Comprehensive Nursing Health Assessment: Physical Systems Study Guide
Assessment of Physical Systems: Breasts and Lymphatic System
Structure and Function of Breasts - Paired Mammary Glands: Located over the muscles of the anterior chest wall, anterior to the pectoralis major and serratus anterior muscles. - Anatomical Range: - Vertically: From the to the rib. - Horizontally: From the sternum to the mid-axillary line. - Developmental Differences: Male and female breasts are similar until puberty. Female breast tissue enlarges due to heavy releases of the hormones estrogen and progesterone from the ovaries. - Female Breast Functions: - Accessory reproductive organ function: Produce and store milk to provide nourishment for newborns. - Aid in sexual stimulation. - Male Breasts: No functional capability. - Anatomical Quadrants: For assessment findings, breasts are divided into four quadrants by imaginary horizontal and vertical lines intersecting at the nipple. - Tail of Spence: The upper outer quadrant extending into the axillary area; most breast tumors occur in this specific quadrant. - Lymph Nodes: Present in both male and female breasts to drain lymph, filter microorganisms, and return water and protein to the blood.
External Breast Anatomy - Skin: Smooth; color varies by skin tone. - Nipple: Located in the center; contains tiny openings of lactiferous ducts for milk passage. - Areola: - Surrounds the nipple ( to radius). - Contains Montgomery Glands (elevated sebaceous glands) that secrete a protective lipid substance during lactation. - Hair follicles are commonly present. - Smooth muscle fibers cause the nipple to become erectile during stimulation. - Pigmentation: The nipple and areola are darker than surrounding breast tissue. Color ranges from dark pink to dark brown. Pigmentation increases during pregnancy and decreases after lactation, though it rarely returns to original coloration entirely. - Milk Line (Ridge): Extends from axilla to groin during embryonic development. It usually atrophies, but supernumerary nipples or extra breast tissue may appear along this line.
Internal Breast Anatomy - Tissue Types: Glandular, Fibrous, and Fatty (Adipose). - Glandular Tissue: - The functional part of the breast allowing for milk production. - Arranged in to lobes radiating from the nipple. - Lobules: Contain secreting alveoli (acini cells) embedded in grape-like clusters. - Mammary Ducts: Converge from alveoli into a single lactiferous duct leaving each lobe. - Lactiferous Sinus (Ampullae): A slight enlargement in each duct before the nipple where milk is stored until released. - Fibrous Tissue: Supports glandular tissue via Cooper’s Ligaments (suspensory ligaments). These run from the skin to the deep fascia of the anterior chest wall muscles. - Fatty Tissue: Subcutaneous and retromammary fat. Determines size and shape. Functional capability is independent of size.
Axillary Lymph Nodes - Anterior (Pectoral): Drains anterior chest wall and breasts. - Posterior (Subscapular): Drains posterior chest wall and portions of the arms. - Lateral (Brachial): Drains most of the arms. - Central (Mid-axillary): Receives drainage from anterior, posterior, and lateral nodes.
Breast Self-Examination (BSE) and Assessment - Timing: Best performed when breasts are not tender or swollen (post-menses). Individuals with implants should have the surgeon identify edges. - Technique: - Lie down with the right arm behind the head to spread tissue evenly. - Use three middle finger pads of the opposite hand in small, overlapping (dime-sized) circular motions. - Pressure levels: Light (superficial tissue), medium (deeper), and firm (tissue close to ribs/chest). - Pattern: Up-and-down vertical pattern is most effective. Cover the entire area from the underarm to the sternum, and from the clavicle to the ribs. - Inspection: Stand before a mirror and press hands firmly on hips to contract chest muscles and emphasize changes like dimpling or redness.
