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Lymph Nodes
27. Inspect for size, shape, mobility, consistency, tenderness and inflammation

28. Palpate the cervical node, supra and infraclavicular nodes axillary nodes and epitochlear nodes to note for tenderness and presence of masses for possible tumor or enlargement of the areas.
Face the client and bend the client's head slightly forward or toward the side being examined to relax the soft tissue and muscles palpate the nodes using the pads of the fingers move the fingertips in a gentle rotating motion

Lymph nodes play an important part in the body's defense against infection. Swelling might occur even if the infection is mild or not apparent

1: Submental 2: Submandibular 3: Supraclavicular 4: Retropharyngeal 5: Buccal

6: 7: 8: 9:

Superficial cervical Jugular Parotid Retroauricular & occipital

Position upright for palpation: With patient sitting, palpate axillary and supra- and infraclavicular lymph nodes Have the client bend the head forward to relax the tissues of the anterior neck and to relaxs the shoulders so that the clavicles drop. Use your hand nearest the side to be examined when facing the client (left hand for the client's right nodes). Use your free hands to flex the client's head forward. Hook your index and third fingers over the clavicle lateral to the sternocleidomastoid muscle.

1.CENTRAL 2.LATERAL 3.PECTORAL 4.INFRACLAVICULAR 5.SUBSCAPULAR

Patient position: Usually the patient is seated or reclined on a couch for this examination. The examiner tends to raise the patients arm, and using the left hand for the patients right axilla, (and vice versa) the examiner passes their extended fingers high into the patients axilla. The patients arm is now brought to rest on the examiners forearm. Now the examiner should palpate for the following groups of nodes: 1) CENTRAL/APEX 2) LATERAL 3) PECTORAL (medial) 4)INFRACLAVICULAR and 5) SUBSCAPULAR . Every effort should be made to feel for nodes in each of these areas.

Palpation: In order to feel for the EPITROCHLEAR node, palpate the area which is proximal and slightly anterior to the medial epicondyle.

Inguinal nodes

Patient position: For clinical purposes, an oblique set of nodes along the inguinal ligament area and a longitudinal set overlying the femoral vessels are usually palpated for. Have the patient reclined on the couch for this assessment. You will need to expose the groin area. Palpation: Now feel around the inguinal ligament area and along the femoral vessel area. Note that small nodes can be commonly detected in otherwise normal patients.

Breast
29. Inspect the areola and the nipples for position, pigmentation, inversion, discharges, crusting and masses.

30. Examine the breast tissue for size, shape, color, symmetry, surface, contour, skin characteristics. Level of retraction or dimpling.

A useful approach to perform CBE systematically includes use of the "7 Ps": positions, palpation, perimeter, pattern of search, pads of fingers for palpation, pressure, and patient education. 1. Position with arms at side for inspection: Ask patient to remove her gown. Visually inspect the breasts with the patient sitting and with arms at sides. Include frontal and lateral views, look at size, shape, symmetry, color, texture, and condition of nipples

Patient in sitting position during clinical breast examination. Clinicians should inspect breasts for size, shape, symmetry, color, texture, and condition of nipples.

2. Position with arms overhead for inspection: Repeat step 1 with arms overhead.

Patient raises arms overhead for inspection.

3. Position with hands on hips for inspection: Repeat step 1 with hands on hips, contracting pectoralis major. Look especially for skin dimpling with this maneuver.

While in sitting position, patient relaxes, then contracts pectoralis major muscle by pressing in on her hips.

5. Position supine for palpation: Help patient lie supine. Cover breast not being examined. Place ipsilateral arm overhead. Examine from ipsilateral side of table. 6. Position breast toward midline: Centralize the breast (manually or with a towel under the shoulder). 7. Perimeter of the breast: Inspect and palpate the perimeter.

Anatomical extent of breast tissue. Perimeter of breasts should be noted during clinical breast examination.

31. Position the patient with pillows under scapulae with arms raised. Palpate the breast. Start with the asymptomatic side. 32. Palpate one breast at a time using the palmar surface in the rotating motion, compressing the breast tissue against the chest wall.

3 patterns of breast palpation 1. hands of the clock or spokes of a wheel 2. concentric circles 3. vertical strips

33. Note the skin texture, moisture, temperature and masses. 34. gently squeeze the nipple and note discharges 35. Repeat the examination of the opposite breast and compare the findings.

