Module 6: GU Breast And Respiratory Flashcards
Mammary glands lie over the …
muscles of the anterior chest wall
Where do the breast lie?
Horizontally over the sternum to the mid axillary line, and vertically from the 2nd to 6th Intercostal Spaces
What determines the difference in breasts between the genders?
Estrogen and Progesterone
The breasts are a _____ reproductive muscle
accessory reproductive muscle
Functions of the Breast
Milk
Sexual Stimulation
Types of Breast Tissue
Glandular
Fibrous
Adipose
Glandular Breast Tissue
- Functional tissue
- Makes milk
- arranged into 15-20 lobes in a circular orientation with 50-75 lobules and 10-100 acini cells producing milk
Acini Cells
Cells producing milk
Fibrous Breast Tissue
The cooper’s suspensory ligaments
Cooper’s Ligaments
ligaments that support the shape of the breast by connecting skin and muscle throughout
Adipose Breast Tissue
Subcutaneous and Retromammary Fat of the breast
Makes up the majority of the breast, determines shape and size, but does not have a functional capacity
How are the mammary ducts constructed to bring milk to the nipples?
lobules, ductules, and lobes converge into a single milk duct that transports the milk
What else is looked at during a breast exam?
The axilla and the lymphatics
What are the sets of lymph nodes examined alongside the breast?
Axillary Lymph Nodes
Clavicular Lymph Nodes
Important Axillary Lymph Nodes to examine in a breast exam?
- Lateral - drains the arm - brachial
- Central - on midaxillary line
- Pectoral - anterior axillary - drains most of the breast
- Subscapular - posterior axillary
The Central Axillary Node…
gets drainage from the other nodes, and a small amount flows into the Clavicular nodes
2 Clavicular Lymph Nodes to Exam
Supraclavicular and Infraclavicular
Concerning Findings in Lymph Node Examination?
Enlargement Tender or Painful Nodes Nonpainful Enlargement Larger than 1 cm enlargement Nonmoving Lymph Node Mass
Non Modifiable Associations for the Health History Breast Exam
- Things that cannot be changed -
Gender Age at Menarche Age at Menopause Genetics (thought as highly important to risk) Race/Ethnicity Family History Personal History Previous Chest Radiation Diethylstilbestrol Exposure Age During Pregnancies (May be modifiable)
Menstruation and Menopause at what ages cause a higher risk for breast cancer?
Menstruation pre age 12 and Menopause post age 55
DES
Diethylstilbestrol
Now banned medicine for miscarriage in the 1940/50s that has been shown to cause a severely high rate of breast cancer in the daughters of the medication’s user
Modifiable Associations for the Health History Breast Exam
Children Oral contraceptives Hormones Medications Breast Feeding Alcohol Excessive Weight Gain Physical Activity Night Light
Children prior to age ____ is thought to be more protective against breast cancer
30
Use of hormone therapy for estrogen and progesterone ____ risk of breast cancer, but cessation of use ____ risk after 2-3 years
increases; decreases
Medications for ____ ____ and ____ can increase breast cancer risk
Breast enlargement and Transgender (breast enlargement)
Breast feeding is ____ against breast cancer
protective
Excessive Weight and Obesity increases estrogen thus leading to …
a higher risk of breast cancer
Physical activity can decrease breast cancer risk by ___%
10
Unclear Associations for the Health History Breast Exam
Night Work Secondhand Smoke Dieting and Vitamins Medications Environmental
How might night work increase breast cancer rate?
it is unclear and undergoing further study right now, but decreased melatonin levels may be linked to a higher risk of cancer
At the start of the Physical Exam of the Breast it is important to do/keep in mind what things?
- Always provide privacy as it may be embarrassing
- you want to teach the patient on breast awareness and to reassure them (decreases anxiety or embarrassment)
- May need a chaperone (especially if you are a male nurse)
Physical Assessment of the Breast includes what techniques?
Inspection
Palpation
Inspection of the breast should be done in what position(s)?
while sitting and while supine
Palpation of the breast includes what parts and intensity?
Light, Mid, and Deep Palpation
Breast, Axillae (tail of spence and lymph nodes), and Clavicular lymph nodes
Tail of Spence
the prolongation of the upper and outer breast quadrant into the axillary direction (“Axillary Tail”)
Why do we inspect breast in a supine position too?
