health assessment final: repro/breasts/axillary (king)

Bartholin's glands

secrete fluids that help lubricate the vagina, located on either side of the vagina

developmental considerations: infant to adolescence (female)

-estrogen stimulates growth of cells in reproductive tract; develop secondary sex characteristics

-first sign of puberty are great development and pubic hair

-increase in vaginal secretions coincides with ovulation

-menarche occurs during latter half of this sequence

Cervix

-opening to the uterus

-most likely to find abnormalities where the boundary of squamous and columnar cells grow

developmental changes of reproductive system-pregnancy

-Changes to genitalia soon after missed period

-Uterine enlargement

-Increased cervical and vaginal secretions

-Change in pH balance, Acidic pH protects against bacteria, Increase in glycogen; more prone to yeast infections (Candidiasis)

developmental changes of reproductive system-aging female

-vagina becomes shorter, narrower, and less elastic

-vagina atrophies to one-half its former length and width

-vaginal epithelium atrophies, becoming thinner, drier, and itchy

-decreased vaginal secretions

-risk for irritation and pain with intercourse (dyspareunia), -vaginal pH becomes more alkaline

-changes in female sexual response

-declining estrogen levels produce physiologic changes in the female sexual response cycle

cultural considerations of reproductive system

female circumcision, infibulation, or female genital mutilation

-invasive surgical procedure (removal partial or total of the clitoris)-usually performed on girls before puberty

timing of puberty is influenced by genetic and environmental factors

common concerns of reproductive system (female)

menarche, menstruation, menopause, postmenopausal bleeding, dysmenorrhea, pregnancy, contraception, vulvovaginal symptoms, sexual preferences and sexual responses, STIs

reproductive health history: menarche, menstruation, and menopause

When did you start? When did your last period start? How often do you have periods? How long do they last? What color is the flow? How heavy is the flow? Dysmenorrhea? Premenstrual syndrome? Emotional and behavioral symptoms? Amenorrhea? Abnormal uterine bleeding?

Amenorrhea

-primary onset: before onset of menarche

-secondary: pregnancy, lactation menopause

the three parts to a woman's reproductive system history

menstrual history, obstetric history, and sexual history

reproductive health history: obstetric history

-pregnancy: early symptoms include amenorrhea, tenderness, tingling, increased size of breasts, urinary frequency, nausea and vomiting, fatigue; sensations/feeling like the baby is moving at about 20 weeks

-contraception: What methods are used? Satisfied with method chosen?

reproductive health history: sexual history (female)

-sexual orientation and gender identity: ask neutral questions

-Relationship history: currently dating? sexually active? In a relationship? Has anyone touched you or tried to have sex with you without your consent? Any problems with sex? Satisfied with sex life?

-family planning: using birth control? Which method? using protection against STIs? Which method? Satisfied with current method

reproductive health history: STIs (female)

-review past history of STIs

-inquire about sexual contacts, number of sexual partners in the past 3 to 6 months

-concerns about HIV or any other STIs?

-Precautions taken to reduce risk of STIs?

menses

monthly flow of bloody fluid from the uterus

menarche

age of onset

menopause

absence of menses for 12 consecutive months progressing through several stages of erratic cyclical bleeding, usually occurring between 48 and 55 years

Perimenopause

-period of years marking the transition to menopause

-average 4 years but can last up to 8

-stages vary in cycle length and include vasomotor symptoms: hot flashes, flushing, sweating

-ovaries stop producing estradiol and progesterone and estrogen levels significantly drop

Postmenopausal bleeding

bleeding occurring 6 months or more after cessation of menses

amenorrhea

absence of menses

dysmenorrhea

pain with menses, often with bearing down, aching, or cramping sensation in the lower abdomen or pelvis

premenstrual syndrome (PMS)

a cluster of emotional, behavioral, and physical symptoms occurring 5 days before menses for three consecutive cycles

abnormal uterine bleeding

bleeding between menses; includes infrequent, excessive, prolonged, or postmenopausal bleeding

frequency of menses

measured from first day of one menses to the first day of the next menses. The interval between periods ranges roughly from 24 to 32 days.

duration of menses

number of days the flow lasts, usually 3 to 7 days

tips for a pelvic exam: the patient

-avoid intercourse, douching, or use of vaginal suppositories for 24 to 48 hours before exam

