Fundamentals of Nursing

Auscultation

Auscultation of the heart detects normal heart sounds, extra heart sounds, and murmurs. Concentrate on detecting low-intensity sounds created by valve closures. To begin auscultation eliminate all sources of room noise and explain the procedure to reduce the patient’s anxiety. Follow a systematic pattern, beginning at the aortic area and inching the stethoscope across each of the anatomical sites. Listen for the complete cycle (“lub-dub”) of heart sounds clearly at each location. Repeat the sequence using the bell of the stethoscope. Sometimes you will have a patient assume three different positions during the examination to hear sounds clearly (Fig. 30-40, A to C): sitting up and leaning forward (good for all areas and to hear high-pitched murmurs), supine (good for all areas), and left lateral recumbent (good for all areas; best position to hear low-pitched sounds in diastole).

FIG. 30-40 Sequence of patient positions for heart auscultation. A, Sitting. B, Supine. C, Left lateral recumbent. (From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)

Learn to identify the first (S₁) and second (S₂) heart sounds. At normal rates S₁ occurs after the long diastolic pause and preceding the short systolic pause. S₁ is high pitched, dull in quality, and heard best at the apex. If it is difficult to hear S₁, time it in relation to the carotid pulsation. S₂ follows the short systolic pause and precedes the long diastolic pause; it is best heard at the aortic area.

Auscultate for rate and rhythm after hearing both sounds clearly. Each combination of S₁ and S₂ or “lub-dub” counts as one heartbeat. Count the rate for 1 minute and listen for the interval between S₁ and S₂ and then the time between S₂ and the next S₁. A regular rhythm involves regular intervals of time between each sequence of beats. There is a distinct silent pause between S₁ and S₂. Failure of the heart to beat at regular successive intervals is a dysrhythmia. Some dysrhythmias are life threatening.

When assessing an irregular heart rhythm, compare apical and radial pulse rates simultaneously to determine if a pulse deficit exists. Auscultate the apical pulse first and then immediately palpate the radial pulse (one-examiner technique). Assess the apical and radial rates at the same time when two examiners are present. When a patient has a pulse deficit, the radial pulse is slower than the apical pulse because ineffective contractions fail to send pulse waves to the periphery. Report a difference in pulse rates to the health care provider immediately.

Assess for extra heart sounds at each auscultatory site. Use the bell of the stethoscope and listen for low-pitched extra heart sounds such as S₃ and S₄ gallops, clicks, and rubs. Auscultate over all anatomical areas. S₃, or a ventricular gallop, occurs after S₂. It is caused by a premature rush of blood into a ventricle that is stiff or dilated as a result of heart failure and hypertension. The combination of S₁, S₂, and S₃ sounds like “Ken-tuck’-y.”

S₄, or an atrial gallop, occurs just before S₁ or ventricular systole. The sound of an S₄ is similar to that of “Ten’-es-see.” Physiologically it is caused by an atrial contraction pushing against a ventricle that is not accepting blood because of heart failure or other alterations. You can hear extra heart sounds more easily with the patient lying on the left side and the stethoscope at the apical site.

The final portion of the examination includes assessment for heart murmurs. Murmurs are sustained swishing or blowing sounds heard at the beginning, middle, or end of the systolic or diastolic phase. They are caused by increased blood flow through a normal valve, forward flow through a stenotic valve or into a dilated vessel or heart chamber, or backward flow through a valve that fails to close. A murmur is asymptomatic or a sign of heart disease (Box 30-19). They are common in children. Keep the following factors in mind when auscultating to detect murmurs:

Box 30-19 Patient Teaching

Heart Assessment

Objective

• Patient will describe risk factors for heart disease and take appropriate steps to eliminate risks from lifestyle.

Teaching Strategies

• Explain risk factors for heart disease, including high dietary intake of saturated fat or cholesterol, lack of regular aerobic exercise, smoking, excess weight, stressful lifestyle, hypertension, and family history of heart disease.

• Refer patient (if appropriate) to resources available for controlling or reducing risks (e.g., nutritional counseling, exercise class, stress reduction programs).

• Teach patient to reduce dietary intake of cholesterol and saturated fats. Explain that approximately 70% to 75% of saturated fatty acids come from meats, poultry, fish, and dairy products. The American Heart Association (2011) recommends a diet that includes an intake that limits total fat to less than 25% to 35% of total calories, saturated fats to less than 7% of daily calories, trans fats to less than 1% of calories, and cholesterol to less than 300 mg/day.

• Encourage patient to have total blood cholesterol levels and triglycerides measured regularly. Desirable levels are less than 200 mg/100 mL. You need more than one cholesterol measurement to assess the blood cholesterol level accurately. Low-density lipoprotein (LDL) cholesterol is the major component of atherosclerotic plaques. Separate measurement of LDL cholesterol is wise in a patient with high total blood cholesterol levels. In an individual with no other risk factors, an LDL cholesterol level of 160 mg/100 mL or higher is high risk (Moore, 2005).

• Encourage patient to discuss with health care provider the need for periodic C-reactive protein (CRP) testing. CRP levels assess a patient’s risk for cardiovascular disease.

• Advise patient to avoid cigarette smoke because nicotine causes vasoconstriction.

• Advise patient to quit smoking because this lowers the risk for coronary heart disease and coronary vascular disease (ACS, 2011).

• Patients who are at risk benefit from taking a daily low dose of aspirin. Consult health care provider before starting therapy.

Evaluation

• Ask patient to identify risk factors for heart disease.

• Have patient develop a meal plan low in saturated fat and cholesterol.

• Check patient’s cholesterol level during follow-up appointments at the clinic or physician’s office.

• Ask patient to describe ways he or she has chosen to reduce cardiac risk factors.

• When a murmur is detected, auscultate the mitral, tricuspid, aortic, and pulmonic valve areas for placement in the cardiac cycle (timing); the place it is heard best (location); radiation; loudness; pitch; and quality.

• If a murmur occurs between S₁ and S₂, it is a systolic murmur.

• If it occurs between S₂ and the next S₁, it is a diastolic murmur.

• The location of a murmur is not necessarily directly over the valves. Experience with hearing murmurs helps with better understanding of where each type of murmur is best heard. For example, mitral murmurs are best heard at the apex of the heart.

• To assess for radiation, listen over areas in addition to where it is heard best. Murmurs can also be heard over the neck or back.

• Intensity or loudness is related to the rate of blood flow through the heart or the amount of blood regurgitated. Feel for a thrust or intermittent palpable sensation at the auscultation site in serious murmurs. A thrill is a continuous palpable sensation that resembles the purring of a cat. Intensity is recorded using the following grades (Seidel et al., 2011):

Grade 1: Barely audible in a quiet room

Grade 2: Clearly audible but quiet

Grade 3: Moderately loud

Grade 4: Loud, with associated thrill

Grade 5: Very loud, thrill easily palpable

Grade 6: Louder, may be heard without stethoscope; thrill palpable and visible

• A murmur is low, medium, or high in pitch, depending on the velocity of blood flow through the valves. A low-pitched murmur is best heard with the bell of the stethoscope. If the murmur is best heard with the diaphragm, the murmur is high pitched.

The quality of a murmur refers to its characteristic pattern and sound. A crescendo murmur starts softly and builds in loudness. A decrescendo murmur starts loudly and becomes less intense.

Vascular System

Examination of the vascular system includes measuring the blood pressure (see Chapter 29) and assessing the integrity of the peripheral vascular system. Table 30-24 reviews the nursing history data collected before the examination. Use the skills of inspection, palpation, and auscultation. Perform portions of the vascular examination during other body system assessments. For example, check the carotid pulse after palpating the cervical lymph nodes. Note signs and symptoms of arterial and venous insufficiency when assessing the skin.

TABLE 30-24

Nursing History for Vascular Assessment

ASSESSMENT	RATIONALE
Determine if patient experiences leg cramps; numbness or tingling in extremities; sensation of cold hands or feet; pain in legs; or swelling or cyanosis of feet, ankles, or hand.	These signs and symptoms indicate vascular disease.
If patient experiences leg pain or cramping in lower extremities, ask if walking or standing for long periods or during sleep aggravate or relieve it.	Relationship of symptoms to exercise clarifies whether problem is vascular or musculoskeletal. Pain caused by vascular condition tends to increase with activity. Musculoskeletal pain usually is not relieved when exercise ends.
Ask patients if they wear tight-fitting garters, socks, or hosiery and sit or lie in bed with legs crossed.	Tight hosiery around lower extremities and crossing legs can impair venous return.
Reconsider previous heart risk factors (e.g., smoking, exercise, nutritional problems).	These predispose patient to vascular disease.
Assess medical history for heart disease, hypertension, phlebitis, diabetes, or varicose veins.	Circulatory and vascular disorders influence findings gathered during examination.

Blood Pressure

When auscultating blood pressure, know that readings between the arms vary by as much as 10 mm Hg and tend to be higher in the right arm (Seidel et al., 2011). Always record the higher reading. Repeated systolic readings that differ by 15 mm Hg or more suggest atherosclerosis or disease of the aorta.

Carotid Arteries

When the left ventricle pumps blood into the aorta, the arterial system transmits pressure waves. The carotid arteries reflect heart function better than peripheral arteries because their pressure correlates with that of the aorta. The carotid artery supplies oxygenated blood to the head and neck (Fig. 30-41). The overlying sternocleidomastoid muscle protects it.

FIG. 30-41 Anatomical position of carotid artery.

To examine the carotid arteries, have the patient sit or lie supine with the head of the bed elevated 30 degrees. Examine one carotid artery at a time. If both arteries are occluded simultaneously during palpation, the patient loses consciousness as a result of inadequate circulation to the brain. Do not palpate or massage the carotid arteries vigorously because the carotid sinus is located at the bifurcation of the common carotid arteries in the upper third of the neck. This sinus sends impulses along the vagus nerve. Its stimulation causes a reflex drop in heart rate and blood pressure, which causes syncope or circulatory arrest. This is a particular problem for older adults.

Begin inspection of the neck for obvious pulsation of the artery. Have the patient turn the head slightly away from the artery being examined. Sometimes the wave of the pulse is visible. The carotid is the only site for assessing the quality of a pulse wave. An absent pulse wave indicates arterial occlusion (blockage) or stenosis (narrowing).

To palpate the pulse ask the patient to look straight ahead or turn the head slightly toward the side you are examining. Turning relaxes the sternocleidomastoid muscle. Slide the tips of the index and middle fingers around the medial edge of the sternocleidomastoid muscle. Gently palpate to avoid occlusion of circulation (Fig. 30-42).

FIG. 30-42 Palpation of internal carotid artery along margin of sternocleidomastoid muscle.

The normal carotid pulse is localized and strong rather than diffuse. It has a thrusting quality. As the patient breathes, no change occurs. Rotation of the neck or a shift from a sitting to a supine position does not change the quality of the carotid impulse. Both carotid arteries are normally equal in pulse rate, rhythm, and strength and are equally elastic. Diminished or unequal carotid pulsations indicate atherosclerosis or other forms of arterial disease.

The carotid is the most commonly auscultated pulse. Auscultation is especially important for middle-age or older adults or patients suspected of having cerebrovascular disease. When the lumen of a blood vessel is narrowed, it disturbs blood flow. As blood passes through the narrowed section, it creates turbulence, causing a blowing or swishing sound. The blowing sound is called a bruit (pronounced “brew-ee”) (Fig. 30-43).

FIG. 30-43 Occlusion or narrowing of the carotid artery disrupts normal blood flow. The resultant turbulence creates a sound (bruit) that is auscultated.

Place the bell of the stethoscope over the carotid artery at the lateral end of the clavicle and the posterior margin of the sternocleidomastoid muscle. Have the patient turn his or her head slightly away from the side being examined (Fig. 30-44). Ask him or her to hold the breath for a moment so breath sounds do not obscure a bruit. Normally you do not hear any sounds during carotid auscultation. Palpate the artery lightly for a thrill (palpable bruit) if you hear a bruit.

FIG. 30-44 Auscultation for carotid artery bruit. (From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)

Jugular Veins

The most accessible veins for examination are the internal and external jugular veins in the neck. Both veins drain bilaterally from the head and neck into the superior vena cava. The external jugular vein lies superficially and is just above the clavicle. The internal jugular vein lies deeper, along the carotid artery.

It is best to examine the right internal jugular vein because it follows a more direct anatomical path to the right atrium of the heart. The column of blood inside the internal jugular vein serves as a manometer, reflecting pressure in the right atrium. The higher the column, the greater is the venous pressure. Raised venous pressure reflects right-sided heart failure.

Normally, when a patient lies in the supine position, the external jugular vein distends and becomes easily visible. In contrast, the jugular veins normally flatten when the patient changes to a sitting or standing position. However, for some patients with heart disease the jugular veins remain distended when sitting.

To measure venous pressure, first inspect the jugular veins. Venous pressure is influenced by blood volume, the capacity of the right atrium to receive blood and send it to the right ventricle and the ability of the right ventricle to contract and force blood into the pulmonary artery. Any factor resulting in greater blood volume within the venous system results in elevated venous pressure. Assess venous pressure by using the following steps:

1. Ask the patient to lie supine with the head elevated 30 to 45 degrees (semi-Fowler’s position).

2. Expose the neck and upper thorax. Use a pillow to align the head. Avoid neck hyperextension or flexion to ensure that the vein is not stretched or kinked (Fig. 30-45).

FIG. 30-45 Position of patient to assess jugular vein distention. (From Thompson JM et al: Mosby’s manual of clinical nursing, ed 5, St Louis, 2001, Mosby.)

3. Usually pulsations are not evident with the patient sitting up. As he or she slowly leans back into a supine position, the level of venous pulsations begins to rise above the level of the manubrium as much as 1 or 2 cm ( to 1 inch) as the patient reaches a 45-degree angle. Measure venous pressure by measuring the vertical distance between the angle of Louis and the highest level of the visible point of the internal jugular vein pulsation.

4. Use two rulers. Line up the bottom edge of a regular ruler with the top of the area of pulsation in the jugular vein. Then take a centimeter ruler and align it perpendicular to the first ruler at the level of the sternal angle. Measure in centimeters the distance between the second ruler and the sternal angle (Fig. 30-46).

FIG. 30-46 Measuring jugular venous pressure. (From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)

5. Repeat the same measurement on the other side. Bilateral pressures higher than 2.5 cm (1 inch) are considered elevated and are a sign of right-sided heart failure. One-sided pressure elevation is caused by obstruction.

Peripheral Arteries and Veins

To examine the peripheral vascular system, first assess the adequacy of blood flow to the extremities by measuring arterial pulses and inspecting the condition of the skin and nails. Next, assess the integrity of the venous system. Assess the arterial pulses in the extremities to determine sufficiency of the entire arterial circulation.

Factors such as coagulation disorders, local trauma or surgery, constricting casts or bandages, and systemic diseases impair circulation to the extremities (Table 30-25). Discuss risk factors and ways to monitor for circulatory problems with the patient (Box 30-20).

Box 30-20 Patient Teaching

Vascular Assessment

Objective

• Patient with vascular insufficiency will avoid activities that worsen circulatory status.

Teaching Strategies

• Instruct patient with risk or evidence of vascular insufficiency in the lower extremities to avoid tight clothing over the lower body or legs, avoid sitting or standing for long periods, avoid sitting with legs crossed, walk regularly, and elevate feet when sitting.

