropriate guidelines slides 11 - 15. • Palpate grooves on either side of olecronon process; palpate for nodules (raised, firm , nontender bony overgrowths) common on olecranon bursa and along extensor surface of ulna. Nodules assoc. with RA • May also see tophi assoc. with gout. o ROM: • Flexion & extension • Supination • Pronation o Muscle strength: Flexion & extension against resistance • Wrists/Hands/Fingers o Landmarks: • Bony tips of radius & ulna • Carpal bones • Metacarpal bones • Metocarpophalangeal joint (MCP) • Proximal interphalangeal joint (PIP) • Distal interphalangeal joint (DIP) o RA - freq. affects (but not limited to) PIP & MCP and wrist o OA - freq. affects (but not limited to) DIP, PIP o Inspect & palpate see guidelines slides 11 - 15. • Swelling of wrist most easily seen on dorsal aspect • Assess for Bouchards (PIP) & Heberdons (DIP) nodules; hard, nontender nodules associated with OA. • Palpate using two hands with pt.'s hand between your thumb and index fingers; palpate around entire finger. o ROM: • Spread fingers apart (abduction) and back together again (adduction) • Make a fist (finger flexion) • Touch thumb to each fingertip and base of little finger (finger flexion) • Bend fingers up (hyperextension) & down (flexion) at MCP joint. • Bend hand up (extension) and down (flexion) at wrist • Turn hand to right & left (radial & ulnar deviation) o Muscle Strength: • For wrist: Flexion & extension against resistance • For fingers: • Flexion & extension against resistance • Abduction & adduction against resistance • Also assess grip strength • Hand abnormalities: Osteoarthritis. This has Bouchard's node and Heberden's nodes. • Hip Joint o Landmarks: Greater trochanter of femur, iliac crest o Inspect & palpate using appropriate guidelines slides 11 - 15. • Assess ant. & post. while client stands • Assess for symmetry in iliac crest height, gluteal folds, buttocks. • Assess gait & posture • Palpate hips/pelvis for stability, tenderness, crepitus while supine • Palpation of hip joint difficult o ROM: Assess in supine, prone & standing depending on movement required. • Hip flexion with leg extended (supine) • Hip hyperextension with knee extended (prone or standing) • Hip flexion with knee flexed (supine) • Abduction (supine or standing) • Adduction (supine or standing) • Internal rotation (supine) - flex knee and rotate leg so flexed knee moves inward toward opposite leg • External rotation (supine) - place side of foot on opposite knee and move flexed knee toward end of exam table/bed. o Muscle strength: • Flexion against resistance (supine) - Apply resistance against flexed knee. • Extension against resistance (prone) - Apply resistance as pt. raises his leg. • Abduction & adduction against resistance (supine) • For hamstring/gluteal/abductor/adductor muscles - ask pt. to sit and perform alternating leg crossing. o Knee Joint • Landmarks: Patella, Femur, Tibia, Fibula, Tibial tuberosity, Medial condyle of tibia, Lateral condyle of tibia, Quadriceps • Inspect & palpate see guidelines slides 11 - 15. • Note gait, posture • Palpate sitting or supine • Apply downward pressure on suprapatellar pouch to localize fluid. • Palpate joint where femur articulates with tibia, not patella. • Special tests - read in book, not responsible for in lab or exam. • ROM: Flexion, extension • Muscle strength (quads & hamstring): • Flexion & extension against resistance o Ankles/feet • Landmarks: Tibiotalor joint, Achilles tendon, Calcaneous, Tarsals, Metatarsals, Phalanx (proximal, middle & distal), Tarsometatarsal joint, Metatarsophalangeal (MTP), Interphalangeal joint • Inspect & palpate using appropriate guidelines slides 11 - 15. • Assess pt. standing, walking, sitting • Palpate ant. surface, toes as you would with palpation of the hand. • ROM: • Dorsiflexion, plantar flexion • Inversion (big toes side up while feet flat on floor) • Eversion (little toe side up while feet flat on floor) • Abduction, adduction at ankle • Flexion and extension of toes • Muscle strength: Dorsiflexion & plantar flexion of foot against resistance • Look at abnormalities on powerpoint!!!! o Spine • Landmarks: • Spinous process of vertebrae • Paravertebral muscles • Iliac crest • Base of neck = C7 - T1, inferior angle of scapulae = T7 - T8 • L4 = highest point of iliac crest • S2 = dimples over posterior iliac spines • Inspection: • Normal Findings: o Concave at cervical area o Convex at thoracic/sacrococcygeal area o Concave at lumbar area o Spinous processes aligned, straight • Normal aging changes: o Intervertebral discs thin and vertebral bodies shorten/collapse o ROM diminishes o Skeletal muscle decrease in bulk and power o Kyphosis is common o Variations: scoliosis, kyphosis, lordosis • Palpation: o Paravertebral muscles, spinous processes for tenderness. N = firm, nontender, spinous processes straight • ROM: o Flexion, extension o Lateral bending o Rotation • Muscle strength - not tested

answer these and check with someone • Why do we auscultate next? • Where do we start to auscultate? • Why do we start there? • What are we listening for? • What are abnormals we might find? • What is the time frame for auscultation?

• Why do we auscultate next? • Where do we start to auscultate? • Why do we start there? • What are we listening for? • What are abnormals we might find? • What is the time frame for auscultation?