-empty bladder before exam

-lay supine with head and shoulders elevated, arms at side or folded across chest to enhance eye contact and reduce tightening of abdominal muscles

tips for a pelvic exam: the nurse

-obtains permission, acts as chaperone

-explains each step of the exam in advance

-drapes patient from mid-abdomen to knees; folds drape between knees to provide eye contact with patient

-warms speculum with tap water

-monitors comfort of the exam by watching the patient's face

trichomonal vaginitis

-often but not always acquired sexually

-discharge: yellowish green or gray, possibly frothy; often profuse and pooled in the vaginal fornix; may be malodorous

-symptoms: pain with urination, small red spots

candidal vaginitis

-discharge: white and curdy; may be thin but typically thick; not malodorous

-symptoms: vaginal soreness, pain or urination, whiteness and redness on vaginal, bleeding when patches are scraped

bacterial vaginosis

-often transmitted sexually

-discharge: gray or white, thin, malodorous, coats the vaginal walls; usually not profuse, may be minimal

-symptoms: unpleasant fishy or musty genital odor reported to occur after intercourse

epidermoid cyst

noncancerous cysts; block of dead hair follicle; benign; can be anywhere but tend to happen around the labia

uterine prolapse

decreased strength of the pelvic floor causes uterus to fall through the vaginal canal

bartholin gland infection

can become blocked which causes swelling and pain; surgical drainage if severe

syphilitic change

could be a painless ulcer with flulike symptoms, so patient may never know they were infected; can be easily cured with penicillin

venereal wart

related to HPV; painless growths on the labia back to the anal region; changes the flow of urine; symptoms will be relived with topical treatments, but disease will not go away; can clear up about 2 years after symptoms, can sometimes remain in body forever

genital herpes

take antivirals to relieve symptoms, but you have this disease for life

male anatomy and physiology

-left testes lies lower than the right

-epididymis is the coiled tubes and then becomes the vas deferens; where the sperm is stored

-vas deferens merges with the seminal vesicles and then empties into the urethra

reproductive developmental changes: infant to adolescence (male)

-if child wears diapers, meatus may be ulcerated from ammonia irritation; more common in circumcised infants

-normally, testes are descended and are equal in size bilaterally

-if scrotal half fells empty, search for testes among inguinal canal; ask toddler or child to squat with knees flexed up; pressure may force the testes down; or have child sit cross-legged to relax reflex

puberty in males

-first sign is enlargement of testes; next pubic hair appears and penis size increases

gynecomastia

-growth of breast tissue during adolescence; normal and typically resolves on its own

-usually unilateral

-reassurance is necessary for adolescent male, whose attention is riveted on his body image

-may reappear in aging male and may be due to testosterone deficiency

reproductive developmental changes - Aging Males

-testicular tissue mass decreases

-andropause: level of testosterone decreases gradually

-continue to make sperm until 80-count decreases gradually over 40

-age related changes in the vascular system decrease level of sensation and may inhibit erectile function

reproductive common concerns (male)

sexual preferences and sexual response, penile discharge or lesions, scrotal pain, swelling or lesions, problems with urination

reproductive health history: penile discharge or lesions

-discharge, leaking, dripping from penis? Color, thickness, how often?

-sores or growths on penis or scrotum? have you had these symptoms before?

reproductive health history: sexual history (male)

-past history of STIs? oral or anal sex? any concerns about HIV infection?

-any sexual contact with a partner having an STI? When was this contact? did you get the disease? how was it treated? were there any complications?

-do you use condoms to help prevent STIs?

health history: scrotal pain or swelling or inguinal pain or swelling

-may indicate inguinal hernia; unilateral or bilateral? where and when does it hurt? continuous or intermittent? does it occur with lifting, standing, bending, or bearing down?

health history: problems with urination (male)

-benign prostatic hyperplasia (BPH) or cancer

-men older than 70 are at greatest risk

-difficulty starting or stopping urination? weak flow? how often? day or night? any blood in the urine? any discomfort or heaviness?

reproductive physical exam (male)

-penis: all surfaces; excoriation? inflammation?

-inspection: skin, prepuce

-smegma: normal whitish material

-glans: ulcers, scars, nodules, inflammation?

-base of penis: changes in skin or color?

-location of urethra meatus: discharge?

