SEMI FINALS COVERAGE

Chapter 4 (…continuation part 1)

PHYSICAL ASSESSMENT

In this chapter physical assessment of the human body primarily Thoracic and Lungs, Cardiovascular
System, Abdomen, Pelvis, Breast and Testicular Exams. Inclusive of subtopics are breath sounds and
great vessels. Subtopics will include normal findings in each structures and techniques used for assessing
each area.

Duration: 12.0 hours

MAJOR TOPICS

Physical Assessment (..continuation)

1. Thoracic and lungs

A. Breath Sounds

2. Cardiovascular System

A. Heart and Great Vessels

3. Abdomen

4. BSE and TSE

Activities:

1. Critical Thinking Exercises: Case Scenarios

Before you proceed…

Intended Learning Outcomes:

1. Discuss the sequence of physical assessment in the different parts of the body
2. To be able to identify normal and abnormal findings of a specific body area during assessment

3. To be able to follow the proper method of physical assessment of the different body areas

4 Properly utilize the different techniques of physical assessment and use specific equipment for each
body area

Key Terms:

 Lungs

 Thorax

 Heart

 Abdomen

 Pelvis

Let’s Begin!

THORAX AND LUNGS ASSESSMENT

 How to measure the chest. Take the measurement at the nipple level with a tape measure;
observe for chest size, shape, movement of the chest with breathing, and any retractions.

 Adolescents. In the older school-age child or adolescent, note evidence of breast development.

 Assess respiratory characteristics. Evaluate respiratory rate, rhythm, and depth; report any
noisy or grunting respirations.

 How to assess breath sounds. Using a stethoscope, the nurse listens to breath sounds in each
lobe of the lung, anterior and posterior, while the patient inhales and exhales; describe,
document, and report absent or diminished breath sounds, as well as unusual sounds such as
crackling or wheezing.

BODY PART TECHNIQUE NORMAL FINDINGS

Thorax and Lungs Inspection. » The chest contour is symmetrical

and the chest is twice as wide as
(Anterior and Have the client sit comfortably. deep (anteroposterior diameter in
Posterior) Inspect for the shape, position of a 1:2 ratio). The spine is straight.
the spine, slope of the ribs,
retraction of the intercostal spaces
(ICS) on inspiration, and bulging of
the ICS on expiration.
Observe for symmetry of the chest
wall during respiration
Posteriorly the ribs tend to slope
across and down. The ribs are
prominent in a thin person. There
is no bulging or retraction of the
ICS during breathing. The chest
wall moves symmetrically during
respiration.

Palpation
» No lumps, masses, areas of
Palpate for lumps, masses, areas of tenderness.
tenderness.
» Sides of the thorax expand
Measure chest excursion (to symmetrically. The examiner’s
determine the depth of breathing). thumb separate approximately 3-5
Place hands on the lower portion centimeters during excursion.
of the rib cage with the thumbs 2
inches apart pointing towards the
spine and fingers.

Elicit tactile fremitus (a thrill felt

by the hand on the chest wall
» Vibrations are prominent over the
while the client is speaking). Place
areas near the bronchi. It increases
the palms of the hand bilaterally
with intensity of the voice.
symmetrical on the chest. Start
Vibrations are strongest between
from the top of the chest wall
the first and second ribs along the
going down. Each time the hands
sternum anteriorly and between
move, ask the client to say “ninety-
the scapulae posteriorly.
nine” or “one--one—one” with the
same intensity of voice

Percussion

For the anterior thorax, the client

is preferably in a lying position. For
posterior thorax, the client is in a
sitting position with the arms
folded across the chest. This
position will separate the scapulae » Percussion note varies with the
to further expose the lungs for thickness of the chest wall:
assessment. Using indirect
percussion, percuss in the ICS over
symmetrical areas of the chest
» Resonance- sound created by air-
starting from the supraclavicular
filled lungs. It is clear, long, low
area. Compare one side of the
pitch.
chest to another.

» Dull- short, high pitch, soft and

thudding, heard over the heart.

» Flat- absolute dullness; absence of

air in the underlying tissue.

» Tympany- moderately loud with

music quality with specific pitch.
Noted in the left upper quadrant
of the abdomen.

