Any pain in the joints?
	Any stiffness in the joints?
	Any swelling, heat, redness in joints?
	Any limitation of movement?
	Any muscle pain or cramping?
	Any deformity of bone or joint?
	Any accidents or trauma to bones?
	Ever had back pain?
	Any problems with the activities of daily living; bathing, toileting, dressing, grooming, eating, mobility, communicating. 
	
	For each joint space state you will look for and inspect
	Inspect size and contour
•	Color, swelling
•	Mass or deformity
	Palpate for temperature
•	Pain
•	Swelling or mass
	
	Cervical spine
•	A ROM
o	Flexion/extension
o	Lateral bending right/left
o	Right rotation/left
	Shoulders
•	A ROM
o	Flexion/extension
o	Abduction/adduction
o	Internal rotation/external rotation
	Elbows
•	A ROM
o	Flexion/extension
o	Pronation/supination
	Wrist and hands
•	A ROM
o	Wrist extension/flexion
o	Finger extension/flexion
o	Ulnar deviation/radial deviation
o	Fingers spread/make fist
o	Touch thumb to each finger
	Hips
•	A ROM
o	Extension/flexion
o	External rotation/internal rotation
o	Abduction/adduction
	Knees
•	A ROM
o	Flexion/extension
o	Walk/ shallow knee bend
	Ankles and feet
•	A ROM
o	Dorsiflexion/plantar flexion
o	Inversion/eversion
	Spine
•	Inspect for straight spinous process
o	Equal horizontal positions for: shoulders scapulae, iliac crests, gluteal folds
o	Equal spaces between arms and lateral thorax
o	Knees and feet align with trunk, point forward
o	From side note curvature; cervical, thoracic, lumbar
o	“spine is in alignment both standing and sitting”
•	Palpate spinous process
o	Feel for any bumps, nodules, or deformities. 
o	Ask if there is any tenderness during touch. 
o	Feel for crepitus when spine bends
o	“the Spinous processes are in a straight line. Patients denies tenderness. The paravertebral muscles are firm. There is no crepitus.”
•	A ROM
o	Flexion/extension
o	Lateral bending right/left
o	Rotation right/left
	Functional assessment 
•	Walk (with shoes on).
•	Climb up stairs.
•	Walk down stairs.
•	Pick up object from floor.
•	Rise up from sitting chair.
•	Rise up from lying in bed. 

	Any leg cramps? Where?
	Any skin change in arms or legs?
	Any sores or lesions in arms or legs?
	Any swelling in legs?
	Any swollen glands? Where?
	What medications are you taking?
	
	Inspection
•	Arms
•	Inspect
o	Color of skin and nailbeds- “nailbeds are pink. Nail–base angle is 180 degrees without clubbing.”
•	Abnormal –capilary refill may be decreased with arterial disease. 
o	Symmetry- note size and symmetry of arms and hands as well as muscle atrophy or hypertrophy. “Arms and hands are symmetrical with full joint movements.” 
•	Abnormal- PAD may resut in muscle atrophy. Hypertrophy may result from activity in which the patient uses one arm more than the other, such as tennis. 
o	Lesions-evaluate for any ecchymoses or lesions of the upper extremities. “Ecchymoses and lesions are absent.”
•	Abnormal-be alert for signs of abuse or falls. Delayed wound healings occurs with arterial disease. 
o	Edema-look at arms and hands. Evaluate for pitting by pressing the tissue with your fingers. “ NO indention remains with you remove your fingers.”
•	Lymphedema results in unilateral edema. BOX 20-3 
•	+1-slight pitting 2mm depression
•	+2- increased pitting 4mm depression
•	+3-deeper pitting. 6mm depression
•	+4- severe pitting. 8mm
•	Palpate
o	Temperature-palpate arms and hands for temperature. “Arms and hands are warm and equal in temperature” 
•	Abnormal- coolness of extremity may indicte arterial occlusion.
o	Texture- assess texture and turger by pinching the skin to evaluate elasticity and hydration. With aging, elasticity decreases. “Skin texture is firm, even, and elastic. Tuger is intact, as shown by rapid return of skin after pinching.” 
