Assessment of the

Assessment of the Breast & Abdomen

Unit 5

Overview/Breast Assessment

Breast
Risk factors for breast cancer
Developmental changes
History
Inspection
Palpation
Male Breast

Incidence of Breast Cancer

Incidence has risen steadily
1 in 8 American women

Risk Factors for Breast Cancer

Beyond our control:

over age 50

Caucasian

family history: Premenopausal Cancer

in mother or sister

personal history of breast Cancer

Risk Factors for Breast Cancer

Not hard data but some evidence:

childless, or first child after age 30
Obesity or thinness
high fat diet
atypical hyperplasia in breast biopsy
no or short duration of breast feeding
early onset of menstruation (<12)
late onset of menopause

Risk Factors for Breast Cancer

Not hard data but some evidence:

high ETOH
high SES
environment (cancer "hot spots")
prolonged BCP
prolonged HRT

Single most important defense against late-stage disease is early detection.

90 % curable if found early
72 % with spread to local nodes
18 % with distant metastases

You need an action plan.

1. Exam by HCP q 3 years; yearly after 40
2. Mammogram: baseline by age 40
40-50 q 1-2 years
50 + q year
3. SBE

Breast Development

During reproductive years
in response to premenstrual hormonal changes

increased size, nodularity, tenderness

3-4 days before menses

tenseness, fullness, heaviness, tenderness, pain
changes from hormones and fluid retention
total breast volume increases significantly

days 4-7 of menstrual cycle

least size, nodularity, tenderness

Breast Development

Menopausal changes
glandular tissue gradually involutes
fat is deposited in breasts
flattening of structures, decreased elasticity
lactiferous ducts more palpable- stringy

Breast Development

Pregnancy
as early as 2nd month- increase in size two to three time usual
feel nodular
areola & nipples darken and become more prominent
express colostrum after 4th month

Breast Assessment

History
Physical exam
Inspection
palpation

Breast Assessment

Privacy
Warm room
Put woman at ease
Assess level of knowledge about BSE
Men may not realize breast exam is necessary

History

frequency & timing of SBE
changes in breast characteristics -

lumps, tenderness, swelling, discharge

related to menstrual cycle, pregnancy?

Axillary tenderness
mammography- age for first - date for last- findings
Risk factors for breast cancer

History

Benign breast disease
Reproductive and menstrual history
Medication history
especially hormones
Nutrition history (caffeine)

Breast Assessment - Inspection

Seat client on side of bed or exam table
Observe breasts, nipples & areola in

4 positions:
arms at sides
arms over head
hands pressed against hips
leaning forward

Why ??

Breast Inspection

Position change may elicit

asymmetry
retraction
fixation

Inspect breasts for
size
symmetry
shape/contour
surface characteristics: color (erythema), texture

hair/venous pattern
retraction
dimpling
edema (peau d’orange)
lesions, scars, masses

Palpating breast tissue

Include 4 quadrants and
Tail of Spence

With client lying with small pillow under shoulder

Palpate breast tissue for

consistency

masses:

location

size, shape

depth

consistency

discreteness

mobility

tenderness

Inspect/palpate areola for:

shape

color

retraction

masses

tenderness
Inspect/palpate nipples for:

erect, inverted

direction in which they point

symmetry

color

retraction

tenderness

discharge

supernumerary nipples
Palpate axilla for:

tenderness

masses

lymph nodes

What is NL?

Characteristics of breast cancer mass

Solitary, unilateral, solid, hard, irregular, poorly delineated, non-mobile, painless, nontender, located in upper outer quadrant

Male Breast Examination

1% of all breast Ca is in men
Inspect while seated
Palpate axillae same as for women
Palpate breasts, nipples and areola while supine
Gynecomastia

Nursing Diagnoses

Knowledge deficit
Body image disturbance
Effective breast feeding
Fear

Teaching

Breast Self Exam (BSE or SBE)

All women over 20 should perform SBE
Perform exam between 4-7th day of menstrual cycle
ages 20-40 - exam q 3 year by HCP

(more frequently if high risk)

40+- q year

Teaching

Mammogram

age 35 - 40 baseline
age 40 - 50 q 1-2 years
age 50 + every year
high risk start yearly at age 35

Teaching

Testicular Self Exam (TSE)

Most common type of cancer ages 15-40
Roll each testis between thumb and fingers feeling for lump or abnormality
Palpate epididymis
See a HCP for a small, pea-sized lump
It is normal for one testis to be larger than the other
NL: Smooth, regular, mobile slightly sensitive to compression

