Phys assess #3 Flashcards
Sensory organ for vision-
Eyes
Important for functioning and ability to perform
Eyes
Transparent protective cover of the eye is the ___
cornea
Lacrimal apparatus-
irrigates the eye by producing tears
Movement of the extraocular muscles stimulated by
three cranial nerves
Cranial nerve VI (6):
abducens nerve, innervates lateral rectus muscle, which abducts eye
Cranial nerve IV (4):
trochlear nerve, innervates superior oblique muscle
Cranial nerve III (3):
oculomotor nerve, innervates all the rest: the superior, inferior, and medial rectus and the inferior oblique muscles
There are _ muscles that move the eye and keep it straight and rotate
6
Each muscle makes sure both eyes move together, known as _____ (eyes remain parallel)
conjugate movement
Parallel axis is important for eye movement bc the human brain is ____ or a single image visual system
Binocular
Both eyes creating one image in the brain
Binocular/Single image visual system
Follow movement of pen light or object proceeding clockwise.
Six cardinal positions of gaze
Assess for potential extra ocular muscle (EOM) weakness, nystagmus or lid lag.
Six cardinal positions of gaze
Normal response is eyes being able to track the movement parallel
Six cardinal positions of gaze
Weakness in cranial nerve or muscle dysfunction if the eyes do not move parallel
Six cardinal positions of gaze
Three concentric coats of the eye
Outer, middle, and inner coat
Outer coat
Sclera and cornea
Middle coat
Choroid, pupil, and the anterior and posterior chambers of the lens
Inner coat
Contains the retina
Internal Anatomy: Outer Layer
Sclera, Cornea, Corneal reflex, Trigeminal nerve, Facial nerve
Sclera:
tough, protective, white covering.
Continuous anteriorly with smooth, transparent cornea, which covers iris and pupil
Sclera
Cornea:
part of refracting media of eye, bending incoming light rays so that they will be focused on inner retina.
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.