-scrotum and its contents

-inspection: skin and scrotal contours

-lift scrotum to inspect posterior surface

-epidermoid cysts: common, benign

hypospadias

infant is born with the opening of the urethra at the wrong place; easy surgical fix

hydrocele

non-tender fluid mass; can happen at birth from trauma or trauma later in life; usually reabsorbed and goes away on its own, may need surgical repair

scrotal hernia

-usually starts as an inguinal hernia

-inspection: inguinal and femoral areas

-valsalva maneuver: if bulge is present, refer patient to physical for follow-up

-absence of bulge does not guarantee absence of hernia, difficult to assess in obese patient

carcinoma of the penis

related to the HPV infection

scrotal edema

could be caused by hernia, hydrocele, cancer, trauma, or congestive heart failure

chancroid

painful in men, causes necrotizing ulcer, not common around this area, much more common in men

primary syphilis (male)

much more noticeable on a male; painless, but erosion of the skin

other STIs to look out for on a male

genital herpes simple and genital warts

testicular self-exam (TSE)

-encourage self care by teaching every male 13-14 years old through adulthood how to examine his own testicles

-overall incidence of testicular cancer is still rare; most commonly occurs in young men 15 to 35 (more common in Caucasian)

-early detection enhanced if male is familiar with his baseline

-T: timing, once a month

-S: shower, warm water relaxes scrotal sac

-E: examine, check for, and report changes immediately

HPV

-most people who have had sex have been infected at some point

-most people never even know they have it; usually no symptoms and body fights it off

-some virus lingers in a women's cervix and can cause changes that may eventually lead to cervical cancer

HPV vaccine

-CDC recommendation for girls or boys starting at age 11 or 12 with a series of 2 injections with 2nd dose given 6-12 months after initial

-recommended for girls and women before they become sexually active because it is not effective if individual is already infected

anatomy of the breast

-breasts lie anterior to pectoralis major and serratus anterior muscles

-three tissue types: ducts/lobules (glandular), fibrous connective tissue, adipose tissue

-areola surround nipples; contain small elevated sebaceous glands called Montgomery's glands

-nipples vary in coloration

Montgomery's glands

secrete protective lipid material during lactation

Lymphatics

-most of the breast drains toward the axilla

-four quadrants by imaginary horizontal and vertical lines intersecting at nipple: convenient map to describe clinical findings; upper outer quadrant is axillary tail of Spence, cone shaped breast tissue that projects up into axilla close to pectoral group of axillary lymph nodes

-upper quadrant is site of most breast tumors

developmental considerations of the breasts: adolescent

-at puberty, estrogen stimulates breast changes

-one breast may grow faster than other; temporary asymmetry

-five stages of great development are correlated with Tanner staging

-beginning of breast development precedes menarche by about 2 years

-breast development usually begins on an average between 8 and 10 years

Tanner staging stage 1

-breast development: papilla elevation only

-pubic hair: prepubertal (no pubic hair)

Tanner staging stage 2

-breast development: breast bud, elevation of breast and papilla; enlargement of the areola

-pubic hair: sparse, long, slightly pigmented hair on labia majora

tanner staging stage 3

-breast development: further enlargement of breast and areola; no separation of contour

-pubic hair: dark, coarse, curled hair spreading sparsely over mons

tanner staging stage 4

-breast development: areola and papilla form secondary mound above level of breast

-pubic hair: adult type hair, abundant, limited to mons

tanner staging stage 5

-breast development: projection of papilla only, recession of areola to contour of breast

-pubic hair: adult type hair, distribution to the medial thigh

developmental considerations for breasts: pregnancy

-breast changes start during the second month/earliest sign of most women

-colostrum may be expressed after fourth month

-lactation, milk production begins 1 to 3 days postpartum; whitish color is from emulsified fat and calcium caseinate

colostrum

-thick, yellow fluid is precursor for milk; protein and lactose, but practically no fat

-breasts produce colostrum for first few days after delivery

rich with antibodies that protects newborn against infection

developmental considerations of the breasts: aging

-decreased breast size due to lower lobules and atrophy of glandular tissue = inner structure become more prominent

-a breast lump may have been present for years but is suddenly palpable

-around nipple, the lactiferous ducts are more palpable and feel firm and stringy because of fibrosis and calcification

-axillary hair decreases

common concerns of the breasts

breast lump or mass, breast pain or discomfort, change in shape, nipple discharge, edema, rashes, scaling, dimpling, retraction, gynecomastia (male)

health history of breasts: lump or mass

When did you first notice? Where? Constant or intermittent? one or multiple?

health history of breasts: pain or discomfort

Describe the pain. Alleviating or aggravating factors? treatments?

health history of the breasts: changes in shape

when did you notice the change? uni or bilateral? can you associate with any other symptoms or trauma?

health history of the breasts: discharge

-When does it occur? uni or bilateral? color? amount? consistency and odor?