• Advise patient to avoid or stop cigarette smoking because nicotine causes vasoconstriction. Offer a referral to a reliable stop smoking program.

• Identify patient with hypertension about the benefits of regular monitoring of blood pressure (daily, weekly, or monthly). Teach patient how to use home monitoring kits.

Evaluation

• Ask patient to identify if blood pressure reading is within normal limits for age.

• Have patient with vascular insufficiency describe precautions to take to avoid further circulatory deficiency.

• Have patient demonstrate self-monitoring of blood pressure.

TABLE 30-25

Indicators for Assessing Local Blood Flow

INDICATOR	RATIONALE
Systemic diseases (e.g., arteriosclerosis, atherosclerosis, diabetes).	Diseases result in changes in integrity of walls of arteries and smaller blood vessels.
Coagulation disorders (e.g., thrombosis, embolus).	Blood clot causes mechanical obstruction to blood flow.
Local trauma or surgery (e.g., contusion, fracture, vascular surgery).	Direct manipulation of vessels or localized edema impairs blood flow.
Application of constricting devices (e.g., casts, dressings, elastic bandages, restraints).	Constriction causes tourniquet effect, impairing blood flow to areas below site of constriction.

Peripheral Arteries

Examine each peripheral artery using the distal pads of your second and third fingers. The thumb helps anchor the brachial and femoral artery. Apply firm pressure but avoid occluding a pulse. When a pulse is difficult to find, it helps to vary pressure and feel all around the pulse site. Be sure not to palpate your own pulse.

Routine vital signs usually include assessment of the rate and rhythm of the radial artery because it is easily accessible. Count the pulse for either 30 seconds or a full minute, depending on the character of the pulse (see Chapter 29). Always count an irregular pulse for 60 seconds. With palpation, normally feel the pulse wave at regular intervals. When an interval is interrupted by an early, a late, or a missed beat, the pulse rhythm is irregular. During cardiac emergencies health care providers usually assess the carotid artery because it is accessible and most useful in evaluating heart activity. To check local circulatory status of tissues (e.g., when a leg cast is in place or following vascular surgery), palpate the peripheral arteries long enough to note that a pulse is present.

Assess each peripheral artery for elasticity of the vessel wall, strength, and equality. The arterial wall is normally elastic, making it easily palpable. After depressing the artery, it springs back to shape when releasing the pressure. An abnormal artery is hard, inelastic, or calcified.

The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. Some examiners use a scale rating from 0 to 4+ for the strength of a pulse (Seidel et al., 2011):

0: Absent, not palpable

1+: Pulse diminished, barely palpable

2+: Expected/normal

3+: Full pulse, increased

4+: Bounding pulse

Measure all peripheral pulses for equality and symmetry. Compare the left radial pulse with that of the right and so on. Lack of symmetry indicates impaired circulation such as a localized obstruction or an abnormally positioned artery.

In the upper extremities the brachial artery channels blood to the radial and ulnar arteries of the forearm and hand. If circulation in this artery becomes blocked, the hands do not receive adequate blood flow. If circulation in the radial or ulnar arteries becomes impaired, the hand still receives adequate perfusion. An interconnection between the radial and ulnar arteries guards against arterial occlusion (Fig. 30-47).

FIG. 30-47 Anatomical positions of brachial, radial, and ulnar arteries.

To locate pulses in the arm have the patient sit or lie down. Find the radial pulse along the radial side of the forearm at the wrist. Thin individuals have a groove lateral to the flexor tendon of the wrist. Feel the radial pulse with light palpation in the groove (Fig. 30-48). The ulnar pulse is on the opposite side of the wrist and feels less prominent (Fig. 30-49). Palpate the ulnar pulse only when evaluating arterial insufficiency to the hand.

FIG. 30-48 Palpation of radial pulse.

FIG. 30-49 Palpation of ulnar pulse.

To palpate the brachial pulse, find the groove between the biceps and triceps muscle above the elbow at the antecubital fossa (Fig. 30-50). The artery runs along the medial side of the extended arm. Palpate it with the fingertips of the first three fingers in the muscle groove.

FIG. 30-50 Palpation of brachial pulse.

The femoral artery is the primary artery in the leg, delivering blood to the popliteal, posterior tibial, and dorsalis pedis arteries (Fig. 30-51). An interconnection between the posterior tibial and dorsalis pedis arteries guards against local arterial occlusion.

FIG. 30-51 Anatomical position of femoral, popliteal, dorsalis pedis, and posterior tibial arteries.

Find the femoral pulse with the patient lying down with the inguinal area exposed (Fig. 30-52). The femoral artery runs below the inguinal ligament, midway between the symphysis pubis and the anterosuperior iliac spine. Sometimes deep palpation is necessary to feel the pulse. Bimanual palpation is effective in obese patients. Place the fingertips of both hands on opposite sides of the pulse site. Feel a pulsatile sensation when the arterial pulsation pushes the fingertips apart.

FIG. 30-52 Palpation of femoral pulse.

The popliteal pulse runs behind the knee. Have the patient slightly flex the knee with the foot resting on the examination table or assume a prone position with the knee slightly flexed (Fig. 30-53). Instruct him or her to keep leg muscles relaxed. Palpate with the fingers of both hands deeply into the popliteal fossa, just lateral to the midline. The popliteal pulse is difficult to locate.

FIG. 30-53 Palpation of popliteal pulse.

With the patient’s foot relaxed, locate the dorsalis pedis pulse. The artery runs along the top of the foot in line with the groove between the extensor tendons of the great toe and first toe (Fig. 30-54). To find the pulse, place the fingertips between the first and second toes and slowly move up the dorsum of the foot. This pulse is sometimes congenitally absent.

FIG. 30-54 Palpation of dorsalis pedis pulse.

Find the posterior tibial pulse on the inner side of each ankle (Fig. 30-55). Place the fingers behind and below the medial malleolus (ankle bone). With the foot relaxed and slightly extended, palpate the artery.

FIG. 30-55 Palpation of posterior tibial pulse.

Ultrasound Stethoscopes: If a pulse is difficult to palpate, an ultrasound (Doppler) stethoscope is a useful tool that amplifies the sounds of a pulse wave. Factors that weaken a pulse or make palpation difficult include obesity, reduction in the stroke volume of the heart, diminished blood volume, or arterial obstruction. Apply a thin layer of transmission gel to the patient’s skin at the pulse site or directly onto the transducer tip of the probe. Turn on the volume control and place the tip of the transducer at a 45- to 90-degree angle on the skin (Fig. 30-56). Move the transducer until you hear a pulsating “whooshing” sound that indicates that arterial blood flow is present.

FIG. 30-56 Ultrasound stethoscope in position on brachial artery.

Tissue Perfusion: The condition of the skin, mucosa, and nail beds offers useful data about the status of circulatory blood flow. Examine the face and upper extremities, looking at the color of the skin, mucosa, and nail beds. The presence of cyanosis requires special attention. Heart disease sometimes causes central cyanosis, which indicates poor arterial oxygenation. Some characteristics of this are a bluish discoloration of the lips, mouth, and conjunctivae. Blue lips, earlobes, and nail beds are signs of peripheral cyanosis, which indicates peripheral vasoconstriction. When cyanosis is present, consult with a health care provider to request laboratory testing of oxygen saturation to determine the severity of the problem. Examination of the nails involves inspection for clubbing, a bulging of the tissues at the nail base. Clubbing is caused by insufficient oxygenation at the periphery resulting from conditions such as chronic emphysema and congenital heart disease.

Inspect the lower extremities for changes in color, temperature, and condition of the skin, indicating either arterial or venous alterations (Table 30-26). This is a good time to ask the patient about any history of pain in the legs. If an arterial occlusion is present, the patient has signs resulting from an absence of blood flow. Pain is distal to the occlusion. The five Ps—pain, pallor, pulselessness, paresthesias, and paralysis—characterize an occlusion. Venous congestion causes tissue changes that indicate an inadequate circulatory flow back to the heart.

TABLE 30-26

Signs of Venous and Arterial Insufficiency

ASSESSMENT CRITERION	VENOUS	ARTERIAL
Color	Normal or cyanotic	Pale; worsened by elevation of extremity; dusky red when extremity is lowered
Temperature	Normal	Cool (blood flow blocked to extremity)
Pulse	Normal	Decreased or absent
Edema	Often marked	Absent or mild
Skin changes	Brown pigmentation around ankles	Thin, shiny skin; decreased hair growth; thickened nails

During examination of the lower extremities, also inspect skin and nail texture; hair distribution on the lower legs, feet, and toes; the venous pattern; and scars, pigmentation, or ulcers. Palpate the legs and feet for color and temperature. Capillary refill, traditionally used to determine adequacy of peripheral blood flow to the digits, has limited value. More useful information is gained from grading pulses, assessing for color and warmth, and assessing pulses with a Doppler (Dufault et al., 2008).

The absence of hair growth over the legs indicates circulatory insufficiency. Remember not to confuse absence of hair on the legs with shaved legs. In addition, men who wear tight-fitting dress socks or jeans may have less hair on their calves. Chronic recurring ulcers of the feet or lower legs are a serious sign of circulatory insufficiency and require a health care provider’s intervention.

Peripheral Veins

Assess the status of the peripheral veins by asking the patient to assume sitting and standing positions. Assessment includes inspection and palpation for varicosities, peripheral edema, and phlebitis. Varicosities are superficial veins that become dilated, especially when the legs are in a dependent position. They are common in older adults because the veins normally fibrose, dilate, and stretch. They are also common in people who stand for prolonged periods. Varicosities in the anterior or medial part of the thigh and the posterolateral part of the calf are abnormal.

Dependent edema around the area of the feet and ankles is a sign of venous insufficiency or right-sided heart failure. It is common in older adults and people who spend a lot of time standing (e.g., waitresses, security guards, and nurses). To assess for pitting edema, use the index finger to press firmly for several seconds and release over the medial malleolus or the shins. A depression left in the skin indicates edema. Grading 1+ through 4+ characterizes the severity of the edema (see Fig. 30-6).

Phlebitis is an inflammation of a vein that occurs commonly after trauma to the vessel wall, infection, immobilization, and prolonged insertion of IV catheters. To assess for phlebitis in the leg, inspect the calves for localized redness, tenderness, and swelling over vein sites. Gentle palpation of calf muscles reveals warmth, tenderness, and firmness of the muscle. Unilateral edema of the affected leg is one of the most reliable findings of phlebitis. Determine if dorsiflexion of the foot (Homans’ sign) causes pain in the calf. However, Homans’ sign is not always a reliable indicator of phlebitis or deep vein thrombosis (DVT) and is present in other conditions (Seidel et al., 2011). Performing the Homans’ sign test is contraindicated in patients with DVT. If a clot is present in the leg, it may become dislodged from its original site during this test, resulting in a pulmonary embolism.

Lymphatic System

Assess the lymphatic drainage of the lower extremities during examination of the vascular system or during the female or male genital examination. Superficial and deep nodes drain the legs, but only two groups of superficial nodes are palpable. With the patient supine, palpate the area of the superficial inguinal nodes in the groin area (Fig. 30-57, A). Then move the fingertips toward the inner thigh, feeling for any inferior nodes. Use a firm but gentle pressure when palpating over each lymphatic chain. Multiple nodes are not normally palpable, although a few soft, nontender nodes are not unusual. Enlarged, hardened, tender nodes reveal potential sites of infection or metastatic disease.

FIG. 30-57 A, Lymphatic drainage for the lower extremities. B, Lymphatic drainage for upper extremities. (From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)

In the upper extremities lymph is carried by the collecting ducts from the upper extremities to the subclavian lymphatic trunk. To assess this lymph system, gently palpate the epitrochlear nodes, located on the medial aspect of the arms near the antecubital fossa (Fig. 30-57, B). The proximal portion of the upper-extremity lymph system is located in the axilla and is usually assessed during examination of the breasts.

Breasts

It is important to examine the breasts of both female and male patients. Men have a small amount of glandular tissue, a potential site for the growth of cancer cells, in the breast. In contrast, the majority of the female breast is glandular tissue.

Female Breasts

New cases of invasive breast cancer were predicted to affect 230,480 women in the United States in 2011, with 2140 new cases expected in men (ACS, 2011). The disease is second to lung cancer as the leading cause of death in women with cancer. Early detection is the key to cure. A major responsibility for nurses is to teach patients health behaviors such as breast self-examination (BSE) (Box 30-21).

Box 30-21

Breast Self-Examination

Patients should perform breast self-examination (BSE) once a month to become familiar with the usual appearance and feel of both breasts. Familiarity makes it easier to notice any changes in the breast from one month to another. Early discovery of a change from baseline is the purpose of BSE.

If menstruating, the best time to do BSE is 2 or 3 days after the monthly period ends, when breasts are least likely to be tender or swollen. If no longer menstruating, pick a day such as the first day of the month as a reminder to do BSE. Instructions for BSE:

1. Stand before a mirror. Inspect both breasts for anything unusual such as discharge from the nipples, puckering, dimpling, or scaling of the skin.

The next two steps are designed to emphasize any change in the shape or contour of the breasts. During each step the patient will feel chest muscles tighten.

2. Watching closely in the mirror, clasp hands behind the head, and swing elbows forward.

3. Press hands firmly on hips and bow slightly toward the mirror while pulling shoulders and elbows forward.

Some women do the next part of the examination in the shower. Fingers glide over soapy skin, making it easy to appreciate the texture underneath.

4. Raise the left arm. Use three or four fingers of the right hand to explore the left breast firmly, carefully, and thoroughly. Beginning at the outer edge, press the flat part of the fingers in small circles, moving the circles slowly around the breast. Gradually work toward the nipple. Be sure to cover the entire breast. Pay special attention to the area between the breast and the armpit, including the armpit itself. Feel for any unusual lump or mass under the skin.

5. Gently squeeze the nipple and look for discharge. Repeat the examination on the right breast.

6. Repeat steps 4 and 5 lying down. Lie flat on back, right arm over the head and a pillow or folded towel under the right shoulder. This position flattens the breast and makes it easier to examine. Use the same circular motion described earlier.

7. Repeat on the right breast.

From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.

If the patient already performs BSE, assess the method she uses and times she does the examination in relation to her menstrual cycle. The best time for a BSE is the fourth through seventh day of the menstrual cycle or right after the menstrual cycle ends, when the breast is no longer swollen or tender from hormone elevations. If the woman is postmenopausal, advise her to check her breasts on the same day each month. The pregnant woman should also check her breasts on a monthly basis.

Older women require special attention when reviewing the need for regular BSE. Fixed incomes limit many older women; thus they fail to pursue regular clinical breast examination and mammography. Unfortunately many older women ignore changes in their breasts, assuming that they are a part of aging. In addition, physiological factors affect the ease with which older women perform a BSE. Musculoskeletal limitations, diminished peripheral sensation, reduced eyesight, and changes in joint range of motion (ROM) limit palpation and inspection abilities. Find resources for older women, including free screening programs. Teach family members to perform the patient’s examination.

The American Cancer Society (ACS, 2011) recommends the following guidelines for the early detection of breast cancer:

• Monthly BSE is an option for women in their 20s.

• Women 20 years of age and older need to report any breast changes to a health care provider immediately.

• Women need a clinical breast examination by a health care provider every 3 years from ages 20 to 40 and annually for women over age 40.