Location Percussion Note

L R

Supra-

clavicular Flat

1st ICS Resonant

2nd ICS Dull Resonant

3rd ICS Dull Resonant

4th ICS Dull Resonant

5th ICS Dull Resonant

6th ICS Resonant Resonant

7th ICS Tympanic Dull

8th ICS Tympanic Dull

Auscultation 9th ICS Tympanic Dull
To assess the movement of air
through the tracheobronchial tree,
room must be quiet.
» Normal breath sounds differ in
character depending on the area
of the lung being auscultated.

» Bronchovesicular sounds are

medium-pitched sound or medium
intensity, heard posteriorly
between the scapulae. The sounds
have a blowing quality with the
inspiratory phase equal to the
expiratory phase.

» Vesicular sounds are heard over

the lung periphery. The sounds are
created by air moving through the
smaller airways. They are soft,
breezy, and low-pitched and the
inspiratory phase is about three
times longer than the expiratory
phase.

» Bronchial sounds are hollow high

pitched; whistling sounds which
are normal if heard over large
airways like the trachea.
Overview

1. The thorax and lungs should be assessed anteriorly, posteriorly, and laterally

Nursing Points

General

1. Supplies needed

a. Stethoscope

Assessment

1. Anterior

a. Inspect

i. Size and shape of thorax

1. Anterior-Posterior diameter should be approximately ½ the lateral

diameter

2. Barrel Chest – COPD

ii. Symmetry

1. Expansion should be symmetrical on inspiration

iii. Ribs should slope downward from the sternum outward

iv. Observe for signs of distress

1. Tachypnea

2. Retractions

3. Cyanosis

v. Observe the overall rate and rhythm of respirations

vi. Inspect skin color and condition on thorax

b. Palpate

i. Using 2 fingers, press lightly on skin over anterior chest, feeling for crepitus –
feels like “rice crispies” under skin

1. Indicates subcutaneous air

c. Percuss

i. Starting at the Apex, percuss in the intercostal spaces moving left to right and
downward

ii. Should hear resonance

iii. May hear dullness over heart and liver

d. Auscultate

i. Listen for audible cough, wheezing, or stridor

ii. Lung sounds

1. Bronchial

a. Upper areas

b. High pitch

c. Insp < Exp

2. Bronchovesicular

a. Middle areas

b. Moderate pitch

c. Insp = Exp

3. Vesicular

a. Outer areas

b. Low pitch

c. Insp > Exp

iii. Listen from left to right starting at the apex and moving downward, including
the lateral areas.

1. The only way to hear the right middle lobe is to listen near the axilla on
the right side.

iv. Should listen in 10-12 areas on the front

v. BEST heard with stethoscope directly on skin

vi. Listen to one full respiration in each area

vii. Make note of any adventitious sounds

1. Crackles

2. Rhonchi
 3. Wheezes

4. Stridor

5. *See Lung Sounds lesson in Respiratory Course for details

2. Posterior

a. Inspect – same as anterior

b. Palpate – same as anterior, plus:

i. Tactile fremitus

1. Use the palm of your hands to palpate from the apex down in 5 places
as the patient says the word “ninety-nine”

2. Should feel vibrations equally bilaterally

1. Decreased vibration = fluid consolidation

ii. Expansion

1. Place hands on lower rib cage with thumbs touching, ask patient to
inhale deeply

2. Should see hands expand and return symmetrically

c. Percuss – same as anterior,

i. Avoid scapula

d. Auscultate – same as anterior

i. Avoid scapula

ii. 8-10 locations

HEART (CARDIAC) and GREAT VESSELS ASSESSMENT

Inspection of the Heart

 The chest wall and epigastrium is inspected while the client is in supine position. Observe for
pulsation and heaves or lifts

Normal Findings:

 Pulsation of the apical impulse may be visible. (this can give us some indication of the cardiac
size).
  There should be no lift or heaves.

Palpation of the Heart

 The entire precordium is palpated methodically using the palms and the fingers, beginning at
the apex, moving to the left sternal border, and then to the base of the heart.

