GROUP III / Page 1

PHYSICAL ASSESSMENT ON ADULTS WITH CANCER

CEPHALOCAUDAL ORDER OF EXAMINATION AREAS HEENT NECK UPPER EXTREMITIES CHEST AND BACK BREAST AND AXILLAE ABDOMEN GENITALS ANUS AND RECTUM LOWER EXTREMITIES Note: SKIN IS CHECKED THROUGHOUT THE ASSESSMENT

General Concepts:
Approach the client calmly and confidently. Provide privacy. Make sure that all needed instruments are available before starting the physical assessment Several positions are frequently required during the assessment. Consider the clients ability to assume a position. Be systematic and organized when assessing the client. (Inspection, Palpation, Percussion, Auscultation If a client is seriously ill, assess the systems of the body that are more at risk Perform painful procedures at the end of the examination (for neurological assessment, noting the pain tolerance of the patient.)

EQUIPMENTS FOR PHYSICAL EXAMINATION

Sphygmomanometer and stethoscope Thermometer Nasal Speculum Ophthalmoscope Otoscope Vaginal Speculum Tongue depressor/blade

METHODS OF EXAMINING INSPECTION - Visual examination of the patient done in a methodical and deliberate manner. PALPATION - Is the use of hand to touch for the purpose of determining temperature, moisture, size, shape, position, texture, consistency, and movement. PERCUSSION - Striking of the body surface with short, sharp strokes in order to produce palpable vibrations and characteristic sound. It is used to determine the location, size, shape, and density of underlying structures; to detect the presence of air or fluid in a body space; and to elicit tenderness. AUSCULTATION - Listening to sounds produced inside the body Penlight Cotton Applicators Tuning fork Reflex hammer Clean gloves Lubricant

GROUP III / Page 2 PHYSICAL ASSESSMENT ON ADULTS I. Inspection: Skin Edema Lesions Rashes Hypo/hyperpigmentation INTEGUMENTARY SYSTEM

Abnormal: Discoloration Pallor Cyanosis Jaundice Skin lesions Macules Papules Pustules Tumor Vesicle

Palpations: Abnormal: tenderness, masses

DANGER SIGNS SUGGESTIVE TRANSFORMATION OF MOLES Hair Presence of dandruff Infection in the sca;p Presence of lice Change in color Diameter Surface characteristics Consistency Shape Surrounding skin

Nail Shape curvature Angle

GROUP III / Page 3 Abnormal: - nail is upward Blanch Test in Nail S swelling P- pulsation E enlargement of thyroid or lymph N neck muscles D distention Presence of grooves Color: pinkish Whitish Pallor Cyanotic Texture: smooth

II.

LYMPHATIC SYSTEM

Anatomical landmarks: pulse sites and lymph nodes Approach: inspection, palpation, and auscultation Position: Supine and sitting Pulse sites: Temporal Carotid Brachial Radial Posterior tibialis Ulnar Femoral Popliteal Dorsalis pedis

Lymph node sites: Cervical Axillary Epitrochlear Inguinal

GROUP III / Page 4 Inspection Upper extremities: color, edema, erythema, lesions, capillary refill Abdomen: ascites Lower extremities: color, edema, lesions, hair distribution, varicosities Palpation Pulses Pulses: Rate Rhythm Equality Amplitude (0 - 4, with 2 as normal)

III.

RESPIRATORY SYSTEM Inspection: Lung cancer - Changein respiration patterns - Unexplained dysnea - Persistent cough - Sputum striated with blood - Rust-color or purulent sputum - Unexplained weight loss - Unexplained chest, shoulder, back, and arm pain - Unexplained fever or hoarseness of voice Percussion: (abnormal findings) Hyper resonance Pneumothorax Dullness may indicate pneumonia or lung cancer

Crackles: Inspection position the patient in a sitting position observer for any signs of cyanosis, nail clubbing, tremors, muscle wasting and pulmonary edema. Ask the patient to extend their hands forward observer for the signs of tremors Ask the patient to turn to the left and observer the JVP (Jugular Venous Pressure) Instruct the patient to inhale and exhale then observer for the symmetry of the chest. Atelectasis Bronchitis Pneumonia Ronchi

GROUP III / Page 5 Palpation Assess the lymph nodes for any signs of lymphonedopathy a. intraclavicular nodes b. superclavicular nodes c. submental nodes d. submandibular node e. subcocipital node Observe the symmetry of the chest during chest expansion. a. Place your both hands in the rectus abdominis, and then instruct the patient to inhale and exhale. b. Place your hands next in the pectoralis major, and then instruct the patient to inhale and exhale. Percussion Check for abnormal tenderness, cripitus sounds and masses. Auscultation Observe for any abnormal breath sounds, wheezing, stridors and presences of fluid in the lungs. Use the same pattern during percussion in the posterior part of the chest.