• Women with a family history of breast cancer need an annual examination by a health care provider.

• Asymptomatic women need a screening mammogram by age 40; women age 40 and over need to have a mammogram annually.

• For women at increased risk, the ACS recommends talking with the health care provider for screening options and additional testing.

The patient’s history (Table 30-27) reveals normal developmental changes and signs of breast disease. Because of its glandular structure, the breast undergoes changes during a woman’s life. Knowing these changes (Box 30-22) allows complete and accurate assessment. Encourage both men and women to observe their breasts for changes.

Box 30-22

Normal Changes in the Breast During a Woman’s Life Span

Puberty (8 to 20 Years)

Breasts mature in five stages. One breast may grow more rapidly than the other. The ages at which changes occur and rate of developmental progression vary.

Stage 1 (Preadolescent)

This stage involves elevation of the nipple only.

Stage 2

The breast and nipple elevate as a small mound, and the areolar diameters enlarge.

Stage 3

There is further enlargement and elevation of the breast and areola, with no separation of contour.

Stage 4

The areola and nipple project into the secondary mound above the level of the breast (does not occur in all girls).

Stage 5 (Mature Breast)

Only the nipple projects, and the areola recedes (varies in some women).

Young Adulthood (20 to 30 Years)

Breasts reach full (nonpregnant) size. Shape is generally symmetrical. Breasts are sometimes unequal in size.

Pregnancy

Breast size gradually enlarges to 2 to 3 times the previous size. Nipples enlarge and become erect. Areolas darken, and diameters increase. Superficial veins become prominent. The nipples expel a yellowish fluid (colostrum).

Menopause

Breasts shrink. Tissue becomes softer, sometimes flabby.

Older Adulthood

Breasts become elongated, pendulous, and flaccid as a result of glandular tissue atrophy. The skin of the breasts tends to wrinkle, appearing loose and flabby.

Nipples become smaller and flatter and lose erectile ability. They sometimes invert because of shrinkage and fibrotic changes.

Data from Ebersole P et al: Toward healthy aging, ed 7, St Louis, 2008, Mosby; Hockenberry MJ, Wilson D: Wong’s nursing care of infants and children, ed 9, St Louis, 2011, Mosby; and Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.

TABLE 30-27

Nursing History for Breast Assessment

ASSESSMENT	RATIONALE
Determine if woman is over age 40; has a personal or family history of breast cancer, early-onset menarche (before age 13), or late-age menopause (after age 50); has never had children or gave birth to first child after age 30; or has recently used oral contraceptives.	These are risk factors for breast cancer (American Cancer Society [ACS], 2011).
Ask if patient (both sexes) has noticed lump, thickening, pain, or tenderness of breast; discharge, distortion, retraction, or scaling of the nipple; or change in size of breast.	Potential signs and symptoms of breast cancer allow nurse to focus on specific areas of breast during assessment.
Determine patient’s use of medications (oral contraceptives, digitalis, diuretics, steroids, or estrogen). Determine his or her caffeine intake.	Some medications cause nipple discharge. Hormones and caffeine cause fibrocystic changes in breast.
Determine patient’s level of activity, alcoholic intake, and weight.	Breast cancer incidence rates correlate with being overweight or obese (postmenopausal), physical inactivity, and consumption of one or more alcoholic beverages per day (ACS, 2011).
Ask if patient performs monthly breast self-examination (BSE). If so, determine time of month she performs examination in relation to menstrual cycle. Have her describe or demonstrate method used.	Nurse’s role is to educate patient about breast cancer and techniques for BSE.
If patient reports a breast mass, ask about length of time since she first noticed the lump. Does lump come and go, or is it always present? Have there been changes in the lump (e.g., size, relationship to menses), and are there associated symptoms?	Assessment helps to determine nature of mass (e.g., breast cancer vs. fibrocystic disease).

Inspection

Have the patient remove the top gown or drape to allow simultaneous visualization of both breasts. Have her stand or sit with her arms hanging loosely at her sides. If possible, place a mirror in front of her during inspection so she sees what to look for when performing a BSE. To recognize abnormalities the patient needs to be familiar with the normal appearance of her breasts. Describe observations or findings in relation to imaginary lines that divide the breast into four quadrants and a tail. The lines cross at the center of the nipple. Each tail extends outward from the upper outer quadrant (Fig. 30-58).

FIG. 30-58 Quadrants of left breast and axillary tail of Spence. (From Seidel HM et al: Mosby’s guide to physical examination, ed 6, St Louis, 2006, Mosby.)

Inspect the breasts for size and symmetry. Normally they extend from the third to the sixth ribs, with the nipple at the level of the fourth intercostal space. It is common for one breast to be smaller. However, inflammation or a mass causes a difference in size. As a woman becomes older, the ligaments supporting the breast tissue weaken, causing the breasts to sag and the nipples to lower.

Observe the contour or shape of the breasts and note masses, flattening, retraction, or dimpling. Breasts vary in shape from convex to pendulous or conical. Retraction or dimpling can result from invasion of underlying ligaments by tumors. The ligaments fibrose and pull the overlying skin inward toward the tumor. Edema also changes the contour of the breasts. To bring out retraction or changes in the shape of breasts, ask the patient to assume three positions: raise arms above the head, press hands against the hips, and extend arms straight ahead while sitting and leaning forward. Each maneuver causes a contraction of the pectoral muscles, which accentuates the presence of any retraction.

Carefully inspect the skin for color; venous pattern; and the presence of lesions, edema, or inflammation. Lift each breast when necessary to observe lower and lateral aspects for color and texture changes. The breasts are the color of neighboring skin, and venous patterns are the same bilaterally. Venous patterns are easily visible in thin or pregnant women. Women with large breasts often have redness and excoriation of the undersurfaces caused by rubbing of skin surfaces.

Inspect the nipple and areola for size, color, shape, discharge, and the direction in which the nipples point. The normal areolas are round or oval and nearly equal bilaterally. Color ranges from pink to brown. In light-skinned women the areola turns brown during pregnancy and remains dark. In dark-skinned women the areola is brown before pregnancy (Seidel et al., 2011). Normally the nipples point in symmetrical directions, are everted, and have no drainage. If the nipples are inverted, ask if this has been a lifetime history. A recent inversion or inward turning of the nipple indicates an underlying growth. Rashes or ulcerations are not normal on the breast or nipples. Note any bleeding or discharge from the nipple. Clear yellow discharge 2 days after childbirth is common. While inspecting the breasts, explain the characteristics you see. Teach the patient the significance of abnormal signs or symptoms.

Palpation

Palpation assesses the condition of underlying breast tissue and lymph nodes. Breast tissue consists of glandular tissue, fibrous supportive ligaments, and fat. Glandular tissue is organized into lobes that end in ducts that open onto the surface of the nipple. The largest portion of glandular tissue is in the upper outer quadrant and tail of each breast. Suspensory ligaments connect to skin and fascia underlying the breast to support the breast and maintain its upright position. Fatty tissue is located superficially and to the sides of the breast.

A large portion of lymph from the breasts drains into axillary lymph nodes. If cancerous lesions metastasize (spread), the nodes commonly become involved. Study the location of supraclavicular, infraclavicular, and axillary nodes (Fig. 30-59). The axillary nodes drain lymph from the chest wall, breasts, arms, and hands. A tumor of one breast sometimes involves nodes on the same and opposite sides.

FIG. 30-59 Anatomical position of axillary and clavicular lymph nodes.

To palpate the lymph nodes have the patient sit with her arms at her sides and muscles relaxed. While facing the patient and standing on the side you are examining, support her arm in a flexed position, and abduct it from the chest wall. Place the free hand against the patient’s chest wall and high in the axillary hollow. With the fingertips press gently down over the surface of the ribs and muscles. Palpate the axillary nodes with the fingertips, gently rolling soft tissue (Fig. 30-60). Palpate four areas of the axilla: at the edge of the pectoralis major muscle along the anterior axillary line, the chest wall in the midaxillary area, the upper part of the humerus, and the anterior edge of the latissimus dorsi muscle along the posterior axillary line.

FIG. 30-60 Support patient’s arm and palpate axillary lymph nodes. (From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)

Normally lymph nodes are not palpable. Carefully assess each area and note their number, consistency, mobility, and size. One or two small, soft, nontender palpable nodes are normal. An abnormal palpable node feels like a small mass that is hard, tender, and immobile. Continue to palpate along the upper and lower clavicular ridges. Reverse the procedure for the patient’s other side.

It is sometimes difficult for a patient to learn to palpate for lymph nodes. Lying down with the arm abducted makes the area more accessible. Instruct the patient to use her left hand for the right axillary and clavicular areas. Take the patient’s fingertips and move them in the proper fashion. Then have the patient use her right hand to palpate for nodes on the left side.

With the patient lying supine and one arm under the head and neck (alternating with each breast), palpate her breast tissue. The supine position allows the breast tissue to flatten evenly against the chest wall. The position of the arm and hand further stretches and positions breast tissue evenly (Fig. 30-61, A). Place a small pillow or towel under the patient’s shoulder blade to further position breast tissue. Palpate the tail of Spence (Fig. 30-61, B).

FIG. 30-61 A, The patient lies flat with arm abducted and hand under head to help flatten breast tissue evenly over the chest wall. B, Each breast is palpated in a systematic fashion. (B from Seidel HM et al: Mosby’s guide to physical examination, ed 6, St Louis, 2006, Mosby.)

The consistency of normal breast tissue varies widely. The breasts of a young patient are firm and elastic. In an older patient the tissue sometimes feels stringy and nodular. A patient’s familiarity with the texture of her own breasts is very important. Patients gain familiarity through monthly BSE (Box 30-23).

Box 30-23 Patient Teaching

Female Breast Assessment

Objective

• Patient will follow prevention and detection practices to ensure breast health.

Teaching Strategies

• Have patient perform return demonstration of breast self-examination (BSE) and offer the opportunity to ask questions.

• Explain recommended frequency of mammography and assessment by a health care provider.

• Discuss signs and symptoms of breast cancer.

• Discuss signs and symptoms of benign (fibrocystic) breast disease.

• Inform a woman who is obese or has a family history of breast cancer that she is at higher risk for the disease (ACS, 2011). Encourage dietary changes, including limiting meat consumption to well-trimmed, lean beef, pork, or lamb; removing skin from cooked chicken before eating it; selecting tuna and salmon packed in water and not oil; and using low-fat dairy products.

• Encourage patient to reduce intake of caffeine and theophyllines. Although this approach is controversial, it can reduce symptoms of benign (fibrocystic) breast disease.

Evaluation

• Have patient demonstrate BSE.

• During follow-up visit, determine whether patient has had mammography performed.

• Ask patient to explain frequency of mammography.

• Have patient describe signs and symptoms of breast cancer compared with benign (fibrocystic) breast disease.

If the patient complains of a mass, examine the opposite breast to ensure an objective comparison of normal and abnormal tissue. Use the pads of the first three fingers to compress breast tissue gently against the chest wall, noting tissue consistency. Perform palpation systematically in one of three ways: (1) clockwise or counterclockwise, forming small circles with the fingers along each quadrant and the tail; (2) using a vertical technique with the fingers moving up and down each quadrant; or (3) palpating from the center of the breast in a radial fashion, returning to the areola to begin each spoke (Fig. 30-62, A to C). Whichever approach you use, be sure to cover the entire breast and tail, directing attention to any areas of tenderness. Use a bimanual technique when palpating large, pendulous breasts. Support the inferior portion of the breast in one hand while using the other hand to palpate breast tissue against the supporting hand.

FIG. 30-62 Various methods for palpation of breast. A, Palpate from top to bottom in vertical strips. B, Palpate in concentric circles. C, Palpate out from center in wedge sections. (From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)

During palpation note the consistency of breast tissue. It normally feels dense, firm, and elastic. With menopause breast tissue shrinks and becomes softer. The lobular feel of glandular tissue is normal. The lower edge of each breast sometimes feels firm and hard. This is the normal inframammary ridge and not a tumor. It helps to move the patient’s hand so she can feel normal tissue variations. Palpate abnormal masses to determine location in relation to quadrants, diameter in centimeters, shape (e.g., round or discoid), consistency (soft, firm, or hard), tenderness, mobility, and discreteness (clear or unclear boundaries).

Cancerous lesions are hard, fixed, nontender, irregular in shape, and usually unilateral. A common benign condition of the breast is benign (fibrocystic) breast disease. Bilateral lumpy, painful breasts and sometimes nipple discharge characterize this condition. Symptoms are more apparent during the menstrual period. When palpated the cysts (lumps) are soft, well differentiated, and movable. Deep cysts feel hard.

Give special attention to palpating the nipple and areola. Palpate the entire surface gently. Use the thumb and index finger to compress the nipple and note any discharge. During the examination of the nipple and areola, the nipple sometimes becomes erect with wrinkling of the areola. These changes are normal. Continue by positioning the patient and examining the other breast.

After completing the examination, have the patient demonstrate self-palpation. Observe the patient’s technique and emphasize the importance of a systematic approach. Urge the patient to see her health care provider if she discovers an abnormal mass during routine monthly BSE. She also needs to know all of the signs and symptoms of breast cancer.

Male Breasts

Examination of the male breast is relatively easy. Inspect the nipple and areola for nodules, edema, and ulceration. An enlarged male breast results from obesity or glandular enlargement. Breast enlargement in young males results from steroid use. Fatty tissue feels soft, whereas glandular tissue is firm. Use the same techniques to palpate for masses used in examination of the female breast. Because breast cancer in men is relatively rare, routine self-examinations are unnecessary. However, men who have a first-degree relative (e.g., mother or sister) with breast cancer, are at risk for breast cancer and need to palpate their breasts at regular intervals. Men at high risk may be scheduled by their health care provider for routine mammograms.

Abdomen

The abdominal examination is complex because of the number of organs located within and near the abdominal cavity. A thorough nursing history (Table 30-28) helps interpret physical signs. The examination includes an assessment of structures of the lower gastrointestinal (GI) tract in addition to the liver, stomach, uterus, ovaries, kidneys, and bladder. Abdominal pain is one of the most common symptoms that patients report when seeking medical care. An accurate assessment requires matching patient history data with a careful assessment of the location of physical symptoms.

TABLE 30-28

Nursing History for Abdominal Assessment

ASSESSMENT	RATIONALE
If patient has abdominal or low back pain, assess character of pain in detail (location, onset, frequency, precipitating factors, aggravating factors, type of pain, severity, course).	Pattern of characteristics of pain helps determine its source.
Carefully observe patient’s movement and position, including lying still with knees drawn up, moving restlessly to find comfortable position, and lying on one side or sitting with knees drawn to chest.	Positions assumed by patient reveal nature and source of pain, including peritonitis, renal stone, and pancreatitis.
Assess normal bowel habits and stool character; ask if patient uses laxatives.	Data compared with physical findings help identify cause and nature of elimination problems.
Determine if patient has had abdominal surgery, trauma, or diagnostic tests of gastrointestinal (GI) tract.	Surgical or traumatic alterations of abdominal organs cause changes in expected findings (e.g., position of underlying organs). Diagnostic tests change character of stool.
Assess if patient has had recent weight changes or intolerance to diet (e.g., nausea, vomiting, cramping, especially in last 24 hours).	Data possibly indicate alterations in upper GI tract (stomach or gallbladder) or lower colon.
Assess for difficulty in swallowing, belching, flatulence (gas), bloody emesis (hematemesis), black or tarry stools (melena), heartburn, diarrhea, or constipation.	These characteristic signs and symptoms indicate GI alterations.
Ask if patient takes antiinflammatory medication (e.g., aspirin, ibuprofen, steroids) or antibiotics.	Pharmacological agents cause GI upset or bleeding.
Ask patient to locate tender areas before examination begins.	Assess painful areas last to minimize discomfort and anxiety.
Inquire about family history of cancer, kidney disease, alcoholism, hypertension, or heart disease.	Data possibly reveal risk for alterations identifiable during examination.
Determine if female patient is pregnant; note last menstrual period.	Pregnancy causes changes in abdominal shape and contour.
Assess patient’s usual intake of alcohol.	Chronic alcohol ingestion causes gastrointestinal and liver problems.
Review patient’s history for the following: health care occupation, hemodialysis, intravenous drug user, household or sexual contact with hepatitis B virus (HBV) carrier, heterosexual person with more than one sex partner in previous 6 months, sexually active homosexual or bisexual male, international traveler in area of high HBV infection rate.	Risk factors for HBV exposure.

