PERIPHERAL VESSEL NORMAL ABNORMAL

 Peripheral Pulses: PALPATE peripheral pulse on both  Symmetric pulse volumes  Asymmetric volumes
sides of client’s body to determine the symmetry of  Full pulsation  Absence of pulsation
pulse volume  Decreased, weak, thready
*sites: radial, ulnar, brachial, femoral, popliteal, pulsation
dorsalis pedis, posterior tibialis
 4 point scale grading of pulses:
 Increased pulse volume
4+=bounding, 3+increase, 2+normal, 1+weak, 0-
absent

 3 point scale grading:

0- absent; non palpable, 1= diminished, 2=
normal or expected, 3=bounding
 INSPECT peripheral veins in the arms and legs for  In dependent position,
superficial veins presence of distention and
nodular bulges at calves
 * Take note: When limbs are
elevated, the veins should
collapse
* Superficial veins: check if it is protruding
 ASSESS the peripheral leg veins for signs of  Limbs not tender
 Symmetric in size
PHLEBITIS
 INSPECT the skin of the hands and feet for color,  Skin color: pink
temperature, edema, and skin changes.  skin temp. not excessively
warm or cold,
 no edema,
 skin texture, skin turgor,
resilient and moist.
 ASSESS the adequacy of arterial flow if arterial  Buerger’s test (when the leg
insufficiency is suspected is raised slowly up to a 90-deg
angle, the limb will still be
pinkish)
 CRT (after 2 secs)
 (-) Allen’s test
 DOCUMENT (DONE NA YEY) -
 Distended veins in the thigh
and/or lower leg or on
posterolateral part of calf from
knee to ankle ʹ if hindi siya mag
collapse this abnormality will
be evident
 * NOTE: To assess for
varicosities - it is better to let
patient stand so that veins are
more prominent
 Pain/tenderness upon
palpation:
 (+) Homan's Sign
 warmth, redness over
vein
 swelling of one calf/leg
 Cyanosis
 Pallor
 dusky red color when limb is
lowered,
 brown pigmentation around
ankles,
 cool skin edema,
 skin thin and shiny or thick,
waxy, fragile with reduced hair
and ulceration
 for checking edema, go
from LOWER to UPPER
 delayed color return or
mottling,
 delayed venous filling,
 marked redness of arms or
legs,
 delayed return of color.

BREAST & AXILLAE NORMAL ABNORMAL

1. Ask if he has noted any lumps,
discharges
2. INSPECT the breast for size,  Male: breasts even with the chest  Recent change in breast
symmetry, and contour or shape wall size,
while the client is in a sitting position.  Swellings
*NOTICE ANY DIMPLING  marked asymmetry
3. INSPECT the skin breast for:  skin uniform in color, smooth, and  Dimpling/retraction,
 Localized discolorations or intact,  swelling/edema, localized
hyperpigmentation (bun-og, chikinini,  diffuse symmetric horizontal or  hyperpigmentation/
hematoma; If naa, ask the pt kanus-a vascular pattern in light-skinned discoloration
nag start ug unsay cause) people,
 Retraction/Dimpling  striae (stretch marks common in
 Swelling / Edema pregnant women), moles, and nevi
 4. INSPECT the areola area for size,  Round/oval and bilaterally the  Any symmetry,
shape, symmetry, color, surface same,  mass or lession
characteristics and any masses or  color varies widely, from light pink
lesions to dark brown
 Irregular placement of sebaceous
glands on the surface of the areola
5. INSPECT the nipples for size, shape,  Round  Asymmetrical size and
position, color, discharge and lesions  Inverted color
 Equal size  Presence of discharge
 Similar color  Crust or cracks
 Soft and smooth  Inversion on one or both
 Point the same point in same nipples
direction
6. PALPATE the axillary, subclavicular,  no tenderness,  Tender
and supraclavicular lymph nodes  No swelling, discomfort  Swollen
a) Lie down
b) Wear gloves
c) Ask pt to relax her arm
d) Reach high into apex of the
axilla, directly behind
pectoral muscle towards
midclavicl
e) Sweep fingers downward
against the ribs

7. PALPATE (you can use the pattern of  No tenderness  Tenderness

the concentric circles, vertical or  No masses  Masses
parallel lines) the breast for masses,  No nodules  Nodules
tenderness, and any discharge from  No nipple discharges  Nipple discharges
the nipples

8. PALPATE the areola and the nipples  no masses and discharges  presence of mass
for masses. Assess any discharge for and/or discharge
amount, color, consistency, and odor.
*Note also any tenderness on
palpation
NOTES:
 If a mobile mass becomes fixed when
the arm relaxes (it is attached to ribs
and intercostal muscles)
 if fixed when hand rests on the hip (it
is attached to the pectoral fascia
DOCUMENT NA KAY MALE MAN SIYA PERO
IF FEMALE(?) TEACH THE CLIENT THE
TECHNIQUE FOR BREAST SELF EXAMINATION
(diba?)