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Health History: Chief Complaints
•Menstrual cycle/problems
- –Dysmenorrhea
- = painful menses
- Menorrhagia = heavy bleeding/menses
•Lower abdominal or pelvic pain
•Discharge (vaginal), pain, masses, itching, or lymphedema
•Genital lesions or rashes
•Changes in urination (burning or incontinence)
•Menopausal symptoms
•Lump or swelling in breast
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Past Health History
- •Problems with uterus/ovaries, or reproduction? Describe.
- •Surgery—what kind, when, why; how affected you?
- •Past history of cancer (ovarian, endometrial or colon)?
- •Chronic illness? (DM, endocrine disorders)
- •Menstruation time period (menarche to menopause)
- •Pregnancies – reproductive history
- –how many times
- –number of babies
- –miscarriages, abortions, stillborn
- Gravida = # pregnancies
- Para
- = # pregnancies > 20 wks. (usually as # preterm births & # term births)
- #
- abortions (spontaneous miscarriages or therapeutic pregnancy terminations)
Last Pap smear, results? - papaniocolaou
- PAP smears q 1yrs after sexually active or age 21
- q2-3 yrs. If 3 in a row normal if > 30 yrs.
- Old
- > 70 yrs. Old can stop PAP tests if not had
- hysterectomy for cancer (ex. 90 y/o nun getting PAP’s)
- Gravida = # pregnancies
- Para
- = # pregnancies > 20 wks. (usually as # preterm births & # term births)
- #
- abortions (spontaneous miscarriages or therapeutic pregnancy terminations)
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Female Exam: Procedures & Techniques
- •External genitalia
- –Inspect pubic hair—distribution, nits
- –Inspect skin mons pubis/inguinal area—surface characteristics
- –Inspect labia majora/minora—pigmentation/surface
- characteristics
- –Inspect urethral meatus, vaginal introitus/entrance,
- perineum—positioning/surface characteristics
Inspect anus—color, surface characteristics
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Breast Tissue
- •Breasts: paired mammary glands
- –Lie over muscles, anterior chest wall - anterior to: pectoralis major, serratus anterior
- –Extend: horizontally:2nd to 6th rib; vertically:sternum to midaxillary line
- –Functions of female breasts:
- •Production & storage of milk for newborn
- •Sexual stimulation
- •Breasts with 3 types of tissue:
- –3 types of tissue:
- •Glandular
- •Fibrous
- •Fatty
•Breasts: divided into 4 quadrants intersecting at nipple
•Tail of Spence: upper outer quadrant; extends to axillary area; location of most frequent occurrences of breast tumors
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Beast Exam
- •Inspect breast for size, shape, contour, & symmetry
- •Inspect skin of breast for color, pigmentation, vascularity , surface characteristics & lesions
- •Inspect areola for color & surface characteristics
- Inspect nipples for position, symmetry, lesion, or discharge
- Notes:
- Male with same exam (can have gynecomastia/bilat enlarged or breast CA/unilat. hard painless lump)
- Inspect in various positions (hands over head, hands on hips, hands squeezed together & leaning forward)
- Breasts slightly asymmetrical without dimpling, retractions or bulges (malignancy)
- Breast color & vascularity
- Smooth, evenly pigmented & slightly lighter than other skin exposed to sun
- Bilateral venous pattern of obese or pregnant
- women; increased circulation with malignancy
- Peau d’orange = rough, tough thickened skin due to edema /blocked lymphatic drainage (orange peal skin)
- No erythema/redness or heat (inflammation)
- Areola color varies pink to black yet bilateral with Montgomery tubercles (raised bumps)
- Nipples normally may be flat, protrude, or inverted as long as not recent change (malignancy)
- Supernumerary nipple line from axilla to groin along milk
- line
- Discharge – only normal = serous/yellow; all others abnormal
- Clear/watery with pharmacologic causes (hormones)
- Serosanguineous (straw) = CA
- Sanguineous (bloody) = CA
- Milky = galactorrhea (inappropriate lactation in 20 – 25% women; pituitary tumor with HA & vision problems, hypothyroid, Cushings,
- Tricyclic antidepressants, histamines, antihypertensives)
- Purulent = infectious process
- Multicolored (green, gray, brown) = fibrocystic process/disease
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Breast Exam Procedure cont
- •Inspect breasts in various postures for bilateral equal pull
- •Inspect & palpate axilla for rashes, lesions or masses
- •Palpate breast for tissue characteristics (tender, temp., mass)
- Palpate nipples for surface characteristics & discharge
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Age Variations: Female Elderly
- •Breasts atrophy beginning at age 40
- •Decrease in estrogen so clitoris smaller & difficult to palpate ovaries
- •Thinning of pubic hair
- •Drying of mucosa with itching of labia & vagina (atrophy)with dyspareunia
- •Pelvic muscles with less elasticity leads to urinary
- incontinence
- •Vagina & cervix smaller & pale
- •Still do breast exams & PAP smears even if mastectomy or hysterectomy, if for cancer
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Breast Cancer
- •Age > 50 yrs. (77%)
- •Family history
- •Genetics (BRCA1 or BRCA2 genes 10%)
- •Early menarche (before 12)
- •Late menopause (after 50)
- Nulliparous or first child after age 30
- •Caucasian > Black
- •High fat diet, obesity
- •oral contraceptive use
- •Radiation exposure
- •Presence of other cancer
- •Dense breast tissue
- •HRT > 5 yrs.
