Phys assess #3 Flashcards by zerlina leilanimalulanimekealoha

Q

Sensory organ for vision-

A

Eyes

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Q

Important for functioning and ability to perform

A

Eyes

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Q

Transparent protective cover of the eye is the ___

A

cornea

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Q

Lacrimal apparatus-

A

irrigates the eye by producing tears

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Q

Movement of the extraocular muscles stimulated by

A

three cranial nerves

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Q

Cranial nerve VI (6):

A

abducens nerve, innervates lateral rectus muscle, which abducts eye

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Q

Cranial nerve IV (4):

A

trochlear nerve, innervates superior oblique muscle

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Q

Cranial nerve III (3):

A

oculomotor nerve, innervates all the rest: the superior, inferior, and medial rectus and the inferior oblique muscles

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Q

There are _ muscles that move the eye and keep it straight and rotate

A

6

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Q

Each muscle makes sure both eyes move together, known as _____ (eyes remain parallel)

A

conjugate movement

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Q

Parallel axis is important for eye movement bc the human brain is ____ or a single image visual system

A

Binocular

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Q

Both eyes creating one image in the brain

A

Binocular/Single image visual system

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Q

Follow movement of pen light or object proceeding clockwise.

A

Six cardinal positions of gaze

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Q

Assess for potential extra ocular muscle (EOM) weakness, nystagmus or lid lag.

A

Six cardinal positions of gaze

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Q

Normal response is eyes being able to track the movement parallel

A

Six cardinal positions of gaze

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Q

Weakness in cranial nerve or muscle dysfunction if the eyes do not move parallel

A

Six cardinal positions of gaze

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Q

Three concentric coats of the eye

A

Outer, middle, and inner coat

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Q

Outer coat

A

Sclera and cornea

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Q

Middle coat

A

Choroid, pupil, and the anterior and posterior chambers of the lens

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Q

Inner coat

A

Contains the retina

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Q

Internal Anatomy: Outer Layer

A

Sclera, Cornea, Corneal reflex, Trigeminal nerve, Facial nerve

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Q

Sclera:

A

tough, protective, white covering.

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Q

Continuous anteriorly with smooth, transparent cornea, which covers iris and pupil

A

Sclera

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Q

Cornea:

A

part of refracting media of eye, bending incoming light rays so that they will be focused on inner retina.

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Corneal reflex—

contact with a wisp of cotton stimulates a blink response in both eyes simultaneously.

Trigeminal nerve-

cranial nerve V, sending message from corneal reflex to the brain, carries afferent sensation into brain.

Facial nerve-

cranial nerve VII, causes the blink reflex, carries efferent message that stimulates blinking

Sensitive to touch-

cornea and sclera

Internal Anatomy: Middle Layer

Choroid, Iris, Muscle fibers, Pupil changes, Lens

Choroid:

has dark pigmentation to prevent light from reflecting internally and is heavily vascularized to deliver blood to retina

Iris:

Functions as a diaphragm, varying opening at its center

The pupil changes size in order to control amount of ___ in the pupil.

light

Dilates when light is dim and focus on far vision. Constricts when light is bright and focus on near vision.

Pupil

Budges to see near objects. Flatten to focus on far objects.

Lens

Muscle fibers of iris contract pupil in ____

bright light and to accommodate for near vision

Pupil:

round and regular; size determined by balance between parasympathetic and sympathetic chains of autonomic nervous system

Stimulation of parasympathetic branch, through ____, causes constriction of pupil.

cranial nerve III

Stimulation of sympathetic branch

dilates pupil and elevates eyelid.

Pupil size also reacts to amount of ___ and to accommodation, or focusing an object on retina.

ambient light

The fight or flight mode is responsible for

constriction and dilation of the pupils

Lens:

biconvex disc located just posterior to pupil

Different pupil size can occur up to 20% of population.

Anisocoria

Can indicate glaucoma, brain bleed, traumatic brain injury, cancer, or concussion.

Anisocoria

Transparent; it serves as a refracting medium, keeping a viewed object in focus on retina

Lens

Anterior and posterior chambers contain clear, watery aqueous humor produced continually by ciliary body.

Lens

Continuous flow of fluid serves to deliver nutrients to surrounding tissues and to drain metabolic wastes.

Lens

Intraocular pressure determined by balance between amount of aqueous produced and resistance to outflow

Lens

Internal Anatomy: Inner Layer

Retina, Optic disk, Retinal vessels, Macula

Retina:

the visual receptive layer of eye where light waves change into nerve impulses

Retinal structures viewed through ophthalmoscope are

optic disc, retinal vessels, general background, and macula.

Optic disc:

area in which fibers from retina converge to form optic nerve

Located toward nasal side of retina, it has characteristics specific to color, shape and margins

Optic disc

Retinal vessels:

normally include a paired artery and vein extending to each quadrant. Receiving and transducing light from central field

located on temporal side of fundus

Macula:

Slightly darker pigmented region surrounding fovea centralis, area of sharpest and keenest vision

Macula:

Receives and transduces light from center of visual field

Macula:

Image that is formed on the retina is going to be

upside down and reversed

normal constriction of pupils when bright light shines on retina.

Pupillary light reflex

Note direct and consensual pupillary constriction.

Pupillary light reflex

Subcortical reflex arc with no conscious control

Pupillary light reflex

a reflex direction of eye toward an object attracting a person’s attention

Fixation:

Image fixed in center of visual field, the fovea centralis

Fixation:

adaptation of eye for near vision.

Accommodation:

Accomplished by increasing curvature of lens through movement of ciliary muscles

Accommodation:

Although lens cannot be observed directly, the following components of accommodation can be observed:

Convergence (motion toward) of the axes of the eyeballs Pupillary constriction

Responses to pupillary light reflex under the influence of alcohol, drugs, fatigued, or not paying attention can show

abnormal movements

____ vision is intact in newborn infant.

Peripheral

Macula, area of keenest vision, is absent at birth but mature by

8 months.

By ___ months of age, infant establishes binocularity. Before that age the muscles are not that strong (cross-eyed).

3 to 4

Can fixate on a single image with both eyes simultaneously

binocularity

Lens is nearly spherical at birth.

Growing flatter throughout life

Consistency changes from that of soft plastic at birth to rigid glass consistency in old age.

Lens

Eye function is limited and movement is poorly coordinated

at birth

Age-related farsightedness

Presbyopia

Lens loses elasticity, becoming hard and glasslike, which decreases ability to change shape to accommodate for near vision.

Presbyopia

Accommodation is lost so it effects near vision.

Presbyopia

Most common causes of decreased visual functioning in older adults are the following:

Cataract formation, Glaucoma, Age-related macular degeneration (AMD), Diabetic retinopathy

Clouding or lens opacity, resulting from a clumping of proteins in lens

Cataract

Decreased peripheral vision and will compensate by turning their head

Glaucoma

Increased intraocular pressure- Chronic open-angle glaucoma is most common type.

Glaucoma

Complain of almost tunnel vision changes that are gradual.

Glaucoma Late stages-

Breakdown of cells in macula of retina; loss of central vision

Age-related macular degeneration (AMD)

Leading cause of blindness in adults ages 25 to 74 years of age.

