HEART AND NECK VESSEL ASSESSMENT
• transports blood from L ventricle to body
CARDIOVASCULAR SYSTEM
• Highly complex
• Includes heart and closed system of blood
vessels
HEART
• Hollow, muscular
• 4-chambered organ
▪ 2 upper chambers (L and R atria)
▪ 2 lower chambers (L and R
ventricles)
• Located in the middle of the thoracic cavity
between Lungs in space called the
mediastinum
• About the size of a clenched fist and
weighs approx 255g in women and 310g in
men.
• “Inverted cone”
• Extends vertically from L second to L fifth
intercostal space (ICS)and horizontally from
R edge of sternum to L midclavicular line
(MCL)
PRECORDIUM
• anterior chest area overlying heart and
great vessels
GREAT VESSELS:
• large veins and arteries leading directly to
and away from the heart
SUPERIOR VENA CAVA (SVC) AND INFERIOR
VENA CAVA (IVC)
• Return blood to the R atrium from the upper
(SVC) and lower (IVC) torso respectively.
PULMONARY ARTERY:
• Exits R ventricle; bifurcates and carries
deoxygenated blood to lungs
PULMONARY VEINS (2 from each lung)
• return oxygenated blood from the lungs to
the L atrium
AORTA
HEART CHAMBERS AND VALVES
Heart consists of four chambers or cavities
• 2 upper chambers (right and left atria)
• 2 lower chambers (right and left ventricle)
SEPTUM
• Separates the right and left sides of the
heart.
ATRIOVENTRICULAR VALVES
o Tricuspid valve – composed of three cusps
or flaps and is located between the right
atrium and the right ventricle
o Bicuspid valve (mitral) – composed of two
cusps or flaps and is located between the
left atrium and the left ventricle.
Chordae Tendineae – collagen fibers that anchor
the AV valve flaps to papillary muscles within the
ventricles.
SEMILUNAR VALVE – located at the exit of each
ventricle at the beginning of the great vessels, look
like half moons
o Pulmonic valve – located at the entrance
of the pulmonary artery as it exits the right
ventricle.
o Aortic valve – located at the beginning of
the ascending aorta as it exits the left
ventricle.
HEART COVERING AND WALLS
PERICARDIUM- tough, inextensible, loose-fitting,
fibro serous sac that attaches to the great vessels
and surrounds the heart.
PARIETAL PERICARDIUM–a serous membrane
lining that secretes a small amount of pericardial
fluid that allows for smooth, friction-free movement
of the heart.
EPICARDIUM–covers the outer surface of the
heart
MYOCARDIUM–thickest layer of the heart and is
made up of contractile cardiac muscle cells.
ENDOCARDIUM– a thin layer of endothelial tissue
that forms the innermost layer of the heart and is
continuous with the endothelial lining of blood
vessels.
ELECTRICAL CONDUCTION OF THE HEART
Pathways
🞑 The sinoatrial (SA) node is located on the
posterior wall of the right atrium near the junction
on the posterior wall of the right atrium near the
junction of the superior and inferior vena cava
🞑The SA node with inherent rhythmicity, generates
Impulses that are conducted over both atria
causing them to contract and send blood into the
ventricles
🞑The current initiated by the SA node is conducted
to the AV node located in the lower intraarterial
septum
🞑The AV node relays the impulse to the AV bundle
(bundle of His) in the upper interventricular septum.
🞑The electrical impulses then travel down the right
and left bundle branches and the Purkinje fibers
🞑The SA node functions as the “pacemaker of the
heart”, this activity shifts to other areas of the
conduction system such as the Bundle of His, if the
SA node cannot function.
ELECTRICAL ACTIVITY
🞑Electrical impulses generated by the SA node and
travel throughout the cardiac conduction circuit can
be detected on the surface of the skin.
🞑This electrical activity can be measured and
recorded by electrocardiography (ECG/EKG) which
records the depolarization and repolarization of the
cardiac muscles
CARDIAC CYCLE
Cardiac cycle- refers to the filling and emptying of
the heart’s chambers
Two Phases
• Diastole - relaxation of the ventricles or
filling
• Systole – contraction of the ventricles or
emptying
HEARTSOUNDS
▪ Heart sounds are produced by valve
closure. The opening of valves is silent
