Male GU Exam Tips and Breast Exam Techniques, Exams of Nursing

Download Male GU Exam Tips and Breast Exam Techniques and more Exams Nursing in PDF only on Docsity! 1 Maryville University Nurs612 Exam 4 Tips Zimmerman Question With Detailed Explanation - Male GU- Understand normal and abnormal assessment of penis, scrotum, and rectum. - Describe how you would examine/inspect and palpate the genital area, penis, urethral meatus and scrotum of the male GU system? What do the abnormal findings indicate as possible differential diagnoses? - To examine the penis, perform the following. •Inspect the genital hair, which is coarser than scalp hair. Typically, genital hair is abundant in the pubic region, scant over the scrotum, and absent on the penis. •Observe the penis, checking the dorsal and ventral surfaces. Vary your technique for an uncircumcised or circumcised patient. For an uncircumcised patient, retract the foreskin. It should move easily, and the glans of the penis may have a bit of white, cheesy smegma. Scant amounts of smegma are normal but patient may need education on importance of retracting foreskin and cleaning. For a circumcised patient, simply observe the glans, which should appear erythematous and dry with no smegma. • Examine the urethral meatus in two ways. First, observe the orifice, which should look like a slit on the ventral surface just millimeters from the tip of the glans. Second, press the glans between your thumb and index finger to open the urethral orifice. The opening should be glistening and pink •Palpate the penis using two techniques. First, palpate the penile shaft to detect any tenderness or induration. The flaccid penis should be nontender, soft, and free of nodules. Second, strip the urethra by applying pressure with your thumb and index finger from the base of the penis to the glans. If this action produces urethral discharge, suspect a sexually transmitted disease. • After performing these maneuvers, be sure to reposition the foreskin if it had been retracted. To examine 2 the scrotum, perform the following. •Inspect the scrotum, noting four characteristics. First, observe its color, which may be more deeply pigmented than the skin on the rest of the body. Second, check its texture. The scrotal surface is likely to be coarse. Third, assess for symmetry. Typically, the scrotum appears asymmetrical because the left testicle has a longer spermatic cord and hangs lower. Fourth, note the thickness of the scrotum, which may vary with temperature, age, and emotional state. Note any unusual thickening. •Using your thumb and first two fingers, palpate the testes, epididymis, and vas deferens. The testes should be sensitive to gentle compression, but not tender. They should feel smooth, rubbery, and free of nodules. There should be no irregularities in texture or size, which suggest an infection, cyst, or tumor. The epididymis, found on the posterolateral surface of each testicle, should be smooth, discrete, and nontender. The vas deferens should feel smooth and discrete with no beads or lumps as you palpate from the testicle to the inguinal ring. •During the scrotal exam, take the opportunity to teach the patient how to perform genital self- examination. •Phimosis: tight foreskin, cannot be retracted •Balanitis: inflammation of glans •Balanoposthitis: inflammation of glans penis and prepuce •Presence of discharge may indicate STI •Priapism: prolonged penile rection: rare but seen in pts with leukemia - What are objective and subjective findings common for GU problems such as inguinal hernia, epididymitis, hydrocele, testicular torsion, STDs and penial infections. Inguinal Hernia - 5 Subjective findings: Soft, painless, wartlike lesions on penis, sexually active Objective findings: single or multiple papular lesions; may be pearly, filiform, fungating (ulcerating and necrotic), cauliflower-like, or plaque-like. genital herpes Subjective findings: painful lesions on penis, sexually active, may report burning and/or pain on urination Objective findings: superficial vesicles- located on glans, penile shaft, or base of penis; often associated with inguinal lymphadenopathy What are the objective and subjective findings of UTI versus pyelonephritis? Pyelonephritis – bacterial infection of the renal pelvis and parenchyma, typically caused by E. Coli ascending from the lower urinary tract. Risk factors include vesicoureteral reflux, neurogenic bladder, stone disease, immunosuppression, diabetes mellitus, or new sexual partner (for women) Subjective