So the tissue spreads out to see something you may not while sitting
Inspection of the breast occurs in what areas?
Between the 2nd and 6th ribs
Between the sternal edge and the midaxillary line
Inspection of the Breast in a Sitting Position involves the patient doing what things?
Sitting with arms at side
Sitting with arms pressed into waist
Sitting with arms above head
Sitting while leaning forward
Inspection of the Breast in a Lying Down position involves the patient doing what?
Having their arm up next to the ear with a pillow under one side, this allows the breast tissue to spread over the chest wall
What should be observed for during breast inspection?
Size Shape Surface Characteristics Edema Dimpling Retractions Venous Patterns Areolar and Nipple Characteristics
Tanner Scale
Scale that assesses breast development during puberty and starts usually around ages 8-13 in women
11 years is the average starting age of breast development
If nipples are seen inverted …
ask whether they normally are inverted, if they are then it is not concerning
Montgomery Tubules
lubricate the nipple/areolar region
Peau D Orange
Dimpling of the breast caused by a blocked duct which causes congestion leading to the pitting orange like look of the breast
Pendulous Breasts
occurs due to gravity pulling on the cooper ligaments with age, so you have the patient lean forward to check the ligaments
What sort of things inspected may be concerning?
Thick Area Felt Dimpling Nipple Crust Red or Hot New Fluid Skin Sores Bumps Growing Venous Patterns New Sunken Nipple New Size/Shape Peel like Skin Hard Lump
Breast Retractions
When the nipple caves inwards
Venous Patterns in the Breast
each side should generally look the same, but different congestion/venous patterns should be noted as it may indicate malignancy
Concerning Nipple Characteristics
Color not being dark pink to dark brown
Dry Patchiness/Eczema
New Discharge other than when breastfeeding
Green/White or Bloody/Clear Discharge
Unilateral differences rather than Bilateral
Persistent or Spontaneous differences
Paget’s Disease
Aggressive Cancer that can be detected in the areolar and nipple region (but it may be hidden by use of creams)
Green and White Discharge from the Nipple May Indicate…
a cyst
Bloody or Clear Discharge from the Nipple may indicate…
metastasis (cancer)
Reasons for Nipple Discharge
Drugs like oral contraceptives, antihypertensive, and tranquilizers
Hypothyroidism
Pituitary Adenoma
Overstimulation
Benign Cancers (Intraductal papilloma, papillomatosis, duct ectasia)
Malignant Cancer
Supernumerary Breast or Nipple
a non concerning “extra” nipple that may have formed along the milk line
Gynecomastia
- more mamillary density in meds
can be from drugs, hormones, thyroid toxosis, or weight gain
Breast health is for …
EVERY patient, not just female
When palpating the breast…
it is best if they enter the supine position now
use a systematic method
use light and then deep palpation
Most Registered nurses do not…
give breast exams - but it is technically within the scope of practice
Areas to Make Sure you Palpate on a Breast Exam
Tail of Spence
Glandular Area
Areola Area
Nipple Compression (check for discharge, may be advised against at times)
Systemic Methods of Palpating Breasts
Concentric Circles
Spokes of Wheel
Grid Top to Bottom
Compass inward and outward
When discussing a finding on the breast, refer to it in terms of…
a clock face
Abnormal Breast Palpation Findings
Mastitis
Benign and Malignant Masses (Fibroids, Growths, Etc)
Mastitis
Milk duct infection
caused usually by a blocked duct (due to blockage or cancer)
important to know if they are lactating currently, because if not it can indicate cancer
Why should mastitis be treated quickly?
because it can lead to systemic problems
Teach the new mom if they have flu like symptoms like malaise or that they are not lactating to immediately see a provider
Fibrocystic Breasts
Catch all term for many benign breast growth conditions
Swollen, painful, tender, “lumpy bumpy”
often due to hormones or a high caffeine and fat diet
if these are painful, tender, or lumpy they should still be checked for a rare inflammatory breast cancer just in case
Fibroadenomas
Benign Solid Breast Tumors
Oval Shape rubbery Mobile 5 mm to 5 cm (huge spectrum) Rare post-menopause can grow "overnight"/quickly large and uncomfortable for the patient can occur even in younger people
Malignant Mass in Breasts
Hard
Sharp Edges / Irregular Shape
Non-Mobile
Non-Tender (Could be tender sometimes though, see Fibrocystic final point)
Nipple Erosion, Retraction, or Blood Discharge may occur
Enlarged, shrunken, or dimpled breasts may occur with no pain present
51% of Breast Cancers occur in what region?
the upper outer breast region (near the axillary area)
Cancer in the breasts are …
very widespread (many different areas can occur)
Invasive (Infiltrating) Ductile Carcinoma
most common breast cancer
When documenting breast exam findings what things should be included?