▪ Normal heart sounds, characterized as “lub
dubb” (S1 and S2) and extra heart sounds,
and murmurs can be auscultated with a
stethoscope
Normal heart sounds
▪ S1 – the first heart sound is the result of
closure of the AV valves: the mitral and
tricuspid; “lub”
▪ S2– the second heart sound results from
the closure of the semilunar valves and
correlates the beginning of diastole; “dubb”
Extra Heart Sounds
▪ S3 and S4 are referred to as diastolic filling
sounds or extra heart sounds which result
from ventricular vibration secondary to rapid
ventricular filling
▪ S3 can be heard early in diastole after S2;
often termed ventricular gallop
▪ S4 can be heard late in diastole just before
S1; atrial gallop
Murmurs
🞑There are conditions that can create turbulent
blood flow in which swooshing or blowing sound
may be auscultated over the precordium
🞑Conditions that contribute to turbulent blood flow
1. Increased blood velocity
2. Structural valve defects
3. Valve malfunction
4. Abnormal chamber openings.
CARDIAC OUTPUT
Cardiac output (CO) is the amount of blood
pumped by the ventricles during a given period of
time (usually 1 min) and is determined by the stroke
volume (SV) multiplied by the heart rate (HR).
Normal adult cardiac output is5 to 6 L/min
CO = SVx HR
Stroke Volume – the amount of blood pumped
from the heart with each contraction (usually 70 ml)
Stroke volume is influenced by:
🞑The degree of stretch of the heart muscle up to a
critical length before contraction (preload). The
greater the preload the greater SV
🞑The pressure against which the heart muscle has
to eject blood during contraction (afterload);
Increased afterload decreased SV
🞑Synergy of contraction (synchronized contraction
of myocardium); asynchronous contraction
decreases SV
🞑Compliance or distensibility of the ventricles;
decrease compliance decrease SV
🞑Contractility or the force of contraction of the
myocardium under given loading conditions;
increased contractility increase SV
Carotid artery Pulse
🞑Supply the neck and head, including the brain
with oxygenated blood.
🞑 It is close to the heart, the pressure wave
pulsation coincides closely with ventricular systole.
🞑Normally have smooth, rapid upstroke early in
systole and gradual downstroke
Jugular veins (2 sets; internal and external)
🞑Return blood to the heart from the head and neck
by way of the superior vena cava.
🞑Pulses important for determining the
hemodynamics of R heart functioning
NECK VESSELS
COLLECTING SUBJECTIVE DATA
HISTORY OF PRESENT HEALTH CONCERN
🞑COLDSPA
🞑Assess for chest pain
Chest pain can be cardiac, pulmonary, muscular
or gastrointestinal in origin
Angina (cardiac chest pain) – described as
Sensation of squeezing around the heart; a steady,
severe pain and sense of pressure.
🞑Assess for palpitations
Palpitations may occur with an abnormality of the
heart’s conduction system or during the heart’s
attempt to increase cardiac output by increasing
the heart rate
🞑Assess for fatigue
Fatigue may result from compromised cardiac
output.
🞑Assess for DOB or SOB
Dyspnea may result from congestive heart failure,
pulmonary disorders, coronary artery disease,
Myocardial ischemia and Myocardial Infarction
🞑Assess for nocturia (urgent need to urinate at
night)
Increased renal perfusion during periods of rest or
recumbency may cause nocturia. The decreased
frequency may be related to decreased cardiac
output.
🞑Assess for dizziness
Dizziness may indicate decreased blood flow to
the brain due to myocardial damage.
🞑Assess for edema in feet, ankles or legs
Edema in lower extremities may occur as a result
of heart failure
🞑Assess for heart burn
Cardiac pain may be overlooked or misinterpreted
as gastrointestinal problems
PAST HEALTH HISTORY
🞑Diagnosed for heart defect or murmur
Congenital or acquired defects affect the heart’s
ability to pump, decreasing oxygen supply to
tissues
🞑Rheumatic fever
Rheumatic fever develop rheumatic carditis
(exposure to A beta-hemolytic streptococci)
🞑 Heart surgery or cardiac balloon interventions
Previous surgery may change heart sound heard
during auscultation
🞑ECG