Abnormal Findings of the Breast - Peau D’orange: Orange peel appearance resulting from edema; associated with cancer. - Paget’s Disease: Redness and mild scaling of the nipple (early signs); tingling, burning, and discharge (late signs). A lump is felt in approximately half of cases. - Retracted Nipple/Tissue/Dimpling: Suggests malignancy. - Fibroadenomas: Lobular, ovoid, or round; firm, well-defined, mobile, and usually non-tender. Common between puberty and menopause. - Cancerous Tumors: Irregular, firm, hard, undefined masses; may be fixed or mobile. Usually non-tender and occur after age . - Benign Breast Disease (Fibrocystic): Round, elastic, defined, tender, and mobile cysts. Common from age to menopause.
Assessment of the Heart and Neck Vessels
Heart Structure and Location - Size/Weight: Hollow, muscular four-chambered organ. Approximately () in women and () in men. - Mediastinum: The space in the middle of the thoracic cavity between the lungs where the heart is located. - Vertical Extent: Left second to left fifth intercostal space (ICS). - Horizontal Extent: Right edge of sternum to left midclavicular line (MCL). - Anatomical Descriptions: - Base: Upper portion, near left second ICS. - Apex: Lower portion, near left fifth ICS and MCL. - Precordium: Anterior chest area overlying heart and great vessels.
Circulation and Great Vessels - Pulmonary Circulation: Right side of the heart pumps blood to the lungs. - Systemic Circulation: Left side pumps oxygenated blood to the body. - Vena Cava: Superior and inferior return blood to the right atrium. - Pulmonary Artery: Carries blood from the right ventricle to the lungs. - Pulmonary Veins: Return oxygenated blood to the left atrium (two from each lung). - Aorta: Transports oxygenated blood from the left ventricle to the body.
Internal Heart Anatomy: Chambers and Valves - Chambers: Two upper (right and left atria); two lower (right and left ventricles). Separated by the septum. - Ventricular Thickness: The left ventricle is thicker because it handles a greater workload. - Atrioventricular (AV) Valves: Located at ventricle entrances. - Tricuspid: Three cusps; between right atrium and ventricle. - Bicuspid (Mitral): Two cusps; between left atrium and ventricle. - Chordae Tendineae: Collagen fibers anchoring AV flaps to papillary muscles. - Semilunar Valves: Located at ventricle exits. - Pulmonic: Entrance of pulmonary artery. - Aortic: Beginning of ascending aorta.
Heart Walls and Coverings - Pericardium: Fibro-serous sac surrounding the heart. - Parietal Pericardium: Serous lining secreting pericardial fluid for friction-free movement. - Epicardium: Serous membrane on the outer heart surface. - Myocardium: Thickest layer; contractile cardiac muscle cells. - Endocardium: Innermost endothelial tissue lining.
Electrical Conduction System - Sinoatrial (SA) Node: The pacemaker; located in the posterior wall of the right atrium. Generates impulses at to per minute. - Atrioventricular (AV) Node: Located in lower interatrial septum; delays impulses before relaying to the Bundle of His. - AV Bundle (Bundle of His): Located in upper interventricular septum; inherent rate of to per minute if SA node fails. - Purkinje Fibers: Final pathway in ventricular myocardium causing contraction.
The Electrocardiogram (ECG/EKG) - P Wave: Atrial depolarization. - PR Interval: Beginning of atrial depolarization to beginning of ventricular depolarization. - QRS Complex: Ventricular depolarization and atrial repolarization. - ST Segment: Period between ventricular depolarization and repolarization. - T Wave: Ventricular repolarization (resting state). - QT Interval: Total time for ventricular depolarization and repolarization. - U Wave: Final phase of ventricular repolarization (not always present).
The Cardiac Cycle - Diastole: Ventricular relaxation and filling (two-thirds of the cycle). - Protodiastolic filling: Early, rapid, passive filling. - Presystole (Atrial Kick): Atrial contraction completing ventricular filling. - Systole: Ventricular contraction and emptying (one-third of the cycle). - Isometric Contraction: Period when all four valves are closed and ventricles contract.
