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NR 509 Final Exam Study Guide.
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NR 509 Final Exam Study GuideChapter 18 Breasts and Axillae
Techniques of examina 琀椀 on
o Arms over head
Can bring out dimpling or retrac 琀椀 on that may be invisible Palpate the br
Best with pt. supine
A thorough examina 琀椀 on takes at least three minutes
Use the ver 琀椀 cal strip pa 琀琀 ern to detect breast mass
Palpate in small, concentric circles applying light, medium, and deep pressu
each examining point
When pressing deeply on the breast a normal rib can be mistaken for a hard
breast mass
To palpate lateral breast, ask pa 琀椀 ent to roll onto the opposite hip,
placing hand on her forehead but keeping the shoulder pressed against the
bed or examining table as this 昀氀 a 琀琀 ens the lateral breast 琀椀 ssue.
To palpate the medial por 琀椀 on of the breast, have pt. lie 昀氀 at with should
against the examining table
Inspect the axillae
Palpate the axillary nodes
By moving in a straight line down the bra line, then move 椀 昀 ngers
medially and palpate in a ver 琀椀 cal trip up the chest to the
clavicle.
Anatomy
o
Female breast/axillae assessment
o Breast lump or mass
Can be physiologic or pathologic ranging from cysts and 椀 昀 broadenomas to
cancer
o Breast cyst
Usually 昀椀 rm, round, mobile, and o 昀琀 en tender, mostly common betwee 25-50
years old
o Breast discomfort or pain
SSRI, Haldol, Aldactone, and dig can cause breast pain Nipple discharge
o
Lymph nodes
o The lympha 琀椀 c drainage of the breast is of great importance in the spread of ca
and about three-quarters of it is to the axillary nodes.
Central nodes (axillary)
o
The male breast
o Gynecomas 琀椀 a: males who develop benign breast enlargement. Causes include i
estrogen, decreased testosterone, and medica 琀椀 on side e 昀 ects
o Inspect the nipple and areola (nodules, swelling, ulcera 琀椀 on)
o Palpate the areola and breast 琀椀 ssue (nodules)
Breast cancer (including screening and risk factors)
, o Redness suggests local infec 琀椀 on or in 氀 昀 ammatory carcinoma Thickening and
pores suggests breast cancer
o Fla 琀� ng of the normally convex breasts suggest cancer Asymmetry in nipple dire
suggests cancer
o Eczematous changes with rash scaling or ulcera 琀椀 on on the nipple extending to
suggests Paget disease
o Inverted nipple suggest cancer
o Breast dimpling or retrac 琀椀 on suggest cancer
o Milky discharge unrelated to pregnancy is nonpuerperal galactorrhea
Caused by hypothyroidism, pituitary prolac 琀椀 noma, and dopamine antago
o Risk factors
Increasing age 65+ un 琀椀 l age 80
Biopsy: con 昀椀 rmed atypical hyperplasia
First-degree family members diagnosed with breast cancer at an early age
Inherited gene 琀椀 c muta 琀椀 ons- BRCA 1 and BRCA2
Personal history of breast cancer or ductal or lobular carcinoma
Rela 琀椀 vely denser breasts on mammography
High-dose radia 琀椀 on to the chest at a young
age High levels of endogenous hormones
Age at 昀椀 rst full term pregnancy
Late menopause
o Modi 昀椀 able risk factors
Breas 琀昀 eeding for less than 1 year, postmenopausal obesity, use of HRT,
alcohol consump 琀椀 on, physical inac 琀椀 vity, and type of contracep 琀椀
on.
Clinical breast examina 琀椀 on (CBE) and self-breast examina 琀椀 on (SBE) techniques
o The best 琀椀 me is in a pa 琀椀 ent who is s 琀椀 ll menstrua 琀椀 ng 5-7 days a 琀 昀 e
menstrua 琀椀 on because breasts tend to swell and become more nodular before m
o Inspect breasts in four views: arms at sides, arms over head, arms pressed against h
and leaning forward.
o Breast self-examina 琀椀 on
A high propor 琀椀 on of breast masses are detected by women examining th
breasts. For screening, the BSE has not been shown to reduce breast cancer
mortality but may promote health awareness and earlier repor 琀椀 ng of bre
changes or masses, which may reduce unnecessary tes 琀椀 ng and biopsies
compared to monthly self-examina 琀椀 on. The BSE is best 琀椀 med 5 to 7
menses, when hormonal s 琀椀 mula 琀椀 on of breast 琀椀 ssue is low.