 Prior ECG allows to evaluate for any changes in COLLECTING OBJECTIVE DATA
cardiac conduction
INSPECT
🞑 Lipid profile
Observe the jugular venous pulse
Dyslipidemia presents the greatest risk for
🞑Normal Findings
developing coronary artery disease
The jugular venous pulse is not normally visible
🞑Medication or use other treatments for heart
with the client sitting upright
disease
🞑Abnormal Findings
Check for compliance. Education about
medications may be needed. Fully distended jugular veins with the client’s
🞑Monitoring of heart rate and blood pressure torso elevated more than 45 degrees indicate
increased central venous pressure – may result to
Self-monitoring of heart rate and blood pressure R ventricular failure, pulmonary HPN, emboli or
cardiac tamponade
Is recommended for client taking antihypertensive
medications Neck Vessels
FAMILY HISTORY Evaluate jugular venous pressure
🞑 History of hypertension, myocardial infarction 🞑Normal findings
(MI), coronary heart disease (CHD), elevated
The jugular vein should not be distended, bulging
cholesterol levels or diabetes mellitus (DM) in the
or protruding at 45 degrees or greater
family
🞑Abnormal findings
A genetic predisposition to these risk factors
increases a client’s chancefor development of heart Distention, bulging or protrusion at 45, 60 or 90
disease. degrees may indicate right-sided heart failure.
LIFESTYLEAND HEALTH PRACTICES Client with obstructive pulmonary disease–
elevated venous pressure only during expiration
🞑 Smoking
🞑 Stress An inspiratory increase in venous pressure
(Kussmaul’s sign) – severe constrictive pericarditis
🞑 Diet
AUSCULTATION AND PALPATION
🞑 Alcohol consumption
Auscultate and palpate carotid arteries
🞑 Exercise
🞑 Normal Findings
🞑 ADL
No blowing or swishing or other sound are heard.
🞑 Sexual activity
Pulses are equally strong; a 2+ or normal with no
🞑Pillow use at night variation in strength from the beatto beat
🞑 Urinating at night Pulse Amplitude Scale
🞑 Self-worth, fears 0 =Absent
Prepare client 1+=Weak
Equipment and supplies 2+=Normal
🞑Stethoscope with bell and diaphragm 3+=Increased
🞑Small pillow; cm rulers(two) 4+=Bounding
🞑Watch (with second hand); light source 🞑 Abnormal Findings
 A bruit, a blowing or swishing sound caused by
turbulent blood flow through narrow vessels –
occlusive arterial disease
Pulse inequality – arterial constriction or
occlusion on one carotid
Weak pulse – hypovolemia, shock, decreased
cardiac output
Bounding firm pulse – hypervolemia or increased
cardiac output
Variations in strength from beat to beat or with
respiration
Delayed upstroke – aortic stenosis
Loss of elasticity – arteriosclerosis
Thrills – narrowing of the artery
HEART
INPECTION
Inspect pulsations
🞑 Normal Findings
Apical impulse may or may not be visible
🞑 Abnormal Findings
Pulsation (heaves or lifts) other than apical
pulsation are considered abnormal
A heave or lift may occur as a result of enlarged
ventricle from an overload of work
PALPATION
Palpate the apical impulse
🞑 Normal Findings
The apical impulse is palpated in the mitral area
and may be the size of a nickel
Amplitude is usually small-like a gentle tap.
🞑 Abnormal Findings
The apical impulse may be impossible to palpate
in clients with pulmonary emphysema
Apical impulse larger than 1 to 2 cm, displaced,
forceful longer duration – cardiac enlargement
Palpate for abnormal pulsations
🞑 Normal Findings
No pulsations or vibration are palpated in the
areas of the apex, left sternal border or base.
🞑 Abnormal Findings
A thrill that feels similar to a purring cat or a
pulsation – grade IV or higher murmur
AUSCULTATION
Auscultate heart rate and rhythm
🞑 Normal Findings
The rate should be 60 to 100 beats per minute
with regular rhythm
🞑 Abnormal Findings
Bradycardia or tachycardia may result in
decreased cardiac output.
Irregular rhythms– predispose to decrease
cardiac output, heart failure or emboli.
Auscultate for a pulse rate deficit
🞑Done by palpating the radial pulse while you
auscultate the apical pulse
🞑 Normal Findings
Radial and apical pulse rates should be identical
🞑 Abnormal Findings
A pulse deficit (difference between the apical and