Heart Sounds - First Heart Sound (S1): Result of AV valve closure (Mitral and Tricuspid); correlates with beginning of systole. Best heard at the apex. - Second Heart Sound (S2): Result of semilunar valve closure (Aortic and Pulmonic); correlates with beginning of diastole. Best heard at the base. - Split S2: Occurs when Aortic (A2) and Pulmonic (P2) closures are distinct, often during inspiration. - S3 (Ventricular Gallop): Vibration from rapid ventricular filling; heard early in diastole. - S4 (Atrial Gallop): Vibration from ventricular resistance during atrial contraction; heard late in diastole. - Murmurs: Turbulent blood flow (swooshing/blowing). Causes: increased velocity, structural defects, or valve malfunction.
Cardiac Output and Stroke Volume - Cardiac Output (CO): . Normal adult CO is to . - Stroke Volume (SV): Amount of blood pumped per contraction (approx. from left ventricle). - Factors Influencing SV: - Preload: Degree of stretch before contraction. - Afterload: Pressure against which the heart must eject blood. - Synergy: Synchronized contraction of myocardium. - Compliance: Ventricular distensibility. - Contractility: Force of contraction.
Neck Vessels - Carotid Artery: Located between trachea and sternocleidomastoid muscle. Pulse coincides with ventricular systole. Normal upstroke is smooth and rapid. - Jugular Veins: Internal (deep/medial) and External (superficial/lateral). - Jugular Venous Pressure (JVP): Reflects right atrial pressure. Components include 'a' wave (atrial contraction), 'x' descent (atrial relaxation), 'v' wave (atrial filling), and 'y' descent (atrial emptying).
Auscultation Areas - Aortic: ICS, right sternal border. - Pulmonic: or ICS, left sternal border. - Erb’s Point: to ICS, left sternal border. - Tricuspid: or ICS, left lower sternal border. - Mitral (Apical): ICS, left midclavicular line.
Assessment of the Peripheral Vascular System
Arteries - Function: Carry oxygenated, nutrient-rich blood from heart to capillaries. High-pressure system. - Arterial Pulse: Surge of blood created by ventricular contraction. - Arm Arteries: Brachial (major supplier), Radial (thumb side), Ulnar (pinky side). Radial and ulnar arteries form superficial and deep palmar arches. - Leg Arteries: - Femoral: Major supplier; becomes Popliteal artery behind the knee. - Dorsalis Pedis: Branch of anterior tibial artery on top of the foot. - Posterior Tibial: Found behind the medial malleolus.
Veins - Function: Carry deoxygenated, waste-laden blood to the heart. Holds nearly of blood volume. - Limb Specifics: Thin walls, larger diameter than arteries to reduce cardiac workload. - Leg Vein Types: - Deep Veins: Femoral and Popliteal ( of venous return). - Superficial Veins: Great Saphenous (longest) and Small Saphenous. - Perforator (Communicator): Connect superficial and deep systems. - Venous Return Mechanisms: - Structure: One-way valves. - Muscular contraction (skeletal muscle pump). - Pressure gradient: Created by breathing (Inspiration decreases intrathoracic pressure). - Venous Stasis: Caused by inactivity, standing/sitting long periods, or varicose veins.
Capillaries and Fluid Exchange - Function: Connection between arterioles and venules. Maintain equilibrium between vascular and interstitial spaces. - Hydrostatic Force: Generated by blood pressure; primary mechanism for fluid to leave capillaries. - Osmotic Pressure: Mechanism for fluid and waste to reenter capillaries.
Lymphatic System - Primary Function: Drain excess fluid and proteins from tissues to prevent edema. Fluid becomes lymph once absorbed. - Immune Function: Lymph nodes trap and destroy microorganisms. - Lipid Absorption: Absorbs fats from the small intestine. - Ducts: - Right Lymphatic Duct: Drains upper right side of body. - Thoracic Duct: Drains the remainder of the body. - Lymph Nodes: Epitrochlear (above elbow; drains lower arm/hand) and Inguinal (Horizontal/Vertical chains; drain legs, groin, lower abdomen).