Overview/Abdominal Assessment

Geography of the abdomen
Systems involved
Developmental Variations
Abdominal exam

history
Inspection
Auscultation
Percussion
Light Palpation

Abdominal Assessment Developmental variations

Infant easy to find sx feeding disorders

organs easily delineated milk intolerance

Child protuberant toddler - toilet training
guarding (should be relaxed) school phobia

Adolescent/ firm musculature bulimia, anorexia

young adult stress, peptic ulcer, IBD

Middle adult < musculature peptic ulcer, IBD

> adipose Ca (check occult blood)

Older adult very soft

Ca (check occult blood) constipation

History

Get info about nutrition, digestion, elimination, reproductive, hernias
Hx of GI disease:

ulcers, IBD *, Ca, gall bladder^* IBD = ulcerative colitis, Crohn’s disease
Sx = diarrhea, bloody stools
fatigue, weight loss
Hx of liver problems:
hepatitis vaccine status
blood transfusion

Hx of surgery, injuries, kidney/bladder problems

History

Nutrition/digestion

appetite, recent changes in eating,

wt > or <

food intolerance, lifestyle influences
indigestion, heartburn, use of antacids
difficulty swallowing, N&V
24 hour recall

History

Elimination

normal stool, change in bowel habits
hemorrhoids
voiding habits
laxative use

History

ETOH - amount and frequency
Allergies (food or medications)

NKA, NKDA

Medications

use of ASA, NSAIDS, acetaminophen

History/Present Health Status

Recent travel- exposure to infectious diseases
Recent stressful events
Possibility of pregnancy- date of LMP

Family History

Kidney problems
Colon Ca
Malabsorption syndromes
Gallbladder disease
Inflammatory bowel disease (IBD)

ulcerative colitis
Crohn’s disease

Crohn’s and Colitis Foundation of America - www.ccfa.org

Physical Exam

Pt relaxed, has voided
supine
arms at side
knees flexed

Inspection

Tangential lighting
Sit at right side of client
Inspect
symmetry
contour NL: flat

scaphoid ?
rounded ?
protuberant ?
distended ?

Inspection

Inspect
umbilicus location

contour
NL ?

movement peristalsis

pulsations
respirations
NL ?

skin

Auscultation

Why not IPPA ?

Auscultation

Auscultate in all 4 quadrants for:
bowel sounds presence

pitch
intensity
(borborygmi)
frequency

vascular sounds bruit

venous hum

Auscultation

Normal bowel sounds ?

irregular
q 5-15 seconds

Hyperactive bowel sounds ? High pitched, rushing, loud

Hypoactive bowel sounds ? Absent ? Must listen for…. ?

Auscultation

Vascular sounds

bruit

listen over abdominal aorta
R and L renal
iliac
femoral

Auscultation

Vascular sounds

bruit

listen over abdominal aorta
R and L renal
iliac
femoral
NL ?
Sound ?
Cause ?
If + DO NOT PALPATE

Auscultation

Vascular sounds

vascular hum

around umbilicus
NL ?
May hear if organ such as liver or spleen is engorged

Percussion

Purpose ?

detect fluid, gaseous distention, masses and position and size of solid structures

Percussion

Percuss 4 quadrants for
tympany
dullness
Which predominates ?
Areas of dullness ?

LUQ
suprapubic
RUQ - liver palpation

NL findings liver palpation ?

4 - 8 cm MSL check Bates

6-12 cm R MCL

Palpation

Palpate lightly in all 4 quadrants
Identify tenderness

resistance, guarding
organs (aorta)
masses

Palpate more deeply
masses location, shape, size

consistency, mobility, tenderness, pulsations

liver

Findings - Normal liver ?
Nonpalpable, nontender
Liver edge palpable just under costal margin on inspiration

Findings - Normal abdominal exam

Rounded, symmetrical contour, no distension, no peristaltic movement, no scars or lesions noted.
Bowel sounds audible in all 4 quadrants, no bruits.
Liver 8 CM MCL, firm, nontender.
No masses.

Nursing Diagnoses

Bowel incontinence
Constipation
Diarrhea
Altered urinary elimination
Stress incontinence
Urge incontinence
Total incontinence

Nursing Diagnoses

Altered nutrition: less than body requirements
Altered nutrition: more than body requirements
Pain
Self-care deficit: feeding

Teaching

Risks for cancer
Colon cancer screening
Prostate cancer screening
Self care of constipation, diarrhea
Prevention of UTI