-fever, chills? any other associated symptoms?

physical exam of the breasts

-general appearance; skin and lymphatic drainage areas

-observe axillary and supraclavicular regions; note any bulging, discoloration, or edema

-four views: arms at sides, arms over head, arms pressed against hips, and leaning forward

-note any dry scaling, any fissure or ulceration, and bleeding or other discharge

physical exam of the nipples

-should be symmetric on same plane on both breasts

-usually protrude, although some are flat and some are inverted

-normal nipple inversion may be unilateral or bilateral and usually can be manually corrected

screening for retraction

1: direct women to change position to check breasts for skin retraction signs; first ask her to lift arms slowly over head; both breasts should move up symmetrically

2: ask patient to push her hands onto her hips and then to push her two palms together; these maneuvers contract pectoralis major muscles; slight lifting of both breasts will occur

3: ask women with large pendulous breasts to lean forward while you support her forearms; note symmetric free-forward movement of both breasts

supernumerary nipple

-located along "milk line"

-only small nipple and areola present

-mistaken for common mole

-no pathologic significance

breast palpation

-best when breast tissue flattened- place in supine position

-use pads of first three fingers and make a gentle rotary motion on breast; vary pressure palpating light, medium, and deep in each location

-vertical strip pattern currently recommended to detect a -breast mass

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

fibrocystic breast

-adult breast is soft, often feels granular, nodular, or lumpy

-uneven texture is normal- may be termed physiologic nodularity or fibrocystic breast

-often bilateral- may increase before menses

inspection and palpation of axillae

-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 ROM to increase surface area you can reach

-usually nodes are not palpable; may feel a small, soft, non-tender node in central group

benign breast disease (fibrocystic breast disease)

cancer, cyst, fibroadenoma

abnormal findings: lactation

plugged duct, breast abscess, mastitis

fibroadenoma

-usual age: 15-25, usually puberty and young adulthood, but may be up to age 55

-number: usually single, may be multiple

-shape: round, disc-like or lobular

-consistency: may be soft, usually firm

-well delineated

-very mobile

-usually nontender

-retraction signs: absent

cysts

-usual age: 30-50, regress after menopause except with estrogen therapy

-number: single or multiple

-shape: round

-consistency: soft or firm, usually elastic

-well delineated

-mobile

-often tender

-retraction signs: absent

breast cancer

-usual age: 30-90, most common over age 50

-number: usually single, though may coast with other nodules

-shape: irregular or stellate

consistency: firm or hard

-not clearly delineated from surrounding tissues

mobility: may be fixed to skin or underlying tissues

-usually non-tender

-retraction signs may be present

other abnormal findings of the breast

-skin dimpling

-nipple retraction and deviation

-edema of the skin (peaux d' orange)

-paget disease of the nipple

-retraction signs

-abnormal contours

-deviation in nipple pointing

health promotion: breasts

breast cancer is second major cause of death from cancer in women

-5 year survival rate for localized breast cancer has increased from 78% in 1940s to 98% today

-if cancer has spread regionally, survival rate is 84%

incidence of breast cancer varies in cultural groups:

-woman who inherit mutations of BRCA1 and BRACA2 on one or both sides are at an increased risk for developing breast or ovarian cancer

-different risks are linked to breast cancer related to age and ethnicity variables

-Women's Health Initiate (WHI); increased risk linkage with use of combined hormone replace therapy (HRT) and development of breast cancer

-screening mammography annual screening is recommended starting at age 40

breast self examination (BSE)

-help woman establish regular schedule of self care

-best time to conduct BSE is right after menstrual period when breasts are smallest and least congested

-advise pregnant or menopausal woman not having menstrual periods to select a familiar date to examine her breasts each month

-stress that self-exam will familiarize woman with own breasts and their normal variation; emphasizes absence of lumps (not the presence of them)

teaching and promoting BSE

-describe correct technique and rationale and expecting findings as woman inspects her own breasts

-teach woman to do this in front of a mirror while she is disrobed to waist

-at home, begin palpation in shower, where soap and water assist palpation

-then palpation should be performed while lying supine

-encourage woman to palpate her own breasts while you monitor her technique