Neck Assessment

1. Inspect neck muscles sternocleidomastoid

muscle and trapezius for normal swelling or
masses. Ask the client to hold her neck erect.
2. Observe head movements. Ask the
client to:
A. Move chin to the chest (Sternocleidomastoid)

B. Move head back so that the chin points upward (Trapezius)

C. Move the head so that the ear is moved toward the shoulder on each
side (sternocleidomastoid)

D. Turn the head to the right and to the left (sternocleidomastoid)

Assess muscle strength. Ask the client
to:

A. Turn the head to one side against the resistance

of the hand. Repeat with the other side.

B. Shrug the shoulder against the resistance of the

hands.
Lymph nodes

4. Palpate the entire lymph node for

enlarge lymph nodes.

Trachea
5. Palpate the trachea for lateral deviation.

A. Place finger tip or thumb on the trachea

in the suprasternal notch and then move
the finger laterally to the left and right in
spaces bordered by the clavicle, the
anterior aspect of the sternocleidomastoid
muscle and trachea.
Thyroid gland
6. Inspect the thyroid gland

A. Observe the lower half of the back overlying

the thyroid gland for symmetry and visible
masses.

B. Ask the client to hyperextend the neck and

swallow. It necessary to offer a glass of water for
the client to swallow.
7. Palpate the thyroid gland for
smoothness. Note any areas of
enlargement, masses and nodules.

8. If enlargement of the gland is suspected,

auscultate over the thyroid area for bruit (a
soft rushing sound created by turbulent
blood flow)

9. Document pertinent findings in the chart.

Breast and Axilla
Assessment
1. Assemble equipment
• Centimeter ruler

2. Inspect the breast for size,

symmetry and contour or
shape while the client is in a
sitting position.
3. Inspect the skin of the breast for localized
discolorations or hyperpigmentation, retraction or
dimpling, localized hypervascular areas, swelling
or edema.
Size/Shape/Symmetry

NORMAL: Convex, pendulous, or conical.

Frequently asymmetric in size.

Texture/Contour

NORMAL: Smooth and uninterrupted.

ABNORMAL: Dimpling or peau d’orange

appearance. Changes or asymmetric appearance.

Skin Color

NORMAL:Consistent color Peau d'orange

ABNORMAL: Areas of discoloration or asymmetric

appearance.
Mastitis
4. Emphasize any retraction by
having the client:

Raise the arms above the head.

EXPECTED: All positions breasts bilaterally symmetric with
even contour

Push the hands together, with

elbows flexed.
UNEXPECTED: Dimpling, retraction, deviation, or
fixation of breasts.

Press the hands down on the hips.

UNEXPECTED: Dimpling, retraction, deviation, or
fixation of breasts.
5. Inspect the areola for size,
shape, symmetry, color, surface
characteristics, and any masses
or lesions.

Size/Shape/Symmetry

NORMAL: Areolae round or oval, bilaterally

equal or nearly equal.

Color

NORMAL: Pink to brown.

ABNORMAL:Nonhomogeneous in color.

Texture/Contour

NORMAL: Smooth
ABNORML: Presence of tender,
montgomery tubercles or with peau
d’orange appearance.
6. Inspect the nipples for
size, shape, symmetry, color,
surface characteristics, and
any masses or lesions.

Size/Shape/Symmetry
NORMAL: Nipples bilaterally equal or
nearly equal in size and usually everted,
although one or both sometimes inverted.
ABNORMAL: Recent unilateral nipple
inversion or retraction.

Color
NORMAL: Pink to brown.
ABNORMAL: Nonhomogeneous in color.

Texture/Contour
NORMAL: Nipples smooth or wrinkled.
ABNORMAL: Nipples crusting, cracking, or
with discharge
7. Palpate the axillary, subclavicular,
and supraclavicular lymph nodes.

8. The client is seated with the arms

abducted and supported on the nurse's
forearm
9. Use the flat surfaces of all finger
tips to palpate the four areas of the
axilla:

• The edge of the greater pectoral

muscle along the anterior axillary line. EXPECTED: Tissue
generally firm,
nontender, free of
nodes
• The thoracic wall in the midaxillary
line.
UNEXPECTED: Nodes,
especially in
supraclavicular area.
• The upper part of the humerus. Describe nodes by
location, size, shape,
consistency,
tenderness, fixation,
delineation of borders.
• The anterior edge of the latissimus
dorsi muscle along the posterior
axillary line.
10. Palpate the breast for masses,
tenderness and any discharge from the
nipples.

EXPECTED: Tissue generally firm,

nontender, free of lumps.

UNEXPECTED: Lumps or nodules.

11. Palpate the areola and the nipples
for masses. Compress each nipples to
determine the presence of any
discharge.
If discharge is present, milk the breast
along its radius to identify the
discharge-producing lobe.

EXPECTED: Tissue generally firm, nontender,

free of lumps.

UNEXPECTED: Lumps or nodules.

12. Assess any discharge for amount,
color, consistency and odor.

Expected: No presence of discharge,

odorless.

13. Note any tenderness on palpation.

Expected: No presence of tenderness.

14. Document Pertinent findings in

the client's record.