Assess the organs anteriorly and posteriorly. A system of landmarks help map out the abdominal region. The xiphoid process (tip of the sternum) is the upper boundary of the anterior abdominal region. The symphysis pubis marks the lower boundary. Divide the abdomen into four imaginary quadrants (Fig. 30-63, A); refer to assessment findings and record them in relation to each quadrant. Posteriorly the lower ribs and heavy back muscles protect the kidneys, which are located from the T12 to L3 vertebrae (Fig. 30-63, B). The costovertebral angle formed by the last rib and vertebral column is a landmark used during kidney palpation.

FIG. 30-63 A, Anterior view of abdomen divided by quadrants. B, Posterior view of abdominal section.

During the abdominal examination the patient needs to relax. A tightening of abdominal muscles hinders palpation. Ask the patient to void before beginning. Be sure that the room is warm and drape upper chest and legs. The patient lies supine or in a dorsal recumbent position with the arms at the sides and knees slightly bent. Place small pillows beneath the knees. If the patient places the arms under the head, the abdominal muscles tighten. Proceed calmly and slowly, being sure that there is adequate lighting. Expose the abdomen from just above the xiphoid process down to the symphysis pubis. Warm hands and stethoscope further promote relaxation. Ask the patient to report pain and point out tender areas. Assess tender areas last.

The order of an abdominal examination differs slightly from previous assessments. Begin with inspection and follow with auscultation. By using auscultation before palpation there is less chance of altering the frequency and character of bowel sounds. Be sure to have a tape measure and marking pen available during the examination.

Inspection

Make it a habit to observe the patient during routine care activities. Note his or her posture and look for evidence of abdominal splinting: lying with the knees drawn up or moving restlessly in bed. A patient free from abdominal pain does not guard or splint the abdomen. To inspect the abdomen for abnormal movement or shadows, stand on the patient’s right side and inspect from above the abdomen. After sitting or stooping down to look across the abdomen, assess abdominal contour. Direct the examination light over the abdomen.

Skin

Inspect the skin over the abdomen for color, scars, venous patterns, lesions, and striae (stretch marks). The skin is subject to the same color variations as the rest of the body. Venous patterns are normally faint, except in thin patients. Striae result from stretching of tissue by obesity or pregnancy. Artificial openings indicate drainage sites resulting from surgery (see Chapter 50) or an ostomy (see Chapters 45 and 46). Scars reveal evidence of past trauma or surgery that has created permanent changes in underlying organ anatomy. Bruising indicates accidental injury, physical abuse, or a type of bleeding disorder. If needle marks or bruises are present, ask if the patient self-administers injections (e.g., low-molecular-weight heparin or insulin). Unexpected findings include generalized color changes such as jaundice or cyanosis. Shiny abdominal skin with a taut (tight) appearance can indicate ascites.

Umbilicus

Note the position; shape; color; and signs of inflammation, discharge, or protruding masses. A normal umbilicus is flat or concave with the color the same as that of the surrounding skin. Underlying masses cause displacement of the umbilicus. An everted (pouched-out) umbilicus usually indicates distention. Hernias (protrusion of abdominal organs through the muscle wall) cause upward protrusion of the umbilicus. Normally the umbilical area does not emit discharge.

Contour and Symmetry

Inspect for contour, symmetry, and surface motion of the abdomen, noting any masses, bulging, or distention. A flat abdomen forms a horizontal plane from the xiphoid process to the symphysis pubis. A round abdomen protrudes in a convex sphere from the horizontal plane. A concave abdomen appears to sink into the muscular wall. Each of these findings is normal if the shape of the abdomen is symmetrical. In older adults there is often an overall increased distribution of adipose tissue. The presence of masses on only one side, or asymmetry, possibly indicates an underlying pathological condition.

Intestinal gas, a tumor, or fluid in the abdominal cavity causes distention (swelling). When distention is generalized, the entire abdomen protrudes. The skin often appears taut, as if it were stretched over the abdomen. When gas causes distention, the flanks (side muscles) do not bulge. However, if fluid is the source of the problem, the flanks bulge. Ask the patient to roll onto one side. A protuberance forms on the dependent side if fluid is the cause of the distention. Ask the patient if the abdomen feels unusually tight. Be careful not to confuse distention with obesity. In obesity the abdomen is large, rolls of adipose tissue are often present along the flanks, and the patient does not complain of tightness in the abdomen. If distention is expected, measure the abdomen by placing a tape measure around it at the level of the umbilicus (this may require the patient to roll side-to-side as you position the tape measure). Consecutive measurements show any increase or decrease in distention. Use a marking pen to indicate the location of the tape measure.

Enlarged Organs or Masses

Observe the contour of the abdomen while asking the patient to take a deep breath and hold it. Normally the contour remains smooth and symmetrical. This maneuver forces the diaphragm downward and reduces the size of the abdominal cavity. Any enlarged organs in the upper abdominal cavity (e.g., liver or spleen) descend below the rib cage to cause a bulge. Perform a closer examination with palpation. To evaluate the abdominal musculature have the patient raise the head. This position causes superficial abdominal wall masses, hernias, and muscle separations to become more apparent.

Movement or Pulsations

Inspect for movement. Normally men breathe abdominally, and women breathe more costally. A patient with severe pain has diminished respiratory movement and tightens the abdominal muscles to guard against the pain. Closely inspect for peristaltic movement and aortic pulsation by looking across the abdomen from the side. These movements are visible in thin patients; otherwise no movement is present.

Auscultation

Auscultate before palpation during the abdominal assessment because manipulation of the abdomen alters the frequency and intensity of bowel sounds. Ask patients not to talk. Patients with GI tubes connected to suction need them temporarily turned off before beginning an examination.

Bowel Motility

Peristalsis, or the movement of contents through the intestines, is a normal function of the small and large intestine. Bowel sounds are the audible passage of air and fluid that peristalsis creates. Place the warmed diaphragm of the stethoscope lightly over each of the four quadrants. Normally air and fluid move through the intestines, creating soft gurgling or clicking sounds that occur irregularly 5 to 35 times per minute (Seidel et al., 2011). Sounds usually last second to several seconds. It normally takes 5 to 20 seconds to hear a bowel sound. However, it takes 5 minutes of continuous listening before determining that bowel sounds are absent (Seidel et al., 2011). Auscultate all four quadrants to be sure that you do not miss any sounds. The best time to auscultate is between meals. Sounds are generally described as normal, audible, absent, hyperactive, or hypoactive. Absent sounds indicate a lack of peristalsis, possibly the result of late-stage bowel obstruction; paralytic ileus; or peritonitis. Normally absent or hypoactive bowel sounds occur after surgery following general anesthesia. Hyperactive sounds are loud, “growling” sounds called borborygmi, which indicate increased GI motility. Inflammation of the bowel, anxiety, diarrhea, bleeding, excessive ingestion of laxatives, and reaction of the intestines to certain foods cause increased motility. Teach patients practices to promote normal elimination patterns (Box 30-24).

Box 30-24 Patient Teaching

Abdominal Assessment

Objective

• Patient will maintain normal bowel elimination.

Teaching Strategies

• Explain factors that promote normal bowel elimination such as diet, regular exercise, limited use of over-the-counter drugs causing constipation, establishment of regular elimination schedule, and a good fluid intake (see Chapter 46). Stress importance for older adults.

• Caution patients about dangers of excessive use of laxatives or enemas.

• Instruct patient to have acute abdominal pain evaluated by a health care provider.

Evaluation

• Reassess patient’s bowel elimination pattern and stool character after therapies begin.

• Observe patient using pain-relief measures and reassess character of pain.

Vascular Sounds

Bruits indicate narrowing of the major blood vessels and disruption of blood flow. The presence of bruits in the abdominal area can reveal aneurysms or stenotic vessels. Use the bell of the stethoscope to auscultate in the epigastric region and each of the four quadrants. Normally there are no vascular sounds over the aorta (midline through the abdomen) or femoral arteries (lower quadrants). You can hear renal artery bruits by placing the stethoscope over each upper quadrant anteriorly or over the costovertebral angle posteriorly. Report a bruit immediately to a health care provider.

Kidney Tenderness

With the patient sitting or standing erect, use direct or indirect percussion to assess for kidney inflammation. You might require an advanced practice nurse to help you with this skill. With the ulnar surface of the partially closed fist, percuss posteriorly the costovertebral angle at the scapular line. If the kidneys are inflamed, the patient feels tenderness during percussion.

Palpation

Palpation primarily detects areas of abdominal tenderness, distention, or masses. As your skill base increases, learn to palpate for specific organs by using light and deep palpation.

Use light palpation over each abdominal quadrant to detect areas of tenderness. Initially avoid areas previously identified as problem spots. Lay the palm of the hand with fingers extended and approximated lightly on the abdomen. Explain the maneuver to the patient and, with the palmar surface of the fingers, depress approximately 1.3 cm ( inch) in a gentle dipping motion (Fig. 30-64). Avoid quick jabs and use smooth, coordinated movements. If the patient is ticklish, first place his or her hand on the abdomen with your hand on the patient’s; continue this until the patient tolerates palpation.

FIG. 30-64 Light palpation of abdomen. (From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)

Use a systematic palpation approach for each quadrant and assess for muscular resistance, distention, tenderness, and superficial organs or masses. Observe the patient’s face for signs of discomfort. The abdomen is normally smooth with consistent softness and nontender without masses. In contrast to firm muscles found among young adults, an older adult often lacks abdominal tone. Guarding or muscle tenseness sometimes occurs while palpating a sensitive area. If tightening remains after the patient relaxes, peritonitis, acute cholecystitis, or appendicitis is sometimes the cause. It is easy to detect a distended bladder with light palpation. Normally the bladder lies below the umbilicus and above the symphysis pubis. Routinely check for a distended bladder if the patient has been unable to void (e.g., because of anesthesia or sedation) or has been incontinent or if an indwelling urinary catheter is not draining well.

With practice and experience perform deep palpation to delineate abdominal organs and detect less obvious masses. You need short fingernails. It is important for the patient to be relaxed while the hands depress approximately 2.5 to 7.5 cm (1 to 3 inches) into the abdomen (Fig. 30-65). Never use deep palpation over a surgical incision or over extremely tender organs. It is also unwise to use palpation on abnormal masses. Deep pressure causes tenderness in a healthy patient over the cecum, sigmoid colon, aorta, and the midline near the xiphoid process (Seidel et al., 2011).

FIG. 30-65 Deep palpation of abdomen. (From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)

Survey each quadrant systematically. Palpate masses for size, location, shape, consistency, tenderness, pulsation, and mobility. Test for rebound tenderness by pressing a hand slowly and deeply into the involved area and letting go quickly. The test is positive if the patient feels pain with the release of the hand. Rebound tenderness occurs in patients with peritoneal irritation such as occurs in appendicitis; pancreatitis; or any peritoneal injury causing bile, blood, or enzymes to enter the peritoneal cavity.

Aortic Pulsation

Palpate with the thumb and forefinger of one hand deeply into the upper abdomen just left of the midline to assess aortic pulsation. Normally a pulsation is transmitted forward. If the aorta is enlarged because of an aneurysm (localized dilation of a vessel wall), the pulsation expands laterally. Do not palpate a pulsating abdominal mass. When enlargement from an aneurysm is present, only lightly palpate this area, referring the finding to the health care provider. In obese patients it is often necessary to palpate with both hands, one on each side of the aorta.

Female Genitalia and Reproductive Tract

Examination of the female genitalia is embarrassing to a patient unless you use a calm, relaxed approach. The gynecological examination is one of the most difficult experiences for adolescents. A person’s cultural background further adds to apprehension. For example, female Mexican Americans have a strong social value that women do not expose their bodies to men or even to other women. Similarly, Chinese Americans believe that the examination of genitalia is offensive. Provide a thorough explanation of the reason for the procedures used in the examination. The lithotomy position assumed during the examination is an added source of embarrassment. A patient is more comfortable when you use correct positioning and draping. Be sure to explain each portion of the examination in advance so patients anticipate necessary actions. Adolescents sometimes choose to have parents present in the examination room.

Sometimes a patient requires a complete examination of the female reproductive organs, including assessing the external genitalia and performing a vaginal examination. You can examine external genitalia while performing routing hygiene measures or when preparing to insert a urinary catheter. An internal examination is part of each woman’s preventive health care because ovarian cancer causes more deaths than any other cancer of the female reproductive system (ACS, 2011).

Adolescents and young adults are examined because of the growing incidence of sexually transmitted infections (STIs). The average age of menarche among young girls has declined, and the majority of male and female teenagers are sexually active by age 19 (Hockenberry and Wilson, 2011). It is important to assess a patient’s level of anxiety when obtaining the nursing history (Table 30-29). Combine rectal and anal assessments with the pelvic examination since the patient is situated in a lithotomy or dorsal recumbent position.

TABLE 30-29

Nursing History for Female Genitalia and Reproductive Tract Assessment

ASSESSMENT	RATIONALE
Determine if patient has had previous illness or surgery involving reproductive organs, including STIs.	Illness or surgery influences appearance and position of organs being examined.
Determine if patient has received HPV vaccine.	HPV increases patient’s risk for development of cervical cancer.
Review menstrual history, including age at menarche, frequency and duration of menstrual cycle, character of flow (e.g., amount, presence of clots), presence of dysmenorrhea (painful menstruation), pelvic pain, dates of last two menstrual periods, and premenstrual symptoms.	This information helps to reveal level of reproductive health, including normalcy of menstrual cycle.
Ask patient to describe obstetrical history, including each pregnancy and history of abortions or miscarriages.	Observed physical findings vary, depending on woman’s history of pregnancy.
Determine whether patient uses safe sex practices; have patient describe current and past contraceptive practices and problems encountered. Discuss risk of STIs and HIV infection.	Use of certain types of contraceptives influences reproductive health (e.g., sensitivity reaction to spermicidal jelly). Sexual history reveals risk for and understanding of STIs.
Assess if patient has signs and symptoms of vaginal discharge, painful or swollen perianal tissues, or genital lesions.	These signs and symptoms may indicate STI or other pathological condition.
Determine if patient has symptoms or history of genitourinary problems, including burning during urination, frequency, urgency, nocturia, hematuria, incontinence, or stress incontinence (see Chapter 45).	Urinary problems are associated with gynecological disorders, including STIs.
Ask if patient has had signs of bleeding outside of normal menstrual period or after menopause or has had unusual vaginal discharge.	These are warning signs for cervical and endometrial cancer or vaginal infection.
Determine if patient has history of HPV (condyloma acuminatum, herpes simplex, or cervical dysplasia); has multiple sex partners; smokes cigarettes; has had multiple pregnancies; or was young at first intercourse.	These are risk factors for cervical cancer (ACS, 2011).
Determine if patient is older than 40, obese, and has history of ovarian dysfunction, breast or endometrial cancer, irradiation of pelvic organs, or endometriosis; has family history of ovarian, breast, or colon cancer; has history of infertility or nulliparity; or use of estrogen (alone) hormone replacement therapy.	These are risk factors for ovarian cancer (ACS, 2011).
Determine if patient is postmenopausal, obese, or infertile; had early menarche; had late menopause; has history of hypertension, diabetes, gallbladder disease, or polycystic ovary disease; has family history of endometrial, breast, or colon cancer; or has a history of estrogen-related exposure (estrogen replacement therapy, tamoxifen use).	These are risk factors for endometrial cancer (ACS, 2011).