Diabetic retinopathy

Pupil size decrease by the age of __

70

Normal transparent clean lens will begin to thicken and yellow which begins formation of

cataracts

Visual acuity diminishes gradually after age __ and more after age of __

50, 70

Open angle glaucoma

Obstructed drainage canal

Closed angle glaucoma

Pressure pushes iris against cornea

most common, no s/sx at the beginning

Open angle

Glaucoma is caused by increased

intraocular pressure

The iris may appear bulging because the aqueous humor cannot circulate throughout the eye and the pressure is increased

Glaucoma

Peripheral vision effected

Glaucoma

Affect central part of vision

Age-related macular degeneration (AMD)

Most common cause of blindless characterized by the loss of central vision

Age-related macular degeneration (AMD)

Its not consistent with vision that is considered normal at any age- not a common finding

Age-related macular degeneration (AMD)

Culturally based variability present in color of

iris and retinal pigmentation

___ are a leading cause of blindness worldwide.

Cataracts

Estimated that 80% are preventable or curable with surgery

Cataracts

Glaucoma incidence increases with __

age.

Glaucoma: African Americans ___ times more likely to develop than Caucasian Americans.

3-6

Culture and Genetics

Age-related macular degeneration

Visual Impairment-

defined by the inability of seeing letters on eye chart at 20/50 or below

Primary angle glaucoma- primary cause of blindness in ___

African Americans and Hispanics

Risk factors for primary angle glaucoma

Positive family history, smoking, light iris color, hypertension, high cholesterol and being female

Visual screenings important for school aged children for safety and address eye issues at early age, helps detect ____

cross eye and lazy eye in children

Patients may complain of shadow or diminished vision in one quarter to one half of visual field.

Retinal detachment

If occurs after trauma or injury it is considered an emergency.

Retinal detachment

Occurs bc part of retina has pulled away from support system

Retinal detachment

Eyes Objective Data

Preparation, Position a person standing for vision screening; then sitting up with head at your eye level.

Snellen eye chart Equipment needed:

Handheld visual screener Opaque card or occluder Penlight Applicator stick Ophthalmoscope

most commonly used and most accurate for visual acuity

Snellen eye chart

normal vision

20/20

visual impairment

20/50

Stand person 20 ft away from chart

Snellen eye chart

if pt has glasses or contacts leave on but if reading glasses take off

Snellen eye chart

Read smallest line of letter possible

Snellen eye chart

If unable to see the largest letters going to shorten the distance from the chart.

Snellen eye chart

If the pt is 10 ft away document it was

10/20

If acuity ___ you can read 20 feet but others normally can see 30

20/30

considered legally blind

20/200

Also known as the Hirschberg test

Corneal Light Reflex

Assess parallel alignment of eye axes by shining a light toward the person’s eyes.

Corneal Light Reflex (Hirschberg test)

Direct the person to stare straight ahead as you hold the light about 30 cm (12 inches) away.

Corneal Light Reflex (Hirschberg test)

Note reflection of light on corneas; should be in exactly same spot on each eye.

Corneal Light Reflex (Hirschberg test)

If any asymmetry can identify deviation of the eye muscles or paralysis

Corneal Light Reflex (Hirschberg test)

Perform cover test is asymmetric. The covered eye must response to reflex

Corneal Light Reflex (Hirschberg test)

If child has untreated strabismus can lead to

permanent visual damage

Younger than ___ could see some types of abnormalities bc muscles are not strong enough yet

6 months

Ask the person to look up; using thumbs, slide lower lids down along orbital rim, being careful not to push against eyeball.

Conjunctiva and Sclera

Inspect exposed area; eyeball should look moist, white, and glossy.

Conjunctiva and Sclera

Numerous small blood vessels normally show through

transparent conjunctiva.

Otherwise, conjunctivae clear and show normal color of structure below;

pink over lower lids and white over sclera.

Note any color change, swelling, or lesions.

Conjunctiva and Sclera

Be aware of ethnic variations.

Conjunctiva and Sclera

Ask the person to look down; with thumbs, slide outer part of upper lid up along bony orbit to expose under lid; inspect for any redness or swelling.

Lacrimal Apparatus

Normally puncta drain tears into

lacrimal sac.

Presence of excessive tearing may indicate blockage of

nasolacrimal duct.

Check by pressing index finger against sac, just inside lower orbital rim, not against side of the nose.

Lacrimal Apparatus

Pressure will slightly evert lower lid, but there should be no other response to pressure.

Lacrimal Apparatus

Tear duct

Lacrimal Apparatus

Shine light from side across cornea and check for

smoothness and clarity.

Oblique view highlights any abnormal irregularities in corneal surface.

Cornea and Lens

Should not be cloudiness or opacities

Cornea and Lens

___ a common finding in geriatric pts, opacity around the cornea

Arcus senilis

Note size, shape, and equality of

pupils

Normally pupils appear

round, regular, and of equal size in both eyes

Normal response includes

pupillary constriction. convergence of axes of eyes.

Test for accommodation by asking the person to focus on a

distant object

Record normal response to all these maneuvers as PERRLA, or

Pupils Equal, Round, React to Light, and Accommodation.

Muscle fibers of the iris are going to contract the pupil in

bright light

Accommodate for near vision, when contracts allow pupil to

constrict

May have smaller pupils and slower responses-

older adults, constriction should be symmetric

Poor coordinated eye movement

Newborns

In newborns, ___ common; eyes appear to deviate down with white rim of sclera visible over iris

setting-sun sign

Many infants have an ___, an excess skinfold extending over inner corner of eye, partly or totally overlapping inner canthus.

epicanthal fold

Iris normally blue or slate gray in light-skinned newborns and brown in dark-skinned infants;

by 6 to 9 months, permanent color differentiated

When assessing children use appropriate assessment for

developmental stage

Adults: Eyes may appear sunken from atrophy of

orbital fat

Orbital fat may herniate, causing bulging at

lower lids and inner third of upper lids.

____ may decrease tear production, causing eyes to look dry and lusterless and the person to report a burning sensation.

Lacrimal apparatus

__ may look cloudy with age

Cornea

Arcus senilis is commonly seen around cornea.

Can be common caused by deposits of lipid material.

Lower eye lids droopy- muscle fiber looses elasticity and roll outward. can complain of dry and itchy.

Ectropion

Hordeolum (Stye)

Hordeolum (Stye)

Localized staph infection

Hordeolum (Stye)

Affects hair follicle along lid margin

Hordeolum (Stye)

Painful, red, swollen

Hordeolum (Stye)

Contagious and rubbing eye can cause cross-contamination

Hordeolum (Stye)

Recommend warm compresses, wash hands, do not rub both eyes, topical antibiotics

Hordeolum (Stye)

Acute localized staph infection that occurs at hair follicles are lid margin

Hordeolum (Stye)

Caused by blunt trauma.

HYPHEMA

Can also results from herpes zoster infection.

HYPHEMA

Can see blood in anterior chamber in the eye and gravy cause blood to settle in front of the iris.

HYPHEMA

External portion of the ear-

Pinna or auricle

Consists of movable cartilage and skin

Ear

Auditory canal-

slight s curvature in the adult patient

External Ear Called the

auricle or pinna

serves as a funnel for sound waves into its opening, shape of the canal

External auditory canal

2.5-3 cm in length

Auditory canal

Extends to the ear drum

Auditory canal

Lined with glands that secrete cerumen that lubricate and protect ear

Auditory canal

Outer one third of canal is cartilage

Auditory canal

inner two thirds of the tunnel is covered by

very thin and sensitive skin

Also called the eardrum

Tympanic Membrane

Translucent membrane with a pearly gray color

Tympanic Membrane

Oval and slightly concave, pulled in at its center by one of middle ear ossicles, the malleus- parts that show through the eardrum called the umbo, manubrium, and short process.