peripheral/radial pulse) – atrial fibrillation, atrial
flutter, premature ventricular contraction, heart
block
Auscultate to identify S1 and S2
🞑 Normal Findings
S1 corresponds with each carotid pulsation and
is loudest at the apex of heart. S2 immediately
follows after S1 and is loudest at the base of the
heart
🞑 Abnormal Findings
Accentuated, diminished, varying or split S1 are
abnormal
Any split S2 heard in expiration is abnormal
Auscultate for extra heart sounds
🞑 Normal Findings
 Normally no sound are heard
🞑 Abnormal Findings
Ejection sounds or clicks
Friction rub
Ventricular gallop–ischemic heart disease,
hyperkinetic states, restrictive myocardial disease
Atrial gallop – coronary artery disease,
hypertensive heart disease, cardiomyopathy, and
aortic stenosis
Auscultate for murmurs
🞑Normal Findings
Normally no murmurs are heard. Innocent and
physiologic mid-systolic murmurs may be present
🞑Abnormal Findings
Pathologic mid systolic, pansystolic and diastolic
murmurs
Auscultate with the client assuming other position
🞑 Abnormal Findings
An S3 or S4 sound or a murmur of mitral stenosis
that was not detected in supine position may be
revealed in the left lateral position
The murmur of aortic regurgitation may be
detected when the client assumes sitting, leaning
forward position
Validate the heart and neck vessel assessment
data collected
Verify that data are reliable and accurate
Document the assessment data
🞑 Actual nursing diagnosis example
Fatigue related to decreased cardiac output
🞑 Collaborative Problem example
PC: Hypertension
BREAST AND LYMPHATIC SYSTEM
Overview of Structure and Function
Breasts
•paired mammary glands that lie over
the muscles of the anterior chest wall,
anterior to the pectoralis major and
serratus anterior muscles.
•Male and female breasts are similar until
puberty when female breast tissue
enlarges in response to the hormones -
estrogen and progesterone
Female breast is an accessory reproductive organ
with
two functions:
to produce and store milk that provides
nourishment for newborns
to aid in sexual stimulation.
Male breasts have no functional capability.
Location Landmarks
Breasts are divided into four quadrants by
drawing horizontal and vertical imaginary
lines that intersect at the nipple.
The upper outer quadrant, which
Extends into the axillary area, is referred
to as the tail of Spence.
Most breast tumors
EXTERNAL ANATOMY
Nipple – located in the center of the breast,
contains the tiny openings of the lactiferous ducts
through which milk passes.
Areola – surrounds the nipple and contains
elevated sebaceous glands (Montgomery glands)
that secrete a protective lipid substance during
lactation.
Smooth muscle fibers in the areola cause the
nipple to become more erectile during stimulation
 Supernumery nipples or other breast tissue
may appear along an area called the “milk line”
INTERNAL ANATOMY
Female breast consists of three types of tissue:
1. Glandular – constitutes the functional part of the
breast, allowing
milk production.
2. Fibrous – provides support for the glandular
tissue largely by way of bands called Cooper’s
ligaments (run from the skin through the breast and
attach to the deep fascia of the muscles of the
anterior chest wall
3. Fatty (adipose) – provides most substance to
the breast and thus determines the size and shape
of the breast.
are present in both male and female breasts.
These structures drain lymph from the breasts
to filter out microorganisms and return water and
protein to the blood.
LYMPH NODES
Major axillary lymph nodes consist of the
anterior (pectoral), posterior (subscapular), lateral
(brachial) and central (midaxillary) nodes.
Anterior nodes drain the anterior chest wall and
breasts
Posterior chest wall and part of the arms are
drained by the posterior nodes
Lateral nodes drain most of the arms and the
central nodes receive drainage from the anterior,
posterior and lateral lymph nodes.
COLLECTING SUBJECTIVE DATA
HISTORY OF PRESENT HEALTH CONCERN
Presence of lumps or swelling in your breast
Lumps may be present with benign breast
disease, fibroadenomas or malignant tumors