Findings: bilateral or unilateral flank pain, fever, chills, nausea, vomiting. LUTS (lower urinary tract symptoms ex: hesitancy, poor and or intermittent stream, straining, prolonged micturition, feeling of incomplete bladder emptying, dribbling, etc) such as dysuria could be present. Objective findings: Pt will appear ill on presentation, usually with fever and tachycardia commonly noted. Severe tenderness and pain noted over affected costovertebral angle. Palpation and percussion over the infected side is painful, may be accompanying abdominal discomfort or abdominal distention. Urinary Tract Infection – most common infection seen in PC setting, esp in women. Subjective findings: negative history of fever, chills, may report a color change or smell change with urine, complaints 6 of LUTS pain with urination Objective findings: patient appears well, no tenderness over costovertebral angle - Risk factors for penile and testicular cancer. Risk for penile cancer - Not being circumcised, history of STDs (particularly condyloma acuminatum or history of balanitis xerotica obliterans BXO) - Breasts- understand a normal and abnormal breast exam. - Risk factors for breast cancer. Risk factors for breast cancer -early menarche less than 11, or later after 14 -menopause older than 55 -mullip of 1st child after 30 -advancing age -family history -lifestyle high fat diet, alcohol use, tobacco use, sedentary lifestyle -hormonal replacement therapy for over 4 years -long term use of oral contraceptives (possibly) Anatomy of breast – nodes that need to be inspected, lymph nodes, tail of spence=Most highly zone of lymph nodes Chief complaint of breast- pain, lump, or nipple discharge HPI- lumps or swelling in breasts or axillae, when discovered, ever happened before, redness, warmth, tenderness, change of firmness of breast, pain, discharge of nipples? Ask PMH, when did they start period, menopause, when did they start menopause, history or prior breast disease, surgery, biopsy, implants, trauma? Family history of breast disease? 7 Have they given birth, what age for first child, oral contraception in past, hormone replacement in past, ask lifestyle and health practices, have they had mammogram if so why before age of 55, do they do breast self exam How to give breast self exam : Lying down with arm above head, use fingertips close together, gently probe breast and axillae in all three patterns (vertical strips, concentric circles, wedge sections) Quadrants of breast (Upper inner, upper outer, lower inner, lower outer) pay attention to tail of spence Inspection- size and symmetry of breast, color and texture, nipples and areolas, retraction and dimpling, palpation- texture, tenderness, any masses 10 contour and no dimpling, retraction, or deviation in any position. For the first position, have the patient extend the arms overhead or flex them behind the neck. For the second position, ask the patient to press the hands on their hips and roll the shoulders forward. Or as an alternative, tell the patient to press their palms together. For the third position, instruct the patient to lean forward while seated. Abnormal: •Unilateral venous patterns can be produced by dilated superficial veins as a results of increased blood flow to a malignancy •Montgomery tubercles is expected finding (pg. 357) Describe how you palpate the breasts including the lymph nodes? What are the normal and abnormal findings indicate as possible differential diagnoses? With the patient seated, perform a chest wall sweep, bimanual digital palpation, and lymph node palpation. Remember that palpation of a man's breasts can be brief but should not be omitted. For the chest wall sweep, place your right palm at the patient's right clavicle at the sternum. Sweep down to the nipple, feeling for superficial lumps and covering the entire right chest wall. Repeat this procedure on the left side, using your left hand. For bimanual digital palpation, place the palm of one hand under the patient's right breast. Walk the fingers of your other hand across the breast tissue, feeling for lumps while compressing the tissue against your palm. Repeat this procedure on the other breast. For lymph node palpation, support the patient's flexed left arm with your left hand and examine the left axilla with your right hand. Move your fingers down from the apex to the bra line and then palpate the medial and lateral aspects, anterior and posterior walls of the axilla, and down the inside of the upper arm to the elbow. Palpate the supraclavicular and