Tympanic Membrane

Separates external and middle ear-

tympanic membrane

Tiny air-filled cavity inside temporal bone

Middle Ear

Middle Ear contains tiny ear bones, or auditory ossicles:

Malleus Incus Stapes

Several openings are present.

Middle Ear

To the outer ear and inner ear eustachian tube:

opening that connects middle ear with nasopharynx and allows passage of air

Normally closed, but opens with swallowing or yawning

Tubea

Conduct sound vibrations from outer ear

Function of middle ear

To central hearing apparatus that is located in the inner ear

Function of middle ear

Protects inner ear by reducing amplitude of loud sounds

Function of middle ear

Allows equalization of air pressure on each side of the tympanic membrane to prevent rupturing

Function of middle ear

Contains the bony labyrinth, which holds sensory organs for equilibrium and hearing.

Inner Ear

Cochlea contains central hearing apparatus.

Inner Ear

Not assessable for direct examination can still assess function of it

Inner Ear

Auditory system can be divided into three levels

Peripheral, Brain Stem, Cerebral Cortex

Amplitude:

loudness

Frequency:

pitch or number of cycles per second

Sound waves produce vibrations on __

Tympanic membrane

Ear transmits sounds and convert sounds into

vibrations.

Then turns them into electrical impulses that the brain analyzes-

Peripheral

Sensory organ of hearing, Numerous fibers on membrane.

Organ of corti

Hair cells bend and mediate vibrations into the

electrical impulses.

The electrical impulses conducted by the auditory portion of

cranial nerve 8 to the brain stem

Function at brainstem level is

binaural interaction

Locates direction of a sound in space, as well as identifying the sound

binaural interaction

___ from each ear sends signals to both sides of brainstem, which are sensitive to differences in intensity and timing of messages from two ears, depending on way head is turned

Cranial nerve VIII

Normal pathway of hearing is _____ described previously; it is the most efficient.

Air conduction (AC)

Alternate pathway of hearing is by

Bone conduction (BC)

Bones of the skull vibrate and are transmitted directly to inner ear and to cranial nerve VIII.

Bone conduction (BC).

___ is to interpret the meaning of that sound and begin appropriate response.

Function of cortex

Hearing loss is anything that

obstructs transmission of sound and effects hearing

Types of hearing loss

Conductive, Sensorineural/Perceptive, Mixed hearing loss

Mechanical dysfunction of external or middle ear.

Conductive hearing loss

Known as partial loss bc if the sound amplitude is increased high enough then the pt will be able to hear it

Conductive hearing loss

Can be caused by impacted cerumen, foreign bodies in the ear canal, perforated tympanic membrane, or any other puss or serum located within the middle ear.

Conductive hearing loss

Can be caused by otosclerosis

Conductive hearing loss

Indicate pathology of the inner ear, Cranial nerve 8, or the auditory areas of the cerebral cortex.

Sensorineural/Perceptive) hearing loss

If increasing amplitude the pt will not be able to hear it.

Sensorineural/Perceptive) hearing loss

Can be caused by presbycusis or other ototoxic drugs that effect hear cells in cochlea.

Sensorineural/Perceptive) hearing loss

Antibiotics, loop directs, nsaids and other cancer treatments- ototoxic

Sensorineural/Perceptive) hearing loss

Mixed hearing loss: both conductive and sensoineural within same ear.

Mixed hearing loss

Inner ear starts to develop early in __ of gestation.

5th week

Early development ears

posteriorly rotated and low set

Can effect hearing in infants-

rubella.

Early during first trimester can harm organ of corti and impair hearing to the fetus.

rubella.

Estuation tube is ___ position in infant.

shorter than, wider and more horizontal

Increases middle ear infections

Estuation tube in infants/Children

Lumen surrounded by lymphoid tissue, which increases during childhood and is

easily occluded.

Infant’s and young child’s external auditory canal is __ to that of adults.

shorter and has a slope opposite

Short and flat, easier for viruses to get in

Infant eustachian tube

More angular, hard for viruses to get in from the nose

Adult eustachian tube

Obstruction of eustachian tube or passage of nasopharyngeal secretions into middle ear

Otitis Media

Common illness in children

Otitis Media

Otitis media risk factors

Drinking bottles when sleeping, not being breastfed first month of life, 2nd hand smoke, attending day care, premature, male gender, fall and winter season.

Increased ambulatory visits

Otitis Media

Persistent effusion may lead to hearing loss.

Otitis Media

Genetic variation regarding

cerumen development

Caucasians and African American-

honey brown and dark down consistency, wet cerumen

Asians and American Indians-

Dry and flakey cerumen with gray

Ears Subjective Data

Earache Infections Discharge Hearing loss Environmental noise Tinnitus Vertigo Patient centered are

Hearing loss-

gradually or recently/quickly

Environmental noise-

damage to hearing

Tinnitus-

comes within the person, describe as ringing of crackling or buzzing sound. complaint of- is it louder when no other noise is present.

Vertigo-

dizziness, room spinning

Low speech pt cannot hear it.

If increase volume or make louder for them can be very painful for pts

At what age was child’s first episode?

Infants and Children Ear infections

Has child had any surgery, such as insertion of ear tubes or removal of tonsils?

Infants and Children Ear infections

Does anyone in the home smoke cigarettes?

Infants and Children Ear infections

Does child receive care outside your home?

Infants and Children Ear infections

Does child seem to be hearing well?

Infants and Children hearing problems

Have you noticed that infant startles with loud noise?

Infants and Children hearing problems

Increased risk for developing recurrent ear infections if first episode of ear infection is before age of

3 months

To determine recurrent otitis media-

3 episodes with in 3 months, 4 within last year, total, and how they treated

Address problems early bc they are at grater risk for hearing loss, delayed speech, social development issues, and learn deficits.

Infants and Children

Inspect and palpate external ear

Size and shape Skin condition Tenderness External auditory meatus

Skin color consistent with the person’s facial skin color Skin intact, with no lumps or lesions

Skin condition

Note size of opening to direct choice of speculum for otoscope; no swelling, redness, or discharge should be present.

External auditory meatus

Some cerumen usually present with color and texture variation

External auditory meatus

Should feel firm and produce no pain upon palpation

Pinna

As you inspect external ear, note size of

auditory meatus.

Choose largest ___ that will fit comfortably in ear canal.

speculum

Pull pinna up and back on an adult or older child to straighten

S-shape of canal.

Pull pinna down and back on an infant and a child

under 3.

Hold pinna gently but firmly; do not release traction on ear until you have

finished examination and removed otoscope.

Insert speculum

slowly and carefully

Last, perform otoscopic examination before you

test hearing.

Never touching boney section of canal wall bc its

very sensitive

If impacted cerumen can give pt sense of

pathologic hearing loss

Note any redness and swelling, lesions, foreign bodies, or discharge.

External Canal

Frank blood or clear, watery drainage (cerebrospinal fluid [CSF]) after head injury suggests

basal skull fracture and warrants immediate referral.

If any discharge is present note

color and odor.