- •Alcohol (more than 2 drinks per day)
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Signs & Symptoms of Breast Canter
- •Asymptomatic, diagnose by mammogram
- •Nontender lump/thickening in breast UOQ
- •Burning, stinging, or pricking (not pain)
- •Abnormal nipple discharge
- •Rash around nipple
- •Nipple retraction
- •Dimpling of skin or nipple off position
- •Lump under arm or above collar bone
- •Peau d’orange
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Female Nursing Diagnoses
- •Readiness for enhanced health management RT female
- reproductive system
- •Health seeking behavior: request information on STD’s, birth control, or HRT
- •Risk for infection RT STD’s
- •Disturbed body image RT perceived feminine role &
- sexuality AEB mastectomy
- •Fear of cancer (CA) of reproductive system
- •Acute pain RT dyspareunia (painful intercourse)
- •Ineffective sexuality pattern RT decreased libido &
- menopause
- Anticipatory grieving RT cervical/uterine/ ovarian CA
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Male Chief Complaint
- •Pain or itching
- •Lumps or swelling in groin, testicles or scrotum
- •Penile lesion or discharge
- •Urinary problems
- •Change in bowel function
- •Rectal bleeding
- Erectile dysfunction
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Make preventative exam
- Hydrocele = fluid accumulation in scrotum
- Variocele = dilation & tortuosity of veins of spermatic cord
- Spermatocele = cystic mass in epididymis or spermatic cord filled with sperm & seminal fluid
- Preventative Exams (Amer. Cancer Society recommends):
- Testicular exam by MD q 3yrs. Ages 30 – 39
- then q 1yr. > age 40 (self exams q month in shower)
- PSA screenings q 1 yr. > age 50 yet younger
- if + family history or Afr. American (age 40-45)
- DRE q 1 yr. > age 40 Digital rectal exam
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Male Exam
- •Inspect & palpate:
- –Penis
- –Scrotum
- –Inguinal areas
- Perform rectal exam & palpate prostate
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Procedure - Male Exam
- •Pubic hair
- –Inspect for distribution, general characteristics, & nits
- •Penis
- –Inspect and palpate for surface characteristics, color,
- tenderness, and discharge
- •Circumcised—variable foreskin, uncircumcised – foreskin folded over glans (ask to retract);
- phimosis =tight foreskin, unable to retract
- paraphimosis=unable to return foreskin over glans
- •If discharge or smegma present, obtain specimen
- •Palpate glans anteroposteriorly to open distal end of urethra
- –Slit like opening at distal tip of glans (central)
- »Epispadias=Urethra opens on upper penis
- »Hypospadias=urethra opens onto lower penis
- •Palpate shaft of penis (non-tender)—semi-firm consistency without nodules
- •Scrotum and testes:
- –Inspect scrotum for color, texture, surface characteristics, position
- •Left side lower; deeply pigmented with sebaceous cysts
- •Appearance affected by temperature
- –Palpate scrotum—surface characteristics and tenderness
- •Scrotum should be nontender
- –Palpate testes, epididymides, vas deferens—location, consistency, tenderness, and nodules
- •Should be smooth and tender
- •Cryptorchidism
- •Transilluminate
- •Teach testicular self-exam
- –Inspect inguinal & femoral areas for bulges while client bears down
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Male anal and rectal exam
- –Inspect perianal area & anus for pigmentation
- & surface characteristics
- –Palpate anus for sphincter tone (hypo or hypertonic tone)
- –Palpate anal canal & rectum for surface characteristics
- (AP)
- –Palpate anterior rectal surface to evaluate prostate (AP)
- –Examine & test stool for presence of occult blood
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Age variations - Older Male
- •Sexual activity declines in frequency
- •Erection develops more slowly; ejaculation less intense
- •Hyperplasia of prostate (rubbery) is major change (BPH)
- •If excessive prostate enlargement , decrease or obstruction of urinary flow will occur
- •Decreased sperm viability
- •Less abundant & finer pubic hair
- •Elongated scrotal sac & softer testes
- •Internal sphincter less responsive so stool retention
- •External sphincter with less control so fecal incontinence
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Male Nursing Diagnosis
- •Health seeking behavior : request information on colorectal exams
- •Risk for ineffective health maintenance RT testicular self
- exams
- •Risk for injury RT hernia due to poor lifting technique
- •Ineffective sexuality pattern RT decreased libido with aging
- •Fear RT prostate cancer
- •Acute pain RT dysuria from STD
- •Disturbed body image RT hernia
- •Anxiety RT prostate surgery/cancer
- •Anticipatory grieving RT testicular cancer
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