•	Abnormal-rough or dry texture and poor turger may be noted with dehydration. 
o	Capillary refill- depression and blanching the nail bed, then releasing and noting the time it takes for color to return. “Capillary refill is <3 seconds.”
•	Capillary refill taking 3 secs or longer may indicate vasoconstriction, decreased cardiac output, impaired circulation, significant edema, or anemia. 
o	Locate and grade Pulses-Palpate the brachial and radial pulses. Grade the pulses. 
•	+1; weak, thready
•	+2; weak
•	+3; Normal
•	+4 ; Bounding
•	Document a normal pulse as +3/4
o	The radial pulse site is used when assessing the pulse for vital signs. 
o	Brachial pulses located at inner third of antecubital fossa when palm is held up. 
o	“A normal pulse is graded +3/4 on the scale shown. The denominator indicates the scale being used and should be indicated when documenting pulses, because two scale variations exist.”
o	Allen test- assess the patency of the collateral circulation of the hands. 
•	Ask patient to make a fist. Occlude the radial and ulnar arteries of one hand. 
•	Have the person open the hand 
•	Release pressure on the ulnar artery. 
o	“Color returns within 2-5 seconds, indicating adequate circulation.”
•	Abnormal-done prior to radial cannulation, such as for the drawing of arterial blood gasses (ABGs) or insertion of the arterial line. 
•	Lack of color return indicates inadequate collateral circulation. Do no draw ABGs or insert an arterial line in this hand- doing so will impede blood flow and ischemia may result. 
o	Epitrochlear Nodes- flex arm and palpate the groove between the biceps and triceps muscles just proximal from the medial epicondyle. “Normally the epitrochlear nodes are not palpable. If palpated note size, consistency, mobility, and tenderness. Normal palpable nodes are 2cm or less.” 
•	Abnormal-enlarged nodes may be noted with regional inflammation, generalized lymphadenopathy, and some types of cancers such as lymphomas. 
•	The legs
•	Inspect
o	Color- evaluate for venous pattern. “Color is symmetrical and consistant without predominant venous pattern”
•	Abnormal- color change to white in toes may indicate on of the raynauds syndromes. Venous insufficiency may result in dilated and tortuous veins.
o	Hair distribution-
o	Size- measure calf size at the widest part. 
o	Swelling/edema-evaluate for pitting by pressing the tissue with your fingers. 
•	Press firmly with thumb for at least 5 secs over dorsum of each foot, over each medial malleolus, and over shins. 
•	No indentation should remain when you remove your thumbs
o	“No edema is found.”
•	Abnormal-Chronic venous insufficiency, DVT, and lymphedema result in edema. Asymmetry between the legs should be further investigated. Calf and leg swelling and unilateral pitting edema are associated with DVT in 88% of patients. 
o	Skin lesions or ulcers-evaluate for any ecchymosis or lesions of the lower extremities. “Ecchymosis and lesions are absent.”
•	Abnormal-Differentiate ulcers as arterial or venous in cause. Table 20-6. Assess for gangrene. 
•	Palpate
o	Temperature- dorsal aspect of hands and assess the extremities simultaneously. “Legs and feet are warm and equal in temperature.”
•	Abnormal-One extremity cooler than the other indicates arterial occlusion. Warm and tender- indicates DVT. 
o	Check Homan’s Sign-is not recommended to test for DVT, because it is not sensitive or specific. 
•	Palpating the calf may dislodge an exisiting DVT. 
•	With Patient supine, slightly support the knee and have the patient sharply dorsiflex the foot. 
o	“Pain or tenderness is positive Homan’s sign.”
•	Abnormal-false positive results are commonly related to muscle tenderness. Additionally, the homan’s sign is only present in 15% of patients with DVT. 
o	Tenderness-
o	Inguinal Lymph nodes-Nodes in the groin. Palpate the upper and medial thigh for the superficial inguinal lymph nodes. “They may be palpable and up to 1-2 cm, moveable, and nontender.”
o	Locate and grade pulses-Femoral, popliteal, dorsalis pedis, and posterior tibial pulses. 
