NURS125: Abdomen & Breast Assessment

• NURS125 Abdomen & Breast Assessment presented by Dr. S. Prendergast PhD NP

Objectives

• Conduct a systematic assessment of the abdomen, breast, and axillae.
• Apply knowledge of anatomy and physiology.
• Describe general survey data.
• Identify pertinent health history questions for assessments.
• Obtain an accurate health history.
• Use appropriate abdominal, breast, and axillae assessment techniques.
• Differentiate between expected and unexpected findings physically.
• Recognize red flags during abdominal and breast assessments.
• Understand the importance of accurate documentation.

Abdominal Pain: Incidence & Prevalence

• Abdominal pain is a common presenting complaint.
• Ponka & Kirlew reported on the prevalence of conditions that cause abdominal pain in 2007.
• The most common cause of abdominal pain in patients under 45 is abdominal pain NYD (28.90%).
• The second most common cause of abdominal pain in patients under 45 is irritable bowel syndrome (21.50%).
• The most common cause of abdominal pain in patients over 45 is abdominal pain NYD (21.21%).
• The second most common cause of abdominal pain in patients over 45 is irritable bowel syndrome (19.20%).

Abdominal Pain - Considerations

• Abdominal pain accounts for 1.5% of primary care visits and 5% of ER visits.
• While mostly benign, approximately 10% in the ER and less in primary care signifies severe/life-threatening issues that may require surgery.

Organs of the Digestive System

Major Organs of the Digestive Tract

• Oral Cavity (Mouth) is responsible for ingestion, mechanical digestion with accessory organs (teeth and tongue), moistening and mixing with salivary secretions
• Pharynx performs muscular propulsion of materials into the esophagus
• Esophagus transports materials to the stomach
• Stomach performs chemical digestion of materials by acid and enzymes, mechanical digestion through muscular contractions
• Small Intestine performs the enzymatic digestion and absorption of water, organic substrates, vitamins, and ions
• Large Intestine performs dehydration and compaction of indigestible materials in preparation for elimination
• Anus is the terminus of the Large Intestine

Accessory Organs of the Digestive System

• Teeth perform mechanical digestion by chewing (mastication)
• Tongue assists mechanical digestion with teeth, and performs sensory analysis
• Salivary Glands secrete lubricating fluid containing enzymes that break down carbohydrates
• Liver secretes bile, which is important for lipid digestion, the liver stores nutrients, and has many other vital functions
• Gallbladder is responsible for the storage and concentration of bile
• Pancreas contains exocrine cells that secrete buffers and digestive enzymes, endocrine cells secrete hormones

Integration of the Digestive System with Other Body Systems

• Integumentary System provides vitamin D3, which is needed for the absorption of calcium and phosphorus and the digestive system provides lipids for storage by adipocytes in the hypodermis
• Skeletal System (axial division and pelvic girdle) supports and protects parts of the digestive tract, teeth are used in mechanical processing of food and the digestive system absorbs calcium and phosphate ions for use in bone matrix and provides lipids for storage in yellow marrow.
• Cardiovascular System distributes hormones of the digestive tract, carries nutrients, water, and ions from sites of absorption, delivers nutrients and toxins to liver and the digestive system absorbs fluid to maintain normal blood volume, absorbs vitamin K and the liver excretes heme (as bilirubin), synthesizes blood clotting proteins
• Respiratory System can assist in defecation by producing increased thoracic and abdominal pressure through contraction of respiratory muscles and the digestive system produces pressure with digestive organs against the diaphragm that can assist in exhalation and limit inhalation
• Muscular System protects and supports digestive organs in the abdominal cavity, controls entrances and exits of digestive tract and the digestive system regulates blood glucose and fatty acid levels and metabolizes lactate from active muscles with the liver
• Nervous System regulates movement and secretion with the ANS and ENS, reflexes coordinate passage of materials along tract, control over skeletal muscles regulates ingestion and defecation, hypothalamic centers control hunger, satiation, and feeding and the digestive system provides compounds essential for neurotransmitter synthesis
• Endocrine System produces epinephrine and norepinephrine that stimulate constriction of sphincters and depress digestive activity, hormones coordinate activity along the digestive tract, the digestive system provides nutrients and substrates to endocrine cells; endocrine cells of pancreas secrete insulin and glucagon and the liver produces angiotensinogen
• Lymphatic System defends against infection and toxins absorbed from the digestive tract, lymphatic vessels carry absorbed lipids to the general circulation and the digestive system secretes acids and enzymes that provide innate (nonspecific) immunity against pathogens
• Digestive System provides organic substrates, vitamins, minerals, electrolytes (inorganic ions), and water required by all cells, it ingests solid and liquid materials into the oral cavity of the digestive tract, mechanically digests solid materials to ease their movement and propels them down the digestive tract, chemically digests food into smaller molecules in the digestive tract, secretes water, acids, enzymes, and buffers into the digestive tract, absorbs small organic molecules (organic substrates), ions, vitamins, and water across the digestive epithelium and eliminates wastes and indigestible materials from the body by defecation.