Objective Data: Doppler Ultrasound - Mechanism: Transmits ultra-high frequency sound waves striking RBCs. - Sounds: Whooshing (artery) vs. non-pulsating rush (vein). - Angle of probe: to degrees.
Lymphedema and Insufficiency - Arterial Insufficiency: Diminished/absent pulses, dry/shiny skin, cool temperature, loss of hair. Ulcers are deep, painful, circular, and usually on tips of toes/heels. - Venous Insufficiency: Aching/cramping, pigmentation in gaiter area, thickened/tough skin. Ulcers are superficial, irregular, with a beefy red base, usually on medial malleolus. - Edema Scale: - : Slight pitting. - : Deeper than . - : Noticeably deep; extremity looks larger. - : Very deep pit; gross edema.
Assessment of the Abdomen
Boundary and Landmarks - Superior: Costal margins. - Inferior: Symphysis pubis and inguinal canals. - Laterally: Flanks. - Quadrants: Right Upper (RUQ), Right Lower (RLQ), Left Upper (LUQ), Left Lower (LLQ). - Common Regions: Epigastric (upper), Umbilical (middle), Hypogastric/Suprapubic (lower).
Abdominal Wall Muscles - Layers: External abdominal oblique (outer), Internal abdominal oblique (middle), Transverse abdominis (inner). - Rectus Abdominis: Vertical muscle of anterior wall. - Linea Alba: White line extending from xiphoid to symphysis pubis.
Internal Viscera - Peritoneum: Parietal (cavity lining) and Visceral (organ covering). - Solid Viscera: Liver (largest, RUQ), Pancreas (behind stomach), Spleen ( wide, LUQ), Kidneys (), Adrenal Glands, Ovaries, Uterus. - Hollow Viscera: Stomach, Gallbladder ( long), Small Intestine ( long, diameter), Colon ( long, diameter), Bladder.
Abdominal Pain Types - Visceral: Organs distended/forcefully contract; dull, aching, poorly localized. - Parietal: Inflammation of parietal peritoneum (e.g., appendicitis); severe, steady, localized. - Referred: Pain at distant sites innervated at the same levels as the affected organ.
Assessment Sequence - Order: Inspection, Auscultation, Percussion, Palpation. (Auscultation is second to avoid altering bowel sounds). - Abdominal Girth: Measure at same time of day at the umbilicus.
Physical Abnormalities - Distention: Causes include Pregnancy, Feces (hard stool), Flatus (gas), Fat (obesity), Fibroids/Masses, Ascitic fluid. - Hernias: - Umbilical: Bowel through umbilical ring. - Diastasis Recti: Bowel through separation between rectus muscles (appears as midline ridge). - Epigastric: Bowel through weakness in linea alba. - Incisional: Near surigical scar. - Organomegaly: - Hepatomegaly: Liver span > 12\,cm at MCL. - Splenomegaly: Area of dullness > 7\,cm. - Aortic Aneurysm: Prominent laterally pulsating mass above umbilicus with a bruit.
Assessment of the Musculoskeletal System
Bones ( total) - Axial Skeleton: Head and trunk. - Appendicular Skeleton: Extremities, shoulders, hips. - Tissue Types: Compact (hard shaft) and Spongy (ends/centers). - Cells: Osteoblasts (form bone) and Osteoclasts (break down). - Periosteum: Covers bones; contains osteoblasts and blood vessels.
Skeletal Muscles ( total) - Attached to bones by tendons. Under voluntary/conscious control. - Movements: - Abduction: Away from midline. - Adduction: Toward midline. - Circumduction: Circular motion. - Flexion: Decreasing angle. - Extension: Increasing angle. - Dorsiflexion: Toes upward. - Plantar flexion: Toes away from ankle. - Pronation: Facing downward. - Supination: Facing upward.
Joint Types and Major Joints - Fibrous: Immovable (e.g., skull sutures). - Cartilaginous: Joined by cartilage (e.g., vertebrae). - Synovial: Space filled with synovial fluid. Bones joined by ligaments. - Spine: bones ( Cervical, Thoracic, Lumbar, Sacral, Coccygeal).