HIV, Human immunodeficiency virus; HPV, human papillomavirus (HPV) vaccine; STI, sexually transmitted infection.

Preparation of the Patient

The beginning nurse is often responsible for assisting a patient’s health care provider with the examination. For a complete examination the following equipment is needed: examination table with stirrups, vaginal speculum of correct size, adjustable light source, sink, clean disposable gloves, sterile cotton swabs, glass slides, plastic or wooden spatula, cervical brush or broom device, cytological fixative, and culture plates or media (Seidel et al., 2011).

Make sure that the equipment is ready before the examination begins. Ask the patient to empty her bladder so the uterus and ovaries are readily palpable. Often it is necessary to collect a urine specimen. Assist the patient to the lithotomy position in bed or on an examination table for the external genitalia assessment. Assist her into stirrups for a speculum examination. Have a woman stabilize each foot in a stirrup and have her slide the buttocks down to the edge of the examining table. Place a hand at the edge of the table and instruct the patient to move until touching the hand. The patient’s arms should be at her sides or folded across the chest to prevent tightening of abdominal muscles.

Some women suffering from pain or deformity of the joints are unable to assume a lithotomy position. In this situation it is necessary to have the patient abduct only one leg or have another assist in separating the patient’s thighs. In addition, use the side-lying position with the patient on the left side with the right thigh and knee drawn up to her chest.

Give a square drape or sheet to the patient. She holds one corner over her sternum, the adjacent corners fall over each knee, and the fourth corner covers the perineum. After the examination begins, lift the drape over the perineum. A male examiner always needs to have a female attendant present during the examination, whereas a female examiner may choose to work alone. An additional female should be present if the patient requests it.

External Genitalia

Make sure that the perineal area is well illuminated. Follow standard precautions and wear clean gloves to prevent contact with infectious organisms. The perineum is sensitive and tender; do not touch the area suddenly without warning the patient. It is best to touch the inner thigh first before touching it.

While sitting at the end of the examination table or bed, inspect the quantity and distribution of hair growth. Preadolescents have no pubic hair. During adolescence hair grows along the labia, becoming darker, coarser, and curlier. In an adult hair grows in a triangle over the female perineum and along the medial surfaces of the thighs. The underlying skin is free of inflammation, irritation, or lesions.

Inspect surface characteristics of the labia majora. The skin of the perineum is smooth, clean, and slightly darker than other skin. The mucous membranes appear dark pink and moist. The labia majora can be gaping or closed, appear dry or moist, and are usually symmetrical. After childbirth the labia majora separate, causing the labia minora to become more prominent. When a woman reaches menopause, the labia majora become thinned; they become atrophied in older age. The labia majora are normally without inflammation, edema, lesions, or lacerations.

To inspect the remaining external structures, use your nondominant hand and gently place the thumb and index finger inside the labia minora and retract the tissues outwardly (Fig. 30-66). Be sure to have a firm hold to avoid repeated retraction against the sensitive tissues. Use the other hand to palpate the labia minora between the thumb and second finger. On inspection the labia minora are normally thinner than the labia majora, and one side is sometimes larger. The tissue feels soft on palpation and without tenderness. The size of the clitoris varies, but it normally does not exceed 2 cm in length and 0.5 cm in width. Look for atrophy, inflammation, or adhesions. If inflamed, the clitoris is a bright cherry red. In young women it is a common site for syphilitic lesions, or chancres, which appear as small open ulcers that drain serous material.

FIG. 30-66 Female external genitalia.

Inspect the urethral orifice carefully for color and position. It is normally intact without inflammation. The urethral meatus is anterior to the vaginal orifice and is pink. It appears as a small slit or pinhole opening just above the vaginal canal. Note any discharge, polyps, or fistulas.

Inspect the vaginal orifice for inflammation, edema, discoloration, discharge, and lesions. Normally the opening is a thin, vertical slit; and the tissue is moist. While inspecting the vaginal orifice, note the condition of the hymen, which is just inside the opening. In the virgin female the hymen restricts the opening of the vagina, but the tissue retracts or disappears after sexual intercourse.

Inspect the anus, looking for lesions and hemorrhoids (see rectal examination). After completion of the external examination, dispose of examination gloves and offer the patient soft disposable cloths for perineal hygiene.

Patients who are at risk for contracting an STI need to learn to perform a genital self-examination (Box 30-25). The purpose of the examination is to detect any signs or symptoms of an STI. Many persons do not know that they have an STI (e.g., chlamydia), and some STIs (e.g., syphilis) remain undetected for years.

Box 30-25 Patient Teaching

Female Genitalia and Reproductive Tract Assessment

Objective

• Patient will use measures to maintain sexual health and prevent acquisition and transmission of sexually transmitted infections (STIs).

Teaching Strategies

• Instruct patient about purpose and recommended frequency of Papanicolaou (Pap) smears and gynecological examinations. Explain that the Pap smear is relatively painless and needed annually with a pelvic examination for women who are sexually active or over the age of 21. Patients are screened more often if certain risk factors exist such as a weak immune system, multiple sex partners, smoking, and a history of infections (e.g., human papillomavirus [HPV]).

• Counsel patient with an STI about the implications of diagnosis and treatment.

• Recommend the HPV vaccine for females ages 9 to 26 years to prevent cervical cancer (American Cancer Society [ACS], 2011; Centers for Disease Control and Prevention, 2011). The HPV vaccine prevents the most common types of HPV that cause cervical cancer and genital warts. It is given as a 3-dose vaccine.

• Instruct in genital self-examination (GSE). using a mirror, position self to examine the area covered by the pubic hair. Spread the hair apart, looking for bumps, sores, or blisters. Also look for any warts, which appear as small, bumpy spots and enlarge to fleshy, cauliflower-like lesions. Next spread the outer vaginal lips apart and look at the clitoris for bumps, blisters, sores, or warts. Look at both sides of the inner vaginal lips. Inspect the area around the urinary and vaginal opening for bumps, blisters, sores, or warts.

• Explain warning signs of STIs: pain or burning on urination, pain during sex, pain in pelvic area, bleeding between menstruation, itchy rash around vagina, and abnormal vaginal discharge.

• Teach measures to prevent STIs: male partner’s use of condoms, restricting number of sexual partners, avoiding sex with persons who have several other partners, and perineal hygiene measures.

• Tell patients with an STI to inform sexual partners of the need for an examination.

• Reinforce the importance of performing perineal hygiene (as appropriate).

Evaluation

• Ask patient to explain when she should routinely have a gynecological examination and Pap test.

• Have patient describe ways to prevent transmission of STIs.

• For patient with an STI, determine during follow-up visit if patient has followed safe sexual practices (use nonthreatening inquiry).

Speculum Examination of Internal Genitalia

An examination of the internal genitalia requires much skill and practice. Advanced nurse practitioners and primary care providers perform this examination. As a nursing student you observe the procedure or assist the examiner by helping the patient with positioning, handing off specimen supplies, and providing emotional support for the patient.

The examination involves use of a plastic or metal speculum consisting of two blades and an adjustment device. The examiner inserts the speculum into the vagina to assess the internal genitalia for cancerous lesions and other abnormalities. During the examination the examiner collects a specimen for a Papanicolaou (Pap) test for cervical and vaginal cancer. The cervix is inspected for color, position, size, surface characteristics, and discharge (Seidel et al., 2011).

Male Genitalia

An examination of the male genitalia assesses the integrity of the external genitalia (Fig. 30-67), inguinal ring, and canal. Because the incidence of STIs in adolescents and young adults is high, an assessment of the genitalia needs to be a routine part of any health maintenance examination for this age-group (Box 30-26). The examination begins by having the patient void. Make sure the examination room is warm. Have the patient lie supine with the chest, abdomen, and lower legs draped or stand during the examination. Apply clean gloves.

Box 30-26 Patient Teaching

Male Genitalia Assessment

Objective

• Patient will use measures to maintain sexual health and prevent acquisition and transmission of sexually transmitted infections (STIs).

Teaching Strategies

• Teach patient how to perform genital self-examination (see Box 30-27).

• Counsel patient who has an STI about diagnosis implications and treatment.

• Explain warning signs of STIs: pain on urination and during sex, abnormal penile discharge (different from usual), swollen lymph nodes, or rash or ulcer on skin or genitalia.

• Teach measures to prevent STIs: use of condoms, avoiding sex with infected partner, restricting number of sexual partners, avoiding sex with persons who have multiple partners, and using regular perineal hygiene.

• Recommend HPV vaccine for males ages 9 to 26 years. Boys and young men may choose to get this vaccine to prevent genital warts and anal cancer (CDC, 2011).

• Tell patients with an STI to inform their sexual partners of the need to have an examination.

• Instruct patient to seek treatment as soon as possible if partner becomes infected with an STI.

Evaluation

• Ask patient to describe methods for preventing and treating STIs.

• During a follow-up visit determine whether patient with an STI has used safe sex practices.

FIG. 30-67 External and internal male sex organs.

Use a calm, gentle approach to lessen the patient’s anxiety. The position and exposure of the body during the examination is embarrassing for some men. To minimize his anxiety, it often helps to offer explanations of the steps of examination so he anticipates all actions. Manipulate the genitalia gently to avoid causing erection or discomfort. Obtain a thorough history (Table 30-30) before the examination, ensuring that the assessment is complete.

TABLE 30-30

Nursing History for Male Genitalia Assessment

ASSESSMENT	RATIONALE
Review normal urinary elimination pattern, including frequency of voiding; history of nocturia; character and volume of urine; daily fluid intake; symptoms of burning, urgency, and frequency; difficulty starting stream; and hematuria (see Chapter 45).	Urinary problems are directly associated with genitourinary problems because of anatomical structure of men’s reproductive and urinary systems.
Assess patient’s sexual history and use of safe sex habits (multiple partners, infection in partners, failure to use condom).	Sexual history reveals risk for and understanding of sexually transmitted diseases (STIs) and human immunodeficiency virus (HIV).
Determine if patient has received the HPV vaccine.	HPV is associated with genital warts in men and can lead to cervical cancer in females (CDC, 2011).
Determine if patient has had previous surgery or illness involving urinary or reproductive organs, including STI.	Alterations resulting from disease or surgery are sometimes responsible for symptoms or changes in organ structure or function.
Ask if patient has noted penile pain or swelling, genital lesions, or urethral discharge.	These signs and symptoms may indicate STI.
Determine if patient has noticed heaviness or painless enlargement of testis or irregular lumps.	These signs and symptoms are early warning signs for testicular cancer.
If patient reports an enlargement in inguinal area, assess if it is intermittent or constant, associated with straining or lifting, and painful and whether pain is affected by coughing, lifting, or straining at stool.	Signs and symptoms reflect potential inguinal hernia.
Ask if patient has difficulty achieving erection or ejaculation; also review whether patient is taking diuretics, sedatives, antihypertensives, or tranquilizers.	These medications influence sexual performance.

Sexual Maturity

First note the sexual maturity of the patient by observing the size and shape of the penis and testes; the size, color, and texture of the scrotal skin; and the character and distribution of pubic hair. The testes first increase in size in preadolescence. During this time there is no pubic hair. By the end of puberty, the testes and penis enlarge to adult size and shape, and scrotal skin darkens and becomes wrinkled. With puberty hair is coarse and abundant in the pubic area. The penis has no hair, and the scrotum has very little hair (Fig. 30-68, A and B). Also inspect the skin covering the genitalia for lice, rashes, excoriations, or lesions. Normally it is clear, without lesions.

FIG. 30-68 Appearance of male genitalia. A, Circumcised. B, Uncircumcised. (From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)

Penis

To inspect penile surfaces, manipulate the genitalia or have the patient assist. Inspect the shaft, corona, prepuce (foreskin), glans, and urethral meatus. The dorsal vein is apparent on inspection. In uncircumcised males retract the foreskin to reveal the glans and urethral meatus. The foreskin usually retracts easily. A small amount of white, thick smegma sometimes collects under this foreskin. Obtain a culture if abnormal discharge is present. The urethral meatus is slitlike in appearance and positioned on the ventral surface just millimeters from the tip of the glans. In some congenital conditions the meatus is displaced along the penile shaft. The area between the foreskin and glans is a common site for venereal lesions. Gently compress the glans between the thumb and index finger; this opens the urethral meatus for inspection of lesions, edema, and inflammation. Normally the opening is glistening and pink without discharge. Palpate any lesion gently to note tenderness, size, consistency, and shape. When inspection and palpation of the glans is complete, pull the foreskin down to its original position.

Continue by inspecting the entire shaft of the penis, including the undersurface, looking for lesions, scars, or edema. Palpate the shaft between the thumb and first two fingers to detect localized areas of hardness or tenderness. A patient who has lain in bed for a prolonged time sometimes develops dependent edema in the penis shaft.

It is important for any male patient to learn to perform a genital self-examination to detect signs or symptoms of STIs, especially men who have had more than one sexual partner or whose partner has had other partners. Men may have an STI but not be aware of it; self-examination is a routine part of self-care (Box 30-27).

Box 30-27

Male Genital Self-Examination

All men 15 years and older need to perform this examination monthly using the following steps.

Genital Examination

• Perform the examination after a warm bath or shower when the scrotal skin is less thick.

• Stand naked in front of a mirror, hold the penis in your hand, and examine the head. Pull back the foreskin if uncircumcised to expose the glans.

• Inspect and palpate the entire head of the penis in a clockwise motion, looking carefully for any bumps, sores, or blisters (bumps and blisters may be light colored or red, resemble pimples).

• Look also for any genital warts (see illustration).

• Look at the opening (urethral meatus) at the end of the penis for discharge.

• Look along the entire shaft of the penis for the same signs.

• Be sure to separate pubic hair at the base of the penis and carefully examine the skin underneath.

Testicular Self-Examination

• Look for swelling or lumps in the skin of the scrotum while looking in the mirror.

• Use both hands, placing the index and middle fingers under the testicles and the thumb on top (see illustration).

• Gently roll the testicle, feeling for lumps, swelling, soreness, or a harder consistency.

• Find the epididymis (a cordlike structure on the top and back of the testicle; it is not a lump).

• Feel for small, pea-size lumps on the front and side of the testicle. Abnormal lumps are usually painless.

• Call your health care provider for abnormal findings.