•	Femoral-halfway between symphysis pubis and anterior iliac spine, just below the inguinal ligament. 
•	Popliteal-with fingers braced on knee, curl your hands around the back and press against the lower edge of the femur. 
•	Lateral or medial tendon
•	Posterior tibial-located in the groove between the medial maleolus and Achilles tendon. 
•	Dorsalis pedis-halfway up the foot, lateral to extensor tendon of the great toe. 
o	Grade the pulses based on scale
o	“A normal +3/4 on the scale shown. The deominator indicates the scale being used and should be indicated when documenting pulses. Evaluate any pulse that cannot be palpated with the Doppler stethoscope for an aterial signal.”
Check Pretibial edema-grade if present. 
o	
	Any change in appetite? Loss?
	Any difficulty swallowing?
	Any foods you cannot tolerate?
	Any abdominal pain?
	Any nausea or vomiting?
	How often are bowel movements?
	Any past history of GI disease?
	What medications are you taking?
	Tell medications are you taking?
	Tell me all food you ate in the last 24 hours, start with
	Breakfast, snack, lunch, snack, dinner, snack
	
	Inspection
•	Contour of abdomen- Pretuberent- pregnancy.
o	Flat- even
o	Scafoid- ribs are higher than the belly
o	Ask patient if the abdomen looks or feels different than normal. 
•	Abnormal countours include bulging flanks, suprapubic bulge of full bladder, enlarged spleen, or a tumor.
•	General symmetry- “not asymmetrical”
•	Skin Color and condition-“Pink in color, and intact”
o	Abnormal- scars, striae, and veins.
•	Pulsations or movements- inspect for any visible aortic pulsations, peristalsis, and respiratory pattern.
o	Abnormal- a peristaltic wave may indicate GI obstruction. It may be a normal finding in thin patients. 
•	Pulsations of the aorta may be increased and lateralized in an abdominal aortic aneurysm. 
•	Umbilicus- Note whether inverted or everted and its position, midline. 
•	“Umbilicus is inverted and midline.”
•	Hair distribution- “regular pattern”
•	State Hydration and nutrition-
•	Person’s facial expression and position in bed- 
	Auscultation
•	Bowel sounds- auscultate all 4 quadrants for bowel sounds. 
o	Start at point of the ileocecal valve, slightly right and below the umbilicus, and proceed CLOCKWISE. 
o	Bowel sounds are high-pitched gurgles or clicks that last from 1 to several secs. 
o	“There are 5-30 clicks per minute or one sound every 5-15 seconds in the average adult. Soun indicate bowel motility and peristalsis. If no sounds are audible, listen for up to 5 min/quadrant.”
•	Abnormal-hyperactive at a point above a partial bowel obstruction and decreased or nonexistent below the point of obstruction. 
•	Increased bowel sounds occur with diarrhea and early intestinal obstruction. 
•	Decreased bowel sounds occur with diarrhea and early intestinal obstruction. 
•	Adynamic ileus and peritonitis. 
•	High pitched, tinkling bowel sounds indicate intestinal fluid, air under the tension in a dilated bowel, and inadequate bowel sonds. 
•	High pitched, rushing sounds indicated partial intestinal obstruction. 
•	Vascular sounds- auscultate all four quadrants for vascular sounds. 
o	USE THE BELL OF THE STETCHOSCOPE- 
•	Listen for bruits, venous hums, and friction rubs. “Buits, venous hums and friction rubs are not detected.” 
•	Bruits-aorta
•	Left renal artery
•	Right renal arter
•	Right iliac artery
•	Left iliac artery
•	Right femoral artery
•	Left femoral artery
•	Bruits-swishing sounds, indicate turbulent blood flow from constriction or dilation of a tortuous vessel. 
•	Bruits in hepatic area indicate liver cancer or alcoholic hepatitis. 
•	Bruits over aorta or renal arteries indcate partial obstruction of the aorta or renal artery. 
•	Epigastric-near liver and over umbilicus, venous hums are best heard. 