Location (in terms of clock face and how far from nipple)
Size (terms of actual measurements)
Shape
Consistency
Mobility of Mass
Tenderness
Erythema
Dimpling over the mass
Depth of the Mass
Ex: 1 cm hard, circular, non-moveable, painless mas noted at 2 O clock, 2 cm from areola in right breast, no erythema or edema noted
Diagnostic Breast Tests
Mammograms
Ultrasounds
Needle Aspirations
Surgical Biopsy
Usually diagnostic breast tests occur between…
patient and provider
Recommended Mammogram Age?
baseline at 35/36 with yearly ones starting at 40, or 10 years prior to a family members diagnosis of breast cancer
Ultrasound
often used in addition to the mammogram to help visualize dense breasts
Needle Aspiration and breast cancer diagnosis
Determines fluid contents of the mass
used depending on lesion type seen and potential risks of this test
Surgical Biopsy and breast cancer diagnosis
Determines whether a mass is malignant
used depending on lesion type seen and potential risks of this test
Breast Awareness should be taught in the patient’s…
early 20s
Most important thing nurses do in regard to breast health?
Patient Teaching of Awareness and Examinations
When should self breast exams be done?
If they no longer menstruate.. choose a day of the month for the exam
If they still menstruate… do shortly after the time of menstruations for a better baseline and less pain
How should the self breast exam be done?
Move in a grid like manner into the axilla
Do it lying down or in the mirror
They may do it themselves or need help from a provider
The overall newer consensus on self breast exams are…
they may not be all that useful, and awareness may be better to teachq
Example Nursing Diagnoses from the Breast Examination
Anxiety Breast Feeding (effective, ineffective, interrupted) Body image disturbance Fear Health Seeking Behaviors Knowledge Deficit Pain (acute, chronic) Risk for infection
Purpose of the Respiratory system
the lungs, in conjunction with the circulatory system, deliver oxygen to and expel carbon dioxide from the cells of the body
To maintain adequate O2 levels in the blood to maintain cellular life
Purpose of the upper respiratory system
warms, humidify, filter inhaled air
make sound
send air to lower airways
The lungs/lower respiratory system…
accomplishes gas exchange
What does the respiratory system include?
Airways lungs bony thorax respiratory muscles central nervous system upper and lower respiratory systems
Structures of the Upper Respiratory Tract
Nose Sinuses and Nasal Passages Pharynx (naso, oro, largynogo) Tonsils and Adenoids Larynx: Epiglottis, Glottis, Vocal Cords, Cartilages
Thorax
base of the neck to the area superior of the diaphragm
Epiglottis
flap of tissue that covers the top of the larynx when the patient swallows.
Protects the person from aspirating food or fluid into the lower airways
The larynx is on top of …
the trachea, and houses the trachea
Structures of the Lower Respiratory System
Trachea Lungs Pleura Mediastinum Lobes of the Lungs Bronchi and Bronchioles Alveoli
Carina
area where the trachea divides into two bronchi
Amount of Lobes per Lung
Right - 3 - upper middle lower
Left - 2 - upper lower
Apex of the Lungs
Located at the top’
sit slightly above the clavicle
Base of the Lungs
located at the bottom
sit slightly superior to the diaphragm
Visceral Pleura
pleura wrapping each lung
Parietal Pleura
lines the chest/thoracic cage wall
has nerve endings
Between the Visceral and Parietal pleura, there is …
pleural fluid
____ is where gas exchange occurs
Alveoli
How many alveoli are in the adult lung?
