Breast Examination Guide

Breast Examination

• Palpate incisional lines and check for lymphedema in clients who have had a mastectomy, breast augmentation, or reconstruction
• Instruct clients to become self-aware of their breast tissue to detect changes
• Instruct clients to perform monthly breast self-exams (BSE) in front of a mirror and during showers
• Pregnant or postmenopausal clients should perform BSE on the same day each month
• The optimal time frame for BSE is 4-7 days after menses begins or right after menstruation ends
• Breast examinations should be performed on all clients
• Use inspection and palpation techniques to examine breasts

Equipment for Breast Exam

• Gloves
• Drape
• Small pillow or folded towel

Documentation of Nodules

• Location (quadrant or clock method)
• Size (centimeters)
• Shape
• Consistency (soft, firm, or hard)
• Discreteness (well-defined borders of mass)
• Tenderness
• Erythema
• Dimpling or retraction over the mass
• Lymphadenopathy
• Mobility

Health History: Questions to Ask

• If clients perform self-examinations and how often
• If clients have noticed any tenderness or lumps, documenting if this changes with the menstrual cycle
• If clients have thickening, pain, drainage, distortion, change in breast size, or retraction/scaling of the nipples
• If clients have ever had a mammogram and how frequently
• If clients have a family history of breast cancer
• If clients are aware of the risks for breast cancer
• If clients are taking medications that affect breast tissue

Inspection

• Women should be in one of four positions: arms at the side, arms above the head, hands on hips, or leaning forward
• Men should be sitting or lying down with arms at the side
• Inspection includes assessing size, symmetry (slight asymmetry is normal), and shape (convex, conical, pendulous)
• Symmetric venous patterns and consistent skin tone should be noted, as well as the absence of lesions, edema, or erythema
• Areolae should be round or oval, and darker-pigmented with color ranging from pink (pale skin) to brown (dark skin); the areola darkens during pregnancy
• Nipples should be everted (recent inversion is unexpected)
• Check for bleeding or discharge and excoriation under the breasts

Palpation

• Palpate axillary and clavicular lymph nodes with the client sitting with arms at both sides, expecting them to be nonpalpable and without tenderness
• When performing a breast exam, wear gloves if skin is not intact
• Use the finger pads of the three middle fingers to feel for lumps
• The best position is with the client lying down with the arm up by the head and a small pillow or folded towel under the shoulder of the side being examined
• Palpate each breast from the sternum to the posterior axillary line, and from the clavicle to the bra line (including the areola, nipple, and tail of Spence)
• Use one of three techniques: circular pattern, wheel pattern (spokes on a clock), or vertical strip pattern
• Compress the nipples carefully between the thumb and index finger to check for discharge (unexpected in nonlactating women); note the color, consistency, and odor
• For pendulous breasts, use one hand to support the lower portion while using the other hand to palpate breast tissue against the supporting hand

Expected and Unexpected Findings in Breast Examination

• Females: Breasts should be firm, dense, elastic, and without lesions or nodules; some females have granular or lumpy breast tissue bilaterally
• Males: No edema, masses, nodules, or tenderness; areolas are round and darker pigmented
• Unexpected findings in females include fibrocystic breast disease (tender cysts more prominent during menstruation)
• Unexpected findings in males include unilateral or bilateral (but asymmetrical) gynecomastia in adolescent boys or bilateral gynecomastia in older adult males (except for those taking estrogen therapy)

Thorax and Lungs

• Examination includes the anterior and posterior thorax and lungs
• Use inspection, palpation, percussion, and auscultation techniques

Equipment

• Stethoscope
• Centimeter ruler
• Wristwatch or clock with a second hand

Positioning

• Posterior thorax: Assess with the client sitting or standing
• Anterior thorax: Assess with the client sitting, lying, or standing
• The right lung has three lobes, while the left lung has two lobes
• Auscultate the right middle lobe via the axillae

Vertical Chest Landmarks

• The midsternal line is through the center of the sternum
• The midclavicular line is through the midpoint of the clavicle
• The anterior axillary line is through the anterior axillary folds
• The midaxillary line is through the apex of the axillae
• The posterior axillary line is through the posterior axillary fold
• The right and left scapular lines are through the inferior angle of the scapula
• The vertebral line is along the center of the spine