Premenstrual breast lumpiness and soreness
subside after the end of menstrual cycle.
Presence of redness, warmth or dimpling
Redness and warmth indicate inflammation.
Dimpling or retraction of nipple may indicate breast
cancer.
Changes in size or firmness
Sudden changes may indicate inflammation or
abnormal growth
Pain in the breast
Pain and tenderness of the breasts are common
in benign breast disease and just before or during
menstruation.
Can also be a late sign of breast cancer.
Presence of discharge from the nipples
Blood or blood-tinged discharge – refer for further
evaluation
Clear discharge – associated with certain
medications
(Oral contraceptives, phenothiazines, steroids,
digitalis and diuretics)
PAST HEALTH HISTORY
Any prior breast disease, surgery, biopsy,
implants or trauma?
Personal history of breast cancer increases risk
for recurrence.
Previous surgery may alter the appearance of the
breast.
Breast problems may occur with silicone breast
implants.
Trauma can result in breast tissue changes.
Age of first menstruation
Early menses (before 13) or delayed menopause
(after 52) increases the risk for breast cancer
Have you given birth? At what age did you have
your first child?
The risk for breast cancer is greater for women
who have never given birth or who had their first
child after age 30.
First and last day of menstrual cycle
Will inform the optimal time to examine the
breast.
FAMILY HISTORY
History of breast cancer in the family?
History in one’s family increases one’s risk for
breast cancer.
LIFESTYLE AND HEALTH PRACTICES
Taking hormones, contraceptives or anti-
psychotic agents
Hormones and anti-psychotic agents can cause
breast engorgement in women.
Hormones and oral contraceptives also increase
the risk of breast cancer.
Haloperidol – can cause galactorrhea (persistent
milk secretion)
Live or work in area of excessive exposure to
radiation, benzene or asbestos?
Increase risk for breast cancer.
Typical Daily Diet
High-fat diet increase risk for breast cancer
Alcohol intake
Alcohol intake exceeding two drinks per day has
been associated with a higher risk for breast
cancer.
Coffee, tea, cola
Aggravate fibrocystic breast disease
Engage in exercise? Type of bra worn during
exercise
Breast tissue can lose its elasticity if vigorous
exercise is performed without support for the breast
Do you examine your breast?
Have you had your breasts examined by
physician? When is the last exam?
Have you had a mammogram? When was the
last one?
Purpose of Breast Assessment
To identify signs of breast disease and initiate
early treatment.
early detection and treatment have resulted in
increased survival rates.
Client Preparation
Explain procedure
Provide privacy
Prepare for the breast examination by having
the client sit in an upright position.
Expose both breasts to compare for symmetry
during inspection.
One breast may be draped while the other
breast is palpated.
The breasts are first inspected in the sitting
position while the client is asked to hold arms in
different positions.
The breasts are then palpated while the client
assumes a supine position.
Key points for physical assessment
Explain to the client what the steps of the
examination are and the rationale for them.
Warm your hands.
Observe and inspect breast skin, areolas, and
nipples for size, shape, rashes, dimpling, swelling,
discoloration, retraction, asymmetry and other
unusual findings.
Palpate breasts and axillary lymph nodes for
swelling, lumps, masses, warmth or inflammation,
tenderness, and other abnormalities.
Remember it is important to carefully perform
the breast examination on male as well as female
clients.
Physical Assessment Skills
1. Gather equipment
✓ Centimeter ruler
✓ Small pillow
✓ Gloves
✓ Slide for specimen
2. Explain the procedure
3. Ask client to put on gown
COLLECTING OBJECTIVE DATA Veins radiate either horizontally and toward the
axilla or vertically with a lateral flare. Veins are
Inspection prominent during pregnancy
Palpation Abnormal Findings
Female Breasts A prominent venous pattern may occur as a
INSPECTION result of increased circulation due to malignancy.