Normal Findings:

 No, palpable pulsation over the aortic, pulmonic, and mitral valves.

 Apical pulsation can be felt on palpation.

 There should be no noted abnormal heaves, and thrills felt over the apex.

Percussion of the Heart

 The technique of percussion is of limited value in cardiac assessment. It can be used to

determine borders of cardiac dullness.

Auscultation of the Heart

 Anatomic areas for auscultation of the heart:

 Aortic valve – Right 2nd ICS sternal border.

 Pulmonic Valve – Left 2nd ICS sternal border.

 Tricuspid Valve – – Left 5th ICS sternal border.

 Mitral Valve – Left 5th ICS midclavicular line

Positioning the client for auscultation:

 1. If the heart sounds are faint or undetectable, try listening to them with the patient seated and
leaning forward, or lying on his left side, which brings the heart closer to the surface of the
chest.

2. Having the client seated and leaning forward is best suited for hearing high-pitched sounds
related to semilunar valves problem.

3. The left lateral recumbent position is best suited low-pitched sounds, such as mitral valve
problems and extra heart sounds.

Auscultating the heart:

1. Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral

2. Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of semilunar valve). S1 sound
is best heard over the mitral valve; S2 is best heard over the aortic valve.

3. Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.

4. Count heart rate at the apical pulse for one full minute.

Auscultation of Heart Sounds

Normal Findings:

 S1 & S2 can be heard at all anatomic site.

 No abnormal heart sounds are heard (e.g. Murmurs, S3 & S4).

  Cardiac rate ranges from 60 – 100 bpm.

BODY
TECHNIQUE NORMAL FINDINGS
PART

HEART Inspection and Palpation

Place client in supine position. Stand on

the client’s right side. Ask the client not to
talk. Inspect and palpate the valve areas
of the heart.

 Aortic
Valve –
found at
the 2nd ICS  No pulsations
on the left
of the angle
of Louis
(felt as a
prominence
on the
sternum)

 Pulmonic
area – at  No pulsations
the 2nd ICS
on the left
of the angle
of Louis.

 Tricupid
 No pulsations
area –
move the
fingers
along the
client’s left
sternal
border to
the 5th ICS.  Pulsations
 visible and
palpable
 Apical area
– move the
fingers
laterally to
the left
mid-
clavicular
line (LMCL)
which is
slightly
below the
nipple. This
point  Abdominal
where the aortic
apex pulsations
touches the visible and
anterior palpable.
chest is
known as
the point of
maximal
impulse
(PMIO)

 Epigastric
area – at
the base of
the
sternum.

 The two
Auscultation sounds are
audible in all
Auscultate the heart in all 4 anatomical
areas but
sites: aortic, pulomonic, tricuspid, and
loudest at
apical (mitral). Eliminate all sources of
apical area.
room noise.

Heart sounds are of low intensity and

other noise hinders the ability of the  Cardiac rate
examiner to hear them. ranges from
60-100
Identify the 1st sound (S1). This is a dull
 low – pitched sound described as “lub”.
Then identify the 2nd sound (S2). This is
higher – pitched than S1, described as beats/minute.
“dub”. Use the bell-shaped diaphragm.

Once S1 and S2 are identified count the

heart rate for one minute. Each
combination of S1 and S2 counts as one
heartbeats.

Overview

1. Major heart assessments:

a. Sounds

b. Murmurs

c. Apical pulse

2. The great vessels to be assessed are:

a. Carotid arteries

b. Jugular veins

c. Aorta

Nursing Points

General

1. Supplies needed

a. Pen light

b. Stethoscope

Assessment

1. Inspect

a. Anterior chest for visible apical pulse

i. 5th ICS, Left MCL

b. Abdomen for pulsation

i. May indicate an abdominal aortic aneurysm

c. Jugular venous pulse

i. Lay patient at 30-45 degrees, turn head away

 ii. Shine penlight on neck

iii. May see slight pulsation

iv. Jugular vein should flatten at 45 degrees or higher

v. Jugular venous distention (engorged at 30 degrees or higher) may indicate heart

failure and/or volume overload

2. Palpate

a. Carotid pulses – locate by sliding two fingers laterally from thyroid

i. ONE AT A TIME

ii. Compare bilaterally

b. Apical pulsation to locate point of maximum impulse (PMI)