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Physical Assessment for Patients with Possible Breast Cancer

Inspection Position the patient and yourself in a place with good lighting. Observer the breasts carefully for any abnormal or unusual findings like a change in the nipples position or its looks, presence of discharges, the symmetry of the breast , and dimples or changes in the skin texture and color. Observe for edema which can indicate lymphatic obstruction suggesting cancer.

peau d orange discharge

progression of inflammation breast cancer

dimple in the breast

nipple

GROUP III / Page 7 Instruct the patient to keep her hands at her sides, raise her arms overhead, place her hands firmly on your hips (to tighten your chest wall muscles), and bend forward. Watch for dimples or changes in the skin. Palpation Instruct the patient to lie down on her back, with a pillow or towel under one shoulder. Put that arm under her head. Examine her breasts one at a time. If starting on the right breast, put a pillow under the right shoulder, and instructs her to raise her right arm, place her right hand behind your head. This depends to the examiner and the patient this could be don done in a sitting or in laying position.

Using the pads of your three middle fingers, move your fingers in in overlapping circular motions about the size of a dime. Move up and down from the outside of the breast (under the armpit) toward the middle of your chest, making sure to cover every area of the breast. Examine up to the collarbone and down to the bottom of the ribcage. Notice what feels normal and what may feel different from the normal.

Use different levels of pressure light, medium, and firm to feel each part of the breast. This will allow you to feel the various layers of tissue in the breast. Start with light pressure, increase to medium pressure, and finish with firm pressure to feel the deepest tissue. When you have covered the entire breast, use your finger and thumb to gently squeeze your nipple, watching for any discharge. Then put your left arm behind your head and check your left breast the same way.

As you feel the breasts, you may notice lumps or bumps. This is usually normal just like so many things about people, breasts are unique. Some girls' breasts are large, some are small; some are symmetrical, others are not. Some healthy breasts feel really bumpy, whereas others are less so. Most teens have healthy breasts no matter what they look or feel like. But if you're worried about the way your breasts look or feel, let your doctor know.

GROUP III / Page 8 Warning Signs If you feel an unusual lump the breast, breast cancer is extremely rare in teens. In fact, among teen girls, the most common type of breast lump is usually related to normal breast growth and development. Other common conditions can cause a breast lump, such as a noncancerous growth known as afibroadenoma, and small, fluid-filled cysts that tend to vary in size with a girl's menstrual cycle and are called fibrocystic breast changes. Fibrocystic breast changes are common. In fact more than half of all women have them. They're related to the normal cycling of hormones associated with menstruation. Fibrocystic breast changes are typically worse just before and at the start of a girl's period. Infections can also cause breast lumps, as can an injury to the breast Watch out for:

pain in the breast that seems unrelated to the period a new lump, bump, or other change in the breast a red, hot, or swollen breast fluid or bloody discharge from the nipple a lump in your armpit or near the collarbone

IV.

G.I ASSESSMENT

Abdominal Inspection Look for the presence of pallor or jaundice. Observe the contour and symmetry of the abdomen, looking for flank or local bulge. Note any scars, striae, dilated veins, rashes. Frequently, the normal aortic pulsation is visible.

Auscultation Listen to the abdomen before percussing or palpating, as these can change the frequency of sounds. Normal sounds, such as clicks and gurgles, are normally heard 5-34 times/minute. Bruits can be sometimes be heard in the epigastrium and upper quadrants due to renal artery stenosis. A bruit during both systole and diastole suggests renal stenosis is the cause of hypertension. Bruits can also be heard over the aorta, the iliac arteries, and the femoral arteries, but can be benign.

GROUP III / Page 9 Percussion Percussion helps assess the amount and distribution of gas and stool, liver and spleen size, as well as ascites, and masses.

Palpation Gentle palpation is useful for helping relax the patient and identify areas of tenderness, muscular resistance, and some superficial masses. If the patient is frightened or ticklish, start with their hand under yours. Observe the patient's face while examining. Deep palpation can be used to find abdominal masses. Rebound tenderness begins with slow, moderately deep pressure and a quick withdrawal. Pain suggests peritoneal inflammation and can be felt at areas other than that of palpation.

The Liver
Due to its location under the rib cage, the liver can be difficult to assess. Percussion Normal liver spans are 6-12 cm in the midclavicular line and 4-8 cm in the midsternal line. While it is the most accurate method, percussion can often underestimate liver size. Palpation Ask the patient to take a deep breath in and try to feel the liver edge as it descends. On inspiration, the liver edge is palpable about 3 cm below the right costal margin midclavicularly. Try to trace the liver edge across its span. Other systemic signs of liver disease include clubbing, spider nevi, gynecomastia, ascites, and others.