Nicki - Patient Scenario

• Nicki is a 40-year-old presenting with abdominal pain.

Process of Assessment

• General Survey
• History
• Physical Examination

General Survey

• State of Health can be acute or chronically ill, frail, fit & robust or somewhere in between.
• Level of Consciousness can be awake, alert, responsive or lethargic, obtunded, comatose.
• Signs of Distress can be cardiac or respiratory distress, and can include pain anxiety or depression.
• Other survey details include any Skin Colour & Obvious Lesions, Dress, Grooming & Personal Hygiene and facial expression.
• Note any Odours of the Body and Breath, Posture, Gait, and Motor Activity and Height & Weight

Symptom History (OLDCAR)

• O – Onset: When did the symptom begin?
• L – Location: Where is the symptom located?
• D – Duration: How long does the symptom last?
• C – Characteristics: What does the symptom feel like?
• A – Aggravating/Alleviating/Associated: What makes the symptom better or worse? Are there any other symptoms related to the current issue?
• R – Radiating: Does the symptom spread anywhere else?
• T – Timing: When does the symptom occur in relation to other activities?
• S – Severity: How would you rate the severity of the symptom on a scale of 0-10?
• P – Prior experiences/Past hx of similar/Previous treatments tried: Have you experienced this before, and what remedies have been tried so far?

Nicki's Symptoms

• Pain began approximately 3 weeks ago.
• Pain is sharp and located in the middle of the upper abdomen below the rib cage.
• It occurs mostly between meals, and is relieved by meals hours later the pain returns.
• Does not report weight loss, anorexia, dysphagia, diarrhea or constipation.
• Stools are darker than usual, but without signs of bright red blood.
• Has never experienced pain like this and has been using antacids without relief.

Health History (PAMFROSSI)

• P – Past Medical History
• A - Allergies
• M - Medications
• F - Family history
• R - Review of Systems
• O - Occupation
• S – Social History
• S - Safety
• I - Immunizations

Nicki's Health History

• Last menstrual period (LMP) was 3 weeks ago and has regular periods (typically 5/28).
• There is no association between menses and pain.
• Sexually active with a male partner of 6 months, using condoms with spermicidal lubricant for birth control.
• Reports no history of sexually transmitted diseases.
• Sees PCP yearly for gynecologic exams.
• Non-smoker
• Rarely drinks or uses other substances.
• Works as legal secretary.
• Divorced for three years.
• One child is away at college, and the other two are at home, including a 12-year-old diagnosed with a learning disability.
• Reports stress as a single parent with shared custody.

Nicki's Hypotheses (Based on Presentation & History)

• The likely diagnoses are yet to be determined.
• The following steps need to be carried out to ensure a correct diagnosis is created.

Abdomen Inspection

• Look at Scars & Striae, asses for Masses, note Distension, note any Pulsation, check for Stomas, and any further Pulsation

Abdomen Auscultation

• Auscultate all four abdomen quadrants to assess bowel sounds.
• Normal bowel sounds are identified as gurgling.
• Tinkling bowel sounds are associated with bowel obstruction
• Absent bowel sounds suggest an ileus.
• It us important to listen for approximately 3 minutes before being able to confidently confirm absent bowel sounds.
• Auscultate over the aorta, renal and iliac arteries to identify vascular bruits, noting any turbulent blood flow:
  • Aortic bruits: At 1-2 cm superior to the umbilicus, indicative of an abdominal aortic aneurysm.
  • Renal bruits: Auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side, and can indicite renal artery stenosis.

Abdomen Percussion & Palpation

• Perform Percussion to assess organs and search for a distended Suprapubic Bladder.
• Perform Palpation from light to deep across each of the 9 Abdominal regions

Nicki- Physical Exam

• Seemingly well and her reported age match each other.
• She reports to way 128 ponds, with no known changes.
• Blood pressure readings of 110/67mmHg (supine) and 105/60mmHg (standing).
• Pulse ranges of 68/min (supine) and 72/min (standing).
• Respiratory rate is approximately 12 breaths per minute, and a temp of approximately 37.6 degrees.
• Her mucous membranes and conjunctiva look to be moist and pale.
• No oral lesions present.
• Clear lungs can be heard well using auscultation and percussion techniques.
• The epigastric tenderness is noted without rebound or guarding.
• No Bruits or thyromegaly.
• Murphy’s sign is negative, and nor organomegaly has been found
• Her stool is Guaiac positive (blood is present) and also darker than normal.