Illustrations from Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.

Scrotum

Be particularly cautious while inspecting and palpating the scrotum because the structures lying within the scrotal sac are very sensitive. The scrotum is divided internally into two halves. Each half contains a testicle, epididymis, and the vas deferens, which travels upward into the inguinal ring. Normally the left testicle is lower than the right. Inspect the size, shape, and symmetry of the scrotum while observing for lesions or edema. Gently lift the scrotum to view the posterior surface. The scrotal skin is usually loose, and the surface is coarse. The scrotal skin is more deeply pigmented than body skin. Tightening of the skin or loss of wrinkling reveals edema. The size of the scrotum normally changes with temperature variations because the dartos muscle contracts in cold and relaxes in warm temperatures. Lumps in the scrotal skin are commonly sebaceous cysts.

Testicular cancer is a solid tumor common in young men ages 18 to 34 years. Early detection is critical. Explain testicular self-examination (see Box 30-27) while examining the patient. The testes are normally sensitive but not tender. The underlying testicles are normally ovoid and approximately 2 to 4 cm (1 to inch) in size. Gently palpate the testicles and epididymis between the thumb and first two fingers. The testes feel smooth, rubbery, and free of nodules. The epididymis is resilient. Note the size, shape, and consistency of the organs. The most common symptoms of testicular cancer are a painless enlargement of one testis and the appearance of a palpable, small, hard lump, about the size of a pea, on the front or side of the testicle. In the older adult the testicles decrease in size and are less firm during palpation. Continue to palpate the vas deferens separately as it forms the spermatic cord toward the inguinal ring, noting nodules or swelling. It normally feels smooth and discrete.

Inguinal Ring and Canal

The external inguinal ring provides the opening for the spermatic cord to pass into the inguinal canal. The canal forms a passage through the abdominal wall, a potential site for hernia formation. A hernia is a protrusion of a portion of intestine through the inguinal wall or canal. Sometimes an intestinal loop enters the scrotum. Have the patient stand during this part of the examination.

During inspection ask the patient to strain or bear down. The maneuver helps to make a hernia more visible. Look for obvious bulging in the inguinal area.

Complete the examination by palpating for inguinal lymph nodes. Normally small, nontender, mobile horizontal nodes are palpable. Any abnormality indicates local or systemic infection or malignant disease.

Rectum and Anus

A good time to perform the rectal examination is after the genital examination. Usually this examination is not performed for young children or adolescents. It detects colorectal cancer in its early stages. The rectal examination also detects prostatic tumors in men. Collect a health history (Table 30-31) to detect the patient’s risk for bowel or rectal disease (men and women) or prostatic disease (men). Teach the patient about the purpose of the examination (Box 30-28).

Box 30-28 Patient Teaching

Rectal and Anal Assessment

Objective

• Patient will be able to identify symptoms of colorectal and prostatic cancer.

Teaching Strategies

• Discuss the guidelines of the American Cancer Society (ACS) (2011) for early detection of colorectal cancer.

• Beginning at age 50, both men and women should follow one of these testing schedules:

• Tests that find polyps and cancer

• Flexible sigmoidoscopy every 5 years, or

• Colonoscopy every 10 years, or

• Double-contrast barium enema every 5 years, or

• CT colonography (virtual colonoscopy) every 5 years

• Tests that primarily find cancer

• Yearly fecal occult blood test (gFOBT), or

• Yearly fecal immunochemical test (FIT) every year, or

• Stool DNA test (sDNA), interval uncertain

• Individuals at increased risk should discuss options with their health care provider.

• Discuss warning signs of colorectal cancer (see Table 30-31).

• Discuss with male patient the ACS guidelines (2011) for early detection of prostate cancer:

• Digital rectal examination performed annually after age 50

• Annual prostate-specific antigen (PSA) blood test for men age 50 and over

• Prostate ultrasound testing if results of either digital rectal examination or PSA test is suspicious

• Need for African American men or those with a first-degree relative diagnosed with prostate cancer to begin testing at age 45

• Discuss warning signs of prostate cancer.

Evaluation

• During follow-up visit determine whether patient has had a rectal examination performed.

• Have patient explain warning signs of colorectal and prostate cancer.

TABLE 30-31

Nursing History for Rectal and Anal Assessment

ASSESSMENT	RATIONALE
Determine whether patient has experienced bleeding from rectum, black or tarry stools (melena), rectal pain, or change in bowel habits (constipation or diarrhea).	These are warning signs of colorectal cancer* or other gastrointestinal alterations.
Determine whether patient has personal or strong family history of colorectal cancer, polyps, or chronic inflammatory bowel disease. Ask if patient is over age 40.	These are risk factors for colorectal cancer.*
Assess dietary habits, including high fat intake, diet high in processed or red meats, or deficient fiber content (inadequate fruits and vegetables).	Bowel cancer is often linked to dietary intake of fat or insufficient fiber intake.*
Determine if patient is obese, is physically inactive, smokes, or consumes alcohol.	These are risk factors for colorectal cancer.
Determine whether patient has undergone screening for colorectal cancer (digital examination, fecal occult blood test, flexible sigmoidoscopy, and colonoscopy).	Undergoing this screening reflects understanding and compliance with preventive health care measures.
Assess medication history for use of laxatives or cathartic medications.	Repeated use causes diarrhea and eventual loss of intestinal muscle tone.
Assess for use of codeine or iron preparations.	Codeine causes constipation. Iron turns the color of feces black and tarry.
Ask male patient if he has experienced weak or interrupted urine flow, inability to urinate, difficulty in starting or stopping urine flow, polyuria, nocturia, hematuria, or dysuria. Does patient have continuing pain in lower back, pelvis, or upper thighs?	These are warning signs of prostatic cancer.* Symptoms also suggest infection or prostate enlargement.

^*Data from American Cancer Society: Cancer facts and figures 2006, Atlanta, 2010, The Society.

The rectal examination is uncomfortable; thus explaining all steps helps a patient relax. Use a calm, slow-paced, gentle approach during the examination. Female patients remain in the dorsal recumbent position following genitalia examination or they assume a side-lying (Sims’) position. The best way to examine men is to have the patient stand and bend over forward with hips flexed and upper body resting across an examination table. Examine a nonambulatory patient in the Sims’ position. Use nonlatex clean gloves.

Inspection

Using the nondominant hand, gently retract the buttocks to view the perianal and sacrococcygeal areas. Perianal skin is smooth, more pigmented, and coarser than skin over the buttocks. Inspect anal tissue for skin characteristics, lesions, external hemorrhoids (dilated veins that appear as reddened protrusions), ulcers, fissures and fistulas, inflammation, rashes, or excoriation. Anal tissues are moist and hairless, and the voluntary external muscle sphincter holds the anus closed. Next ask a patient to bear down as though having a bowel movement. Any internal hemorrhoids or fissures appear at this time. Use clock reference (e.g., 3 o’clock or 8 o’clock) to describe location of findings. Normally there is no protrusion of tissue.

Digital Palpation

Examine the anal canal and sphincters with digital palpation, and in male patients palpate the prostate gland to rule out enlargement. Usually advanced practitioners perform this portion of the examination. This technique is not discussed here.

Musculoskeletal System

The musculoskeletal assessment can be performed as a separate examination or integrated with other parts of the total physical examination. In addition, you can assess the patient’s movements while performing other nursing care measures such as bathing or positioning. The assessment of musculoskeletal function focuses on determining range of joint motion, muscle strength and tone, and joint and muscle condition. Assessing musculoskeletal integrity is especially important when a patient reports pain or loss of function in a joint or muscle. Because muscular disorders are often the result of neurological disease, you may choose to perform a simultaneous neurological assessment.

While examining a patient’s musculoskeletal function, visualize the anatomy of bone and muscle placement and joint structure (see Chapter 47). Joints vary in degree of mobility, depending on the type of joint.

For a complete examination expose the muscles and joints so they are free to move. Have the patient assume a sitting, supine, prone, or standing position while assessing specific muscle groups. Table 30-32 lists the information gathered in the nursing history.

TABLE 30-32

Nursing History for Musculoskeletal Assessment

ASSESSMENT	RATIONALE
Determine if patient is involved in competitive sports (particularly involving collision and contact), fails to warm up adequately, is in poor physical condition, or has had a rapid growth spurt (adolescents).	These are risk factors for sports injury.
Review patient history for use of alcohol and/or caffeine; cigarette smoking; constant dieting; calcium intake less than 500 mg daily; thin and light body frame; nulliparous status; menopause before age 45; estrogen deficiency; postmenopause status; family history of osteoporosis; white, Asian, Native American, or northern European ancestry; advanced age; history of fractures/falls; inadequate calcium intake and vitamin D; sedentary lifestyle; chronic diseases (Cushing’s hyperthyroidism and hypothyroidism, malabsorption/malnutrition disorders, neoplasm); long-term use of corticosteroids, methotrexate, phenytoin, aluminum-containing antacids; lack of weight-bearing exercise; lack of exposure to sunlight (Walker, 2010).	These are risk factors for osteoporosis.
Ask patient to describe history of problems in bone, muscle, or joint function (e.g., recent fall, trauma, lifting of heavy objects, history of bone or joint disease with sudden or gradual onset, location of alteration).	History helps to assess nature of musculoskeletal problem.
Assess nature and extent of pain, including location, duration, severity, predisposing and aggravating factors, relieving factors, and type.	Pain frequently accompanies alterations in bone, joints, or muscle. This has implications not only for comfort, but also for ability to perform activities of daily living.
Assess patient’s normal activity pattern, including type of exercise routinely performed.	Provides baseline in assessment. Sedentary lifestyle and lack of appropriate exercise increase bone loss and risk of fractures.
Determine how alteration influences ability to perform activities of daily living (e.g., bathing, feeding, dressing, toileting, ambulating) and social functions (e.g., household chores, work, recreation, sexual activities).	The extent to which patient is able to perform self-care determines the level of nursing care. Type and degree of restriction in continuing social activities influence topics for patient education and ability of nurse to identify alternative ways to maintain function.
Assess height loss of woman over age 50 by subtracting current height from recall of maximum adult height.	Measurement is useful screening tool to predict osteoporosis.

General Inspection

Observe the patient’s gait when entering the examination room. When the patient is unaware of the nature of your observation, gait is more natural. Later, a more formal test has the patient walk in a straight line away from and return to the point of origin. Note how the patient walks, sits, and rises from a sitting position. Normally patients walk with the arms swinging freely at the sides and the head leading the body. Older adults often walk with smaller steps and a wider base of support. Note foot dragging, limping, shuffling, and the position of the trunk in relation to the legs.

Observe the patient from the side and while facing the patient in a standing position. The normal standing posture is upright with parallel alignment of the hips and shoulders (Fig. 30-69, A to C). There is an even contour of the shoulders, level scapulae and iliac crests, alignment of the head over the gluteal folds, and symmetry of extremities. While observing from the side of the patient, note the normal cervical, thoracic, and lumbar curves. Holding the head erect is normal. As the patient sits, some degree of rounding of the shoulders is normal. Older adults tend to assume a stooped, forward-bent posture with the hips and knees somewhat flexed and arms bent at the elbows, raising the level of the arms.

FIG. 30-69 Inspection of overall body posture. A, Anterior view. B, Posterior view. C, Lateral view. (From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)

Common postural abnormalities include lordosis, kyphosis, and scoliosis (Fig. 30-70, A to C). Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine. This postural abnormality is common in older adults. Lordosis, or swayback, is an increased lumbar curvature. A lateral spinal curvature is called scoliosis. Loss of height is frequently the first clinical sign of osteoporosis, in which height loss occurs in the trunk as a result of vertebral fracture and collapse. Osteoporosis is a systemic skeletal condition that is noted to have both decreased bone mass and deterioration of bone tissue, making bones fragile and at risk for fracture (Nelson et al., 2010). Osteopenia, characterized by low bone mass of the hip, puts persons at risk for osteoporosis, fractures, and potential complications later in life. Approximately 80% of people with osteoporosis are women; approximately 20% of the time the disease affects men. It affects any age-group, including children. Patients should be taught ways to reduce the chance of developing this disease (Box 30-29).

Box 30-29 Patient Teaching

Health Promotion to Prevent Osteoporosis in Women

Objective

• Patient will follow measures to prevent or minimize osteoporosis.

Teaching Strategies

• Recommend women age 65 and older for routine screening for osteoporosis. Recommend men for screening as well; they are equally at risk for development of osteoporosis as they age.

• To reduce bone demineralization, instruct older adults in a proper exercise program (e.g., weight-bearing, muscle-strengthening, and balance-training exercises) to be followed 3 or more times a week.

• Encourage intake of calcium to meet the recommended daily allowance. Increased vitamin D aids calcium absorption.

• Recommendation for calcium supplements for adults over age 25 is 1000 to 1500 mg/day. Instruct patient to take no more than 600 mg of calcium at one time.

• Instruct older adults and those with osteoporosis in proper body mechanics and range-of-motion and moderate weight-bearing exercises (e.g., swimming and walking) to minimize trauma and subsequent fracture of bones.

• Instruct older patients to pace activities to compensate for loss in muscle strength.

Evaluation

• Observe patient’s posture.

• Ask patient to describe therapies for preventing osteoporosis.

• Observe patient perform range-of-motion exercises.

• Have patient keep log of regular weight-training exercises.

FIG. 30-70 Common postural abnormalities. A, Lordosis. B, Kyphosis. C, Scoliosis.

During general inspection look at the extremities for overall size, gross deformity, bony enlargement, alignment, and symmetry. Normally there is bilateral symmetry in length, circumference, alignment, and position and in the number of skinfolds (Seidel et al., 2011). A general review pinpoints areas requiring specialized assessment.

Palpation

Apply gentle palpation to all bones, joints, and surrounding muscles during a complete examination. For a focused assessment only examine the involved area. Note any heat, tenderness, edema, or resistance to pressure. The patient should not feel any discomfort when you palpate. Muscles should be firm.

Range of Joint Motion

The examination includes comparison of both active and passive ROM. Ask the patient to put each major joint through active and passive full ROM (see Chapter 47). Learn the correct terminology for the movements that the joints are capable of making (Table 30-33) and teach the patient how to move through each ROM. Demonstrate ROM to the patient when possible. To assess ROM passively, ask the patient to relax and then passively move the extremities through their ROM. Compare the same body parts for equality in movement. Fig. 30-71, A to F, shows an example of ROM positions for the hand and wrist. Do not force a joint into a painful position. Know the normal range of each joint and the extent to which you can move the patient’s joints. ROM is equal between contralateral joints. Ideally assess the patient’s normal range to determine a baseline for assessing later change.