•	Venous hums- soft pitched humming noise with a systolic and diastolic component. 
•	Indicate obstruction of an artery and reduced blood flow to the organ. 
•	Friction rubs- auscultate over liver and spleen. 
•	Friction rubs are greater sounds that increase with inspiration. 
•	Indicate liver tumor, splenic infarction, or peritoneal inflammation. 
Percussion-
•	Percuss in all four quadrants- listen carefully for tympany or dullness. 
o	Ask for any abdominal pain. 
o	If area is painful, percuss that area last. 
o	“Normal percussion findings include dullness over the liver in the RUQ and hollow tympanic notes in the LUQ over the gastric bubble. Over most abdomen, tympanic sounds should be heard and indicates the presence of gas.”
•	Abnormal-dullness may be heard over organs, masses, or fluid such as ascites, GI obstruction, pregnant uterus, and an ovarian tumor. 
•	Percuss borders of liver span in RMCL- liver span test gives you an estimate of the size of the liver in the MCL. 
o	Upper edge-start at right MCL at the 3rd intercostals space over lung tissue. 
o	Percuss down until you hear resonance change to dullness over the liver between 5 and 7th ICS. 
o	Place mark where dullness begins. 
o	Lower border of liver, start at right MCL at level of umbilicus and percuss upward until tympany turns to dullness, usually at the sternal border. Mark this. Measure distance. 
o	“Liver span is 6-12 cm. If the liver span in the MCL is >12cm, measure it in the midsternal line. Normal Midsternal liver span is 4-8cm.” 
•	If suspect ascites, test fluid wave and shifting dullness- detectable only after 500mL of fluid has accumulated, is done in two ways:
o	Shifting dullness or fluid wave
o	Abnormal-ascites is found in patients with cirrhosis or primary or metastatic tumors of the liver. 
•	Shifting dullness-percussing dullness in the umbilical area when the patient is supine, then having the patient lie on the right side and percussing again. 
•	You can repeat this maneuver by having the patient turn to the left side. 
•	Abnormal-dullness will move to the most dependent area. 
•	Fluid wave- have patient place hand vertically in the middle of the abdomen. Place your hands on both sides of patient’s abdomen and tap one side while palpating the other. 
•	Abnormal-ascites present, the tap will cause a fluid wave through the abdomen and your will feel the fluid with the other hand. 
	Palpation
•	Light palpation in all 4 quadrants- general survey of surface characteristics and to put the patient at ease. 
o	Press down 1-2cm in a rotating motion, then lift your fingertips and move to the next location. 
o	Observe for nonverbal signs of pain, such as grimacing and guarding. 
•	If guarding is present, place a pillow under the patients knees and have him take a few deep breaths. 
•	While patient is concentrating on breathing, lightly palpate the rectus abdominus muscles on expiration. 
•	The patient cannot voluntarily guard this muscle during expiration. 
o	“No tenderness should be noted.”
•	Abnormal-guarding is a sign of possible peritoneal inflammation and should be carefully evalulated. 
•	If you find a mass, not its location, size, shape, consistency, tenderness, pulsation, mobility, and movement with respiration. 
•	Size and changes over time offer insight into pathology and extent of involvment. 
•	Deep palpation in all 4 quadrants- organs-masses
o	Used to asses organs, masses, and tendeness. 
o	Single handed deep palpation- use tips of fingers and depress 4-6 cm in a dipping motion in all 4 quadrants
o	“Tenderness may be noted in an adult near the xiphoid process, over the cecum, or over the sigmoid colon.”
o	Bimanual deep palpation is necessary when palpating a large abdomen. 
•	Place nondominant hand on your dominant hand and depress your hands 4-6cm. 
o	Kidneys- assess the left kidneys, stand on patients right side and place left hand in the left CVA. 
•	Place right hand at the left anterior costl margin
•	Have patient take a deep breath; then press your hands together to “capture” the kidnesys. 
•	As patients exhales, lift your left hand and palpate the kidneys with your right hand. 