infraclavicular areas. Nodes should not be palpable in an adult. •With the patient supine, continue palpation of the breast 11 tissue, following six steps. First, have the patient raise one arm behind their head and place a small pillow or folded towel under that shoulder. For ideal positioning, have the patient's nipple pointing toward the ceiling. Second, systematically palpate all quadrants and the tail of Spence, rotating your finger pads and using light, medium, and deep pressure. For breast palpation, you may use the vertical strip technique (palpating up and down as you move across the breast), the concentric circle technique (palpating at the outer edge and spiraling in toward the nipple), or the wedge technique (palpating from the center of the breast out as if along the spokes of a wheel). Third, gently depress the nipple into the well behind the areola. The tissue should easily move inward. Fourth, if the patient reports spontaneous nipple discharge, compress the nipple. If discharge occurs, obtain a specimen using a glass slide and cytologic fixative. Fifth, consider your findings. A woman's breast tissue should feel dense, firm, and elastic with no masses, lumps, or nodules. Do not be fooled by the inframammary ridge: This ridge of firm compressed tissue at the lower edge of the breast is not a breast mass. In a man, expect to feel a thin layer of fatty tissue overlying the muscle. Sixth, characterize any breast mass and palpate its dimensions, consistency, and mobility. Use ultrasonography to evaluate if there is fluid in the mass. - How do you prepare a patient for a breast of pelvic exam? - Breast exam position: - Start with patient sitting, arms loosely at their sides, inspect each breast in this position for size, symmetry, contour, color, texture, venous patterns or any lesions. This is the same for men and women, if a woman next lift breast with fingertips to inspect lower and lateral aspect of breast. Next exam the patient with; 1)Arms extended over head or flexed behind the neck. 2)Hands pressed on hips with shoulder forward 3)Seated and leaning over (Watch here for retraction, dimpling or deviation here, poss. malignancy) 4) In recumbent position (lying on their side) (Pgs. 355-358) 12 - Pap exam position: - Lithotomy. Utilize stirrups, slide buttocks to end of table. If patient unable to tolerate lithotomy can use the; 1)Knee Chest position with patient on her side and her knees bent to chest. 2)Diamond shaped position with patient on back, knees bend and heels touching 3)Obstetric Stirrup patient is on back with special stirrups to better support lower legs 4)M-shaped with patient on back, knees bent and apart with feet resting flat on table 5)V-shaped with patient on back, legs straight and separated, legs may need to be held by assistants (Pg What are normal and abnormal findings of female genitalia? Female Genitalia: What questions do you ask a patient with a chief complaint of a a female GU problem? Abnormal bleeding: character, change in flow, number of pads, onset, duration, pain, cramping, abd distention, pelvic fullness •Pain: date, time of onset, sudden or gradual, character, location, assoc symptoms: vaginal discharge or bleeding, GI symptoms, abd distention, pain assoc with menstrual cycle, aggravating factors, relieving factors •Vaginal Discharge: character-amount, odor, consistency •Premenstrual symptoms: headache, wht gain, edema, breast tenderness •Menopausal symptoms: menstrual changes, mood changes, tension, hot flashes, sleep disturbances • Infertility • Urinary symptoms - Female genitalia- understand the steps to do a pelvic and PAP. Describe how you examine the external female genitalia? What are the normal and abnormal findings indicate as possible differential diagnoses? 15 clear. Sixth, note the size and shape of the os. In a nulliparous woman, it should be small and round or oval. In a multiparous woman, it may be a horizontal slit or an irregular or star-shaped opening. Abnormal: •Pale cervix is associated with anemia •Deviation of cervix to rt or lt may indicate pelvic mass •Projection of cervix greater than 3cm into vagina may indicate pelvic mass •Nabothian cysts: small, white or yellow, raised areas on cervix, expected finding, if swollen with fluid infection may be present •Bacterial or fungal infection will have an odor, normal discharge is odorless Describe how you perform a Pap smear, and obtain a vaginal/cervical culture for specimen. For a Papanicolaou (Pap) smear, use a spatula or cervical brush or broom to obtain