Patient education: During the process, the patient should be asked:

1. 2. 3. 4. if if if if she is comfortable the pressure is causing any discomfort she performs BSE, how often, and her level of confidence she has any questions or concerns

Emphasize to the patient the importance of the triad of clinical breast examination, breast self-examination, and mammography for early detection of breast problems.

Thorax and Lungs

Changes in respiratory status can happen very slowly, or very quickly, so respiratory status is assessed carefully, and frequently See figure 28-47, p. 571 and figure 28-48 and 49, p. 572 for chest landmarks - need to know angle of Louis, how to count ribs, how to describe locations, what is under the surface
Landmarks are things felt or seen used to document location of something

36. Have the patient seated; examine the posterior chest and the lungs

37. Inspect the spine for mobility and the presence of deformities.
Have the client stand. Form a lateral position, observe the three normal curvature; cervical, thoracic, and lumbar.

38. Observe the symmetry, posture and mobility of the thorax upon respiration. 39. Palpate the posterior chest with the patient sitting; identify the areas of tenderness, masses and inflammation.
40. Palpate the rib, costal margin for symmetry, mobility and tenderness and the spine for tenderness

Gently palpate over the spinous process from the cervical region down. Is there any tenderness (if so this may indicate local pathology in that vertebra).

The facet joints may be palpated laterally to the spinous processes and further lateral, the paraspinal muscles.

Curvature Cervical Lordosis Thoracic Kyphosis Lumbar Lordosis Sacral Kyphosis

Normal Curvature 20 to 40 degrees 20 to 40 degrees 40 to 60 degrees Sacrum fused in a kyphotic curve

41. To assess the respiratory excursion, place the thumb at the level of the 10th vertebrae with the hand paralleled to the 10th rib, then ask the patient to inhale deeply. Observe the movement.

Posterior palpation.

Anterior palpation.

42. To check for vocal and tactile fremitus, ask the client to say 99 and use the ball of one hand.
Follow this Procedure to Palpate Properly. * Use the ball of the hand (the palm of the hand at the base of the fingers), palpate and compare like areas of the lungs. To be more accurate, use only one hand rather than both hands. Do not let your fingers touch the patient's chest. * Have the patient repeat a sound that will make full and rich sounds such as "ninety-nine" or "one-one-one." Symmetrically move your hand over the patient's chest. * You should feel vibrations of equal intensity on either side of the patient's chest.

Normally, you will feel fremitus on the upper chest, close to the bronchi. Also, normally, you should feel little or no fremitus in the lower chest. Compare like (symmetrical) areas of the lungs.

Sequence of tactile fremitus examination.

PERCUSSION OF CHEST

o perform a percussion examination, strike the surface of the body. When this is done, various sounds can be heard. The sounds are different depending on the underlying structure of the body. There are two reasons to use percussion as an examination technique. First, percussion results in setting the chest wall and underlying tissues in motion. This produces sounds that can be heard. Second, percussion sounds can be divided into four recognizable notes. Train your ear to recognize the pitch and duration of these notes. The sound can indicate whether the underlying tissues are filled with air, filled with fluid, or solid.

Procedure. In order to perform the percussion examination technique, strike the stationary finger of one hand with a flexed finger of the other hand. The technique, described here, can be practiced on any surface. Here are the key points: Firmly rest the first joint of the middle finger of one hand on the patient's chest, but don't let the rest of the hand touch the chest.

Hand and finger placement.

Keep the fingers of the other hand flexed and the wrist loose.

Hand position.

With the tip of the middle finger of the flexed hand, strike the first joint of the middle finger of the hand that is on the patient's chest. Have the motion come from the wrist. Striking position. Withdraw the striking finger immediately to avoid damping the vibration.
Strike once or twice, then move your hands symmetrically to another part of the chest.

Areas of Percussion. Ideally, the patient should lie in the supine position (lying on the back, face upward) for percussion on the front of the chest. The patient should be sitting up for percussion on the back.

If the patient is ill and unable to sit up, examine with the patient lying on the right or left side.
Percuss the patient's anterior chest. In a healthy patient, the entire upper chest is resonant except for the area of cardiac dullness. Percuss across the top of the body and work downward, symmetrically. Anterior percussion.

Percuss the patient's posterior chest, symmetrically down the chest wall making a side to side comparison. Percussion over lung fields should reveal equal bilateral findings. Omit percussion over the shoulder blades.

Posterior percussion.