Lung Landmarks

• Percussion and auscultatory sites are in the intercostal spaces (ICSs): The number of the ICSs corresponds to the rib above it

Thorax Examination Sites

• Posterior thorax: Between the scapula and the vertebrae on the upper back and along the right and left scapular lines below the scapula
• Anterior thorax: Along the midclavicular lines bilaterally, with several sites at the anterior/midaxillary lines bilaterally in the lower portions of the chest wall and on either side of the sternum following along the rib cage
• Observe for accessory muscle use
• Systemic percussing and auscultating allow side-to-side comparisons

Maximizing Lung Sounds

• Instruct the client to take deep breaths with an open mouth each time the stethoscope is moved
• Placing the diaphragm of the stethoscope directly on the skin helps prevent muffling or distortion of sound
• Facilitate breathing by medicating for pain, giving clear directions, and assisting the client to a sitting position

Health History: Questions to Ask

• If clients have any chronic lung conditions, such as asthma or emphysema, and if they take any medications for respiratory problems
• If clients have ever had pneumonia, and when
• If clients frequently get coughs and colds
• If clients have environmental allergies
• If clients ever have shortness of breath or difficulty breathing with activity
• If clients have a cough, and if so, what the sputum looks like
• If clients currently smoke or have ever smoked, including when they quit, how long they smoked, how much they smoke, and interest in quitting
• If clients are exposed to secondhand smoke or environmental pollutants in their work area or residence
• If clients have a family history of lung cancer or tuberculosis, and if they have had any exposure to tuberculosis
• If clients receive an influenza vaccine and a pneumonia vaccine every year, and if so, which one
• If clients have had a TB test, and if so, what the results were

Inspection Notes

• The anteroposterior diameter should be one third to one half of the transverse diameter
• The chest should be symmetric with no deformities of the ribs, sternum, scapula, or vertebrae, and equal movements during respiration
• There should be no excessive retractions
• Rate and pattern: 12 to 20/min and regular
• Character of breathing (diaphragmatic, abdominal, thoracic)
• Note use of accessory muscles and chest wall expansion
• Respirations should be unlabored and quiet
• If there is a productive cough, note the color and consistency of sputum
• The trachea should be midline

Palpation of the Thorax

• Surface characteristics: Assess for tenderness, lesions, lumps, and deformities (tenderness is an unexpected finding)
• Avoid deep palpation if the client reports pain or tenderness
• Assess chest excursion or expansion of the posterior thorax: With thumbs aligned parallel along the spine at the level of the tenth rib and the hands flattened around the client's back, instruct the client to take a deep breath
• Thumbs should move outward approximately 5 cm (2 in) when the client takes a deep inspiration

Vocal (Tactile) Fremitus

• Palpate the chest wall using the palms of both hands, comparing side to side from top to bottom
• Instruct the client to say "99" each time you move your hands
• Expected findings: Vibration should be symmetric and more pronounced at the top, near the level of the tracheal bifurcation
• Unexpected findings: Increased fremitus (pneumonia) or decreased to absent fremitus (pneumothorax)

Percussion

• Compare sounds from side to side
• Percussion of the thorax should elicit resonance

Unexpected Findings

• Dullness: In fluid or solid tissue, this can indicate pneumonia or a tumor
• Hyperresonance: In the presence of air, this can indicate pneumothorax or emphysema

Auscultation: Expected Sounds

• Bronchial: Loud, high-pitched, hollow quality, expiration longer than inspiration over the trachea
• Bronchovesicular: Medium pitch, blowing sounds and intensity with equal inspiration and expiration times over the larger airways
• Vesicular: Soft, low-pitched, breezy sounds, inspiration three times longer than expiration over most of the peripheral areas of the lungs

Auscultation: Unexpected or Adventitious Sounds

• Crackles or rales: Fine to coarse bubbly sounds (not cleared with coughing) as air passes through fluid or re-expands collapsed small airways
• Wheezes: High-pitched whistling, musical sounds as air passes through narrowed or obstructed airways, usually louder on expiration
• Rhonchi: Coarse, loud, low-pitched rumbling sounds during either inspiration or expiration resulting from fluid or mucus, can clear with coughing
• Pleural friction rub: Dry, grating, or rubbing sound as the inflamed visceral and parietal pleura rub against each other during inspiration or expiration
• Absence of breath sounds: From collapsed or surgically removed lobes

Cardiac Examination

• Includes measuring heart rate and blood pressure, examining the jugular veins, and auscultating heart sounds.

