Breast Abdomen & Genitourinary Assessment PDF

Breast Assessment Abdominal & Genitalia Assessment "Copyrighted material contained herein is reproduced under ss. 29-29.4 of the Canadian Copyright Act. This document is available for your individual use; further distribution may infringe copyright”. Breasts Breast General Survey, Health Histo...

Breast Assessment Abdominal & Genitalia Assessment "Copyrighted material contained herein is reproduced under ss. 29-29.4 of the Canadian Copyright Act. This document is available for your individual use; further distribution may infringe copyright”. Breasts Breast General Survey, Health History, ROS Health history How would you ask questions about breast health? ◦ Changes? ◦ Concerns? ◦ Cyclical or ongoing? Risk Factors for breast cancer: https://www.mycanceriq.ca/Cancers/Breast http://plastytalk.com/wp-content/uploads/2014/10/simona-halep-before-breast-reduction-surgery.jpg Inspect Observe Disrobed To the Waist ◦ Breast areola and nipple ◦ Size, Symmetry, Shape ◦ Skin (Redness, Swelling, Ulcers, Edema) ◦ Masses ◦ Discharge ◦ Gynecomastia Move to diagnostic imaging Breast Development Thelarche – the beginning of adult breast development signaling the start of puberty. ◦ USA 8.8-10.3 years ◦ 8.9-11.5 years Asia ◦ 9.8-10.8 years Europe ◦ 10.1-13.2 years Africa https://jamanetwork.com/journals/jamapediatrics/fullarticle/2760573 https://ars.els-cdn.com/content/image/1-s2.0-S0091218298000652-gr3.gif Average time between Tanner stage 2 and 5 is 4-4.5 years. Palpate Breasts and Lymphnodes Horizontal pattern across the breast tissue Lymphatic assessment Into axilla for Tail of Spence Breast Cancer Most breast findings are not cancer Most common area for cancerous findings ◦ Tail of Spence ◦ Upper lateral quadrant  Know Your Body Canadian Cancer Society (2023) Recommends a “Know Your Breasts” approach. https://cancer.ca/en/cancer-information/find-cancer-early/know-your-body/know-your-breasts Know your breasts “All women should be aware of what is normal for their breasts even if they get regular screening tests. Many women find their own breast cancer by noticing changes in the look and feel of their breasts. Women can become familiar with their breast tissue by looking at and feeling their breasts. In the past, experts suggested that women should do this in a certain way each month. Research shows that this isn’t necessary. There really isn’t a right or wrong way for women to examine their breasts. They just need to know the whole area of their breast tissue well enough to notice changes. This includes the entire breast area up to the collarbone and under the armpits, as well as the nipples. Tell your doctor about any unusual changes to your breasts. Most breast changes are not cancer. It may be normal for your breasts to be lumpy or tender before your period. Clinical Breast Exam: “A clinical breast exam (CBE) is a thorough examination of your breasts by a trained healthcare professional. It is used to check for abnormalities. Research has not shown that CBE is an effective screening tool, but it may still help doctors find an abnormality in the breast or armpit (also called the axilla)”.  Breast Cancer and Men Less than 1% of breast cancers in men (just over 200 new cases/year in Canada) Usually detected when a man finds a lump in his chest under or near the nipple or in the armpit Delay in care seeking often results in more advanced disease at diagnosis. Most often over 60 years. Risk Factors Include: Radiation Exposure, High Estrogen Levels, Family History https://s-media-cache-ak0.pinimg.com/originals/0e/87/73/0e87739a858a5a39c8a0b7a0eaee25b3.jpg http://www.cancer.ca/en/cancer-information/cancer-type/breast/breast-cancer/breast-cancer-in-men/?region=on Red Flags Breast Changes as discussed already Mastitis Breast infection Galactorrhoea: a milky nipple discharge unrelated to the usual milk production of breastfeeding Gynecomastia Persistent discharge in newborn https://www.slideshare.net/tejasvicharan/neonatal-mastitis-03 Abdomen & Genitourinary GI/GU Link Shared autonomic and somatic (S2-S4) innervation Bowels affect bladder Common signs and symptoms ◦ Nausea and vomiting ◦ Diarrhea ◦ Abdominal discomfort/distention ◦ Difficult to diagnose, especially in children and elderly Pain: ◦ Kidney – costovertebral angle ◦ Bladder - Suprapubic ◦ Ureteral – Costovertebral angle, flank, lower abdominal, testis or labium ◦ Prostatic – Perineum and rectum ◦ Urethral – Along penis to meatus or urethra to meatus http://cdn.qdnurses.com/wp-content/uploads/2016/03/stomach-pain-locations.jpg?x76037 Giddens (2017) Concepts Homeostasis and Regulation ◦ Fluid and electrolytes ◦ Acid base balance ◦ Glucose regulation ◦ Hormonal Regulation ◦ Nutrition ◦ Elimination Protection and Movement ◦ Immunity ◦ Inflammation ◦ Infection ◦ Mobility ◦ Tissue Integrity ◦ Sensory Perception ◦ Pain Sexuality and Reproduction ◦ Reproduction ◦ Sexuality Giddens (2017, p. 159) Putting things Together Abdominal assessment spans many systems ◦ Neuro ◦ GI ◦ From the oral cavity (outside of the abdominal cavity) down to stomach & intestines ◦ Accessory organs (e.g.. Liver, pancreas) ◦ Endocrine ◦ Pancreas, adrenal glands Head to Toe ◦ Hematopoietic/Lymphatic ◦ Spleen ◦ Cardiovascular + ◦ Major vessels & Kidneys ◦ Urinary ◦ Kidneys, ureters & bladder Systems Thinking! ◦ Kidneys regulate blood pressure = cardiovascular system ◦ Reproductive ◦ Spermatic cord, testes; uterus & ovaries General Survey Mesha on TicTok Health History (Systems GI) Pain Nausea & vomiting Dysphagia Diet patterns Regurgitation, GERD, peptic ulcer disease, indigestion, belching Change in bowel habits: diarrhea, constipation, flatulence, melena Hemorrhoids Colonoscopy Jaundice, pruritus Family history (e.g.. Colon cancer, GERD, IBD, celiac disease?) Travel  Health History (Systems GU) Promote patient comfort Genitalia - female ◦ Menstruation (duration, flow, regularity, frequency), Urinary Tract LMP__, ◦ Frequency (polyuria), blood (hematuria), changes? ◦ Contraceptives ◦ Hesitancy, nocturnal urination (nocturia), ◦ Vaginal changes/discharge incontinence? ◦ Pregnancy (OB assessment in future course) ◦ Burning? pain? (dysuria), back pain? Genitalia – male ◦ Pain, discharge, trauma Medications? ◦ Changes in function (dysfunction) ◦ Testicular discomfort Use of contraception? ◦ PSA/Prostate Exam Sexually Transmitted Infections (STI)? Sexual History HPV Immunization? ◦ Changes in libido ◦ Sexual life Abdominal findings: pain Where is the appendix (usually)? McBurney’s Point ASIS (2/3 of the way http://www.healthhype.com/wp-content/uploads/appendix_location.jpg Landmarking: Quadrants vs Regions Landmarking: quadrants Landmarking: Major Arteries Landmarking: PNS & MSK Ilistrations by Christy Krames https://www.aafp.org/afp/2018/1001/p429.html Landmarking Genitourinary http://image.slidesharecdn.com/reproductivesystemsofmalefemale-130123042026-phpapp02/95/reproductive- systems-of-male-female-10-638.jpg?cb=1358915347 Physical Assessment: IAPP! Inspection Auscultation Percussion Palpation https://en.wikipedia.org/wiki/Abdominal_examination Physical assessment: Abdomen Positioning ◦ Supine ◦ Pregnant females not supine; roll under right side (left lateral recumbent position about 30 degrees). ◦ Expose entire abdomen and drape accordingly ◦ Explain what you are going to do ◦ And explain what you are doing while assessing http://www.dnatube.com/thumb/1_9110.jpg Inspection: Expose the abdomen Inspection Skin ◦ Color/visible veins, moisture, temperature, texture, scars Overall impression ◦ Size, shape/contour, symmetry, bulges/inflammation/masses Umbilicus Deep inhale ◦ Assess: movement, symmetry, masses Urinary: urine is clear & light yellow BM (stool): soft, shape of intestines, & light brown If emesis: contents and appearance Inspection: Skin Inspection: Shape/contour Inspection: Hernias https://my.clevelandclinic.org/health/diseases/15757-hernia  Inspection: Jaundice Ascites >500 mL of extravascular peritoneal fluid; confirm with ‘shifting dullness’ percussion assessment technique Fluid wave – not specific https://floatbizimages.s3.amazonaws.com/actual/565325374ec0a624a4d0ef54.jpg  Auscultation: Bowel Sounds Indicates bowel motility ◦ Use stethoscope diaphragm ◦ RLQ & proceed clockwise ◦ Listen for clicks, gurgles and occasional borborygmi“ ◦ All four quadrants” Normal: ◦ Peristalsis sounds ◦ 5-30 sounds/minute ◦ RLQ most active – ileocecal area No sounds ◦ Do 5 minute auscultation in one place. Bowel sounds are WIDELY transmitted! https://www.youtube.com/watch?v=9U-kiOFdyfQ Auscultation: Vascular Sounds Bruits ◦ Hypertension pts./narrowing of arteries from