AUSCULTATION OF CHEST
Auscultation (listening with a stethoscope) of the lungs is useful in estimating the airflow through the tracheobronchial tree, detecting an obstruction, and assessing the condition of the surrounding lungs and the pleural space. Position the patient. Have the patient sitting or in a supine position. When the patient is lying down, examine his back by turning the patient from side to side. Show the patient how you want him to breath through the mouth, deeper and more forcefully than usual. Listen with the stethoscope. Start at the top of the back and work downward, comparing the right and the left sides.

Then, start at the top of the chest and work downward, comparing symmetric points sequentially. * Listen to one full breath in each location. * Be alert for patient discomfort--light-headedness, faintness--that signals hyperventilation. Check for abnormal sounds. Check for sounds in the lungs that are not modifications of breath or voice.

Auscultation over lung surfaces

Lungs
Inspect, Palpate, Percuss (normal note is resonance), Auscultate (normal is clear and equal bilaterally)
Auscultate using diagram in Figure 28-55 and 28-59, p. 577-578

Assess and document respiratory rate, rhythm, and effort

Respiratory Terminology
Eupnea Tachypnea Bradypnea Apnea Hyperventilation Hypoventilation Dyspnea

Abdomen
Assist the client to a supine position, with the arms placed comfortably at the sides.
Place small pillows beneath the knees and the head to reduce tension in the abdominal muscle. Expose only the abdomen from the chest line to the pubic area to avoid chilling and shivering, which can tense the abdominal muscle.

Topographically, the abdomen can be divided into right and left upper and right and left lower quadrants by vertical and horizontal lines through the umbilicus.

The abdomen may also be divided into nine regions by two longitudinal lines (right and left midclavicular lines) and two transverse planes (subcostal and interspinous planes).

43. Let the patient empty his/her bladder

to promote comfort with the patient and to avoid any interruption during the procedure.

44. Observe the general contour of the abdomen, symmetry, visible peristalsis and aortic pulsation. 45. Check the umbilicus for contour or hernia and skin for rashes, striae and scar.

While observing the patient, pay particular attention to: 1. Appearance of the abdomen. Is it flat? Distended? If enlarged, does this appear symmetric or are there distinct protrusions, perhaps linked to underlying organomegaly? The contours of the abdomen can be best appreciated by standing at the foot of the table and looking up towards the patient's head.

46. Auscultate and note the frequency and characters of bowel sounds (pitch, duration)

47. Listen over the aorta and renal arteries for bruits.

Exam is made by gently placing the pre-warmed (accomplished by rubbing the stethoscope against the front of your shirt) diaphragm on the abdomen and listen for active bowel sounds 15 or 20 seconds.

What exactly are you listening for and what is its significance? Three things should be noted: 1. Are bowel sounds present? 2. If present, are they frequent or sparse (i.e. quantity)? 3. What is the nature of the sounds (i.e. quality)?

Percussion: The technique for percussion is the same as that used for the lung exam. First, remember to rub your hands together and warm them up before placing them on the patient. Then, place your left hand firmly against the abdominal wall such that only your middle finger is resting on the skin. Strike the distal interphalangeal joint of your left middle finger 2 or 3 times with the tip of your right middle finger, using the previously described floppy wrist action (see under lung exam).

There are two basic sounds which can be elicited: 1. Tympanitic (drum-like) sounds produced by percussing over air filled structures. 2. Dull sounds that occur when a solid structure (e.g. liver) or fluid (e.g. ascites) lies beneath the region being examined. *Special note should be made if percussion produces pain, which may occur if there is underlying inflammation, as in peritonitis. This would certainly be supported by other historical and exam findings.

Palpation:

First warm your hands by rubbing them together before placing them on the patient.
The pads and tips (the most sensitive areas) of the index, middle, and ring fingers are the examining surfaces used to locate the edges of the liver and spleen as well as the deeper structures. You may use either your right hand alone or both hands, with the left resting on top of the right.

Apply slow, steady pressure, avoiding any rapid/sharp movements that are likely to startle the patient or cause discomfort.
Examine each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel.

Start in the right upper quadrant, 10 centimeters below the rib margin in the mid-clavicular line. This should insure that you are below the liver edge. In general, it is easier to detect abnormal if you start in an area that you're sure is normal. Gently push down (posterior) and towards the patient's head with your hand oriented roughly parallel to the rectus muscle, allowing the greatest number of fingers to be involved in the exam as you try to feel the edge of the liver. Advance your hands a few cm cephelad and repeat until ultimately you are at the bottom margin of the ribs. Initial palpation is done lightly.

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