i. Should be 5th ICS, Left MCL

3. Auscultate

a. Heart Sounds

i. APE To Man

1. Aortic

a. 2nd ICS, RSB

2. Pulmonic

a. 2nd ICS, LSB

3. Erb’s Point

a. 3rd ICS, LSB

4. Tricuspid

a. 4th ICS, LSB

5. Mitral

a. 5th ICS, Left MCL

ii. Listen with Diaphragm, then Bell (for murmurs)

iii. Make note of quality and timing, presence of extra sounds

b. Carotid bruit – listen over carotid with bell

c. Auscultate to count Apical pulse (5th ICS, Left MCL) for a full minute.
 ABDOMINAL ASSESSMENT

 In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the
client in a supine position with the knees slightly flexed to relax abdominal muscles.

Inspection of the abdomen

 Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus).

 Contour (flat, rounded, scaphoid)

 Distension

 Respiratory movement.

 Visible peristalsis.

 Pulsations

Normal Findings:

 Skin color is uniform, no lesions.

 Some clients may have striae or scar.

 No venous engorgement.

 Contour may be flat, rounded or scaphoid

 Thin clients may have visible peristalsis.

 Aortic pulsation may be visible on thin clients.

Auscultation of the Abdomen

 This method precedes percussion because bowel motility, and thus bowel sounds, may be
increased by palpation or percussion.

 The stethoscope and the hands should be warmed; if they are cold, they may initiate
contraction of the abdominal muscles.

 Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. Intestinal
sounds are relatively high-pitched, the bell may be used in exploring arterial murmurs and
venous hum.

Peristaltic sounds
  These sounds are produced by the movements of air and fluids through the gastrointestinal
tract. Peristalsis can provide diagnostic clues relevant to the motility of bowel.

 Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:

o Divide the abdomen into four quadrants.

o Listen over all auscultation sites, starting at the right lower quadrants, following the
cross pattern of the imaginary lines in creating the abdominal quadrants. This direction
ensures that we follow the direction of bowel movement.

o Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen
for at least 5 minutes, especially at the periumbilical area, before concluding that no
bowel sounds are present.

o The normal bowel sounds are high-pitched, gurgling noises that occur approximately
every 5 – 15 seconds. It is suggested that the number of bowel sound may be as low as 3
to as high as 20 per minute, or roughly, one bowel sound for each breath sound.

o Some factors that affect bowel sound:

 Presence of food in the GI tract.

 State of digestion.

 Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus,

peritonitis).

 Bowel surgery

 Constipation or Diarrhea.

 Electrolyte imbalances.

 Bowel obstruction.

Percussion of the abdomen

 Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites), gaseous

distension, and masses, and in assessing solid structures within the abdomen.

 The direction of abdominal percussion follows the auscultation site at each abdominal guardant.

 The entire abdomen should be percussed lightly or a general picture of the areas of tympany
and dullness.

 Tympany will predominate because of the presence of gas in the small and large bowel. Solid
masses will percuss as dull, such as liver in the RUQ, spleen at the 6th or 9th rib just posterior to
or at the midaxillary line on the left side.

 Percussion in the abdomen can also be used in assessing the liver span and size of the spleen.

Percussion of the liver

  The palms of the left hand are placed over the region of liver dullness.

 The area is strucked lightly with a fisted right hand.

 Normally tenderness should not be elicited by this method.

 Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.

Renal Percussion

 Can be done by either indirect or direct method.

 Percussion is done over the costovertebral junction.

 Tenderness elicited by such method suggests renal inflammation.

Palpation of the Abdomen

Light palpation

 It is a gentle exploration performed while the client is in supine position. With the examiner’s
hands parallel to the floor.

 The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without
digging, but gently palpating with slow circular motion.

 This method is used for eliciting slight tenderness, large masses, and muscles, and muscle
guarding.

 Tensing of abdominal musculature may occur because of:

o The examiner’s hands are too cold or are pressed to vigorously or deep into the
abdomen.

o The client is ticklish or guards involuntarily.

o Presence of subjacent pathologic condition.