300 million
2 Important Structures of the Respiratory System
Thorax / Thoracic Cage
Respiratory Muscles
Thoracic Cage
Everything under the thorax:
Clavicles Sternum Scapulae 12 Sets of ribs 12 Thoracic Vertebrae
Respiratory Muscles
Diaphragm
External Intercostal Muscles
Accessory inspiratory muscles (Trapezius, Sternocleidomastoid, Scalenes)
Respiration
the process of gas exchange between atmospheric air and the blood at the alveoli and between the blood and the cells of the body
exchange of gases occurs because…
of differences in partial pressures
Pulmonary Ventilation
Inspiration + Expiration
it is the movement of air in and out of the airways
Inspiration
active phase of ventilation
involves the movement of muscles and thorax to bring air into the lungs
Expiration
the passive phase of ventilation (normally)
movement of air out of the lungs
What occurs in the thoracic cavity during Inspiration?
contraction of the diaphragm (downwards/flattening) and contraction of the external intercostal muscles increases thoracic space
The lowered pressure causes air to enter through the airways to inflate lungs
The thoracic cavity is a ___ chamber
airtight
The floor of the thoracic cavity is the …
diaphragm muscle
What occurs in the thoracic cavity during expiration?
The diaphragm relaxes (bowl shape upward) and intrathoracic pressure increases
Increased pressure means air is pushed out of the lungs as the lungs deflate
Expiration as a passive process requires the elastic recoil of the lungs to occur
Inspiration is normally X/3rd of the Respiratory Cycle, and Expiration is X/3rds
Inspiration is 1/3
Expiration is 2/3
Pressure in the thoracic cavity on inspiration
lowered
Pressure in the thoracic cavity on expiration
increased
Ventilation Perfusion (V/Q Ratio)
Ventilation is the movement of air in and out of the lungs, while perfusion is the blood that reaches the alveoli
So an adequate V/Q ratio determines adequate gas exchange as air must reach the alveoli to be available for gas exchange
___ occurs when there is an imbalance of ventilation and perfusion which results in ____
Shunting; Hypoxia
Tidal Volume (TV)
air volume of each breathe
measure several breaths since it can vary form breath the breath
Inspiratory Reserve Volume (IRV)
maximum amount that can be inhaled AFTER a normal inhalation
Expiratory Reserve Volume (ERV)
maximum volume that can be exhaled AFTER a normal exhalation
Vital Capacity (VC)
the maximum volume of air exhaled from a maximal inspiration
VC = TV + IRV + ERV
Forced Expiratory Volume (FEV)
volume exhaled forcefully over time in seconds. Time is indicated as a subscript, usually 1 second
Who usually does measurement of volume and inspiratory forces?
a respiratory therapist (but we need to be able to teach use, like how we teach COPD patients the spirometer for use at home)
Spirometer
measures volumes of air exhaled and is used to assess lung capacities
Pulmonary Function Tests
assess respiratory function and determine the extent of dysfunction
Peak Flow Rate
reflects maximal expiratory flow and is frequently done by patients using a home spirometer
Diagnostic Procedures and Tests for the Respiratory System
ABGs Sputum collection and Analysis CXR, CT, MRI PFT - measure inspiration and expiration rates and ratios O2 Sat
Sputum is best collected…
in the morning while noting color and density
White Sputum indicates…
normal function or a viral/cold infection
Green Sputum indicates …
bacteria
Rust color Sputum may indicate …
Pneumonia or Tuberculosis
Pink Frothy Sputum may indicate..
pulmonary edem
Bright Red Sputum indicates
blood
Brown/Black Sputum indicates
blood or hemoptysis
Arterial Blood Gases (ABGs)
measurement of arterial oxygenation and CO2 levels
Used to assess adequacy of alveolar ventilation, ability of the lungs to provide O2 and remove CO2, and acid base level
Pulse Oximetry
Non invasive method of monitoring oxygen saturation of the blood
DOES NOT REPLACE ABGs
may be unreliable if they smoke, have nail poliush, etc
Normal Pulse OX level is…
95-100%
What information to glean from the Subjective health history portion of the respiratory exam?
- present symptoms
- past and family history
- onset of symptoms (COLDSPA)
- Precipitating Factors (QRST/COLDSPA)
- aggravating and alleviating factors
- treatments and self care interventions
- immunizations - pneumovax, influenza annually, etc
Listen and Learn what things during the health history respiratory assessment?