Nicki - Diagnosis

• Final diagnosis can be found using these next steps
• You must integrate the history and physical exam findings to determine the most likely diagnosis.

Peptic Ulcer Disease

• An illustration depicts key factors related to Peptic Ulcer Disease.
• Helicobacter pylori infection, protease and inflammation all play a part in Peptic Ulcer Disease

Differential Diagnoses

Commonly Mistaken for PUD

• Esophagitis
• Functional Dyspepsia
• Gastritis
• Gastroenteritis
• GERD

Less Commonly Mistaken for PUD

• Celiac Disease
• Cholangitis
• Cholecystitis
• Cholelithiasis
• Esophageal Perforation.
• Inflammatory Bowel Disease
• Irritable Bowel Syndrome

Rarely Mistaken for PUD

• Abdominal Aortic Aneurysm
• Acute Coronary Syndrome
• Barrett Esophagus
• Gastric Cancer
• Viral Hepatitis
• Zollinger-Ellison Syndrome

Abdominal Pain - Differential Diagnosis

• Right Upper Quadrant: biliary: cholecystitis, cholelithiasis, cholangitis colonic: colitis, diverticulitis hepatic: abscess, hepatitis, mass pulmonary: pneumonia, embolus renal: nephrolithiasis, pyelonephritis
• Epigastric: biliary: cholecystitis, cholelithiasis, cholangitis cardiac: myocardial infarction, pericarditis gastric: esophagitis, gastritis, peptic ulcer pancreatic: mass, pancreatitis
• Left Upper Quadrant: cardiac: angina, myocardial infarction, pericarditis gastric: esophagitis, gastritis, peptic ulcer pancreatic: mass, pancreatitis renal: nephrolithiasis, pyelonephritis
• Periumbilical: colonic: early appendicitis gastric: esophagitis, gastritis, peptic ulcer, small bowel mass or obstruction
• Right Lower Quadrant: colonic: appendicitis, colitis, diverticulitis, IBD, IBS gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID renal: nephrolithiasis, pyelonephritis
• Suprapubic: colonic: appendicitis, colitis, diverticulitis, IBS gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID renal: cystitis, nephrolithiasis, pyelonephritis
• Left Lower Quadrant Pain: colonic: colitis, diverticulitis, IBD, IBS gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID renal: nephrolithiasis, pyelonephritis
• Any Location: abdominal wall: herpes zoster, muscle strain, hernia other: bowel obstruction, mesenteric ischemia, peritonitis, narcotic withdrawal, sickle cell crisis, porphyria, IBD, heavy metal poisoning

Evaluation of Abdominal Pain in Special Populations Diagram

• Provides a flowchart for determining the method of care and diagnostic options based on various symptoms

Abdominal Pain - Red Flags

• Sudden Onset Abdominal Pain
• Haematemesis
• Unexplained Weight Loss
• Change in Bowel Habit for > 3 Weeks
• Unexplained PV Bleeding
• Post-Coital Bleeding
• Shortness of Breath
• Dysphagia
• Bleeding per Rectum/Melena
• Personal / Family History of Serious Bowel Pathology
• Increased Vaginal Discharge
• Bloodstained Vaginal Discharge
• Pre-syncopal Symptoms
• Haematuria
• Fever
• New Onset Dyspepsia
• Persistent Unexplained Vomiting
• Amenorrhoea
• Testicular Pain
• Clavicular Nodes
• Pain Awakening the Patient at Night

Potentially Life-Threatening Conditions

• MI
• Perforated Viscus
• Ruptured Abdominal Aortic Aneurysm
• Ectopic Pregnancy
• Acute Pancreatitis
• Acute Cholecystitis
• IBD
• Renal Stone
• Bowel Obstruction
• Diabetic Ketoacidosis
• PID
• Incarcerated Inguinal Hernia
• Pyelonephritis
• Ischaemic Colitis
• Acute Hepatic Failure
• Appendicitis
• Diverticulitis

Breast Anatomy & Physiology Review

• A review of breast anatomy and physiology is included in this study module.

Breast Assessment Process

• The assessment process includes a general survey, history taking, and a physical examination.