TABLE 30-33

Terminology for Normal Range-of-Motion Positions

TERM	RANGE OF MOTION	EXAMPLES OF JOINTS
Flexion	Movement decreasing angle between two adjoining bones; bending of limb	Elbow, fingers, knee
Extension	Movement increasing angle between two adjoining bones	Elbow, knee, fingers
Hyperextension	Movement of body part beyond its normal resting extended position	Head
Pronation	Movement of body part so front or ventral surface faces downward	Hand, forearm
Supination	Movement of body part so front or ventral surface faces upward	Hand, forearm
Abduction	Movement of extremity away from midline of body	Leg, arm, fingers
Adduction	Movement of extremity toward midline of body	Leg, arm, fingers
Internal rotation	Rotation of joint inward	Knee, hip
External rotation	Rotation of joint outward	Knee, hip
Eversion	Turning of body part away from midline	Foot
Inversion	Turning of body part toward midline	Foot
Dorsiflexion	Flexion of toes and foot upward	Foot
Plantar flexion	Bending of toes and foot downward	Foot

FIG. 30-71 Range of motion of hand and wrist. A, Metacarpophalangeal flexion and hyperextension. B, Finger flexion: thumb to each fingertip and to the base of the little finger. C, Finger flexion, fist formation. D, Finger abduction. E, Wrist flexion and hyperextension. F, Wrist radial and ulnar movement. (From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)

A goniometer, frequently used by physical and occupational therapists, measures the precise degree of motion in a particular joint and is mainly for patients who have a suspected reduction in joint movement. The instrument has two flexible arms with a 180-degree protractor in the center. Position the center of the protractor at the center of the joint you are measuring (Fig. 30-72). The arms extend along the body parts on each side of the protractor. Measure the joint angle before moving the joint. After taking the joint through a full ROM, measure the angle again to determine the degree of movement. Compare the reading with the normal degree of joint movement.

FIG. 30-72 The patient flexes the arm; the goniometer measures joint range of motion. (From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)

Joints are typically free from stiffness, instability, swelling, or inflammation. There should be no discomfort when applying pressure to bones and joints. In older adults joints often become swollen and stiff with reduced ROM resulting from cartilage erosion and fibrosis of synovial membranes (see Chapter 47). If a joint appears swollen and inflamed, palpate it for warmth.

Muscle Tone and Strength

Assess muscle strength and tone during ROM measurement. Integrate these findings with those from the neurological assessment. Note muscle tone, the slight muscular resistance felt as you move the relaxed extremity passively through its ROM.

Ask the patient to allow an extremity to relax or hang limp. This is often difficult, particularly if the patient feels pain in it. Support the extremity and grasp each limb, moving it through the normal ROM (Fig. 30-73). Normal tone causes a mild, even resistance to movement through the entire range.

FIG. 30-73 Assessing muscle tone.

If a muscle has increased tone, or hypertonicity, there is considerable resistance with any sudden passive movement of a joint. Continued movement eventually causes the muscle to relax. A muscle that has little tone (hypotonicity) feels flabby. The involved extremity hangs loosely in a position determined by gravity.

For assessment of muscle strength, have the patient assume a stable position. He or she performs maneuvers demonstrating strength of major muscle groups (Table 30-34). Use a grading scale of “0 to 5” to compare symmetrical muscle pairs for strength (Table 30-35). The arm on the dominant side normally is stronger than the arm on the nondominant side. In older adults a loss of muscle mass causes bilateral weakness, but muscle strength remains greater in the dominant arm or leg.

TABLE 30-34

Maneuvers to Assess Muscle Strength

MUSCLE GROUP	MANEUVER
Neck (sternocleidomastoid)	Place hand firmly against patient’s upper jaw. Ask patient to turn head laterally against resistance.
Shoulder (trapezius)	Place hand over midline of patient’s shoulder, exerting firm pressure.
	Have patient raise shoulders against resistance.
Elbow
Biceps	Pull down on forearm as patient attempts to flex arm.
Triceps	As you flex patient’s arm, apply pressure against forearm. Ask patient to straighten arm.
Hip
Quadriceps	When patient is sitting, apply downward pressure to thigh. Ask patient to raise leg up from table.
Gastrocnemius	Patient sits while examiner holds shin of flexed leg. Ask patient to straighten leg against resistance.

TABLE 30-35

Muscle Strength

^*Passive movement.

Modified from Walker J: The role of the nurse in the management of osteoporosis, Br J Nurs 19(19):1243, 2010.

Examine each muscle group. Ask the patient to first flex the muscle you are examining and then to resist when you apply an opposing force against that flexion. It is important to not allow the patient to move the joint. Gradually increase pressure to a muscle group (e.g., elbow extension). Have the patient resist the pressure you apply by attempting to move against resistance (e.g., elbow flexion) until instructed to stop. Vary the amount of pressure applied and observe the joint move. If you identify a weakness, compare the size of the muscle with its opposite counterpart by measuring the circumference of the muscle body with a tape measure. A muscle that has atrophied (reduced in size) feels soft and boggy when palpated.

Neurological System

The neurological system is responsible for many functions, including initiation and coordination of movement, reception and perception of sensory stimuli, organization of thought processes, control of speech, and storage of memory. A close integration exists between the neurological system and all other body systems. For example, urine production relies in part on the adequacy of blood flow to the kidneys, and the size of arterioles supplying the kidneys is under neural control.

A full assessment of neurological function requires much time and attention to detail. For efficiency, integrate neurological measurements with other parts of the physical examination. For example, test cranial nerve function while assessing the head and neck. Observe mental and emotional status during the initial interview.

Consider many variables when deciding the extent of the neurological examination. A patient’s level of consciousness influences his or her ability to follow directions. General physical status influences tolerance to assessment. A patient’s chief complaint also helps determine the need for a thorough neurological assessment. If a patient complains of headache or a recent loss of function in an extremity, he or she needs a complete neurological review. Table 30-36 lists the data collected in the nursing history. You will need the following items for a complete examination:

TABLE 30-36

Nursing History for Neurological Assessment

ASSESSMENT	RATIONALE
Determine if patient uses analgesics, alcohol, sedatives, hypnotics, antipsychotics, antidepressants, nervous system stimulants, or recreational drugs.	These medications alter level of consciousness or cause behavioral changes. Abuse sometimes causes tremors, ataxia, and changes in peripheral nerve function.
Determine if patient has recent history of seizures/convulsions: clarify sequence of events (aura, fall to ground, motor activity, loss of consciousness); character of any symptoms; and relationship of seizure to time of day, fatigue, or emotional stress.	Seizure activity often originates from central nervous system alteration. Characteristics of seizure help determine its origin.
Screen patient for symptoms of headache, tremors, dizziness, vertigo, numbness or tingling of body part, visual changes, weakness, pain, or changes in speech. Presence of any symptom requires more detailed review (onset, severity, precipitating factors or sequence of events).	These symptoms frequently originate from alterations in central or peripheral nervous system function. Identification of specific patterns aids in diagnosis of pathological condition.
Discuss with patient’s family any recent changes in patient’s behavior (e.g., increased irritability, mood swings, memory loss, change in energy level).	Behavioral changes sometimes result from intracranial pathological states.
Assess patient for history of change in vision, hearing, smell, taste, or touch.	Major sensory nerves originate from brainstem. These symptoms help to localize nature of problem.
If an older patient displays sudden acute confusion (delirium), review history for drug toxicity (anticholinergics, diuretics, digoxin, cimetidine, sedatives, antihypertensives, antiarrhythmics), serious infections, metabolic disturbances, heart failure, and severe anemia.	Delirium is one of the most common mental disorders in older persons. Condition is always potentially reversible (see Box 30-31).
Review past history for head or spinal cord injury, meningitis, congenital anomalies, neurological disease, or psychiatric counseling.	Factors cause neurological symptoms or behavioral changes to develop, focusing assessment on possible cause.

• Reading material

• Vials containing aromatic substances (e.g., vanilla extract and coffee)

• Opposite tip of cotton swab or tongue blade broken in half

• Snellen eye chart

• Penlight

• Vials containing sugar or salt

• Tongue blade

• Two test tubes, one filled with hot water and the other with cold water

• Cotton balls or cotton-tipped applicators

• Tuning fork

• Reflex hammer

Mental and Emotional Status

You learn a great deal about mental capacities and emotional state simply by interacting with a patient. Ask questions during an examination to gather data and observe the appropriateness of emotions and thoughts. Special assessment tools are designed to assess a patient’s mental status. The Mini-Mental State Examination (MMSE) is an instrument developed by Folstein et al. (1975) that measures orientation and cognitive function. The questions in Box 30-30 offer examples of questions found on the MMSE. The maximum score on the MMSE is 30. Patients with scores of 21 or less generally reveal cognitive impairment requiring further evaluation.

Box 30-30

Mini-Mental State Examination Sample Questions

• Orientation to time

“What is the date?”

• Registration

“Listen carefully. I am going to say three words. Say them back after I stop.

Ready? Here they are . . .

HOUSE (pause), CAR (pause), LAKE (pause). Now repeat these words back to me.”

(Repeat up to 5 times but score only the first trial.)

• Naming

“What is this?” (Point to a pencil or pen.)

• Reading

“Please read this and do what it says.” (Show examinee the words on the stimulus form.)

CLOSE YOUR EYES

Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Fla 33549, from Mini-Mental State Examination, by Marshal Folstein and Susan Folstein, Copyright 1975, 1998, 2001 by Mini Mental, LLC, Inc. Published 2001 by Psychological Assessment Resources, Inc. Further reproduction is prohibited without permission of PAR, Inc. The MMSE can be purchased from PAR, Inc. by calling (800) 331-8378 or (813) 968-3003.

To ensure an objective assessment, consider a patient’s cultural and educational background, values, beliefs, and previous experiences. Such factors influence response to questions. An alteration in mental or emotional status reflects a disturbance in cerebral functioning. The cerebral cortex controls and integrates intellectual and emotional functioning. Primary brain disorders, medication, and metabolic changes are examples of factors that change cerebral function.

Delirium is an acute mental disorder that occurs among hospitalized patients. Obtain a thorough history of a patient’s behavior before delirium develops so as to recognize the condition early. Family members are usually a good resource. Among older adults delirium most often presents within the first 48 to 72 hours of hospital admission (Rigney, 2010). It is an acute mental disorder characterized by confusion, disorientation, and restlessness. It is often a sign of an impending or underlying physical illness in older adults (Flood and Buckwalter, 2009). The acute condition differs from dementia, a more progressive, organic mental disorder such as Alzheimer’s disease. You need to recognize the difference so you can try to learn the underlying cause of delirium. Fortunately the condition often reverses when it is correctly assessed and the underlying cause is treated (i.e., central nervous system [CNS], metabolic, and cardiopulmonary disorders; systemic illnesses; and sensory deprivation or overload). To avoid misdiagnosis you need to adequately assess mental status. Frequently patients who develop delirium are labeled with “sundown syndrome” because the delirium frequently worsens at night. Many practitioners mistake this as being common with old age. Be aware that children are vulnerable to delirium from causes such as infection, drugs, serious trauma, autoimmune disorders, general anesthesia, and after transplant (Hatherill and Fisher, 2010). Box 30-31 summarizes clinical criteria for delirium.

Box 30-31

Clinical Criteria for Delirium

Definition: An acute disturbance of consciousness that is accompanied by a change in cognition. It is not caused by a preexisting or evolving dementia. Delirium develops over a short period of time, usually hours to days, and tends to fluctuate during the course of the day. It is usually a direct physiological consequence of a general medical condition. It is most common in older adults but occurs occasionally in younger patients.

• There is reduced clarity of awareness of the environment.

• Ability to focus, sustain, or shift attention is impaired (questions must be repeated).

• Irrelevant stimuli easily distract the person.

• There is an accompanying change in cognition (memory impairment, disorientation, or language disturbance).

• Recent memory is commonly affected.

• Disorientation usually occurs, with patient disoriented to time, place, or person.

• Language disturbance involves impaired ability to name objects or ability to write; speech is sometimes rambling.

• Perceptual disturbances include misinterpretations, delusions, or visual and auditory hallucinations. Neurological signs include tremor, unsteady gait, asterixis, or myoclonus.

Level of Consciousness

A person’s level of consciousness exists along a continuum from full awakening, alertness, and cooperation to unresponsiveness to any form of external stimuli. Talk with the patient, asking questions about events involving his or her concerns about any health problems. A fully conscious patient responds to questions quickly and expresses ideas logically. With a lowering of a patient’s consciousness, use the Glasgow Coma Scale (GCS) for an objective measurement of consciousness on a numerical scale (Table 30-37). The patient needs to be as alert as possible before testing. Take care when using the scale if the patient has sensory losses (e.g., vision or hearing). The GCS allows evaluation of a patient’s neurological status over time. The higher the score, the better the patient’s neurological function. Ask short, simple questions such as “What is your name?” “Where are you?” and “What day is this?” Also ask the patient to follow simple commands such as “Move your toes.”

TABLE 30-37

Glasgow Coma Scale

If the patient is not conscious enough to follow commands, try to elicit the pain response. Apply firm pressure with the thumb over the root of the patient’s fingernail. The normal response to the painful stimuli is withdrawal of the body part from the stimulus. A patient with serious neurological impairment exhibits abnormal posturing in response to pain. A flaccid response indicates the absence of muscle tone in the extremities and severe injury to brain tissue.

Behavior and Appearance

Behavior, moods, hygiene, grooming, and choice of dress reveal pertinent information about mental status. Remain perceptive of a patient’s mannerisms and actions during the entire physical assessment. Note nonverbal and verbal behaviors. Does the patient respond appropriately to directions? Does his or her mood vary with no apparent cause? Does he or she show concern about appearance? Is his or her hair clean and neatly groomed, and are the nails trim and clean? The patient should behave in a manner expressing concern and interest in the examination. He or she should make eye contact with you and express appropriate feelings that correspond to the situation. Normally the patient shows some degree of personal hygiene.

Choice and fit of clothing reflect socioeconomic background or personal taste rather than deficiency in self-concept or self-care. Avoid being judgmental and focus assessment on the appropriateness of clothing for the weather. Older adults sometimes neglect their appearance because of a lack of energy, finances, or reduced vision.

Language

Normal cerebral function allows a person to understand spoken or written words and express the self through written words or gestures. Assess the patient’s voice inflection, tone, and manner of speech. Normally a patient’s voice has inflections, is clear and strong, and increases in volume appropriately. Speech is fluent. When communication is clearly ineffective (e.g., omission or addition of letters and words, misuse of words, or hesitations), assess for aphasia. Injury to the cerebral cortex results in aphasia.

The two types of aphasia are sensory (or receptive) and motor (or expressive). With receptive aphasia a person cannot understand written or verbal speech. With expressive aphasia a person understands written and verbal speech but cannot write or speak appropriately when attempting to communicate. A patient sometimes suffers a combination of receptive and expressive aphasia. Assess language capabilities when it is clear that a patient is communicating ineffectively. Some simple assessment techniques include the following:

• Point to a familiar object, and ask the patient to name it.

• Ask the patient to respond to simple verbal and written commands such as “Stand up” or “Sit down.”

• Ask the patient to read simple sentences out loud.

Normally a patient names objects correctly, follows commands, and reads sentences correctly.

Intellectual Function

Intellectual function includes memory (recent, immediate, and past), knowledge, abstract thinking, association, and judgment. Testing each aspect of function involves a specific technique. However, because cultural and educational background influences the ability to respond to test questions, do not ask questions related to concepts or ideas with which a patient is unfamiliar.

Memory

Assess immediate recall and recent and remote memory. Patients demonstrate immediate recall by repeating a series of numbers (e.g., 7, 4, 1) in the order they are presented or in reverse order. Patients normally recall a series of five to eight digits forward and four to six digits backward.

First ask to test the patient’s memory. Then state clearly and slowly the name of three unrelated objects. After mentioning all three, ask the patient to repeat each. Continue until he or she is successful. Later in the assessment, ask the patient to repeat the three words again. He or she should be able to identify them. Another test for recent memory involves asking the patient to recall events occurring during the same day (e.g., what was eaten for breakfast). Validate information with a family member.