1. Inspect size and symmetry. An asymmetric venous pattern maybe due to

malignancy
Have the client disrobe and sit with arms
4. Inspect the areolas
hanging freely
Note the color, size, shape and texture of the
Normal Finding: areolas of both breasts
Breasts can be a variety of sizes and are
Normal Findings
somewhat round and pendulous. One breast may
normally be larger than the other. Areolas vary from pink to dark brown. Round and
may vary in size. Small Montgomery tubercles are
Abnormal Findings:
present.
Recent increase in the size of one breast may
Abnormal Findings
indicate inflammation or an abnormal growth.
A pigskin-like or orange-peel (peau d’orange) – Peau d’orange skin associated with carcinoma.
results from edema, seen in metastatic breast Red, scaly, crusty areas are indicative of Paget’s
disease.
disease

2. Inspect color and texture

Be sure to note overall skin tone when inspecting
the
breast skin. Note any lesions.

Normal Findings

Color varies depending on the client’s skin tone.

Texture is smooth with no edema
Linear stretch marks may be seen during and
after pregnancy

Abnormal Findings 5. Inspect the nipples

Redness is associated with breast inflammation Note the size and direction of the nipples of both
breast. Note dryness, lesions, bleeding or
3. Inspect superficial venous pattern
discharge.
Observe visibility and pattern of breast veins
Normal Findings
Normal Findings
Nipples are nearly equal bilaterally in size and
are in the same location on each breast
 Nipples are usually everted, but maybe inverted
or flat.
Supernumerary nipples may appear
Abnormal Findings
A recently retracted nipple that was previously
everted suggests malignancy.
Spontaneous discharge should be referred.
6. Inspect for retraction and dimpling
Ask the client to remain seated while performing
several different
maneuvers.Askthe client to raise her arms
overhead; then press her hands against her hips.
Next ask her to press her hands together .Ask the
client to lean forward from waist
Normal Findings
The client breasts should rise symmetrically with
no dimpling or retraction
Breast should hang freely and symmetrically
Abnormal Findings
Dimpling or retraction – a malignant tumor
Restricted movement of the breast or retraction
of the skin or nipple indicates fibrosis and fixation of
the underlying tissues
PALPATION
1. Palpate texture and elasticity
Normal Findings:
Palpation reveals smooth, firm, elastic tissue.
Abnormal Findings:
Thickening of the tissues may occur with an
underlying malignant tumor.
2. Palpate for tenderness and temperature.
Normal Findings:
A generalized increase in nodularity and
tenderness may be a normal finding associated
with the menstrual cycle or hormonal medications.
Breasts should be a normal body temperature.
Abnormal Findings:
Painful, tender breasts may be indicative of
fibrocystic breasts, especially right before
menstruation.
Pain may also occur with a malignant tumor -
refer the client for further evaluation.
Heat in the breasts of women who have not just
given birth or who are not lactating indicates
inflammation.
3. Palpate for masses.
Note location, size in centimeters, shape,
mobility, consistency, and Tenderness. Also note
the condition of the skin over the mass.
Normal Findings:
No masses should be palpated.
Abnormal Findings:
Malignant tumors are most often found in the
upper outer quadrant of the breast, unilateral, with
irregular, poorly delineated borders, hard, non-
tender and fixed to underlying tissues.
Fibro adenomas are usually 1-5 cm, round or
oval, mobile, firm, solid, elastic, nontender, single or
multiple benign masses.
Benign breast disease consists of bilateral,
multiple, firm, regular, rubbery, mobile nodules with
well-demarcated borders
4. Palpate the nipples.
Wear gloves, compress the nipple gently with
your thumb and index finger. Note any discharge.
Normal Findings:
The nipple may become erect and the areola
may pucker in response to stimulation.
 Abnormal Findings:
Discharge may be seen in endocrine disorders
and with certain medications (i.e.,
antihypertensives, tricyclic antidepressants, and
estrogen).
Discharge from one breast may indicate benign
intraductal papilloma, fibrocystic disease, or cancer
of the breast.
5. Palpate mastectomy or lumpectomy site.
If the client has had a mastectomy or
lumpectomy, it is still important to perform a
thorough examination. Palpate the scar and any
remaining breast or axillary tissue for redness,
lesions, lumps, swelling, or tenderness.
Normal Findings:
Scar is whitish with no redness or swelling. No
lesions, lumps, or tenderness noted.
Abnormal Findings:
Redness and inflammation of the scar area may
indicate infection. Any lesions, lumps, or
tenderness should be referred for further
evaluation.
AXILLAE
Inspect and palpate the axillae
Ask the client to sit up. Inspect the axillary skin
for rashes or infection
Hold the client’s elbow with one hand and use
the three finger pads of your other hand to palpate
firmly the axillary lymph nodes.
First palpate high into the axillae. Moving
downward against the ribs to feel for the central
nodes. Continue to move down the posterior axillae
to feel for the posterior nodes. Use bimanual
palpation to feel for the anterior axillary nodes.
Finally palpate down the inner aspect of the upper
arm
Ask the client to perform BSE
MALE BREAST
1. Inspect and palpate the breasts, areolas, nipples,
and axillae.
Note any swelling, nodules, or ulceration. Palpate
the flat disc of undeveloped breast tissue under the
nipple.
Normal Findings:
No swelling, nodules, or ulceration should be
detected.
Abnormal Findings:
Soft, fatty enlargement of breast tissue is seen in
obesity.
Gynecomastia, a smooth, firm, movable disc of
glandular tissue, may be seen in one breast in
males during puberty, usually temporary.
However, it may also be seen in hormonal
imbalances, drug abuse, cirrhosis, leukemia, and
thyrotoxicosis.
Irregularly shaped, hard nodules occur in breast
cancer.
Validate the breast and lymph node assessment
data collected.
Verify the data are reliable and accurate.
Document the assessment data following the
health care facility or agency policy
ABDOMINAL ASSESSMENT
•Abdominal borders:
– Superiorly by coastal margins
– Inferiorly by symphysis pubis and inguinal canals
– Laterally by flanks
•Abdominal wall muscle functions
– Protect internal organs
– Allow normal compression of internal organs
during functional activities: coughing and sneezing;
urination and defecation; childbirth
• Internal abdominal anatomy:
– Peritoneum (parietal, visceral)
– Viscera:
•SOLID
• Liver, pancreas, spleen, adrenal glands, kidneys,
ovaries, uterus
•HOLLOW • Vascularity
• stomach, gallbladder, small intestine, colon, – Dilated veins and spider angioma
bladder
• Cirrhosis
• Internal abdominal anatomy,
• Striae
•Viscera normally NOT palpable: pancreas, spleen,
– Ascites
stomach, gallbladder, small intestine
– Dark, bluish striae
– Vascular structures: abdominal aorta; right and
left iliac arteries • Cushing’s syndrome
•Key assessment points: Abdominal Contours
– Sequence: IAPePa • Protuberant/distended abdomen
– Palpate painful areas LAST Key assessment – Air/gas or fluid accumulation
points, continued:
– BELOW umbilicus:
– Common abnormal findings:
• Full bladder
•abdominal edema (ascites);
• Uterine enlargement
•abdominal masses (growths or constipation);
• Ovarian cyst or tumor
•unusual pulsations;
– ABOVE umbilicus:
•pain
• Pancreatic masses
Promoting Relaxation
• Gastric dilation
• Pillow under knees
Abdominal Contours
• Slow deep breaths through the mouth
• Scaphoid
• Apply light pressure over sternum with left hand
while palpating with right hand – Severe weight loss

