Physical Assessment Discussion 1. When inspecting the breasts of a female what abnormalities would be an indication of possible breast cancer? Increase in the size of the breast, nipple discharge, nipple retraction, enlarged nodes, presence of a non-tender lump or mass, fixation of one breast, and deviation in nipple pointing, hyperpigmentation, redness and heat with inflammation, dimpling or a pucker of the skin 2. Describe the appropriate way to tell a client how to perform self – breast exam?
NOTE: I have found an excellent place to watch videos and practice physical assessment skills. There are accepted practice videos, step by step viewing, practice challenges, documentation, etc. I have also included several specific links within my discussion below. If anyone is interested, it is as follows: http://www.atitesting.com/ati_next_ge n/skillsmodules/content/physicalassessmentadult/equipment.html?id=undefined.
Set aside a scheduled time each month for BSE. If you are still menstruating, the best time for BSE is 2 to 3 days after your period ends, when your breasts are less likely to be tender and swollen. If you have gone through menopause, whether naturally or surgically, pick a specific day of the month for this routine. It is very important that you make BSE a lifetime habit. Visual inspection Stand in front of a mirror with your upper body unclothed, and press both hands behind your head. Look for changes in the shape, color and size of your breasts. Check for dimples of the skin or “pulling in” of the nipples. Check for scaling or a rash on your nipples. Next, place your hands on your hips and tighten the chest muscles by pressing firmly inward while looking for any change from your breasts’ usual appearance. Perform this step while leaning slightly forward, then again while standing upright. Physical examination You may use 1 of 3 different methods — the circular method, the “wheel spokes” method, or the grid method. During breast self-exam, be sure to use the fat pads of the fingertips of the 3 middle fingers. Circular method Use the hand opposite the breast you are examining. Beginning at the outermost top of your breast, press the flat portions of the 2nd, 3rd, and 4th fingertips into your breast.
Physical Assessment Discussion
Moving in small circles slowly around your breast, work toward the nipple. Press firmly to feel deep tissues and gently to feel tissues under the skin. Be sure to cover the entire breast without skipping any areas. Repeat for your opposite breast. “Wheel spokes” method Imagine that your breast is divided into pie-shaped sections, much like spokes divide a wheel. Begin at the outermost top of the breast. Press the flat portions of the fingertips into your left breast, moving first toward the nipple, then away from the nipple. When you complete that section, slide your fingers slightly to the next area and repeat the process gradually moving around your entire breast. Repeat for your opposite breast. Vertical Strip Pattern Start high in the axilla and palpate down just lateral to the breast. Proceed in overlapping vertical lines ending at the sternal edge. In every pattern, take care to palpate every square inch of the breast and to examine the tail of Spence high into the axilla. Be consistent and thorough.
It is important that you choose the method that’s most comfortable for you, and use the same method each month. Whichever method you use, do not skip any areas of the breast. Check for lumps, thickening, or any change from the previous examination. Lying down To examine your left breast, using one of the 3 methods mentioned, lie flat on your back with a small pillow or a folded towel under your left shoulder. Raise your left arm over your head. Use the flat portions of the 2nd, 3rd, and 4th fingertips of your right hand to examine the left breast. Press firmly to feel deep tissues and more gently to feel tissues under the skin. Repeat the entire procedure for the right breast. In addition, be sure to check the area between the upper outer breast and your armpit as well as the armpit itself. Check the area just above your collarbone for enlarged lymph nodes. Pay special attention to the area between the breast and your armpit, including the armpit itself. Check the area just above your collarbone for enlarged lymph nodes.