Physiologic changes associated with the normal aging process
o Fibroadenoma
very mobile, round dislike, typically small (1-2cm), 昀椀 rm, usually single bu
well delineated. 15-25 years, puberty.
o Cyst
mobile, round, well delineated, so 昀琀 to 昀椀 rm, single, 30-50 years.
o Cancer
may be 椀 昀 xed to the skin or underlying 琀椀 ssues, usually single, irregular in
shape, 椀 昀 rm or hard, most common over age of 50
Lacta 琀椀 on
o
,Chapter 19 Abdomen
Techniques of examina 琀椀 on
o Di 昀 eren 琀椀 als for epigastric pain
GERD
Pancrea 琀椀琀椀 s
Perforated ulcers
MI
o Abdomen
Note the general appearance
Inspect the surface, contours, and movements of the abdomen including skin
temp, color, and scares or striae
Ecchymosis is seen in intraperitoneal or retroperitoneal hemorrhage.
Asymmetry suggests a hernia, enlarged organ or a mass.
Bulging 昀氀 anks of ascites, suprapubic bulge, large liver or spleen, tu
Peristalsis waves
Increased in GI obstruc 琀椀
on Listen for bowel sounds
Less than 5 per minute is considered hypoac 琀椀 ve >34 a minute is
considered hyperac 琀椀 ve
Fric 琀椀 on rubs
Liver tumor or splenic infarct
Percuss in all four quadrants
A tympanic abdomen throughout suggests intes 琀椀 nal obstruc 琀椀 o
paraly 琀椀 c ileus.
Palpate lightly then deeply
Palpa 琀椀 ng an abdominal mass
Occasionally there are masses in the abdominal wall rather than
inside the abdominal cavity.
Ask the pa 琀椀 ent to either raise the head and shoulders or to
strain down, this 琀椀 ghtens the abdominal muscles, then feel
the mass again.
Check for signs of peritoni 琀椀 s
o Liver
Es 琀椀 mate the size along the right midclavicular line by percussion
Palpate and characterize the liver edge
In chronic liver disease an enlarged palpable liver edge below the ribs is
sugges 琀椀 ve of an enlarged liver and cirrhosis
Firmness or hardness of the liver, bluntness or rounding of its edge, and surf
irregularity are suspicious for liver disease
An obstructed distended gallbladder may merge with the liver, forming a 昀
椀
oval mass below the liver edge and an area that is dull to percussion
There is increased dullness with percussion in hepatomegaly from acute
hepa 琀椀琀椀 s, heart failure, decreased dullness in cirrhosis
Hepa 琀椀 c bruit in carcinoma of the liver and alcoholic hepa 琀椀琀椀 s.
o Spleen
, Percuss for splenic enlargement along the traube space
Palpate the splenic edge with the pa 琀椀 ent supine and in the right lateral
decubitus posi 琀椀 on (lying on the right side with legs 昀氀 exed at hips and
A change in percussion note from tympany to dullness on inspira 琀椀 on is a
posi 琀椀 ve splenic percussion sign, but this sign is only moderately useful fo
detec 琀椀 ng splenomegaly
Splenomegaly is 8 琀椀 mes more likely when the spleen is palpable
Caused by portal hypertension, hematologic malignancies, HIV infec 琀椀 on,
in 昀椀 ltra 琀椀 ve diseases like amyloidosis and splenic infarct or hematoma
o Kidneys
Check for costovertebral angle (CVA) tenderness (Flank pain)
Tenderness in pyelonephri 琀椀 s
Pain with pressure or 昀椀 st percussion supports pyelonephri 琀椀 s if associat
fever and dysuria but may also be MSK
o Urinary bladder
Blood in urine can be caused by BPH, urolithiasis, UTI, or prostate, bladder,
kidney cancer.
Percuss for disten 琀椀 on and tenderness
Suprapubic tenderness is common in bladder infec 琀椀 on
Pink-purple striae are a hallmark of Cushing syndrome
Forms on incon 琀椀 nence
Stress incon 琀椀 nence
the urethral sphincter is weakened so that transient increases i
intra-abdominal pressure raise the bladder pressure to levels
that exceed urethral resistance.
Causes
childbirth, surgery, postmenopausal atrophy of
the mucosa, and urethral infec 琀椀 on. May follow
prostate surgery in men.
Urge incon 琀椀 nence
detrusor contrac 琀椀 ons are stronger than normal and overcom
the normal urethral resistance. The bladder is usually small.
Mechanisms
decreased cor 琀椀 cal inhibi 琀椀 on of detrusor
contrac 琀椀 ons from stroke, brain tumor,
demen 琀椀 a, and lesions of the spinal cord above
the sacral level. Also, hyperexcitability of
sensory pathways ie: bladder infec 琀椀 ons tumor
and fecal impac 琀椀 on. Decondi 琀椀 oning of voi
re 氀 昀 exes, such as frequent voluntary voiding at low
bladder volumes.
Over 氀 昀 ow incon 琀椀 nence
detrusor contrac 琀椀 ons are insu 昀 cient to overcome urethral
resistance, causing urinary reten 琀椀 on. The bladder is typical
accid and large, even a 昀琀 er e 昀昀 ort to void.
Mechanisms
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