Normal Findings:

 No tenderness noted.

 With smooth and consistent tension.

 No muscles guarding.

Deep Palpation

 It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces
of the fingers into the abdominal wall.

 The abdominal wall may slide back and forth while the fingers move back and forth over the
organ being examined.
  Deeper structures, like the liver, and retroperitoneal organs, like the kidneys, or masses may be
felt with this method.

 In the absence of disease, pressure produced by deep palpation may produce tenderness over
the cecum, the sigmoid colon, and the aorta.

Liver palpation

 There are two types of bimanual palpation recommended for palpation of the liver. The first one
is the superimposition of the right hand over the left hand.

o Ask the patient to take 3 normal breaths.

o Then ask the client to breathe deeply and hold. This would push the liver down to
facilitate palpation.

o Press hand deeply over the RUQ

 The second methods:

o The examiner’s left hand is placed beneath the client at the level of the right 11th and
12th ribs.

o Place the examiner’s right hands parallel to the costal margin or the RUQ.

o An upward pressure is placed beneath the client to push the liver towards the
examining right hand, while the right hand is pressing into the abdominal wall.

o Ask the client to breathe deeply.

o As the client inspires, the liver maybe felt to slip beneath the examining fingers.

Normal Findings:

 The liver usually cannot be palpated in a normal adult. However, in extremely thin but otherwise
well individuals, it may be felt the coastal margins.

 When the normal liver margin is palpated, it must be smooth, regular in contour, firm and non-
tender.

BODY PART TECHNIQUE NORMAL FINDINGS

ADBOMEN Divide the abdomen into 4

imaginary quadrants. Draw a
vertical line from the xiphoid
process to the symphysis pubis and
a horizontal line across the
umbilicus. These quadrants are
labeled right upper quadrant
(RUQ), left upper quadrant (LUQ),
right lower quadrant (RLQ), and
left lower quadrant (LLQ).

Ask client if he needs to void.

Drape the upper chest and legs.
Expose the abdomen from the
xiphoid process to the symphsis
pubis. The client lies in supine
position with arms down at the
sides a small pillow may be placed
under the head.

Inspection

Inspect the abdomen for skin

integrity, color, contour,
symmetry, movement or
pulsations and color and
placement of umbilicus.

» Skin is unblemished, no scars,

color is uniform, flat, rounded
(convex), or scaphoid (concave),

» Symmetrical movements caused

by respiration, aortic pulsation at
epigastric area visible in thin
persons

» Umbilicus is flat or concave,

positioned midway between the
xiphoid process and the
symphysis pubis

» Color is the same as the

surrounding skin.
Auscultation

Warm the diaphragm of the

stethoscope. Cold stethoscope
» There are clicks and gurgles, the
may cause the client to contract
frequency of which has been
the abdominal muscles and the
estimated at from 5-34 per
contractions may be heard during
minute. Occasionally, borborygmi
auscultation. Diaphragm is used
(loud prolonged gurgles of
because intestinal sounds are high
hyperperistalsis) the familiar
– pitched sounds. Place the
“stomach growling” can be heard.
diaphragm in each of the 4
quadrants over all auscultation
sounds.

Percussion

Reveals presence of air in the

stomach and abdomen.

To identify the boarders start

percussion at the right iliac rest
upward along the midclavicular
line. Percuss each quadrant » Tympany predominates because of
starting from the right clockwise. the presence of air in the stomach
and intestines
Palpation
» Percussion is dull at the liver’s
Perform light palpation first to lower boarder.
detect areas of tenderness, muscle
guarding, (Voluntary tightening of
abdominal muscles), lumps of
masses, consistency and
organomegaly.

Depress the abdominal wall lightly,

about 1 cm. with the pads of your
fingers. Move the finger pads in a
slight circular motion. Palpate all 4 » Soft abdomen, no tenderness, no
quadrants. muscle guarding, no lumps, or
masses, or organomegaly.
Palpate the liver using deep
palpation. Stand on the client’s
right side. Place your left hand on
the posterior thorax at about the
11th or 12th rib and then apply
upward pressure. With the fingers
 of the right hand pointing upward,
place the hand on the RUQ well
below the liver’s lower boarder,
then press gently until you reach
the depth of 1 ½ - 2 inches. Ask
the client to take a deep breath
using the abdominal muscles. As
he inhales, try to palpate the
liver’s edge as it descends.