Loss of hearing esp. upper respiratory infection needs to be

reported and followed up immediately

Tympanic Membrane (Ear Drum) Color and characteristics

Shiny pearl grey translucent

Cone-shaped light reflex prominent in anteroinferior quadrant, a reflection of the otoscope light

Tympanic Membrane (Ear Drum)

Sections of malleus are visible through translucent drum: the umbo, manubrium, and short process.

Tympanic Membrane (Ear Drum)

May notice some scarring- If several ear infections

Tympanic Membrane (Ear Drum)

Screening for hearing deficit begins during history;

how well does a person hear conversational speech?

Measure hearing air conduction (AC) or by bone conduction (BC), in which

sound vibrates through cranial bones to the inner ear.

When performing be careful to not injure the patient esp pain with increased sounds.

Tuning fork Tests

Infants and young children hard to assess-

look at startle reflex, making loud noise to see response and if they can see toward.

___ infant able to turn their head to localize sound and should respond to own name.

6-8 month

Weber test Rinne test

Tuning fork Tests

If the child is being seen for any type of illness or fever

Autoscopic examination

Should always be done in order to rule out ear infection.

Autoscopic examination

Recommend to do this exam at the end of the examination bc parent may need to hold down

Autoscopic examination

In addition to its place in complete examination

Otoscopic examination Infants and Young Children

Positioning of child to get clear view of canal

Otoscopic examination Infants and Young Children

Remember to pull pinna

straight down on an infant or a child younger than 3 years old; this will match slope of ear canal.

Otoscopic examination is not performed at birth because

canal is filled with amniotic fluid and vernix caseosa; after a few days the TM is examined.

Amber yellow color in tympanic membrane-

serum or puss with in middle ear.

May complain of feelings of fullness or transient hearing loss or

popping sound when swallowing

Young children to determine hearing loss-

may not pay attention to any normal conversation and react more to movement/facial expressions than they do to sound.

Present with a speech problem and appear confused esp when talking to them.

Hearing problem

May have pendulous ear lobes with linear wrinkling because of loss of elasticity of pinna (dangle)

Aging Adult

High-tone frequency loss apparent for those affected with presbycusis

Aging Adult

White in color, more opaque duller nad thicker than in younger adults

Aging Adult

If high toned frequency loss they may complain of individuals mumbling when talking to them

Aging Adult

Infection of outer ear

Otitis externa

Severe pain with movement of pinna or tragus

Otitis externa

S/Sx: Redness and swelling, drainage, scaling, itching, fever, enlarged regional lymph nodes

Otitis externa

Can diminish hearing on affected ear

Otitis externa

Dense white patches on ear drum

Scarred Drum

Caused by repeated infections

Scarred Drum

Do not necessarily affect hearing

Scarred Drum

Repeated infections causes scars but wont affect pts ability to hear

Scarred Drum

Middle ear fluid infection

Acute Otitis Media

Absent light reflex- early sign of infection

Acute Otitis Media

Increasing pressure in middle ear

Acute Otitis Media

S/Sx: Fever, redness and bulging drum, earache (throbbing) Hearing loss (transient)

Acute Otitis Media

If bright red color of eardrum-

indicates acute otitis media

Surgical intervention to treat chronic or recurrent middle ear infections. Decrease number of infection to promote drainage (aeration)

Tympanostomy Tubes

Relieves middle ear pressure

Tympanostomy Tubes

Promotes drainage

Tympanostomy Tubes

Tubes are going to Spontaneously squeeze out 6 months to 1 year after insertion

Tympanostomy Tubes

First part of the respiratory system

Nose

Upper portion of the nose is made of

bone and the rest is cartilage

First segment of respiratory system

Nose

Upper third made up of bone; rest is cartilage

Nose

Nasal cavity divided medially by septum into

two slit-like air passages

Olfactory receptors, hair cells, lie at roof of

nasal cavity and upper third of septum.

These receptors for smell merge into olfactory nerve, cranial nerve I, which transmits to

temporal lobe of brain.

Paranasal sinuses:

air-filled pockets within the cranium

Anterior part of the septum, Rich vascular network-

kiesselbach plexus- common site for nose bleeds

Lateral walls contain 3 parallel boney progections called -

superior, middle, and the inferior turbonets

Turbinates

Rich in blood vessels and purpose is to warm, filter and humidify air Projections in the nasal cavity that increase the surface area

Two pairs of sinuses are accessible to

examine.

Frontal sinuses in frontal bone

above and medial to orbits

Maxillary sinuses in

maxilla (cheekbone) along side walls of nasal cavity

Other two sets are smaller and deeper.

Ethmoid and Sphenoid

Ethmoid sinuses between

the orbits

Sphenoid sinuses deep within skull in the

sphenoid bone

Only maxillary and ethmoid sinuses are present at

birth.

Adolescents the maxillary sinuses meet full size when the

permanent teeth are adult

First segment of digestive system and an airway for the respiratory system

Mouth

short passage bordered by lips, palate, cheeks, and tongue

Oral cavity:

anterior border of oral cavity, transition zone from outer skin to inner mucous membrane lining the oral cavity

Lips:

striated muscle, that is arranged in a crosswise pattern. So it can change shape and position for speaking chewing swallowing speech cleaning the teeth. Also assists in taste sensation.

Tongue:

Mouth contains three pairs of

salivary glands.

___ lies within cheeks in front of ear.

Parotid gland

___ runs forward to open on buccal mucosa opposite second molar.

Stensen’s duct

_____ lies beneath mandible at angle of jaw

Submandibular gland l

____ runs up and forward to the floor of mouth and opens at either side of frenulum

Wharton’s duct

____, the smallest, almond-shaped, lies within floor of mouth under tongue and has many small openings along sublingual fold under tongue.

Sublingual gland

Largest of salivary glands-

Parotid

located in front of the ear from the zygomatic arch and down the angle of the jaw

Parotid

Glands secrete ____, the clear fluid that moistens and lubricates the food bolus, starts digestion, and cleans and protects the mucosa.

saliva

Teeth-

32 permanent teeth adult, 16 in each arch

(gingivae) collar the teeth.

Gums

Thick fibrous tissues covered with mucous membrane

Gums

Different from rest of oral mucosa because of their pale pink color and stippled surface

Gums

Crown neck and root-

parts of teeth

Area behind mouth and nose

Throat or Pharynx

separated from mouth by a fold of tissue on each side, the anterior tonsillar pillar

Oropharynx:

located behind the folds, mass of lymphoid tissue. Appear more granular in appurtenance and surface shows deep crypts (holes).

Tonsils:

___ enlarges during childhood until puberty. Reaches adult length and then deteriorates

Tonsillar tissue

___ starts at 3 months

Salivation

Baby will drool periodically for a few months before learning to

swallow saliva.

Development of teeth- begins in

utero.

Children have 20 deciduous (2 1/2 years), or temporary, teeth that erupt between

6 months and 24 months of age.

Deciduous teeth lost beginning at age ____; replaced by permanent, starting with central incisors

6 through 12

____ develops shape during adolescence, along with other secondary sex characteristics.

Nose

Nasal stuffiness and epistaxis(nose bleeds) may occur during pregnancy bc of

increased vascularity to the respiratory tract.

Gums may be hyperemic and softened.

Pregnancy

Bleeding gums when brushing teeth

Pregnancy

Aging adult: Gradual loss of subcutaneous fat starts during later middle adult years,

making the nose appear more prominent in some people.

Aging adult: Atrophic tissues ulcerate easily. Gums and nose drier and sensitive.

increasing risk for older people for infections, such as oral moniliasis and malignant lesions.

Aging adult: Natural tooth loss exacerbated by inadequate dental care, poor oral hygiene, and tobacco use

can lead to malocclusion leading to further tooth loss and pain.

Diminished sense of taste and smell

Can contribute to malnutrition in older adults

Decreasing number of olfactory nerves related to

normal aging

Protein, vitamin and mineral malnutrition occurrence due to

malnutrition

Cleft lip and cleft palate-

congenital defect.

Most common in Asians, intermediate in whites, and least common in blacks

Cleft lip and cleft palate

A bony ridge running in middle of hard palate is seen in 20% to 35% of the US population.

Torus palatinus

A benign lesion occurring on buccal mucosa is seen more often in black patients.

Leukoedema

Dental caries if poor oral health (broken teeth, cavities.)- broken skin tissue within the mouth leaves greater risk for infection and dental disease.

Increased evidence of oral cancers by HPV and changes in sexual norms

Subjective Data: Nose

Discharge-color, consistency Frequent colds (upper respiratory infections) Sinus pain Trauma Epistaxis (nosebleeds) Allergies Altered smell

Altered smell Causes:

cigarette smoking, chronic allergies and aging

Overuse of over-the-counter nasal medications irritates the

mucosa

Causes rebound swelling- only use when needed bc can cause rebound congestion due to irritation of the lining of the nose.

Overuse of over-the-counter nasal medications

EPISTAXIS (Nose bleed) Management:

Sit up Head tilted forward Pinch nose with thumb and forefinger For 5 to 15 minutes

Most common site- kiesselbach plexus

Epistaxis

Subjective Data: Mouth and Throat

Sores or lesions Sore throat Bleeding gums Toothache Hoarseness Dysphagia Altered taste Smoking, alcohol consumption Patient-centered care regarding specific dental maintenance

Patient-centered care regarding specific dental maintenance

Dental care pattern Dentures or appliances

Does child have any mouth infections or sores, such as thrush(candidiasis of the mouth) or canker sores? How frequently?

Infants and Children History

Does child have frequent sore throat or tonsillitis? How often? How are these treated? Have they ever been documented as streptococcal infections?

Infants and Children History

Any dryness in the mouth? (increase in Dry mouth) Are you taking any medications? (Note prescribed and over-the-counter medications.)

Aging adult history

>250 meds cause

dry mouth

Are you able to care for your own teeth or dentures?

Aging adult history

Have you noticed a change in your sense of taste or smell?

Aging adult history

Test patency of nostrils.

External nose

Sense of smell, mediated by __, is usually not tested in a routine examination.

cranial nerve I

Inspect nasal mucosa, noting its normal

red color and smooth moist surface.

Note any swelling, discharge, bleeding, or foreign body.

External nose

Assessing for symmetry for midline and no deviations

External nose

Highly vascularized, should be moist. Note any bleeding

External nose

Inspect turbinates.

Nose

Superior turbinate may

not be in view.

___ turbinates appear the same light red color as nasal mucosa; note any swelling but do not try to push speculum past it

Middle and inferior

Humidify, warm and increase surface area function of

Turbinates

Never put direct pressure on the

nasal cavity

Lift nose very gently to

avoid injury

Never touch on tissues

inside of the nose

Both hands, applying gentle pressure esp. complaining of pain bc of upper respiratory infecting

Inspection/Palpation of Sinus Area

Utilize the thumbs. Press frontal sinus by up and under the eyebrows

Inspection/Palpation of Sinus Area

Assess the maxillary sinus below the cheekbones

Inspection/Palpation of Sinus Area

Begin with anterior structures and move posteriorly; use tongue blade to retract structures and bright light for optimal visualization. Be careful bc it can elicit gag reflex in pts.

Inspection of the Oral Cavity

Inspect lips:

noting cracks or open areas. Assess for moisture and remember any cultural variations depending on the pt assessing. African Americans-bluish tint to lips

Condition of teeth is an index of the

person’s general health

Check for swelling; retraction of gingival margins; and spongy, bleeding, or discolored gums.

Inspection of the Oral Cavity

Check tongue for

color, surface characteristics, and moisture.

Dorsal and underneath the tongue entire

U shape area of the tongue located behind the teeth.

If any lesion or pt with a lesion over 50 years old esp. alcohol and smoking use,

palpate area with a gloved hand.

Any lesions that last more than

2 weeks requires a follow up.

Anterior hard palate white with irregular transverse rugae

Palate/Uvula

Posterior soft palate is pinker, smooth, and upwardly movable.

Palate/Uvula

Uvula normally looks like a fleshy pendant hanging structure in the

midline of the throat.

Have pt open mouth and say “ah” and note any movement of the soft palate and make sure uvula is moving midline (cranial nerve 10, vagus nerve)

Palate/Uvula

Observe oval, rough-surfaced tonsils.

Color is same pink as oral mucosa, and their surface peppered with indentations, or crypts; there should be no exudate on tonsils.

Tonsils graded in size as follows:

1+ - tonsils visible 2+ - half way between tonsil and pillars ad uvula 3+ - touching the uvula 4+ - tonsils touching each other

You may normally see 1+ or 2+ tonsils in healthy people, especially in children, WHY?

Still growing, lymphoid tissue still enlarged

Test hypoglossal nerve (12)-

open mouth and stick out tongue. should protrude midline and note any tremor, loss of movement, or deviation to one side

Throat culture for strep throat.-

untreated can lead to secondary heart issues, kidney issues, and joint infection.

Ask patients if difficulty swallowing if they do make sure if they have hx CVA, gerd, or esophageal cancer

Inspection of Throat

Because oral examination is intrusive for infant or young child, timing is best toward

end with ear examination.

With a toddler, be alert for possible

foreign body lodged in nasal cavity.

Normal finding in infants is sucking tubercle, a small pad in middle of upper lip from friction of breastfeeding or bottle-feeding.

Mouth and throat

Be alert to any foreign body lodged in the nasal cavity- toddlers esp. if there is a

very strong odor and not able to breath on that side

Be careful when using tongue blade bc

elicits gag reflex

Mobility should allow tongue to extend at least as far as alveolar ridge.

Infants and Children

Note any ___ on buccal mucosa or gums of infant or young child.

bruising or laceration

___ on palate are normal finding in newborns and infants.- will go away

Epstein pearls

___ are not visible in newborn; gradually enlarge during childhood, remaining proportionately larger until puberty. Larger if crying or gagging, wait until stop to inspect

Tonsils

example of candidiasis or thrush

Can occur in breastfed children and if individual is taking antibiotics or long tx, steroids, or if immunocompromised

Gum hypertrophy

Pregnant Woman

Surface looks smooth and stippling disappears.

Pregnant Woman Gums

May occur normally at puberty or during pregnancy (pregnancy gingivitis).

Pregnant Woman Gums

Nose may appear more prominent on face from loss of subcutaneous fat.

Aging Adult

In edentulous person, mouth and lips fold in, giving a “purse-string” appearance.

Aging Adult

Teeth may look slightly yellowed, but color is uniform.

Aging Adult

Yellowing results from dentin visible through worn enamel.

Aging Adult

Teeth may look longer as gum margins recede.

Aging Adult

If issues with dental work make sure

no malnutrition

Complain of pressure and pain in both of the sinus locations- eyebrow level or below cheek bones

Suspect it after an upper respiratory infection with facial pain Throbbing in cheeks

Cleft lip, Herpes simplex 1, Angular cheilitis, carcinoma, retention cyst

Lip Abnormalities

Herpes simplex 1 (HSV-1)-blisters rupture and crust over in about 10 days Lasts 4-10 days They will rupture, weep, crust, and heal over

Herpes simplex 1 (HSV-1)-

Erythema, scaling, and shallow and painful fissures at corners of the mouth occur with excess salivation and candida infection.

Angular cheilitis- (Stomatitis, perlèche)

Carcinoma-The initial lesion is round and indurated; it becomes crusted and ulcerated with an elevated border.

Carcinoma-

A round well defiend translucent nodule that may be very small or up to 1-2 cm.

Retention “cyst” - Mucocele

Teeth and Gum Abnormalities

Baby bottle tooth decay Dental caries Tooth avulsion Epulis Gingival hyperplasia Gingivitis Meth mouth

Destruction of numerous deciduous who take a bottle of milk, juice, or sweetened drink to bed and prolong bottle feeding past the age of 1 year

Baby bottle tooth decay

A traumatic injury may dislodge a primary (deciduous) or permanent tooth from alveolar socket

Tooth avulsion

Progressive destruction of tooth

Dental caries

A benign nontender, fibrous nodule of the gum seen emerging between teeth

Epulis

Painless enlargement of gums, sometimes overreaching the teeth

Gingival hyperplasia

Gym margins are red swollen and bleed easily

Gingivitis

Illicit methamphetamine abuse leads to extensive dental caries, gingivitis, tooth cracking, and edentulism

Meth mouth

Make sure determining if using a bottle-

not to use it at night, do not use for juice or soda only milk

Prolonged bottle use –

increase infection and tooth decay

Buccal Mucosa Abnormalities

Aphthous ulcers Koplik spots Leukoplakia Candidiasis or monilial infection Candidiasis in adult Herpes simplex 1

A common canker sore is a vesicle at first and then a small round punched out ulcer with a white base surrounded by a red halo

Aphthous ulcers

Small blue-white spots with irregular red halo scattered over mucosa opposite the molars

Koplik spots

Chalky white, thick, raised patch with well defined borders

Leukoplakia

A white, cheesy, curdlike patch on the buccal mucosa and tongue Teach to not scrape the white film off bc the tongue is going to be irritated, raw, and bleed

Candidiasis or monilial infection

The candida species as normal flora is present in 60% of healthy adults. caused by steroids, hiv infection, broad spectrum antibiotics, leukemia, malnutrition, reduced immunity.

Candidiasis in adult

Infection on the hard palate

Herpes simplex 1

Tongue Abnormalities

Ankyloglossia Geographic tongue (migratory glossitis) Smooth, glossy tongue (atrophic glossitis) Black hairy tongue Carcinoma Fissured or scrotal tongue Enlarged tongue (macroglossia)

A short lingual frenulum, here fixing tongue tip to the floor of the mouth and gums

Ankyloglossia

Pattern of normal coating intersped with bright red shiny, circular bald areas caused by atrophy of the filiform papillae, with raised pearly borders

Geographic tongue (migratory glossitis)

The surface is slick and shiny; the mucosa thins and looks red from decreased papillae.

Smooth, glossy tongue (atrophic glossitis)

caused by fungal infection. Color can vary from brown to yellow. Caused by use of antibiotics which inhibits the normal bacteria which allows the fungus to grow.

Black hairy tongue

An ulcer with rolled edges; indurated

Carcinoma

Deep furrows divide the papillae into small irregular rows

Fissured or scrotal tongue

The tongue is enlarged and may protrude from the mouth

Enlarged tongue (macroglossia)

Oropharynx Abnormalities

Bifid uvula Oral Kaposi’s sarcoma Peritonsillar abscess Acute tonsillitis and pharyngitis Cleft palate- congenital defect

Appears to be severed. Effect speech and development bc it prevent necessary air from passing through the airway. More common in American Indians.

Bifid uvula

Bruise like dark red violet confluent macule usually on the hard palate may be on soft palate or gingival margin

Oral Kaposi’s sarcoma

Untreated acute streptococcal pharyngitis may cause suppurative complications, peritonsillar abscess, or suppurative thrombophlebitis.

Peritonsillar abscess

Bright red throat, swollen tonsils, white or yeellow exudate on tontils and pharynx, swollen uvula, and enlarged, tender anterior cervical and tonsillar nodes.

Acute tonsillitis and pharyngitis

Congenital defect, the failure of fusion of the maxillary process

Cleft palate

Breasts lie

Anterior to pectoralis major and serratus anterior muscles.

Located between second and sixth ribs, extending from side of sternum to midaxillary line

Breasts

Tail of Spence:

Superior lateral corner projects up and laterally into axilla. Located on either side of the breast located in the axilla area.

Areola surrounds

nipples.

Montgomery’s Glands: Small elevated sebaceous glands

Secrete protective lipid material during lactation

Tail of Spence- location for most tumors

Tail of Spence-

Cone shaped breast tissue located close to pectoral group of the axillary lymph nodes

Tail of Spence-

Breast is composed of

glandular tissue.(mostly) fibrous tissue, including suspensory ligaments. adipose tissue.

Glandular tissue (produce milk) contains 15 to 20 lobes radiating from

nipple, and these are composed of lobules.

Fibrous bands extending vertically from surface to attach on chest wall muscles

Cooper’s Ligaments:

Lobes are embedded in

adipose tissue.

Breast may be divided into four quadrants by imaginary

horizontal and vertical lines intersecting at nipple.

Upper outer quadrant is the site of most

breast tumors.

Clusters alveoli produce

milk

Breast has extensive

lymphatic drainage.

Four groups of axillary nodes are present

Central axillary nodes, Pectoral (anterior), Subscapular (posterior), Lateral

located high in the middle of the axilla

Central axillary nodes-

located along the edge of the pectorallis major

Pectoral (anterior)-

lateral edge of the scapula. deep in the axialiry fold

Subscapular (posterior)-

along the humorous inside the upper arm

Lateral-

From the central axillary nodes, drainage flows up to

infraclavicular and supraclavicular nodes.

More than 75% of breast tissue is going to drain in the

equilateral or same side axillary nodes.

During embryonic life, ventral epidermal ridges, or “milk lines,” are present and

curve down from axilla to groin bilaterally.

Develops along ridge over thorax, and rest of the ridge usually atrophies.

Breasts

Supernumerary nipple occasionally persists and is visible along track of

mammary ridge.

At birth, the only breast structures present are

lactiferous ducts within nipple.

If there is a third nipple presented the individual it is located along those lines,

ventral epidermal ridges

At puberty, estrogen stimulates

breast changes.

Temporary asymmetry:

Occasionally one breast may grow faster than other

Tanner Staging:

Five stages of breast development are included as levels of sexual maturity. Stages 2-5 takes on average of 3 years.

Tanner Stage 1:

Preadolescent: there is only a small elevated nipple

Tanner Stage 2:

Breast bud stage: A small mound of breast and nipple develops; the areola widens

Tanner Stage 3:

The breast and areola enlarge; the nipple is flush with breast surface

Tanner Stage 4:

The areola and nipple from a secondary mound over the breast

Tanner Stage 5:

Mature breast: only the nipple protrudes; the areola is flush with the breast contour

Thelarche precedes menarche by about 2 years.

Breasts develop before the period starts by about 2 years.

One breast can grow faster than the other-

can produce asymmetry and can cause distress and mensural issues, provide reassurance that it is still changing and is normal

Breast changes start during the ___ of pregnancy and are an early sign for most women.

second month

Thick yellow fluid is precursor for milk, containing same amount of protein and lactose, but practically no fat.

Colostrum

Colostrum (first milk that comes in that has protein. Perfect nutrition for the infant) may be expressed after

fourth month.

Breasts produce colostrum for first

few days after delivery.

Rich in antibodies that protect newborn against infection, so breastfeeding is important.

Colostrum

Lactation:

Milk production

Begins 1 to 3 days postpartum

Milk production

Whitish color is from emulsified fat and calcium caseinate.

Milk production

Teach pregnancy women that breastfeeding is important for

newborn

Breastfeeding for infant for at least ___ decreased risk for ear infections and increase bonding between baby and mother and increase relaxation

6 months

After menopause, ovarian secretion of estrogen and progesterone decreases, causing

Breast glandular tissue to atrophy.

Decreased breast size makes inner structures more prominent.

Aging woman

A breast lump may have been present for years but is suddenly palpable.

Aging woman

Around nipple, the lactiferous ducts are more palpable and feel firm and stringy because of fibrosis and calcification.

Aging woman

Axillary hair decreases.

Aging woman

After menopause- decreases in elasticity and have a flabby appearance and kyphosis makes it worse

Aging woman

Rudimentary structure consisting of a thin disk of undeveloped tissue underlying nipple.

Male Breast

Gynecomastia: during adolescence, it is common for breast tissue to temporarily enlarge.

Male Breast

Increase in body hair

Aging woman

Condition is usually unilateral and temporary.

Gynecomastia

May reappear in aging male and may be due to testosterone deficiency.

Gynecomastia

Review statistics of breast cancer morbidity, mortality, and prognosis.

BRCA1 and BRACA2 mutation Cumulative risk Survival varies by stage when diagnosed.

Breast Cancer: Consider family history(prevalence), ethnicity, and other environmental variables

Racial disparity in survival Socioeconomic conditions affecting access to health care

Reassurance is necessary for adolescent male, whose attention is riveted on his body image.

Gynecomastia

Screening mammography recommendations

Breast Cancer

Breast Cancer Review lifestyle risk factors:

Alcohol dose-dependent effect Postmenopausal weight gain Decreased physical activity

Two different tumor suppression genes- BRCA1 and BRCA 2

Mutation of one or both genes- risk of breast cancer is at risk significantly

Early detection is ideal in recovery/tx. Recommend screening

Breast Cancer

Pain, lump, sore areas and discharge(noting color and consistency) except with lactation other discharge is abnormal

Breast Subjective Data

Rash, swelling, trauma History of breast disease Surgery or radiation Medications Patient-centered care Perform breast self-examination/last mammogram

Breast Subjective Data

Tenderness, lump, or swelling Rash

Axilla Subjective Data

Some meds can cause breast discharge-

Contraceptives dietetics, digitalis and steroids

In many cultures, female breasts signify more than their primary purpose of lactation.

Plays a role by Affecting body image Influenced by society and media response Integrated with women’s self-concept

A woman who has found a breast lump may come to you with

fear, anxiety, and panic.

Although many breast lumps are benign, women initially assume worst possible outcome, including

cancer, disfigurement, and death.

Be sensitive to individual’s perception of

female body image.

If diagnosis with beginning breast disease or any type of lump or hx of lumps it makes

diagnosis breast cancer more difficult.

If they been treated for breast cancer before or have had it in the past the risk is going to be

higher

Subjective Data Questions: Pain, Any pain or tenderness in breasts(contraceptives)?

Onset

Subjective Data Questions: Pain, Pain location

Localized or diffuse

Is painful spot sore to touch? Do you feel a burning or pulling sensation?

Subjective Data Questions: Pain

Subjective Data Questions: Pain, Appearance of pain cyclic?

Any relation to menstrual cycle?

Subjective Data Questions: Pain, Precipitating factors

Brought on by strenuous activity? Change in activity? Sexual manipulation?

If lump identified-

address the location, when did first noticed and has it changed/grown/moved/smaller or impact by menstrual period

Lump location

Ever noticed lump or thickening in breast? Where?

Lump onset

When did you first notice it? Changed at all since then?

Lump appearance

Does lump have any relation to your menstrual period?

Subjective Data Questions: Lump and Discharge

Lump- needs to be evaluated

Lump- Noticed any change in overlying skin: Redness, warmth, dimpling, swelling?

Redness, warmth, dimpling, swelling?

Discharge Onset:

Any discharge from nipple? When did you first notice this?

Discharge Characteristics:

What color is discharge? Is consistency thick or runny? Odor?

Meds that cause discharge

Contraceptives, diuretics, digitalis, phenothiazines, steroids, methyldopa, ccbs

Rash Appearance:

Any rash on breast?

Rash Onset:

When did you first notice this?

Rash Location:

Where did it start? On the nipple, areola, or surrounding skin?

Swelling Location:

Any swelling in breasts? In one spot or all over?

Swelling Appearance:

r/t your menstrual period, pregnancy, or breastfeeding? Any change in bra size

appears flatter, broad, underlying crater- indicative of cancer

Dimpling-

Starts at the nipple apex and spread outwards-

Paget's disease

Any trauma or injury to the

breasts?

Trauma Presentation:

Did it result in any swelling, lump, or break in skin?

History of breast disease

Any history of breast disease yourself?

History of breast disease Medical management:

When did this occur? How is it being treated?

History of breast disease Diagnosis:

What type? How was this diagnosed?

breast disease Family history:

Any breast cancer in your family? Who? Sister, mother, maternal grandmother, maternal aunts, daughter? At what age did this relative have breast cancer?

Detect risk for breast cancers by

asking questions

Surgical intervention: Biopsy with results

Mastectomy? Mammoplasty, augmentation, or reduction?

Radiation as part of

therapy?

Imaging studies:

Mammography, a screening x-ray examination of breasts? When was last x-ray?

Medications

Have you taken oral contraceptives ? How long? Have you been on Hormone Replacement Therapy? How long? Types of medications: Rx and OTC

Ask about self-breast exam (SBE)

Teaching moment to review basics of examination

Review screening guidelines recommendations based on

age and patient history

Begin at ages 40 to 44,

screening mammography

Annual mammography from ages

45 to 54

Biennial mammography over age

55 or continuation of annual

Try to teach to stay on schedule every month.

BSE

Perform right after menstrual period or the 4th through the 7th day after the menstrual cycle. – breast is the smallest and least congested

BSE

Teach to pick a day on each month if no menstrual cycle

BSE

Axilla Tenderness,

lump, or swelling

Axilla Appearance:

Any tenderness or lump in the underarm area?

Axilla Location:

Where? When did you first notice this?

Axilla Rash Appearance:

Any axillary rash? Please describe it. (feels, looks, starts)

Axilla Precipitating factor:

Does it seem to be a reaction to deodorant?

Breasts in Preadolescent girl Appearance:

Have you noticed your breasts changing?

Breasts in Preadolescent girl Onset:

How long has this been happening?

Breasts in Preadolescent girl Description:

What have you noticed?

Breasts in Preadolescent girl Feelings:

What do you think about all this?

Breasts in Pregnant woman Appearance:

Have you noticed any enlargement or fullness in the breasts?

Breasts in Pregnant woman Presentation:

Is there any tenderness or tingling?