To assess past memory, ask the patient to recall his or her mother’s maiden name, a birthday, or a special date in history. It is best to ask open-ended rather than simple yes/no questions. A patient usually has immediate recall of such information. With older adults do not interpret hearing loss as confusion. Good communication techniques are essential throughout the examination to ensure that a patient clearly understands all directions and testing.

Knowledge

Assess knowledge by asking how much the patient knows about his or her illness or the reason for seeking health care. A knowledge assessment allows you to determine a patient’s ability to learn or understand. If there is an opportunity to teach, test a patient’s mental status by asking for feedback during a follow-up visit.

Abstract Thinking

Interpreting abstract ideas or concepts reflects the capacity for abstract thinking. For an individual to explain common phrases such as “A stitch in time saves nine” or “Don’t count your chickens before they’re hatched” requires a higher level of intellectual function. Note whether a patient’s explanations are relevant and concrete. A patient with altered mental status probably interprets the phrase literally or merely rephrases the words.

Association

Another higher level of intellectual functioning involves finding similarities or associations between concepts: a dog is to a beagle as a cat is to a Siamese. Name related concepts and ask the patient to identify their associations. Ask questions that are appropriate to the patient’s level of intelligence, using simple concepts.

Judgment

Judgment requires a comparison and evaluation of facts and ideas to understand their relationships and form appropriate conclusions. Attempt to measure the patient’s ability to make logical decisions with questions such as “Why did you seek health care?” or “What would you do if you became ill at home?” Normally a patient makes logical decisions.

Cranial Nerve Function

To assess cranial nerve function, you may test all 12 cranial nerves, a single nerve, or related group of nerves. A dysfunction in one nerve reflects an alteration at some point along the distribution of the cranial nerve. Measurements used to assess the integrity of organs within the head and neck also assess cranial nerve function. A complete assessment involves testing the 12 cranial nerves in their numerical order. To remember the order of the nerves, use this simple phrase, “On old Olympus’ towering tops, a Finn and German viewed some hops.” The first letter of each word in the phrase is the same as the first letter of the names of the cranial nerves listed in order (Table 30-38).

TABLE 30-38

Cranial Nerve Function and Assessment

Sensory Function

The sensory pathways of the CNS conduct sensations of pain, temperature, position, vibration, and crude and finely localized touch. Different nerve pathways relay the sensations. Most patients require only a quick screening of sensory function unless there are symptoms of reduced sensation, motor impairment, or paralysis. The risk of skin breakdown is greater in a patient with impaired sensation. When assessing decreased sensation, complete a skin and tissue assessment of the area affected by the sensory loss. In addition, teach the patient to avoid pressure, thermal, and/or chemical trauma to the area.

Normally a patient has sensory responses to all stimuli that are tested. He or she feels sensations equally on both sides of the body in all areas. Assess the major sensory nerves by knowing the sensory dermatome zones (Fig. 30-74, A and B). Some areas of the skin are innervated by specific dorsal root cutaneous nerves. For example, if assessment reveals reduced sensation when checking for light touch along an area of the skin (e.g., the lower neck), this determines in general where a neurological lesion exists (e.g., fourth cervical spinal cord segment).

FIG. 30-74 Dermatomes of body (body surface areas innervated by particular spinal nerves); C1 usually has no cutaneous distribution. A, Anterior view. B, Posterior view. It appears that there is a distinct separation of surface area controlled by each dermatome, but there is almost always overlap between spinal nerves. (From Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)

Perform all sensory testing with the patient’s eyes closed so he or she is unable to see when or where a stimulus touches the skin (Table 30-39). Then touch the patient’s skin in a random, unpredictable order to maintain his or her attention and prevent detection of a predictable pattern. Ask the patient to describe when, what, and where he or she feels each stimulus. Compare symmetrical areas of the body while applying stimuli to the patient’s arms, trunk, and legs.

TABLE 30-39

Assessment of Sensory Nerve Function

Motor Function

An examination of motor function includes assessments made during the musculoskeletal examination. In addition, the nurse assesses cerebellar function. The cerebellum coordinates muscular activity, maintains balance and equilibrium, and controls posture.

Coordination

To avoid confusion, demonstrate each maneuver and then have the patient repeat it, observing for smoothness and balance in his or her movements (Box 30-32). In older adults normally slow reaction time causes movements to be less rhythmical.

Box 30-32 Patient Teaching

Neurological Assessment

Objective

• Patient and family or significant others will understand relationship of patient’s behavioral and mental changes to physical status.

Teaching Strategies

• Explain to family caregiver the implications of any behavioral or mental impairment shown by patient.

• If patient has sensory or motor impairments, explain measures to ensure safety (e.g., use of ambulation aids or safety bars in bathrooms or stairways).

• Teach older adult to plan enough time to complete tasks because reaction time is slow.

• Teach older adult to observe skin surfaces for areas of trauma since pain perception is reduced.

Evaluation

• Ask family member to discuss patient behaviors that result from neurological impairments.

• Have patient explain safety measures used to avoid injury from sensory and motor limitations.

• Have older patient explain reason for inspecting skin surface routinely.

To assess fine-motor function, have the patient extend the arms out to the sides and touch each forefinger alternately to the nose (first with eyes open, then with eyes closed). Normally a patient alternately touches the nose smoothly. Performing rapid, rhythmical, alternating movements demonstrates coordination in the upper extremities. While sitting, the patient begins by patting the knees with both hands. Then he or she alternately turns up the palm and back of the hands while continuously patting the knees. Normally patients perform the maneuver smoothly and regularly with increasing speed.

An additional maneuver for upper-extremity coordination involves touching each finger with the thumb of the same hand in rapid sequence. A patient moves from the index finger to the little finger and back, with one hand tested at a time. The dominant hand is slightly less awkward when performing this movement. Movement is smooth and in succession.

Test lower-extremity coordination with the patient lying supine, legs extended. Place a hand at the ball of the patient’s foot. The patient taps the hand with the foot as quickly as possible. Test each foot for speed and smoothness. The feet do not move as rapidly or evenly as the hands.

Balance

Use one or two of the following tests to assess balance and gross-motor function. When examining the older adult for balance and equilibrium, be aware of the risk for falls. Some older adults need help with this portion of the examination.

Have the patient perform a Romberg’s test by standing with feet together, arms at the sides, both with eyes open and eyes closed. Protect the patient’s safety by standing at the side, observe for swaying. Expect slight swaying of the body in the Romberg’s test. A loss of balance (positive Romberg) causes a patient to fall to the side. Normally he or she does not break the stance.

Have the patient close the eyes, with arms held straight at the sides, and stand on one foot and then the other. Normally patients are able to maintain balance for 5 seconds with slight swaying. Another test involves asking the patient to walk a straight line by placing the heel of one foot directly in front of the toes of the other foot.

Reflexes

Eliciting reflex reactions provides data about the integrity of sensory and motor pathways of the reflex arc and specific spinal cord segments. Assessment of reflexes does not determine higher neural center functioning. Fig. 30-75 traces the pathway of the reflex arc. Each muscle contains a small sensory unit called a muscle spindle, which controls muscle tone and detects changes in the length of muscle fibers. Tapping a tendon with a reflex hammer stretches the muscle and tendon, lengthening the spindle. The spindle sends nerve impulses along afferent nerve pathways to the dorsal horn of the spinal cord segment. Within milliseconds the impulses reach the spinal cord and synapse to travel to the efferent motor neuron in the spinal cord. A motor nerve sends the impulses back to the muscle, causing the reflex response.

FIG. 30-75 Pathway of the reflex arc.

The two categories of normal reflexes are deep tendon reflexes, elicited by mildly stretching a muscle and tapping a tendon, and cutaneous reflexes, elicited by stimulating the skin superficially. Grade reflexes as follows (Seidel et al., 2011):

0: No response

1+: Sluggish or diminished

2+: Active or expected response

3+: More brisk than expected, slightly hyperactive

4+: Brisk and hyperactive with intermittent or transient clonus

When assessing reflexes have the patient relax as much as possible to avoid voluntary movement or tensing of muscles. Position the limbs to slightly stretch the muscle being tested. Hold the reflex hammer loosely between the thumb and fingers so it is able to swing freely and tap the tendon briskly (Fig. 30-76). Compare the responses on corresponding sides. Normally the older adult presents with diminished reflexes. Reflexes are hyperactive in patients with alcohol, cocaine, or opioid intoxication. Table 30-40 summarizes common deep tendon and cutaneous reflexes.

TABLE 30-40

Assessment of Common Reflexes

FIG. 30-76 Position for eliciting patellar tendon reflex. The lower leg normally extends.

Review Questions

Are You Ready to Test Your Nursing Knowledge?

1. The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship?

1. Appearance and behavior

2. Measurement of vital signs

3. Observing specific body systems

4. Conducting a detailed health history

2. The nurse is teaching a young mother to palpate her 8-year-old child to quickly evaluate if the child has a fever. Which information is important for the nurse to include?

1. Place the palm of the hand on the child’s back.

2. Lightly touch the child’s forehead with the fingertips.

3. Place the back of your hand against the child’s forehead and then on the back of the neck.

4. Use the pads of your fingers and press against the child’s neck and over the thorax.

3. While assessing the adult patient’s lungs, the nurse identifies the following assessment findings. Which finding should be reported to the health care provider?

1. Respiratory rate: 14

2. Pain reported when palpating posterior lower thorax

3. Thorax rising and falling symmetrically for right and left lungs

4. Vesicular breath sounds heard with auscultation of peripheral lung fields

4. The nurse is teaching a young female patient to practice good skin health. Which information is important for the nurse to include?

1. Avoid sunbathing between 3 pm and 7 pm.

2. Oral contraceptives and antiinflammatories make the skin more sensitive to the sun.

3. Call the health care provider for the presence of a mole on an arm or leg that appears uniformly brown.

4. Wear sunscreen with an SPF of 30 or greater if using a sunlamp or tanning parlor.

5. As a nurse prepares to provide morning care and treatments, it is important to question a patient about a latex allergy before which intervention? (Select all that apply.)

1. Applying adhesive tape to anchor a nasogastric tube

2. Inserting a rubber Foley catheter into the patient’s bladder

3. Providing oral hygiene using a standard toothbrush and toothpaste

4. Giving an injection using plastic syringes with rubber-coated plungers

5. Applying a transparent wound dressing

6. The nurse is assessing a patient who returned 3 hours ago from a cardiac catheterization, during which the large catheter was inserted into the patient’s femoral artery in the right groin. Which assessment finding would require immediate follow-up?

1. Palpation of a femoral pulse with a heart rate of 76

2. Auscultation of a heart murmur over the left thorax

3. Identification of mild bruising at the catheter insertion site

4. Palpation of a right dorsalis pedis pulse with strength of +1

7. The patient reports having a sore throat, coughing, and sneezing. While performing a focused assessment, which finding supports the patient’s reported symptoms related to upper respiratory infection?

1. Buccal mucosa is moist and dark pink.

2. Respiratory rate is 18, rhythm is even.

3. Retropharyngeal lymph nodes are enlarged and firm.

4. Inspection with a tongue depressor on the posterior tongue causes gagging.

8. The nurse is teaching a patient with poor arterial circulation about checking blood flow in the legs. Which information should the nurse include? (Select all that apply.)

1. A normal pulse on the top of the foot indicates adequate blood flow to the foot.

2. To locate the dorsalis pedis pulse, take the fingers and palpate behind the knee

3. When there is poor arterial blood flow, the leg is generally warm to the touch.

4. Loss of hair on the lower leg indicates a long-term problem with arterial blood flow.

9. How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast?

1. Supine with both arms overhead with palms upward

2. Sitting with hands clasped just above the umbilicus

3. Supine with the right arm abducted and hand under the head and neck

4. Lying on the right side, adducting the right arm on the side of the body

10. The nurse is planning a staff education conference about abdominal assessment. Which point is important for the nurse to include?

1. The aorta can be felt using deep palpation in the upper abdomen near the midline.

2. The patient should be sitting to best determine the contour and shape of the abdomen.

3. Always wear gloves when palpating the skin on the patient’s abdomen.

4. Avoid palpating the abdomen if the patient reports any discomfort or feelings of fullness.

11. The nurse is teaching a patient how to perform a testicular self-examination. Which statement by the nurse is correct?

1. “The testes are normally round and feel smooth and rubbery.”

2. “The best time to do a testicular self-examination is before your bath or shower.”

3. “Perform a testicular self-examination weekly to detect signs of testicular cancer.”

4. “Since you are over 40 years old, you are in the highest risk group for testicular cancer.”

12. The patient is assessed for range of joint movement. He or she is unable to move the right arm above the shoulder. How should the nurse document this finding?

1. Patient was not able to flex arm at shoulder.

2. Extension of right arm is limited.

3. Patient’s abduction of right arm was limited to 100 degrees.

4. Internal rotation of right arm is limited to less than 90 degrees.

13. The nurse plans to assess the patient’s abstract reasoning. Which task should the nurse ask the patient to perform?

1. “Tell me where you are.”

2. “What can you tell me about your illness?”

3. “Repeat these numbers back to me: 7…5…8.”

4. “What does this mean: ‘A stitch in time saves nine?’”

14. The nurse teaches a patient about cranial nerves to help explain why the patient’s right side of the mouth droops instead of moving up into a smile. What nerve does the nurse explain to the patient?

1. VII—Facial

2. V—Trigeminal

3. XII—Hypoglossal

4. XI—Spinal accessory

15. The nurse is planning to teach the student nurse how to assess the hydration status of an older adult. Which techniques are appropriate for this situation? (Select all that apply.)

1. Inspect the lips and mucous membranes to determine if they are moist.

2. Pinch the skin on the back of the hand to see if the skin tents.

3. Check the patient’s pulse and blood pressure.

4. Weigh the patient daily.

Answers: 1. 1; 2. 3; 3. 2; 4. 2; 5. 1, 2, 4; 6. 4; 7. 3; 8. 1, 4; 9. 3; 10. 1; 11. 1; 12. 3; 13. 4; 14. 1; 15. 1, 3, 4.

Auscultation

Vascular System

Blood Pressure

Carotid Arteries

Jugular Veins

Peripheral Arteries and Veins

Peripheral Arteries

Peripheral Veins

Lymphatic System

Breasts

Female Breasts

Inspection

Palpation

Male Breasts

Abdomen

Inspection

Skin

Umbilicus

Contour and Symmetry

Enlarged Organs or Masses

Movement or Pulsations

Auscultation

Bowel Motility

Vascular Sounds

Kidney Tenderness

Palpation

Aortic Pulsation

Female Genitalia and Reproductive Tract

Preparation of the Patient

External Genitalia

Speculum Examination of Internal Genitalia

Male Genitalia

Sexual Maturity

Penis

Scrotum

Inguinal Ring and Canal

Rectum and Anus

Inspection

Digital Palpation

Musculoskeletal System

General Inspection

Palpation

Range of Joint Motion

Muscle Tone and Strength

Neurological System

Mental and Emotional Status

Level of Consciousness

Behavior and Appearance

Language

Intellectual Function

Memory

Knowledge

Abstract Thinking

Association

Judgment

Cranial Nerve Function

Sensory Function

Motor Function

Coordination

Balance

Reflexes

After the Examination

Key Points

Preparing for Clinical Practice

References

Research References