» Liver’s edge feels firm and not

tender.

Overview

1. Remember the order of assessment is different!

a. Inspect

b. Auscultate

c. Percuss

d. Palpate

Nursing Points

General

1. Supplies needed

a. Stethoscope

b. Pen light (optional)

Assessment

1. Inspect

a. Shape and contour

i. Look across abdomen left to right

ii. Can use pen light to look for visible bulging or masses

iii. Look for distention

b. Umbilicus – discoloration, inflammation, or hernia

c. Skin texture and color

d. Lesions or scars

i. Note details – length, color, drainage, etc.

e. Visible pulsations

f. Respiratory movements (belly breather)

2. Auscultate

a. Start in RLQ → RUQ → LUQ → LLQ

i. This follows the large intestine

b. Use diaphragm of stethoscope to listen for 1 full minute per quadrant

i. Active – Should hear 5-30 clicks per minute

ii. Hypoactive

iii. Hyperactive

iv. Absent – must listen for 5 minutes per quadrant to confirm this

c. Use bell of stethoscope to listen for bruits

i. Aorta – over the epigastrium

ii. Iliac and femoral arteries – Inguinal are

iii. Renal arteries – A few cm above and to the side of the umbilicus

1. Press firmly

iv. The presence of a bruit could indicate narrowing of the arteries – if this is a new
finding, report to provider

3. Percuss

a. Percuss x 4 quadrants, starting in RLQ as with auscultation

 b. Expect to hear tympany

c. Dullness could indicate a mass, fluid-filled bladder, blood in the belly, or significant
adipose tissue

i. Exception – dullness over the liver is expected

d. CVA tenderness

i. Place nondominant hand flat over the costovertebral angle (flank).

ii. Strike your hand with the ulnar surface of your dominant hand

iii. Should be nontender

iv. Repeat bilaterally

4. Palpate

a. Light palpation – small circles in all 4 quadrants

i. Can do 4 small areas in each quadrant to be thorough

b. Deep palpation – deeper circles in all areas

c. Palpating for masses – make note of size, location, consistency, tenderness, and mobility

d. Make note of any guarding or tenderness

e. Assess for rebound tenderness

i. Press down slowly and deeply

ii. Release quickly

iii. Ask patient which hurt most (down or up)

iv. Rebound tenderness over RLQ could indicate appendicitis

f. If distended, perform Fluid-Wave test to look for ascites:

i. Place patient’s hand over umbilicus

ii. Place your hand on right flank, then tap or push on the left flank with your other
hand

iii. If you feel the tap/push on the opposite hand, that’s a Positive Fluid-Wave test

1. Indicates Ascites

iv. You may also see the patient’s hand ‘wave’ with the fluid

BREAST EXAMINATION
Inspection of the Breast

 There are 4 major sitting position of the client used for clinical breast examination. Every client
should be examined in each position.

o The client is seated with her arms on her side.

o The client is seated with her arms abducted over the head.

o The client is seated and is pushing her hands into her hips, simultaneously eliciting
contraction of the pectoral muscles.

o The client is seated and is learning over while the examiner assists in supporting and
balancing her.

 While the client is performing these maneuvers, the breasts are carefully observed for
symmetry, bulging, retraction, and fixation.

 An abnormality may not be apparent in the breasts at rest a mass may cause the breasts,
through invasion of the suspensory ligaments, to fix, preventing them from upward movement
in position 2 and 4.

 Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and shortened
suspensory ligaments.

Normal Findings:

 The overlying the breast should be even.

 May or may not be completely symmetrical at rest.

 The areola is rounded or oval, with same color, (Color varies from light pink to dark brown
depending on race).

 Nipples are rounded, everted, same size and equal in color.

 No “orange peel” skin is noted which is present in edema.

 The veins may be visible but not engorge and prominent.

 No obvious mass noted.

 Not fixated and moves bilaterally when hands are abducted over the head, or is leaning forward.