Muscle Strength Rating Scale - (Normal): Active motion against full resistance. - (Slight weakness): Active motion against some resistance. - (Average weakness): Active motion against gravity. - (Poor ROM): Passive ROM. - (Severe weakness): Slight flicker of contraction. - (Paralysis): No contraction.
Abnormalities - Spine: Kyphosis (rounded thoracic), Lordosis (exaggerated lumbar), Scoliosis (lateral curve), Flattening (herniated disc). - Hands: - RA: Boutonni re (PIP flexion, DIP hyperextension) and Swan-Neck (PIP hyperextension, DIP flexion). - OA: Heberden's nodes (DIP) and Bouchard's nodes (PIP). - Feet: Hallux Valgus (great toe overlaps second), Hammer toe (PIP flexion on second toe).
Assessment of the Neurologic System
Central Nervous System (CNS) - Meninges: Three protective layers. - Cerebrospinal Fluid (CSF): Formed in ventricles; cushions and nourishes CNS. - Brain Divisions: - Cerebrum: Right/Left hemispheres joined by corpus callosum. Lobes: Frontal (voluntary movement, speech), Parietal (sensory), Temporal (hearing), Occipital (vision). - Diencephalon: Thalamus (relay station) and Hypothalamus (body function regulation: temperature, vitals, etc.). - Brain Stem: Midbrain (reflexes), Pons (reflex actions), Medulla Oblongata (vitals: breathing, heart rate). - Cerebellum: Coordination, smoothing movements, equilibrium. - Spinal Cord: Extends to . Conducts sensory (ascending) and motor (descending) impulses.
Peripheral Nervous System (PNS) - Nerves: pairs Cranial; pairs Spinal (named by vertebrae exit points). - Divisions: - Somatic: Voluntary skeletal muscles. - Autonomic: Involuntary smooth muscles. - Sympathetic: Fight-or-flight; increased heart rate, bronchiole dilation. - Parasympathetic: Maintains homeostasis; restores normal function (e.g., decreasing heart rate).
Deep Tendon Reflexes (DTRs) - Rating Scale: - : Hyperactive (clonus); indicative of disorder. - : More brisk than normal. - : Normal. - : Decreased. - : No response.
Abnormal Findings - Muscle Movements: Athetosis (slow writhing), Chorea (jerky/irregular), Tics (repetitive wink/grimace). - Gaits: Cerebellar Ataxia (wide-based/staggering), Parkinsonian (shuffling/stooped), Scissors (thighs overlap), Footdrop (lift foot high/slap down).
Assessment of Mouth, Throat, Nose, and Sinuses
Structure and Function - Salivary Glands: - Wharton’s Ducts: Opening for submandibular glands; either side of frenulum. - Stensen’s Ducts: Opening for parotid glands; inside cheek across from upper second molar. - Nose: Kiesselbach’s area (rich blood supply in anterior septum; common site for epistaxis). Turbinates (conchae) increase surface area for filtered air. - Sinuses: Frontal and Maxillary (accessible for examination); Ethmoidal and Sphenoidal (deep/not accessible).
Key Findings and Abnormalities - Lips: Circumoral pallor (anemia), Cyanotic (hypoxia), Reddish (ketoacidosis/COPD). - Buccal Mucosa: Leukoplakia (precancerous raised patch), Thrush (white curdlike patches). - Tongue: - Atrophy/Fasciculations: CN XII (Hypoglossal) damage. - Black hairy tongue: Antibiotic use or bismuth toxicity. - Smooth reddish tongue: Vitamin or Niacin deficiency. - Throat/Tonsils Grading: - : Visible. - : Midway between pillars and uvula. - : Touching uvula. - : Touching each other. - Breath Odor: - Acetone: Diabetic ketoacidosis. - Ammonia: Chronic Kidney Disease (CKD). - Fecal: Bowel obstruction. - Sulfur (Fetor hepaticus): End-stage liver disease (ESLD).