atherosclerosis ◦ Aorta (midline) https://www.youtube.com/watch?v=PrlTdsJ7lWg ◦ Renal arteries (RUQ & LUQ) ◦ Iliac arteries (RLQ & LLQ) ◦ Systole, extend into diastole, or continuous FYI: Venous hum: continuous sound, may also lightly palpate if found Hepatic Friction Rub: movement of liver during respiration Splenic Friction Rub: Movement of spleen during respiration Percussion Percuss to assess organ size & tenderness: ◦ Liver (anterior percussion) ◦ Spleen (anterior percussion) ◦ Kidneys (posterior percussion) ◦ Ascites presence Liver percussion 1. Percuss from: ◦ RMCL, 3rd ICS & move down ◦ Note when dullness begins 2. Percuss from: ◦ RMCL, at umbilicus & move up ◦ Note when dullness begins Mean Liver Size by Percussion ◦ 7 cm women ◦ 10.5 cm men Normal finding: dullness (liver) btw 5-7th ICS  Splenic percussion Supine position & Elevate left arm Expected size: 8-10 cm, Location: left axillary, 9-11th rib Castell’s Method: ◦ Find last intercostal space, left anterior axillary line ◦ 1) Percuss on expiration – 2) Have client inhale and hold – 3)Percuss ◦ Expiration = Resonant or tympany ◦ Inspiration = Positive if Dull; expected is resonant or tympany (no change) ◦ Sensitivity 82%, specificity 83% http://lh3.ggpht.com/bharatsiddharth/SOUh0i1PAsI/AAAAAAAAAaw/dNtnLOTD_v0/traube%20space%5B5%5D.jpg?imgmax=800 Bladder Percussion (FYI) Percuss from Umbilicus to Pelvic Brim FYI Bladder Scanner Used to Assess Residual https://download.e-bookshelf.de/download/0000/5952/91/L-X-0000595291-0001346903.XHTML/images/c01f003.jpg Kidney percussion http://healthfixit.com/kidney-pain-and-location http://www.buzzle.com/img/articleImages/603315-42730-54.jpg Palpation Light palpation: ◦ 1-2 cm depression ◦ Use finger pads & dipping motion ◦ RLQ & proceed clockwise ◦ All 4 quadrants ◦ Note: ◦ Guarding ◦ Masses ◦ character, location ◦ Tenderness (grimacing) Deep Palpation (know but practice is beyond this course!) ◦ Murphy’s sign (RUQ) – gallbladder disease ◦ Rosving’s sign - appendicitis ◦ Liver (RUQ) ◦ Spleen - should not be palpable Anatomical Thinking While Palpating! Palpation Tips If tensing muscles ◦ Bend knees ◦ Palpate on expiration Ticklish – hand over yours If you note a mass in the suprapubic region ◦ Note: distended bladder is palpable in this region – make sure patient has voided prior to abdominal assessment! http://biology-forums.com/gallery/2137_21_07_12_7_29_44.jpeg Palpation: Inguinal Nodes Gloves Horizontal Nodes ◦ Inferior & parallel to the inguinal ligament. ◦ Palpate from symphysis pubis to ASIS Vertical Nodes ◦ Medial to femoral canal from superior ramus to 5 cm distally Expected Findings ◦ Non-tender and slightly palpable ◦ Less than 2 cm http://images.slideplayer.com/25/8042650/slides/slide_19.jpg  The Rectum & Stool Inspection ◦ Anus (fissures, fistulas, hemorrhoids, tumors, warts) ◦ Stool https://upload.wikimedia.org/wikipedia/commons/thumb/9/9e/BristolStoolChart.png/370px-BristolStoolChart.png Rectum Palpation Sphincter: tone (S2-S4), stenosis, blood, mucus, polyps, masses Digital Rectal Exam (DRE) ◦ lots of water soluble lubrication ◦ feel for smooth walls ◦ note masses, pain, bleeding ◦ prostate (see GU) ◦ check examining finger ◦ Stool characteristics, blood https://www.hemorrhoidinformationcenter.com/hemorrhoid-treatment/ Further tests Blood work FIT (Fecal Immunochemical Test) Ultrasound Colonoscopy CT scan MRI https://i.ytimg.com/vi/5CISERO2FlA/hqdefault.jpg Red Flag: Acute abdomen Rebound tenderness = more pain when palpation withdrawn Appendicitis ◦ Pain at umbilicus – toward RLQ (McBurney’s Point) ◦ Rovsing sign: Deep palpation in LLQ, quick withdraw of this stimuli, elicits rebound tenderness in RLQ Peritonitis ◦ Abdominal Surgery ◦ Ectopic Pregnancy ◦ Perforation ◦ Trauma ◦ Ulcer ◦ Appendix ◦ Diverticulum What other findings? http://vignette2.wikia.nocookie.net/muppet/images/2/24/Vets210.jpg/revision/latest?cb=20060912171833 http://www.belmarrahealth.com/wp-content/uploads/2015/06/iprove-digestion.jpg Focus on GU Urine Output/Fluid Balance We lose water through sweat, activity, exhaling, in urine & feces. Adequate intake depends on gender, age, air temperature, activity levels, vomiting/diarrhea. Adults need a minimum of 1500 ml/day Children need 100 ml/kg/24 hr first 10kg, 50 next 10kg, 20 rest up to 2400ml total (4, 2, 1 rule) Red Flag Oliguria: