NCM 101 – HEALTH ASSESSMENT RLE

PERFORMING PHYSICAL ASSESSMENT

PART 2

ASSIGNMENT

NAME: Kyra Bianca R. Famacion DATE: January 8, 2020

BLOCK: NB CI: Sir Jethro Daños SCORE:_______________

PROCEDURE Normal Findings Abnormal Findings

1. Wash your hands.
2. Prepare all required
equipments.
3. Identify the client.
4. Explain the purpose and
the procedure to the client.
5. Close doors and/or use a
screen.
6. Assist the client to a
comfortable position.
NOSE & SINUSES Color is the same as the Nasal tenderness on
7. Inspect and palpate the rest of the face; the nasal palpation accompanies a
external nose. Note nasal structure is smooth and local infection.
color, shape, consistency symmetric; the client reports
and tenderness. no tenderness.
8. Check the patency of air Client is able to sniff Client cannot sniff through
flow through the nostrils by through each nostril while a nostril that is not
occluding one nostril at a other is occluded. occluded, nor can he or
time and asking client to she sniff or blow air through
sniff or exhale. the nostrils. This may be a
sign of swelling, rhinitis, or
a foreign object obstructing
the nostrils. A line across
the tip of the nose just
above the fleshy tip is
common in clients with
chronic allergies.
9. With nasal speculum, The nasal mucosa is dark Nasal mucosa is swollen
examine: pink, moist, and free of and pale pink or bluish gray
 Nasal septum exudate. The nasal septum in clients with allergies.
 Discharges is intact and free of ulcers Nasal mucosa is red and
 Obstructions or perforations. Turbinates swollen with upper
 Mucous membrane are dark pink (redder than respiratory infection.
color oral mucosa), moist, and Exudate is common with
 Turbinates for color free of lesions. infection and may range
and swelling from large amounts of
A deviated septum may watery discharge to thick
 Hold the nasal appear to be an overgrowth yellow-green, purulent
speculum in your of tissue. This is a normal discharge. Purulent nasal
right hand and finding as long as breathing discharge is seen with
inspect the client’s is not obstructed. acute bacterial
left nostril, and in rhinosinusitis. Bleeding
your left hand to (epistaxis) or crusting may
inspect the client’s be noted on the lower
right nostril. anterior part of the nasal
  Tip the client’s head septum with local irritation.
back. Ulcers of the nasal mucosa
 Facing the client, or a perforated septum may
insert the tip of the be seen with use of
closed speculum cocaine, trauma, chronic
about 1 cm or up to infection, or chronic nose
the point at which picking. Small, pale, round,
the blade widens. firm overgrowths or masses
Care must be taken on mucosa (polyps) are
to avoid pressure on seen in clients with chronic
the sensitive nasal allergies.
speculum.
 Stabilize the
speculum with your
index finger against
the side of the nose.
Use the other hand
to position the head
and then to hold the
light.
 Inspect the lining of
the nares and the
coarse hairs that
filters the air.
Observe for the
presence of
redness, swelling,
growth and
discharges.
10. Palpate sinuses for Frontal and maxillary Frontal or maxillary sinuses
tenderness: sinuses are nontender to are tender to palpation in
 Frontal palpation, and no crepitus is clients with allergies or
 Ethmoid evident. acute bacterial
 Sphenoid rhinosinusitis. If the client
 Maxillary has a large amount of
exudate, crepitus may be
MOUTH felt upon palpation over the
If the client wears dentures, maxillary sinuses. This may
offer a piece of paper towel also be present with a viral
and ask to remove it so that upper respiratory infection
you can see the mucosa (URI).
underneath.
11. Inspect the lips of color, Pink, moist and intact skin. Lips bluish (cyanosis) and
moisture, pigment, masses, No bluish, discoloration, Pallor.
ulceration and fissures. cracks and ulcers. Presence of cracks, ulcer.
 Ask the patient to
purse the lips as if to
whistle.

12. Using the tongue

depressor and penlight,
examine the:
 Teeth Thirty-two pearly whitish Clients who smoke, drink
 Gums teeth with smooth surfaces large quantities of coffee or
 Buccal mucosa and edges. Upper molars tea, or have an excessive
 Pharynx should rest directly on the intake of fluoride may have
 Ask the client to lower molars and the front yellow or brownish teeth.
open the mouth and upper incisors should Tooth decay (caries) may
say “ah:. This slightly override the lower appear as brown dots or
actions, help to see incisors. Some clients cover more extensive areas
the pharynx well. normally have 28 teeth if of chewing surfaces.
 Uvula the four wisdom teeth do Missing teeth can affect
 Tonsils not erupt. chewing as well as self-
 Tongue image. A chalky white area
There are decayed areas; in the tooth surface is a
 Salivary glands
no missing teeth. cavity that will turn darker
 Odor of the breath Client may have appliances with time. Malocclusion of
 Voice on the teeth (e.g., braces). teeth is seen when upper
Client may have evidence or lower incisors protrude.
of repair work done on teeth Poor occlusion of teeth can
(e.g., fillings, crowns, or affect chewing, wearing
cosmetics such as down of teeth, speech, and
veneers). self-image. Brown or yellow
stains or white spots on
Jaws are aligned with no teeth may result from
deviation seen with biting antibiotic therapy or tooth
down. trauma.

Color and consistency of Receding gums.

tissues along cheeks and
gums are even.

Gums are pink, moist, and Red, swollen gums that

firm with tight margins to the bleed easily are seen in
tooth. No lesions or gingivitis, scurvy (vitamin C
masses. deficiency), and leukemia.
Receding red gums with
loss of teeth are seen in
periodontitis. Enlarged
reddened gums
(hyperplasia) that may be
seen in pregnancy,
puberty, leukemia, and with
use of some medications,
such as phenytoin. A
bluish-black or grey-white
line along the gum line is
seen in lead poisoning.
There is a significant link
between periodontal
disease and cardiovascular
disease.

Tissue is smooth and moist Leukoplakia (chalky white

without lesions. raised patches) may be
seen in chronic irritation,
heavy smoking, and
alcohol use. These are
precancerous lesions and
should be referred to the
client’s primary health care
provider for further
assessment.
 Whitish, curd-like patches
that scrape off over
reddened mucosa and
bleed easily indicate
“thrush” (Candida albicans)
infection.

Koplik spots (tiny whitish

spots that lie over
reddened mucosa) are an
early sign of the measles.

Canker sores may be seen.

Brown patches inside the
cheeks of clients with
Addison disease (chronic
adrenocortical
insufficiency).

Pink throat; pink and small Exudative tonsillitis (red

tonsils; no swelling, and enlarged tonsils).
exudates, and ulceration; Throat with white exudates;
no difficulty in swallowing. redness and varcularity of
the pillars and uvula in
pharyngitis. Throat is dull
red and gray. Exudates is
present in uvula, pharynx
and tongue, which cause
airway obstruction.
Difficulty in swallowing. In
CN X paralysis, the soft
palate fails to rise and the
uvula deviates to the
opposite site.

No lesions, ulcers, or Canker sores may be seen

nodules are apparent; on the sides of the tongue
tongue offers strong in clients receiving certain
resistance; the client can kinds of chemotherapy.
distinguish between sweet Leukoplakia, persistent
and salty. lesions, ulcers, or nodules
may indicate cancer and
should be further evaluated
medically. Decreased
tongue strength may occur
with a defect of CN XII or
with a shortened frenulum
that limits motion. Loss of
taste discrimination occurs
with trauma, viral
infections, sinusitis and
polyposis, increasing age,
neurologic illnesses such
as Parkinson’s or
Alzheimer’s; and zinc
deficiency, or use of certain
medication that affect smell
threshold.
 Stensen ducts are visible Reddened opening of
with flow of saliva. No Stensen ducts is seen with
redness, swelling, pain, or mumps.
moistness in area. Fordyce
spots or granules,
yellowish-whitish raised
spots, are normal ectopic
sebaceous glands.

Wharton ducts are visible, Abnormal findings include

with salivary flow or lesions, ulcers, nodules or
moistness in the area. The hypertrophied duct
client has no swelling, openings.
redness, or pain.

No unusual or foul odor is Fruity or acetone breath is

noted. associated with diabetic
ketoacidosis. An ammonia
odor is often associated
with kidney disease. Foul
odors may indicate an oral
or respiratory infection, or
tooth decay. Alcohol or
tobacco use may be
identified by breath odor.
Fecal breath odor occurs in
bowel obstruction; sulfur
odor (fetor hepaticus)
occurs in end-stage liver
disease.
NECK
13. Inspect for symmetry, Neck is symmetric, with Sweling, enlarged masses
masses, unusual swelling, head centered and without or nodules may indicate an
pulsations. bulging masses. enlarged thyroid gland,
inflammation of lymph
nodes, or a tumor.

Range of Motion (ROM)

 Move the chin to the C7 (vertebrae prominens) is Prominence or swellings
chest usually visible and palpable. other than the C7
vertebrae.

 Move the head back Neck movement should be Pain at any particular
so that the chin smooth and controlled with movement, limited
points upward 45-degree flexion, 55- movement due to cervical
 Move the head so degree extension, 40- arthritis or inflammation on
that the shoulder on degree lateral abduction, of the neck muscles. Rigid
each side and 70-degree rotation. neck with arthritis.
 Turn the head to the
right and to the left.
14. Test the strength of Equal strengthen in both Muscular weakness on one
cervical muscle and sides. No muscular or both sides.
trapezius muscle weakness.
 Cervical muscle
 Turn the head to one
side against the
resistance of your
hand. Repeat with
  the other side.
 Trapezius muscle
 Shrug the shoulders
against the
resistance of your
hands.
15. Examine the external The jugular venous pulse is Fully distended jugular
jugular veins. not normally visible with the veins with the client’s torso
 Client is in Semi- client sitting upright. This elevated more than 45
Fowler’s position position fully distends the degrees indicate increased
with the head vein, and pulsations may or central venous pressure
supposed with a may not be discernible. that may be the result of
pillow, right ventricular failure,
pulmonary hypertension,
pulmonary emboli, or
cardiac tamponade.

The jugular vein should not Distention, bulging, or

be distended, bulging, or protrusion at 45, 60, or 90
protruding at 45 degrees or degrees may indicate right-
greater. sided heart failure. Clients
with obstructive pulmonary
disease may have elevated
venous pressure only
during expiration. An
inspiratory increase in
venous pressure called
Kussmaul sign, may occur
in clients with severe
constrictive pericarditis.
16. Palpate the: Stensen ducts are visible Reddened opening of
 Salivary glands with flow of saliva. No Stensen ducts is seen with
- Parotid gland redness, swelling, pain, or mumps.
- Sublingual gland moistness in area. Fordyce
- Maxillary gland spots or granules,
yellowish-whitish raised
spots, are normal ectopic
sebaceous glands.

The frenulum is midline; Lesions, ulcers, nodules, or

Wharton ducts are visible, hypertrophied duct
with salivary flow or openings on either side of
moistness in the area. The frenulum.
client has no swelling,
redness, or pain.

17.
 Trachea
Place your fingers or Trachea is in midline. The Masses in the neck may
thumb on the trachea in space should be symmetry push the trachea to one
the suprasternal notch, on both sides. No deviation side. Tracheal deviation
then move your finger from the midline. may also signify important
laterally to the left and problems in thorax, such as
right in spaces bordered a mediastinal mass,
by the clavicle, the atelectasis or large
anterior aspect of the pneumothorax.
sternocleidomastoid
 muscle, and the
trachea.
18.
 Thyroid gland
 Stand in front of the Thyroid gland is in midline. Goiter as a general tern for
client. The space should be an enlarged thyroid gland.
 Observe the lower symmetry on both sides. No
half of the neck deviation from the midline.
overlying the thyroid
gland for symmetry
and visible masses.
 Ask the client to Glandular thyroid tissue Coarse tissue or irregular
hyperextend head may be felt rising consistency may indicate
and swallow. If underneath fingers when an inflammatory process.
necessary, offer a palpated. Lobes should feel Nodules should be
glass of water to smooth, rubbery, and free described in terms of
make it easier for of nodules. location, size, and
the client to swallow. consistency.
19.
 Carotid arteries Pulses are equally strong; a Pulse inequality may
 Palpate only one 2+ or normal with no indicate arterial constriction
carotid artery at a variation in strength from or occlusion in one carotid.
time. This ensures beat to beat. Contour is Weak pulses may indicate
adequate cerebral normally smooth and rapid hypovolemia, shock, or
flow through the on the upstroke and slower decreased cardiac output.
other and thus and less abrupt on the A bounding, firm pulse may
prevents possible downstroke. Arteries are indicate hypervolemia or
ischemia. elastic and no thrills are increased CO. Variations in
 Avoid exerting too noted. strength from beat to beat
much pressure and or with respiration are
massaging the area. abnormal and may indicate
Pressure can a variety of problems. A
precipitate delayed upstroke may
bradycardia. indicate aortic stenosis.
 Ask the client to turn Loss of elasticity may
the head slightly indicate arteriosclerosis.
toward the side Thrills may indicate a
being examined. narrowing of the artery.
This makes the
carotid artery more
accessible.
20. LYMPH NODES
 Palpate the lymph Cervical nodes often are Parotid is swollen with
nodes by using the palpable in healthy person, Mumps. Tender nodes
pads of your index although this palpability suggest inflammation. Hard
and middle fingers. decrease with age. Normal or fixed nodes suggest
 Move the underlying nodes feel movable, Malignancy.
tissues in each area. discrete, soft, non-tender. Lymphadenopathy is
 Examine both sides enlargement of the lymph
at once. nodes( > 1 cm) due to
 Feel in sequence for infection, allergy or
the following nodes: neoplasm. Enlargement of
 Cervical a supraclavicular node,
 Supra and especially on the left,
Infraclavicular nodes suggests possible
 Axillary nodes metastasis from a thorax or
 Inguinal nodes an abdominal malignancy.
 Epithroclear node Diffuse lymphadenopathy
 raises the suspicious of
HIV/AIDs
.
THORAX & LUNGS
 Poserior Thorax
21. Inspect configuration. Scapulae are symmetric Spinous processes that
While the client sits with and nonprotruding. deviate laterally in the
arms at the sides, stand Shoulders are scapulae are thoracic area may indicate
behind the client and at equal horizontal scoliosis.
observe the position of positions.
scapulae and the shape
and configuration of the The ratio of anteroposterior Spinal configurations may
chest wall. to transverse diameter is have respiratory
1:2. implications. Ribs
appearing horizontal at an
Spinous processes appear angle greater than 45
straight, and thorax appears degrees with the spinal
symmetric, with ribs sloping column are frequently the
downward at approximately result of an increased (1 to
a sloping downward of 1) ratio between the
approximately a 45-degree anteroposterior and
angle in relation to the transverse diameter (barrel
spine. chest). This condition is
commonly the result of
emphysema due to
hyperinflation of the lungs.

Trapezius, or shoulder,
muscles are used to
facilitate inspirations in
cases of acute and chronic
airway obstruction or
atelectasis.
22. Observe use of
The client does not use Client leans forward and
accessory muscles. Watch accessory uses arms to support
as the client breathes and(trapezius/shoulder) weight and lift chest to
note use of muscles. muscles to assist breathing. increase breathing
The diaphragm is the major capacity, referred to as the
muscle at work. tripod position.
23. Inspect the client’s Client should be sitting up Tender of painful areas
positioning. and relaxed, breathing may indicate inflamed
Note the client’s posture easily with arms at sides or fibrous connective tissue.
and ability to support in lap. Pain over the intercostal
weight while breathing spaces may be from
comfortably. inflamed pleurae. Pain over
the ribs, especially at the
costal chondral junctions, is
a symptom of fractured
ribs.
24. Palpate for tenderness Client reports no Muscle soreness from
and sensation. Palpation tenderness, pain, or exercise or the excessive
may be performed with one unusual sensations. work of breathing (as in
or both hands. Use your Temperature should be COPD) may be palpated as
fingers to palpate for equal bilaterally. tenderness. Increased
tenderness, warmth, pain warmth may be related to
or other sensations. Start local infection.
toward the midline at the
level of the left scapulae
(over the apex of the left
lung) and move your hand
left to right, comparing
findings bilaterally. Move
systemically downward and
out to cover the lateral
portions of the lungs at the
bases.
25. Palpate for crepitus. The examiner finds no Crepitus can be palpated if
Follow the sequence palpable crepitus. air escapes from the lung
above. or other airways into the
subcutaneous tissue, as
occurs after an open
thoracic injury, around a
chest tube, or
tracheostomy. It also may
be palpated in areas of
extreme congestion or
consolidation.
26. Palpate surface Skin and subcutaneous A physician or other
characteristics. tissue are free of lesions appropriate professional
Put on gloves and use your and masses. should evaluate any
fingers to palpate any unusual palpable mass.
lesions that you noticed
during inspection. Feel for
any unusual masses.
27. Palpate for fremitus. Fremitus is symmetric and Unequal fremitus is usually
Following the sequence easily identified in the upper the result of consolidation
described previously, use regions of the lungs. If (which increases fremitus)
the ball or ulnar edge of fremitus is not palpable on or bronchial obstruction, air
one hand to assess for either side, the client may trapping in emphysema,
fremitus. As you move your need to speak louder. A pleural effusion, or
hand to each area, ask the decrease in the intensity of pneumothorax (which all
client to say “ninety-nine”. fremitus is normal as the decrease fremitus).
Assess all areas for examiner moves toward the Diminshed fremitus even
symmetry and intensity of base of the lungs. However, with a loud spoken voice
vibration. fremitus should remain may indicate an obstruction
symmetric for bilateral of the tracheobronchial
positions. tree.
28. Assess chest When the client takes a Unequal chest expansion
expansion. deep breath, the examiner’s can occur with severe
Place your hands on the thumbs should move 5 to atelectasis (collapse or
posterior chest wall with 10 cm apart symmetrically. incomplete expansion),
your thumbs at the level of pneumonia, chest trauma,
T9 or T10 and pressing or pneumothorax (air in the
together a small skin fold. pleural space).
As the client takes a deep
breath, observe the Depressed chest excursion
movement of your thumbs. at the base of the lungs is
characteristics of COPD.
This is due to decreased
diaphragmatic function.
29. Percuss for tone. Resonance is the Hyperresonance is elicited
Start at the apices of the percussion tone elicited in cases of trapped air such
scapulae and percuss over normal lung tissue. as in emphysema or
across the tops of both Percussion elicits flat tones pneumothorax.
shoulders. Then percuss over scapula.
the intercostals spaces
across and down,
comparing sides. Percuss
to the lateral aspects at the
bases of the lungs,
comparing sides.
30. Percuss for Excursion should be equally Dullness is present when
diaphragmatic excursion. bilaterally and measure 3-5 fluid or solid tissue replaces
cm in adults. The level of air in the lung or occupies
the diaphragm may be the pleural space, such as
higher on the right because in lobar pneumonia, pleural
of the position of the liver. In effusion, or tumor.
well-conditioned clients, Diaphragmatic descent
excursion can measure up may be limited by
to 7 or 8 cm. actelectasis of the lower
lobes or by emphysema, in
which diaphragmatic
movement and air trapping
are minimal. The
diaphragm remains in a low
position on inspiration and
expiration. Other possible
causes for limited descent
can be pain or abdominal
changes such as extreme
ascites, tumors, or
pregnancy. Uneven
excursion may be seen
with inflammation from
unilateral pneumonia,
damage to the phrenic
nerve, or splenomegaly.
31. Auscultate for breath Three types of normal Diminished or absent
sounds. breath sounds may be breath sounds often
auscultated: bronchial, indicate that little or no air
bronchovesicular, and is moving in or out of the
vesicular. Sometimes lung area being
breath sounds may be hard auscultated. This may
to hear with obese or indicate obstruction within
heavily muscled clients due the lungs as a result of
to increased distance to secretions, mucus plug, or
underlying lung disease. a foreign object. It may also
indicate abnormalities of
the pleural space such as
pleural thickening, pleural
effusion, or pneumothorax.
In cases of emphysema,
the hyperinflated nature of
the lungs, together with a
loss of elasticity of lung
tissue, may result in
diminished inspiratory
breath sounds. Increased
(louder) breath sounds
often occur when
consolidation or
compression results in a
denser lung area that
enhances the transmission
of sound.
32. Auscultate for voice
sounds.
 Bronchophony: Ask Voice transmission is soft,The words are easily
the client to repeat muffled, and indistinct. The
understood and louder over
the phrase “ninety- sound of the voice may be areas of density. This may
nine” while you heard but the actual phraseindicate consolidation from
auscultate the chest cannot be distinguished. pneumonia, atelectasis, or
wall. tumor.
 Egophony: Ask the Voice transmission will be Over areas of consolidation
client to repeat the soft and muffled but the or compression, the sound
letter “E” while you letter “E” should be is louder and sounds like
listen over the chest distinguishable. “A”.
wall.
 Whispered Transmission of sound is Over areas of consolidation
pectoriloquy: ask the very faint and muffled. It or compression, the sound
client to whisper the may be inaudible. is transmitted clearly and
phrase “one-two- distinctly. In such areas, it
three” while you sounds as if the client is
auscultate the chest whispering directly into the
wall. stethoscope.
 Anterior Thorax The anteroposterior Anteroposterior equals
33. Inspect for shape and diameter is less than the transverse diameter,
configuration. transverse diameter. The resulting in a barrel chest.
Have the client sit with ratio of anteroposterior This is often seen in
arms at the sides. Stand in diameter to the transverse emphysema because of
front of the client and diameter is 1:2. hyperinflation of the lungs.
assess shape and
configuration.
34. Inspect the position of
Sternum is positioned at Pectus excavatum is a
the sternum. midline and straight. markedly sunken sternum
Observe the sternum from and adjacent cartilages
an anterior and lateral (often referred to as funnel
viewpoint. chest). Pectus carinatum is
a forward protrusion of the
sternum causing the
adjacent ribs to slope
backward (often referred to
as pigeon chest). Both
conditions may restrict
expansion of the lungs and
decrease lung capacity.
35. Watch for sternal Retractions not observed. Sternal retractions are
retractions. noted, with several labored
breathing.
36. Inspect slope of the Ribs slope downward with Barrel-chest configuration
ribs. symmetric intercostal results in a more horizontal
spaces. Costal angle is position of the ribs and
within 90 degrees. costal angle of more than
90 degrees. This often
results from long-standing
emphysema.
37. Observe quality and Respirations are relaxed, Labored and noisy
pattern of respiration. effortless, and quiet. They breathing is often seen with
are of a regular rhythm and severe asthma or chronic
normal depth at a rate of bronchitis. Abnormal
10-20 per minute in adults. breathing patterns include
Tachypnea and bradypnea tachypnea, bradypnea,
may be normal in some hyperventilation,
 clients. hypoventilation, Cheyne-
Stokes respiration, and Biot
respiration.
38. Inspect intercostal No retractions or bulging of Retraction of the intercostal
spaces. intercostal spaces are spaces indicates an
noted. increased inspiratory effort.
This may be the result of
an obstruction of the
respiratory tract or
atelectasis. Bulging of the
intercostal spaces indicates
trapped air such as in
emphysema or asthma.
39. Observe for use of Use of accessory muscles Neck muscles
accessory muscles. (sternomastoid and rectus (sternomastoid, scalene,
abdominis) is not seen with and trapezius) are used to
normal respiratory effort. facilitate inspiration in
After strenuous exercise or cases of acute or chronic
activity, clients with normal airway obstruction or
respiratory status may use atelectasis. The abdominal
neck muscles for a short muscles and the internal
time to enhance breathing. intercostal muscles are
used to facilitate expiration
in COPD.
40. Palpate for tenderness, No tenderness or pain is Tenderness over thoracic
sensation and surface palpated over the lung area muscles can result from
masses. with respirations. exercising (e.g. pushups)
especially in a previously
sedentary client.
41. Palpate for tenderness Palpation does not elicit Tenderness or pain at the
at costochondral junctions tenderness. costochondral junction of
of ribs. the ribs is seen with
fractures, especially in
older clients with
osteoporosis.
42. Palpate for crepitus as No crepitus is palpated. In areas of extreme
you would on the posterior congestion or
thorax. consolidation, crepitus may
be palpated, particularly in
clients with lung disease.
43. Palpate for any surface No unusual surface masses Surface masses or lesions
masses or lesions. or lesions or palpated. may indicate cysts or
tumors.
44. Palpate for fremitus. Fremitus is symmetric and Diminished vibrations, even
Palpate for fremitus using easily identified in the upper with a loud spoken voice,
the same technique as for regions of the lungs. A may indicate an obstruction
the posterior thorax. decreased intensity of of the tracheobronchial
fremitus is expected toward tree. Clients with
the base of the lungs. emphysema may have
However, fremitus should considerably decreased
be symmetric bilaterally. fremitus as a result of air
trapping.
45. Palpate anterior chest Thumbs move outward in a Unequal chest expansion
expansion. symmetric fashion from the can occur with severe
midline. atelectasis, pneumonia,
chest trauma, pleural
effusion, or pneumothorax.
Decreased chest excursion
 at the bases of the lungs is
seen with COPD.
46. Percuss for tone. Resonance is the Hyperresonance is elicited
Percuss the apices above percussion tone elicited in cases of trapped air such
the clavicles. Then percuss over normal lung tissue. as in emphysema or
the intercostals spaces Percussion elicits dullness pneumothorax. Dullness
across and down, over breast tissue, the may characterize areas of
comparing sides. heart, and the liver. increased density such as
Tympany is detected over consolidation, pleural
the stomach, and flatness is effusion, or tumor.
detected over the muscles
and bones.
47. Auscultate for anterior Breath sounds are usually Decreased or abscent
breath sounds, adventitious louder in upper anterior lung breath sounds occur i.g.,
sounds and voice sounds. fields. Normal breath atelectasis, pleural
Place the diaphragm of the sounds include bronchial, effusion, pneumothorax,
stethoscope firmly and brochovesicular, and COPD. Increased breath
directly on the anterior vesicular breath sounds. No sounds occur when
chest wall. adventitious sounds. consolidation or
compression yields a
dense lung area, e.g.,
pneumonia, fluid in the
intrapleural space.
Presence of adventitious
breath sounds include
discontinuous sounds
which include fine or
coarse crackles, and
continuous sounds which
include pleural friction rub,
wheeze sibilant, or wheeze
sonorous.
BREAST (USE BREAST Areolas vary from dark pink Peau d’orange skin,
DUMMY/MODEL) to dark brown, depending associated with carcinoma
48. Inspect the areola and on the client’s skin tones. may be first seen in the
nipples for position, They are round and may areola. Red, scaly, crusty
pigmentation, inversion, vary in size. Small areas may appear in Paget
discharge, crusting and Montgomery tubercles are disease.
masses. present.

Nipples are nearly equal A recently retracted nipple

bilaterally in size and are in that was previously everted
the same location on each suggests malignancy.
breast. Nipples are usually Explore any discharge,
everted, but they may be especially in the presence
inverted or flat. of a breasts mass.
Supernumerary nipples may
appear along the embryonic
“milk line.” No discharges
should be present.
49. Examine the breast Symmetry or a slight A sudden increase in the
tissue for size, shape, asymmetry in size. Often size of one breast signifies
color, symmetry, surface, the left breast is slightly inflammation or new
contour, skin larger than the right. The growth. Hyperpigmentation.
characteristics, level of skin normally is smooth and Redness and heat with
retraction or dimpling. of even color. A fine blue inflammation. Unilateral
vascular network is visible dilated superficial veins in a
normally during pregnancy. nonpregnant woman.
 Pale linear striae, or stretch Edema.
Accentuate retraction by marks, often follow
having the client: pregnancy. No edema
 Raise the arms
above the head
 Press the hands The client’s breasts should A lag in movement of one
down on the hips rise symmetrically, with no breast. A dimpling or a
sign of dimpling or pucker (skin retraction).
retraction.
50. Position the patient with Palpation reveals smooth, Thickening of the tissue
pillows under the scapulae firm, elastic tissue. may occur with an
with arms raise. Palpate underlying malignant
the breast. Start with the tumor.
asymptomatic side.
A generalized increase in Painful, tender breasts may
Three ways in palpating the nodularity and tenderness be indicative of fibrocystic
breast: may be a normal finding breasts, especially right
 Hands of the clock associated with the before menstruation.
 Concentric circle menstrual cycle or However, pain may also
 Vertical strips hormonal medications. occur with a malignant
51. Palpate one breast at a Breasts should be a normal tumor. Therefore, refer the
time using the palmar body temperature. client for further evaluation.
surface in rotating motion Heat in the breasts of
compressing the breast women who have not just
tissue against the chest given birth or who are not
wall. lactating indicates
52. Note the skin texture, inflammation.
moisture, temperature and
masses. No masses should be Malignant masses or
palpated. However, a firm tumors are most often
intramammary transverse found in the upper outer
ridge may normally be quadrant of the breast.
palpated at the lower base These masses generally
of the breasts. are hard, immobile, and
fixed to surrounding skin
and soft tissue, with poorly
defined or irregular
margins.

Fibrocystic breast tissue Fibroadenomas areusually

that feels ropy, lumpy, or 1-5cm, round or oval,
bumpy in texture is referred mobile, firm, solid, elastic,
to as “nodular” or nontender, single or
“glandular” breast tissue. multiple benign masses
Benign breast disease found in one or both
consists of bilateral, breasts. Milk cysts (sacs
multiple, firm, regular, filled with milk) and
rubbery, mobile nodules infections (mastitis), may
with well-demarcated turn into an abscess and
borders. Pain and fullness occur if breastfeeding or
occurs just before menses. recently given birth. If one’s
breast is bruised from an
injury, there will be a blood
collection that appears as a
lump, which goes away in
days or weeks, or the blood
may have to be drained by
a health care provider.
 Lipomas are a collection of
fatty tissue that may also
appear as a lump.
Intraductal papilloma is a
small growth inside a milk
duct of the breast, often
near the areola. It is
harmless and occurs in
women ages 35-50.

53. Gently squeeze the The nipple may become Common causes of nipple
nipple and note discharges. erect and the areola may discharge in addition to
54. Repeat the examination pucker in response to pregnancy, include
of the opposite breast and stimulation. A milky lactation, hypothyroidism,
compare the findings. discharge is usually normal pituitary adenoma, oral
only during pregnancy and contraceptives,
lactation. However, some antihypertensives, and
women may normally have tranquilizers. Nipple
a clear discharge. discharge may be bloody
(possibly from a papilloma
in the duct); greenish (often
from a draining breast
cyst); or clear (more likely
associated with cancer
unless from both nipples).

References

Khadka, S., Kisi, D., Raya, P., & Shrestha, S. (2008). Fundamental of Nursing

Procedure Manual. (K. Miyamoto, Ed.). Kathmandu, Nepal: Japan International

Cooperation Agency (JICA) Nepal Office.

Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (2017). Fundamentals of nursing

(9th ed., Vol. 1). St. Louis, MO: Mosby Elsevier.

Weber, J., & Kelley, J. (2018). Health assessment in nursing (6th ed.). Philadelphia:

Wolters Kluwer.