•Physical assessment: Abdomen – Cachexia due to starvation and terminal illness

– Inspect: skin, contour, symmetry, movement; • Asymmetry

umbilicus – Organ enlargement, large masses, hernia, bowel
Abnormal Findings obstruction
• Color • Bulging/protrusion
– Bluish periumbilical area: – Hernia
• Cullen’s sign Abdominal Movement
– Purple flanks: • Diminished breathing
• Grey Turner’s sign – Peritonitis
– Yellow? • Aortic pulsations
– Pale, taut skin – Abdominal aortic aneurysm
• Ascites • Peristaltic waves
Abnormal Findings – Pyloric stenosis
– Intestinal obstruction • Hypersensitivity test
Physical assessment: Abdomen Test for referred rebound tenderness Palpate
deeply in the LLQ and quickly release pressure
– Auscultate: bowel and vascular sounds; friction
rubs Pain in the RLQ during pressure in the LLQ
suggest appendicitis.
Abnormal Findings
• Severe pain
– Peritonitis, infection
– Tumors
– Trauma
– Enlarged or diseased organs.
Abnormal Findings
• Masses
– Olive-shaped mass
• Pyloric stenosis
– Sausage-shaped mass
• intussusception
– Pulsating abdominal mass
• AAA
DO NOT PALPATE ABDOME
• Wilm’s tumor (nephroblastoma)
• AAA
• Polycystic kidneys
• Transplantation
• Suspected splenic trauma
•Special Abdominal Tests
– Test for shifting dullness
– Ascites and fluid wave test
– Ballottement test for masses
Test for appendicitis:
• Rebound tenderness
• Direct – Romberg’s sign
• Indirect – Rovsing’s sign

• Psoas sign
• Obturator sign