 No retractions or dimpling.

Palpation of the Breast

 Palpate the breast along imaginary concentric circles, following a clockwise rotary motion, from
the periphery to the center going to the nipples. Be sure that the breast is adequately surveyed.
Breast examination is best done 1-week post menses.

 Each areolar areas are carefully palpated to determine the presence of underlying masses.
  Each nipple is gently compressed to assess for the presence of masses or discharge.

Normal Findings:

 No lumps or masses are palpable.

 No tenderness upon palpation.

 No discharges from the nipples.

 NOTE: The male breasts are observed by adapting the techniques used for female clients.
However, the various sitting position used for woman is unnecessary.

BODY PART TECHNIQUE NORMAL FINDINGS

BREASTS Inspection Females: variable in size depending on

body build.
Ask client to remove the top gown
or drape to allow simultaneous * obese - large and pendulous.
visualization of both breasts. Have
the client sit comfortably with
arms at the side. Inspect the breast *Slender - thin and small.
for size, symmetry and contour or
shape. Inspect the skin of the
breast for color, retraction or *Young clients - firms, elastic in
dimpling. consistency, cone shaped symmetrical,
skin surface smooth.

*older women - breasts sag, nipples lower,

stringy and nodular.
Palpation

Assist the client in a supine

position. This position allows the
breast tissues to flatten evenly Males: flat, symmetrical. If obese, may be
against the chest wall facilitating slightly rounded.
palpation. Ask client to raise
his/her hand and place it under the
head. Palpate the breasts for
lumps or masses, areas of
tenderness, and consistency of » Color of the skin same
breast tissues. with the abdomen, no
retraction, no dimpling.

The palmar surface of the three

 » No mass or lump, no areas
of tenderness.

» In younger client, borders

of the breasts are clearly
delineated. In older client
irregular consistency,
glandular/nodular.
fingers is used to compress breast
tissues against the chest wall.
» Lobular feel of glandular
tissue is normal.

Perform palpation in a clockwise » The lower edge of the

rotary motion from the boarders each breast may feel firm
going inward. and hard.

» Premenstrual fullness,
nodularity and tenderness
may be present.

» Warm to touch and

smooth.

AREOLA Inspection

Inspect the size, shape, color, and » Round or oval, color darker than
symmetry. surrounding skin, symmetrical.

» For dark – skinned client, color is

darker than other skin surfaces.

» No masses and areas of

Palpation
tenderness.
Palpate for masses and areas of
tenderness.
 NIPPLES Inspection

Inspect for size, shape position, » Round or inverted, equal in size,

discharge, and lesions. similar in color, nipples point in
one direction, no discharge, no
lesion, no dimpling, and no
crusting.

Palpation

Using thumb and index finger, » No masses, no tenderness, no

compress the nipple to determine discharge.
any discharge.

MALE GENITALIA EXAMINATION ( Overview)

Risk Factors for Testicular Cancer

1. Age 20-34 (15-35)

2. History of undescended testes

3. Early puberty

4. Family history

5. White race

6. Higher social class

7. Obesity

8. Never married or late marriage

9. Maternal use of oral contraceptives or diethylstilbestrol during early pregnancy

10. Maternal abdominal/pelvic x-ray during pregnancy

11. Mother or sisters with breast cancer

Warning Signs for Cancer of the Testicle

1. A small, hard, painless lump-about the size of a pea

2. Feeling of heaviness in the testicle

3. Enlargement of the testicle

4. Change in how the testicle feels to the touch

 5. Sudden accumulation of fluid/blood in the scrotum

6. Dull ache in the groin

7. Swelling or tenderness in other parts of the body (groin, breast, neck)

Testicular Self-Examination

1. Perform after a warm bath/shower

2. Use both hands and start on right testicle

3. Place index and middle finger underneath testicle

4. Place thumb on top of testicle

5. GENTLY roll the testicle between thumbs and fingers

6. Check all sides of the right testicle and repeat procedure on left testicle

7. Find the epididymis on the top and back of each testicle.

8. Examine the testes in mirror while standing. Look for unusual contours and swelling of
testes (noting that one usually hangs lower than the other)