Cardiac Exam Equipment

• Stethoscope
• Blood pressure cuff
• Wristwatch or clock to count seconds
• Two rulers

Cardiac Cycle and Heart Sounds

• Closure of the mitral and tricuspid valves signals the beginning of ventricular systole (contraction), and produces the S1 sound ("lub"); place the diaphragm of the stethoscope at the apex
• Closure of the aortic and pulmonic valves signals the beginning of ventricular diastole (relaxation), and produces the S2 sound ("dub"); place the diaphragm of the stethoscope at the aortic area
• An S3 sound (ventricular gallop) indicates rapid ventricular filling and can be an expected finding in children and young adults; use the bell of the stethoscope
• An S4 sound reflects a strong atrial contraction and can be an expected finding in older and athletic adults and children; use the bell of the stethoscope
• Dysrhythmias occur when the heart fails to beat at regular successive intervals
• Gallops are extra heart sounds and you should use the bell of the stethoscope
  • Ventricular gallop occurs after S2, sounds like "Ken-tuck'-y"
  • Atrial gallop occurs before S1, sounds like "Ten'-es-see"
• Murmurs are audible when blood volume in the heart is increased, or its flow is impeded or altered
• Use the bell of the stethoscope to hear the characteristic blowing or swishing sound; murmurs can be asymptomatic or a finding of heart disease
  • Systolic murmurs occur just after S1
  • Diastolic murmurs occur just after S2
• Thrills are a palpable vibration that can accompany murmurs or cardiac malformation
• Bruits are blowing or swishing sounds that indicate obstructed peripheral blood flow; use the bell of the stethoscope

Auscultatory Sites for the Heart

• Aortic: Just right of the sternum at the second ICS
• Pulmonic: Just left of the sternum at the second ICS
• Erb’s point (second pulmonic area): Just left of the sternum at the third ICS
• Tricuspid: Just left of the sternum at the fourth ICS
• Apical/mitral: Left midclavicular line at the fifth ICS

Health History: Questions to Ask (Heart Related)

• Any problems with your heart or medications for it
• Any history of heart trouble, pre-existing diabetes, lung disease, obesity, or hypertension
• High blood pressure or high cholesterol
• If feet and ankles ever swell
• Frequent coughing
• Chest pain, including when it occurs, how long it lasts, it's frequency, description, and if it radiates
• Any nausea, shortness of breath, sweating, dizziness, or other problems when pain occurs
• What clients have tried to relieve the pain and if it works
• Client energy level & fatigue
• Fainting spells or dizziness
• Stress level
• History of smoking, drinking, caffeine, prescriptive or recreational drugs
• Exercise habits
• Dietary pattern and intake
• Familiarity with the risk factors for heart disease
• Family history of heart problems

Inspection and Palpation

• Vital signs: Pulse and blood pressure reflect cardiovascular status
• Peripheral vascular system:
  • Inspect jugular veins with client in bed, head at 30-45° angle, to assess for right-sided heart failure
  • No neck vein distention
• Jugular venous pressure (JVP): Measure less than 2.5 cm (1 in) above the sternal angle
  • Place one ruler vertically at the sternal angle
  • Locate pulsation in the external jugular vein, place straightedge of another ruler parallel to the floor at pulsation level
  • Line up rulers as a T square, keep horizontal ruler at pulsation level
  • Measure JVP where horizontal ruler intersects vertical ruler
  • Bilateral pressures greater than 2.5 cm (1 in) considered elevated, a finding of right-sided heart failure; one-sided elevation indicates obstruction
  • Examine one carotid artery at a time: Occluding both simultaneously loses client consciousness due to inadequate brain circulation

Heart Inspection and Palpation

• Apical pulse or point of maximal impulse (PMI) should:
  • Be visible just medial to the left midclavicular line at the fourth or fifth ICS
  • Displace the breast to locate in clients with large breast tissue
  • Palpate where you visualized it or palpate the location to feel pulsations
  • Heaves (or lifts): Unexpected, visible elevations of the chest wall that indicate heart failure, often along the left sternal border or at the PMI
  • Thrills: Feel for vibration like a purring kitten (unexpected finding)