Breasts in Pregnant woman Medical history:

Do you have inverted nipples?

Breasts in Pregnant woman Anticipatory planning:

Are you planning to breastfeed your baby?

Breasts in Menopausal woman

Have you noticed any change in breast contour, size, or firmness?

Should occur 2 years before first period-

breast development

___ is second major cause of death from cancer in women

Breast cancer

Early detection and improved treatment have increased survival rates.

Breast cancer

Review factors associated with “relative risk”

RR above 1 indicates a higher likelihood of occurrence among exposed than unexposed persons.

Early mammograms and screening if hx of

breast cancer

Preparation Woman sitting up facing examiner

An alternative draping method is to use a short gown, open at back, and lift it up to woman’s shoulders during inspection.

During palpation when woman is supine, cover one breast with gown while examining other.

Be aware that many women are embarrassed to have their breasts examined; use a sensitive but matter-of-fact approach.

After examination, be prepared to teach woman

breast self-examination.

Breast examination Equipment

Small pillow Ruler marked in centimeters Pamphlet or teaching aid for breast self-examination (BSE)

Inspection of the Breast General appearance

Note symmetry of size and shape. Common to have a slight asymmetry in size

Normally smooth and of even color

Inspection of the Breast Skin

Note any localized areas of redness, bulging, or dimpling; also any skin lesions or focal vascular pattern.

Inspection of the Breast Skin

Fine blue vascular network visible during pregnancy; pale linear striae, or stretch marks, follow pregnancy.

Inspection of the Breast Skin

Normally no edema is present.

Inspection of the Breast Skin

Inspection of the Breast Lymphatic drainage areas

Observe axillary and supraclavicular regions; note any bulging, discoloration, or edema.

Should be symmetric on same plane on both breasts

Inspection of the Breast Nipple

Nipples usually protrude, although some are flat and some are inverted.

Inspection of the Breast Nipple

Normal nipple inversion may be unilateral or bilateral and usually can be pulled out.

Inspection of the Breast Nipple

Note any dry scaling, any fissure or ulceration, and bleeding or other discharge.

Inspection of the Breast Nipple

Supernumerary nipple is normal variation.

Inspection of the Breast Nipple

Check the breast for skin retraction

Perform sequence of maneuvers to assess for this abnormality.

Examine axillae while woman is

sitting.

Inspect skin, noting any rash or infection; lift woman’s arm and support it so that her muscles are loose and relaxed;

use right hand to palpate left axilla.

Reach fingers high into axilla;

move them firmly down in four directions.

Move woman’s arm through range-of-motion to increase

surface area you can reach.

Usually nodes are not palpable, although you may feel a small,

soft, nontender node in central group.

Note any enlarged and tender lymph nodes.

Axillae

If any lump or nodule note the location.

Cancerous breast masses are solitary unilateral and not tender.

As cancer become more invasive become solid hard and dense.

Become fixed to underlining tissues.

Cancerous borders- irregular, poorly delineated, cannot figure out the border

painless

Mass with rubbery texture, regular border, and pt complain heavy pain upon palpation-

benign breast disease

Vertical strip pattern is recommended to detect for any type breast masses.

Palpation of the Breasts

Two other patterns are in common use:

From the nipple palpating out to periphery as if following spokes on a wheel Palpating in concentric circles out to periphery

In nulliparous women, normal breast tissue feels firm, smooth, and elastic.

After pregnancy, tissue feels softer and looser.

Premenstrual engorgement is normal from

increasing progesterone.

After palpating over four breast quadrants, palpate nipple; note any induration or subareolar mass.

With your thumb and forefinger, gently depress nipple tissue into well behind areola; tissue should move inward easily.

If woman reports spontaneous nipple discharge

press areola inward with your index finger. repeat from a few different directions; note color and consistency of any discharge.

If woman mentions a breast lump that she has discovered herself, examine unaffected breast first to learn a

baseline of normal consistency for this woman.

Characteristics of Lump or Mass

Location, size, shape, consistency, moveable, Distinctness, Nipple, Note skin over lump, Tenderness, Lymphadenopathy

Location

As with clock face, describe distance in centimeters from nipple; or diagram breast in woman’s record and mark in location of lump.

Size

Judge in centimeters in three dimensions: width, length, and thickness.

Shape

State whether lump is oval, round, lobulated, or indistinct.

Consistency

State whether lump is soft, firm, or hard.

Movable

Is lump freely movable or fixed when you try to slide it over chest wall?

Increased size in lymph nodes bc

breast cancer can spread

Distinctness

Is lump solitary or multiple?

Nipple

Is it displaced or retracted?

Note skin over lump

Is it erythematous, dimpled, or retracted?

Tenderness

Is lump tender to palpation?

Lymphadenopathy

Are any regional lymph nodes palpable?

Lie down. Press 3 middle fingers in a circular motion and use three levels of pressure.

Follow up and down pattern

Sit up. Examine underarm with

arm slightly raised

Note surface changes with hands pushed on hips

shoulders hunched

The simpler the plan, the more likely the person is to comply.

BSE

Describe correct technique and rationale and expected findings to note as woman inspects her own breasts.

BSE

Teach woman to do this in front of a mirror while she is disrobed to waist.

BSE

At home, she can start palpation in shower, where soap and water assist palpation.

BSE

Encourage woman to palpate her own breasts while you monitor her technique.

BSE

Then palpation should be performed while lying supine.

BSE

Use of model for return demonstration as well as pamphlets may be helpful.

BSE

Examination of male breast can be abbreviated, but do not

omit it.

Normal male breast has

flat disk of undeveloped breast tissue beneath nipple.

Benign growth of this breast tissue, making it distinguishable from other tissues in chest wall.

Gynecomastia

Feels like a smooth, firm, movable disk

Gynecomastia

Occurs normally during puberty and is temporary

Gynecomastia

The adolescent is acutely aware of his body image.

Gynecomastia

Reassure him that this change is normal, common, and temporary.

Gynecomastia

Abnormal Breast Findings

Peau d' orange, benign breast disease, Male breast cancer,

Lymphatic obstruction produces edema Thickens skin and exaggerates hair follicles Suggestive of cancer

PEAU D’ORANGE

Non-cancerous

BENIGN BREAST DISEASE

Creates lumpy or ropelike texture

BENIGN BREAST DISEASE

Hormonal changes

BENIGN BREAST DISEASE

Pain, tenderness, lumpiness

BENIGN BREAST DISEASE

More bothersome before period

BENIGN BREAST DISEASE

If new changes need medical evaluation

BENIGN BREAST DISEASE

Rare in men Less than 1 percent (1 in every 100 diagnosed)

MALE BREAST CANCER

Hard to examine breasts or identify new lump in new breast bc there is

always something different in the breast

Make it hard to examine breasts as may conceal new lump

BENIGN BREAST DISEASE

Same types of cancer as women Lump/swelling in breast

MALE BREAST CANCER

Red/flaky skin on the breast Irritation or dimpling

MALE BREAST CANCER

Nipple discharge Pulling in of the nipple or pain surrounding the nipple

MALE BREAST CANCER

Inspect breasts as woman sits, raises arms overhead, pushes

hands on hips, and leans forward.

Inspect the

supraclavicular and infraclavicular areas.

Palpate the

axillae and regional lymph nodes.

With woman supine, palpate the breast tissue, including

tail of spence, the nipples, and areolae.