SOB Cough - productive, chronic, etc Sputum Production Wheezing Chest Pain History of Smoking What is their normal posture or breathing style Recent Chest Trauma General health Work Asthma
Make sure to get specific information on attempts to quit smoking because…
they could say they quit but only started a day ago
make sure to be non judgmental and not preachy
5 As to advising smokers
Ask, Advice, Assess, Assist, Arrange
____ patients who move toward quitting smoking
praise
Important Landmarks for the Physical Respiratory Assessment
Anterior: Midsternal, Midclavicular, Anterior Axillary Lines
Posterior Chest: C7, T1, T4, T7, T10, Vertebral Line, Scapular Line, Posterior Axillary line
Lateral Chest: Midaxillary line, T9, T5
Suprasternal Notch
Notch in anterior neck above the manubrium and angle of louis - great starting point
Angle of Louis
Notch distal to the suprasternal notch indicating the 2nd Intercostal
Positioning of client for Physical Respiratory Assessment
Sitting for Posterior and Lateral and Anterior, or Supine for Anterior Assessment
You can hear lung sounds from what side?
The posterior sides
Techniques and order used for Physical Respiratory Assessment
Inspection –> Palpation –> Percussion –> Auscultation
It is important to look at ____ for comparison in the physical respiratory assessment
symmetry
Inspection during the Physical Respiratory Assessment
- Hallway Assessment
- Introduction
- Use good lighting
- check LOC
- measure and assess respiration pattern and retractions
- assess skin, color, condition, lesions, cyanosis potential (nail beds and lips), signs of respiratory distress
- thoracic configuration, symmetry, AP diameter
- abnormalities like barrel chest, kyphosis, scoliosis, funnel and pigeon chest
- assess neck muscles
- assess bilateral symmetric chest expansion (Thoracic Expanse)
Signs of Respiratory Distress
SOB Diaphoresis Grunting Nasal Flaring Audible Wheezing Intercostal Retractions
LOC
level of consciousness
hypoxic patients may be disoriented or confused or agitated so be aware and do not assume that it is their typical personality
Respiratory rate in adults should not go above..
24 maximum (typically 12-20)
Infant Respiration Rate
20-40
AP Diameter
Ratio of lateral and anterior/posterior thorax - should be a 2:1 ratio normally
Kyphosis
curvature in the spine/back
Barrel Chest
AP diameter of 1:1 - seen often chronic bronchitis/ COPD patients (due to trouble expiring)
It is very to important to do what during palpation, percussion, and auscultation of the chest?
Do a bilateral comparison !!!
Pattern of Anterior Chest Physical Examination (Palp/Perc/Ausc)
- Anterior neck
- Bilateral ICS 2 (angle of louis)
- Bilateral ICS 4
- Bilateral ICS 6
- Bilateral Lateral ICS 6
Pattern of Posterior Chest Physical Examination (Palp/Perc/Ausc)
- Anterior neck
2.Bilateral T1 - Bilateral T4
- Bilateral T7
5 Bilateral T10 - Bilateral Lateral 9
- Bilateral lateral 5
When Palpating the Chest what should you keep in mind?
- perform with one hand or two
- feel thoracic muscles and skeleton for pulsations, tenderness, depressions, masses, unsual movement or positions
- Crepitus
- Location of trachea
- Thoracic Expansion
- Vocal or Tactile Fremitus
Crepitus
snap crackle pop sound/feeling during palpation indicating an air pocket
Fremitus
vibrations recognized in the upper lungs and decreasing in intensity as you move away from the vocal cords while the patient says “99”
absence is concerning
Palms of the hand can indicate patient ___
pain (palms used in resp exam)
Percussion used in a respiratory assessment?
Indirect (tap on your own fingers)
compare bilaterally for sounds
Lots of air does what to fremitus
less fremitus occurs
Lots of fluid accumulation does what to fremitus
more fremitus occurs
Resonant Percussion (loud, low, long, hollow) indicates what?
Normal Lung Tissue
Bronchitis
Flat Percussion (soft, high, short, very dull) indicates what?
Consolidations
Bones
Dull Percussion (medium, med to high duration, medium dull thud) indicates what?
A solid area like in pneumonia
The heart
Tympanic Percussion (loud, high, medium, drum like) indicates what?