The Spleen
An enlarged spleen usually points anteriorly, downward, and medially. Percussion Percussion raises suspicion of splenomegaly but must be confirmed with palpation. Dullness in Traube's space, above the left midaxillary costal margin, suggests an enlarged spleen, and can occur on inspiration. Palpation The spleen can be palpated with two hands.

GROUP III / Page 10

Assessing for Ascites A large belly with bulging flanks suggests ascites, as normally, obesity protrudes forwards. This is a sensitive, but not very specific, sign. Fluid-filled flanks will be dull on percussion.

Shifting dullness Percuss for air resonance, starting at the middle. make a mark where the resonance becomes dull. Then, have the person roll onto their side and repercuss, noting potential changes in fluid markers. not very sensitive, but specific. Fluid wave Have someone push their hand down in the midline. tap one side and feel for a fluid wave across the abdomen. sensitive but not specific.

The Kidneys
Although kidneys are not normally palpable, detecting an enlarged kidney may be very important.

Physical Assessment of GIT

Mouth and Throat: Assess the mouth and throat for sores, condition of teeth and gums, irritations, or any other conditions that could affect the intake of food and liquid. Lift the tongue and look under it for any tumors or lesions. Assess for any unusual breath odor. Abdomen: Inspect for contour, symmetry, abdominal aorta pulsation, and distention. Do not touch the abdomen during the inspection or peristalsis can be stimulated which will provide false data during the auscultation portion of the assessment. Instruct the patient to not touch the abdomen during the inspection phase. Abdominal distention can be caused by three factors: 1. Obesity Abdomen is soft and rounded with a sunken umbilicus. 2. Ascites Skin is shiny and glistening with an everted umbilicus. Veins are dilated and prominent (more visible in thin, malnourished skin). 3. Obstruction There may be visible, marked peristalsis; restlessness; lying with knees flexed; grimacing facial expression; and uneven respirations.

GROUP III / Page 11 Auscultation Bowel Sounds: Bowel sounds are best heard with the diaphragm portion of the stethoscope. Note the character (high-pitched, gurgling, clicking, etc.) and frequency. Normally the sounds occur intermittently at 5-15 times per minute. Judge if the sounds are normal, hypoactive or hyperactive. You must listen for 5 minutes to each quadrant before deciding that bowel sounds are absent (20 minutes is unrealistic to expect someone to stand and listen for bowel sounds so we often rely on the patients other sign s and symptoms). If the patient is experiencing an obstruction due to an ileus (absence of peristalsis), bowel sounds will be absent as there is no enervation by the nervous system to the area. If the patient is experiencing a mechanical obstruction (feces, volvulus, tumor, etc.), the bowel sounds can alter between being hyperactive (as the gut tries to push feces around the obstruction) or absent (as the gut rests and prepares for the next peristaltic wave; the patient will also complain of pain when bowel sounds are heard). Peritonitis presents with absent bowel sounds. Vascular sounds: Vascular sounds are best heard with the bell of the stethoscope. Assess all four quadrants listening for bruits (whooshing, blowing sounds that represent impaired circulation within an artery or an aneurysm). An aortic pulsation may be heard over the left upper quadrant in the presence of hypertension, aortic insufficiency, or aortic aneurysm. Percussion Tympani: Tympani should predominate as air rises to surface of the abdominal cavity. Hyperresonance: Will be heard in the presence of gaseous distention. Dullness: Percussed over a distended bladder, adipose tissue, fluid, or a mass in the abdomen. Palpation: Prior to palpating the abdomen, have the patient bend the knees and relax the abdominal muscles. Ask the patient to point to any painful or tender areas. Save those areas to palpate last so the patient becomes more accustomed to your touch and does not guard throughout the exam. Lightly palpate the abdomen by quadrants. Note any muscle guarding, rigidity, tenderness, or masses. Rectal Area: Examine the external rectal area for the presence of external hemorrhoids, masses or evidence of inflammation.

GROUP III / Page 12 Republic of the Philippines UNIVERSITY OF EASTERN PHILIPPINES University Town, Northern Samar COLLEGE OF NURSING

PHYSICAL ASSESSMENT ON ADULTS WITH CANCER ______________________________

Presented by: (GROUP III)

1.

GALVEZ, Jillian Rose D.

8.

2. GIRAY, Gencris M. 3. GOBRIN, Dareen F. 4. GOYENA, John O. 5. HONEY, Czarina O. 6. HONEY, Walberto G. 7. ICAWAT, Mark L. 9. LARGO, Reziel B. 10. LARIOSA, Beryl F. 11. LOPEZ, Kent Ian F.

INFANTE, April Rose D.

12.

MAGDARAOG, Kent Chester C. 13. MANANQUIL, Lyka M. 14. MARIBOJOC, Eur A.