Physical Assessment Discussion In the shower The next part of breast self-examination is performed in the shower, where the soapy, wet surface of the skin can make it easy to feel lumps. Breast self-examination in the shower is important because masses in the upper part of the breast are easier to detect while standing upright; masses in the lower part may be felt more easily while lying down. Place your left hand behind your head and, with the flat portions of the 2nd, 3rd, and 4th fingertips of the right hand, examine your entire left breast using 1 of the methods described. Repeat for your right breast. Changes in the breast It is important that you see your health care provider if you detect a lump or change in the breast, such as nipple discharge, change in texture, dimpling of the skin, or “pulling in” of the nipple. Eighty percent of all lumps found are normal tissue, benign (non-cancerous) cysts, or benign masses. Only your health care provider can determine the reason for the change. If you notice a change in your breast tissue, don’t wait. See your health care provider right away — even if you have had a negative mammogram in the past. 3. What are the primary muscles of respiration? The primary muscles of respiration include the external intercostal muscles (located between the ribs) and the diaphragm (a sheet of muscle located between the thoracic & abdominal cavities). The external intercostals plus the diaphragm contract to bring about inspiration. 4. How and why do you assess tactile fremitus? This is a palpable vibration. Use the palmar base (the ball) of the fingers of one hand and touch the person’s chest while he or she repeats the words “ninety-nine” or “blue moon.” Start over the lung apices and palpate from one side to another; the vibrations should feel the same in the corresponding area on each side. Typically, fremitus is most prominent between the scapulae and around the sternum, sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as you progress down because more and more tissue impedes sound transmission. Decreased fremitus occurs when anything obstructs transmission of vibrations. For example: obstructed bronchus, pleural effusions or thickening, pneumothorax, and emphysema. Increased fremitus occurs with compression or consolidation of lung tissue. For example: lobar pneumonia.
Physical Assessment Discussion 5. What technique is used when assessing breath sounds? Instruct the person to breathe through the mouth, a little bit deeper than usual. While standing behind the person, listen to the following lung area – posterior from the apices at C7 to the bases (around T10) and laterally from the axillae down to the seventh or eighth rib. Use the side – to – side sequence. You should expect to hear three types of normal breath sounds: bronchial (sometimes called tracheal or tubular), Broncho vesicular, and vesicular. NOTE: Link for respiratory examination skills. http://www.atitesting.com/ati_next_gen/skillsmodules/content/physical-assessmentadult/equipment/respiratory_assessment.html What is a potential cause of crackles? What do they sound like? Fine Crackles (formerly called rales) – high pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing; you can simulate this sound by rolling a strand of hair between your fingers near your ear or by moistening your thumb and index finger and separating them near your ear. Late inspiratory crackles occur with restrictive disease; pneumonia, heart failure, and interstitial fibrosis. Early inspiratory crackles occur with obstructive disease: chronic bronchitis, asthma, and emphysema. Posturally induced crackles (PIC’s) are fine crackles that appear with a change from sitting to the supine position or with a change from supine to supine with legs elevated. NOTE: Persistent fine crackles that are scattered over the chest occur with pneumonia, bronchiolitis, or atelectasis. If they are only in the upper lung fields: indicates cystic fibrosis. If they are only in the lower lung fields: indicates heart failure. Coarse Crackles (coarse rales) – Loud, low –pitched, bubbling and gurgling sounds that start in early inspiration and may be present in expiration; may decrease somewhat by suctioning or coughing but will reappear shortly – sounds like opening a Velcro fastener. Clinical examples include: pulmonary edema, pneumonia, pulmonary fibrosis, and the terminally ill who have a depressed cough reflex. Atelectatic Crackles (atelectatic rales) – Sounds like fine crackles but do not last and are not pathologic; disappear after the first few breaths; heard in axillae and bases (usually dependent) of lungs. These usually occur in again adults, in bedridden persons, or in persons just aroused from sleep. 6. What creates the S1 and S2 sounds of the cardiac cycle? Where do you hear S1 the loudest? S2?
Physical Assessment Discussion S1 (1st heart sound: lub) – occurs w/closure of the AV valve and thus signals the beginning of systole. You can hear S1 over all the precordium, but usually it is loudest at the apex. S2 (2nd heart sound: dub) – occurs w/closure of the semilunar valves and signals the end of systole. Although it is heard over all the precordium, S2 is loudest at the base. NOTE: Cardiac physical assessment skills link. http://www.atitesting.com/ati_next_gen/skillsmodules/content/physical-assessmentadult/equipment/cardiac.html 7. Where should you auscultate the apical pulse? (for this course always count apical for one minute) Auscultating should include the four traditional valve areas: 2nd right interspace – aortic valve area, 2nd left interspace – pulmonic valve area, (L) lower sternal border – tricuspid valve area, and 5th interspace at around (L) midclavicular line – mitral valve area. The valve areas are not over the actual anatomic locations of the valves but are the sites on the chest wall where sounds produced by the valves are best heard. The sound radiates w/the direction of blood flow. Auscultation should not be limited to only these 4 areas. Learn to inch the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. Or, start at the apex and work upwards including the above mentioned sites. Note: should also use the bell of the stethoscope to listen. NOTE: Here is a great place to watch short, quick video on each of the areas to auscultate: http://www.atitesting.com/ati_next_gen/skillsmodules/content/physical-assessmentadult/equipment/cardiac.html 8. The bell of the stethoscope is best for listening to what type sound? The bell end piece has a deep, hollow, cuplike shape. It is best for soft low-pitched sounds, such as extra heart sounds or murmurs. Hold it lightly against the person’s skin, just enough so it forms a perfect seal. Pressing harder causes the skin to act as a diaphragm, obliterating the lowpitched sounds. 9. Summarize the complete abdominal assessment on a healthy patient. What you should be doing and what are your findings. Inspection: includes contour, symmetry, skin, pulsation or movement, demeanor. Have person lie down on bed; get eye level with abdomen for observation. Observe for contour (flat, rounded, scaphoid, or protuberant). Look for symmetry. Statement example: “Abdomen flat and symmetrical.”