Auscultation of the Heart

• Position the client in three ways for optimal assessment of heart sounds amplified by these positions
  • Sitting, leaning forward
  • Lying supine
  • Turned toward the left side (best position for auscultating extra heart sounds/murmurs)
• Use both diaphragm and bell of stethoscope in a systematic manner at all auscultatory sites
• Measure heart rate, listen and count for 1 min to determine regular rhythm
• If dysrhythmia exists, check for pulse deficit (radial pulse slower than apical pulse) and report difference in pulse rates to the provider immediately

Peripheral Vascular System

• Locations for assessing bruits:
  • Carotid arteries: Over the carotid pulses
  • Abdominal aorta: Just below the xiphoid process
  • Renal arteries: Midclavicular lines above the umbilicus on the abdomen
  • Iliac arteries: Midclavicular lines below the umbilicus on the abdomen
  • Femoral arteries: Over the femoral pulses

Abdomen Examination

• Observing shape, palpating for masses, and auscultating for vascular sounds are all part of this exam
• Inspection, auscultation, percussion, and palpation are used
• Note that assessment order changes: auscultate after inspection (percussion & palpation can alter bowel sounds)

Abdomen Examination Equipment

• Stethoscope
• Tape measure or ruler
• Marking pen

Abdomen Examination Procedure

• Ask the client to urinate before the abdominal exam
  • Have the client lie supine with arms at both sides and knees slightly bent
  • Imagine vertical and horizontal lines through umbilicus to divide abdomen into four quadrants: xiphoid process as upper boundary and symphysis pubis as lower boundary
    • Right upper quadrant
    • Left upper quadrant
      • Right lower quadrant
      • Left lower quadrant

Abdomen: Health History Questions

• Any nausea, vomiting, or cramping
• Any change in appetite or food intolerances & any recent weight changes
• Any difficulty with swallowing, belching, or gas
• Any vomit containing blood
• Any bowel problems, when was the last bowel movement, and use of laxatives or enemas
• Any black or tarry stools
• Aspirin or ibuprofen use (how often)
• Ever have heartburn (when & how often) and take medications to treat it
• Low abdominal or back pain/tenderness
• Any abdominal surgery, injuries, or diagnostic tests
• Family history of colon cancer
• Clients over 50: routine colonoscopies -Aware of changes that indicate colon cancer
• Drink alcohol? how much?
• What do you eat and drink on a typical day
• If pregnant, when was your last menstrual period

Abdominal Inspection

• Note any guarding or splinting of the abdomen
• Inspect umbilicus for position, shape, color, inflammation, discharge, and masses

Abdominal Skin Assessment

• Lesions: Bruising, rashes, or other primary lesions
• Scars: Location and length
• Silver striae or stretch marks (expected findings)
• Dilated veins: An unexpected finding possibly reflecting cirrhosis or inferior vena cava obstruction
• Jaundice, cyanosis, or ascites: Reflecting cirrhosis

Abdominal Shape or Contour

• Flat: In a horizontal line from the xiphoid process to the symphysis pubis
• Convex: Rounded
• Concave: A sunken appearance
• Distended: Large protrusion of the abdomen caused by fat, fluid, or flatus. Measure at the umbilicus to monitor changes in clients with fluid retention
  • Obese: Client has rolls of adipose tissue along both sides, but skin doesn't look taut
  • Fluid: Flanks also protrude and protrusion moves to the dependent side when client turns onto one side - Flatus: Protrusion is mainly midline and there is no change in the flanks - Hernias: Protrusions through the abdominal muscle wall are visible, especially when flexing abdominal muscles

Abdominal Movement

• Peristalsis: Wavelike movements visible in thin adults or those with intestinal obstructions
  • Pulsations: Regular beats of movement midline above the umbilicus are expected in thin adults, but a pulsating mass is unexpected

Abdominal Auscultation

• Bowel sounds result from movement of air and fluid in the intestines; best time to auscultate is between meals
  • Technique: Listen in all four quadrants using the diaphragm of stethoscope
  • Expected sounds: High-pitched clicks and gurgles 5-35 times/minute
    • To determine absent bowel sounds, must hear no sounds after listening for a full 5 minutes
  • Unexpected sounds: Loud, growling sounds are hyperactive and indicate increased gastrointestinal motility caused by diarrhea, anxiety, bowel inflammation, or reactions to some foods
  • Friction rubs result from the rubbing together of inflamed layers of the peritoneum
    • Listen with the diaphragm over the liver and spleen

Abdominal Percussion

• Expect tympany over most of the abdomen with a lower pitch over the gastric bubble that is common in the left upper quadrant
• Expect dullness over the liver or a distended bladder
• Liver span measurement: Liver size at the right midclavicular line (expected finding: 6-12 cm/2.4-4.7 in); findings outside that range indicate hepatomegaly
• Test for kidney tenderness: Fist percussion over the costovertebral angles at the scapular lines on the back; no tenderness is expected

Abdominal Palpation

• Palpate tender areas last

Abdominal Light Palpation

• Use the fingerpads to palpate to a depth of 1.3 cm (0.5 in) in each quadrant - Expect softness and no nodules or guarding
• Only palpable when full

Abdominal Deep Palpation

• May be reserved for advanced/experienced practitioners
• Two-handed approach: Top hand depresses the bottom hand to 2.5-7.5 cm (1-3 in) in depth (bottom hand assesses organ enlargement or masses)
• Stool may be palpable in the descending colon
• Rebound tenderness (Blumberg’s sign): Indication of irritation or inflammation somewhere in the abdominal cavity
  • Apply firm pressure for 4 seconds with the hand at a 90° angle and with fingers extended in all four quadrants
  • Observe the client’s reaction to see if release caused pain
  • Ask if there is abdominal pain or tenderness
  • Never palpate an abdominal mass, tender organs, or surgical incisions deeply

Expected Changes with Aging

• Breasts: - Menopause causes glandular tissue atrophy and replacement by adipose tissue (feel softer/more pendulous) - The atrophied ducts feel like thin strands - Nipple no longer have erectile ability and can invert
• Lungs: - Chest shape change (AP diameter becomes similar to transverse diameter - barrel chest) reduces vital capacity - Chest excursion/expansion & cough reflex reduces - Cilia ineffectively remove dust and irritants from the airways - Alveoli dwindle & airway resistance increases to increase pulmonary infection risk - Kyphosis increases thoracic spine curvature (osteoporosis & weakened cartilage) leads to vertebral collapse and reduce respiratory effort
• Cardiovascular System: - Systolic hypertension (widened pulse pressure) common with atherosclerosis - PMI more difficult to palpate (AP diameter of the chest widens) - Coronary blood vessel walls thicken & become rigid with a narrowed lumen - Cardiac output decreases & contraction strength leads to poor activity tolerance - Heart valves stiffen (calcification) and the left ventricle thickens - Pulmonary vascular tension and systolic blood pressure both increase - Peripheral circulation reduces
• Abdomen: - Weaker abdominal muscles declining in tone and more adipose tissue produce a rounder, protruding abdomen - Peritoneal inflammation more difficult to detect (less pain, guarding, fever, & rebound tenderness) - Saliva, gastric secretions, & pancreatic enzymes reduce and peristalsis as well as small-intestine motility decrease

Sample Documentation

• Breasts are conical and symmetric in size, without masses or lesions
• Nipples and areolae are darkly pigmented and symmetric with everted nipples and no discharge
• No palpable axillary or clavicular lymph nodes are present and the client reports no pain or tenderness
• Respiratory rate is 16/min and regular and respirations are easy and unlabored
• The thorax has a greater transverse than AP diameter and their are no chest wall deformities
• The trachea is midline and movement is symmetric with 5cm of expansion
• Tactile fremitus is equal and the resonance sounds are resonant
• Vesicular sounds are primarily heard bilaterally and there are no adventitious sounds
• The client denies cough, shortness of breath, or difficulty breathing
• Regular heart rythm and rate at 72/min and has a blood pressure of 118/76 mm Hg
• No thrills or heaves are present and the PMI is approximately 1 cm at the fifth ICS left midclavicular line
• S1 is louder at the apex than S2 while S2 is loudest in the pulmonary area on inspiration
• There are no extra heart sounds, murmurs, or bruits, JVP 2 cm bilaterally with no chest pain or discomfort
• The abdomen is flat with active bowel sounds every 10-20 seconds in all four quadrants
• There are no bruits of friction rubs, the abdomen is soft, nontender, and without masses or enlargement of spleen/liver
• No costovertebral angle tenderness, a nonpalpable bladder, or abdominal pain in the abdominal region