cervical cells, according to facility policy. To prepare the specimen, follow the manufacturer's instructions. For a gonococcal culture specimen, hold a cotton swab in the cervical os for 10 to 30 seconds. Then spread the specimen in a Z pattern over the culture medium. For a DNA probe for chlamydia and gonorrhea, rotate a Dacron swab in the endocervical canal for 30 seconds. Then place the swab in the reagent tube. For a wet mount, obtain a vaginal discharge specimen with a swab. Smear the specimen on a glass slide and add a drop of normal saline. With a microscope, check for trichomonads and clue cells. How do you assess for bacterial vaginosis using a potassium hydroxide test? For a potassium hydroxide test, obtain a vaginal discharge specimen with a swab. Place the specimen on a glass slide and add a drop of 10% potassium hydroxide. A fishy odor suggests bacterial vaginosis. With a microscope, check for budding 16 yeast cells and other signs of candidiasis. • As you slowly remove the unlocked speculum, inspect the vaginal walls for four characteristics. First, note their color, which should be as pink as the cervix or a little lighter. Second, observe the surface, which should be moist, smooth or rugated, and homogeneous. Third, check for secretions. Expected secretions are thin, clear or cloudy, and odorless. Fourth, observe for hernial protrusions. A cystocele is bladder protrusion through the anterior vaginal wall. A rectocele is rectal protrusion through the posterior vaginal wall. Describe how you perform a bimanual exam. What are the normal and abnormal findings indicate as possible differential diagnoses? After changing your gloves and lubricating the index and middle fingers of one hand, insert those fingers fully into the vagina. During insertion, palpate the vaginal walls, which should be smooth, homogeneous, and nontender. •Remember to avoid touching the clitoris with your thumb: It can cause discomfort. •Palpate the cervix, noting its size, length, shape, consistency, and position. Then gently move the cervix from side to side between your fingers. It should move painlessly 1 to 2 cm in each direction. •With your other hand on the abdominal midline, bimanually palpate the uterus for three characteristics. First, check its location and position. The uterus should be midline regardless of its position (e.g., anteverted or retroflexed). Second, palpate its size, shape, and contour. The uterus should be 5.5 to 8 cm long, pear-shaped, rounded, and firm. Third, assess for mobility, which should cause no tenderness. The uterus should move in the anteroposterior plane. • In the right and left lower quadrants, palpate the ovaries and adnexa. If palpable, the ovaries should feel firm, smooth, ovoid, and about 3 cm by 2 cm by 1 cm in size. A healthy ovary is slightly tender on palpation. Except for round ligaments, the adnexa usually are not palpable. Note any adnexal masses. To do a rectovaginal examination, perform the 17 Abnormal: •Cysts, masses, nodules, growths •Cervical cancer: usually asymptomatic, may report unexpected vaginal bleeding or spotting •Endometriosis: presence of growth of endometrial tissue outside of uterus, pelvic pain, dysmenorrhea, heavy or prolonged menstrual flow •Uterine Prolapse: descent or herniation of uterus into or beyond vagina - Mental health- understand how you perform screenings for mental status changes. - How do you assess for depression? Ask patient how he or she feels. Whether feelings are a problem in everyday life and whether they have had some recent difficult times or experiences. Then ask 1)Over the past two weeks have you felt down, depressed, or hopeless? 2) Over the past two weeks have you felt little interest or pleasure in doing things? - What are the screening guidelines questions for the patient health questionnaire? The Patient Health Questionnaire 2-item (PHQ-2) is a brief screening tool for major depression (see two questions above) - What do these results tell you for a differential diagnosis? - A PHQ-2 score ranges from 0-6. The authors identified a score of 3 as the optimal cutpoint when using the PHQ-2 to screen for depression. - If the score is 3 or greater, major depressive disorder is likely. - Patients who screen positive should be further evaluated with the PHQ-9, other diagnostic instruments, or direct interview to determine whether they meet criteria for a depressive disorder. https://www.hiv.uw.edu/page/mental-health-screening/ phq-9 - How do you screen for suicidal ideations? PH-9 question 9 screens