Physical Assessment Discussion Auscultation: include bowel sounds, vascular sounds. Listen to all 4 quadrants beginning in the RLQ using the diaphragm of the stethoscope. Example state “Bowel sounds present in all 4 quadrants.” Percussion: include all four quadrants, borders of liver and spleen. Percussion all 4 quadrants beginning at RLQ using Middle finger and taping with middle finger of other hand. Tympany should be heard throughout. Example state: “Bowel sounds active in all 4 quadrants. Tympany percussed in all 4 quadrants.” Palpation: include light palpation in all four quadrants, deep palpation in all four quadrants, liver, spleen, kidneys. : Lightly palpate all 4 quadrants beginning in RLQ. Example state: “Abdomen soft, no abnormalities palpated.” How does the abdominal assessment differ from the assessment of other body systems? Abdominal assessment is unique in that the order in which you implement the assessment techniques is different. When assessing most body systems, the appropriate order is inspection, palpation, percussion, and auscultation. However with the abdominal assessment, auscultate before you manipulate the abdomen with palpation and percussion. The rationale for this is that manipulation of the abdomen w/palpation and percussion may stimulate peristalsis and thereby alter your examination findings. So the appropriate order for the abdominal examination is inspection, then auscultation, followed by palpation and percussion. However, sometimes a child may not be cooperative during a physical examination. Percussion cannot always be accomplished in this instance. NOTE: Here is a couple of links for abdominal assessment skills. http://www.atitesting.com/ati_next_gen/skillsmodules/content/physical-assessmentchild/equipment/ap_abdominal.html http://www.atitesting.com/ati_next_gen/skillsmodules/content/physical-assessmentadult/equipment/ad_exam.html 10. What is JVD? How do you assess for JVD? Inspect for jugular-vein distention (called jugular venous distention, or JVD), found when blood flow refluxes, or flows backward, from the right atrium into the jugular veins. To check for JVD. Position the patient supine w/head elevated at about a 45 degree angle. Then ask the patient to turn head to one side, while you observe his neck, looking for a pulsation. Shining tangential light onto the neck may be helpful in visualizing a pulsation. If you do see a pulsation, determine whether it is generated by a carotid pulse or it reflects JVD. An easy way to tell is to palpate the radial pulse while watching his neck. If you see a single pulsation in his neck that coincides
Physical Assessment Discussion w/the radial pulse, you are not observing JVD; you are seeing just the carotid pulse. Jugulovenous pulsations occur in several waves w/each cardiac cycle. Gently pressing over the vessel proximal to the neck pulsation may also be useful. Jugular pulsation is easily obliterated by gentle pressure, while a carotid pulse is not. Remember, you should not press on both sides of the neck at the same time. Normally, the jugular veins are not distended when the head is elevated at 45 degrees. What does it mean, specifically related to the heart, if the patient exhibits JVD? Unilateral distention could be due to local cause like kinking or aneurysm. Full distention signifies increased central venous pressure (CVP) as with heart failure. NOTE: Here is a link to a JVD assessment. http://www.atitesting.com/ati_next_gen/skillsmodules/content/physical-assessmentadult/equipment/head_face_neck_exam.html
References Breast Self-Exam (BSE). (2012, August 1). Retrieved from http://www.upmc.com/patientsvisitors/education/cancer/pages/breast-self-exam.aspx Jarvis, C. (2008). Physical examination & health assessment (6th ed., pp. 383 - 498). St. Louis, Mo.: Saunders/Elsevier. Physical assessment (adult). (n.d.). Retrieved from http://www.atitesting.com/ati_next_gen/skillsmodules/content/physical-assessmentadult/about.html?id=undefined