Air collection
Emphysema
Pneumothorax
(not as common as Hyperresonant)
Hyperresonant Percussion (very loud, very low, longer, booming, abnormal air trapped sounds) indicates what?
Large Pneumothorax
What lung sounds are heard through auscultation?
Bronchial/tubular, Bronchovesicular, Vesicular
Breath smells can be indicative of …
illness
Bronchial / Tubular Sounds
Blowing, hollow sounds
over the trachea, above the clavicles on each side of the sternum
loud, high pitched
Inspiration < Expiration
Bronchovesicular Sounds
Medium pitched
found in 2nd intercostal space and T4 (posterior)
Next to the sternum between the scapulae
Inspiration = Expiration
Vesicular Sounds
soft low pitched
over the lung periphery
Inspiration > Expiration
Abnormal Breath Sounds in Auscultation?
Crackles Rhonchi Wheezing Pleural Friction rub Silence
Crackles
FINE high pitched, discrete (crackling on inspiration)
heard at the end of inspiration
medium lower more moist sounding in the mid stage of inspiration with coarse loud bubbly sounds heard in inspiration
All are not cleared by coughing
mostly found in the base of the lungs usually
Rhonchi
Sonorous Wheeze (low snore like during inhale and exhale)
low, low course sound, snore like
continuous during inspiration or expiration
may clear with cough accompanied by mucus accumulated in the trachea or large bronchi
Wheeze
Sibilant Wheeze (musical during inhale and exhale)
musical sound squeak
louder on expiration
Pleural Friction Rub
dry rubbing grating inflammation of the pleural surfaces (rubbing heard on inhale and exhale)
loudest at the anterior lateral surface
Silence (During Auscultation)
Diminished sound indicative of things like emphysema, atelectasis, and bronchospasm
Atelectasis
complete or partial collapse of the entire long or an area (lobe) because alveoli deflated or filled with fluid
common complication following surgery
“Collapse in Alveoli”
Crackles late on inspiration may indicate …
Pneumonia, Congestive Heart Failure, or Edema
During Auscultation the patient should…
breathe deeply through the mouth
Physiological Changes of the Respiratory System With Age?
Decrease in:
- Stretching and compliance of chest wall
- rib motility and tone
- strength and function of respiratory muscles
- depth and oxygenation
- ability to cough and expectorate
Increase in:
- risk for accumulation of secretions leading to pneumonia
- potential increase in respiration rate
Interventions to improve the airway?
- Administer Oxygen when ordered
- Sit them at the head of the bed upright (high fowlers 90deg)
- Encourage coughing and deep breathing (10 times at least every hour)
- Lots of fluid intakes, but restrictions (dont want to overhydrate and cause edema)
Hyperventilation
an increase in rate and depth of rbeathing
Kussmaul
rapid deep labored breathing often seen during diabetic ketoacidosis
Tachypnea
respiration greater than 24 per minute
Bradypnea
respiration lower than 10 per minute
Hypoventilation
decreased depth and rate of breathing, and an abnormal pattern
Chain Stokes
alternating periods of rapid breathing along with periods of apnea
Ataxic
significant disorganization of varying irregular and regular types of respirations (disorganized respiration)
Air Trapping
in COPD / obstructive respiratory disorders
increased difficulty getting air out
normal adult chest sounds should be ..
resonant
When auscultating the chest make sure to be touching?
the patients skin directly with the diaphragm
Right way to use an Incentive Spirometer
Set goal with yellow marker –> Sit up and exhale completely –> seal mouth around device –> inhale slowly to keep side indicator within normal range –> keep inhaling until impossible then hold breath for 6 seconds –> exhale slowly allowing the piston to fall completely –> do 10 times every hour or two while patient is awake
Atmospheric Oxygen is ___%
21
Flow Meter
device that goes into the wall to regulate oxygen output in L/Min
Nasal Canular
delivers lower flow rate of oxygen to a higher rate (1-6 L) and are often called nasal prongs
may need to get humidified at higher rates
Simple Face Mask
Step up in flow rate from nasal canula
Rebreather
step up in flow rate from simple face mask
Non-rebreather/Modified Rebreather
step up in flow rate from rebreather (largest flow rate)
Oxy Mask
Good for claustrophobia due to more holes
can deliver flow rate of any other device (1-15 L with 24-90% FiO2)