•	To asses right kidney (only palpable if enlarged), remain on patients right side, place your right hand on the right CVA, 
•	Left hand on right costal margin
•	When Patien exhales palpate the right kidney 
o	“It is common to be unable to palpate the kidneys except in slender patients.”
•	Abnormal-kidneys enlarged from hydrophrosis or tumors may be palpable. 
	
	Any pain or tenderness in the breast?
	Any lump or thickening in breasts?
	Any discharge from nipples?
	Any rash on breasts?
	Any swelling in the breasts?
	Any history of breast disease?
	Ever had surgery on breasts?
	Ever been taught breasts Self-exam?
	Ever had mammography?
	
	Inspection
•	Breasts
o	Symmetry- “The left breast is often slightly larger than the right breast.”
•	Abnormal-approximately 3% of women have one breast that is underdeveloped compared to the other. 
o	Skin color and condition- Skin tone determines actual color
•	Abnormal-redness (erythema) and heat can indicate infection or inflammation. 
•	Hyperpigmentation can signify cancer. 
•	Unilateral vascular appearance could indicate increased blood flow to a malignancy- produced by dilated superficial veins. 
o	Texture- Pale, linear stretch marks (striae) may be evident after pregnancy or if a woman has gained then lost significant weight. 
•	Peau d’ orange appearance is caused by breast edema from blocked lymph drainage and indicates advanced cancer. 
•	Rash or ulceration may occur in Paget’s disease of the breast. 
o	Lesions- any striae? 
o	“Breasts are symmetrical; skin is smooth and even without redness, bulging, or dimpling. There is no rash edema, or lesions.”
•	Aerolae and nipples
o	Areola- “Round or oval, and pink to dark brown or black.”
o	Nipples- “everted, but it may be normal for one or both nippes to be inverted.”
o	“Nipples are symmetrical and protuberant. Nipples and areolae are the same color and smooth or wrinkled in appearance. There is no discharge (unless the woman is pregnant or lactating), cracking or crusting.”
•	Response to arm Movement- patient lifting arms over head, pressd firmly on the hips, leaning forward from waist, and then lying supine. 
o	Abnormal-any change in color, size (especially unilateral) symmetry, or contour of breasts or change in nipple characteristics require further investigation. 
•	Lifting the arms over the heads add tension to the suspensory ligaments and accentuates any dimpling or retraction. Leaning forward may reveal breast or nipple asymmetry. 
•	Axilae- while patient is sitting, noting any rashes, infections, texture changes, or unusual pigmentation.
o	Abnormal- these signs suggest underlying cancer but may also be from benign lesions. 
•	Rashes or infection may occur from laundry detergent or deodorant. 
•	Velvety axillary skin or deep pigmentation is associated with malignancy. 
Palpation
•	Breasts
o	Best accomplished with the patient supine with arm raised overhead and a small pillow or towl under the side being examined- flattens breast tissue. 
o	Palpate from clavicle to the inframammary fold (bra line) and from midsternum to the posterior axillary line making sure to examin the tail of Spence
o	Vertical strip pattern-most effective means of examining the entire breast. 
•	Using finger pads of the first 3 fingers, palpate in small, concentric circles beginning in the axilla and moving in a straight line down toward the bra line. 
•	Apply light medium, and then deep pressure at each examining point to reach the entire breast tissue
•	Continue vertical overlapping lines until the sternal edge is met. 
o	Circular
o	Wedge
o	Masses- nodular masses may be present prior to menses, disappearing after menses has occurred. 
o	Texture-“ The breast of a nuliparous woman feels smooth, elastic, and firm. Prior to menstration, breasts are often engorged secondary to increased progesterone. The patient may notice nodules, a slight enlargment, and tenderness during this time. Upon examination, the lobes may be more prominent with distinct margins. After pregnancy , breasts feel softer and have less tone.”
o	Tenderness-Breasts are often tender during the premenstrual period. 
•	Abnormal-tenderness or pain at other times may be from infection or trauma. 
o	Masses-if a lump is palpated document the location, size, shape, consistency, mobility, tenderness, and distinctness. 
•	Note the skin over the lump, the nipple and lymphadenopathy. 
•	Abnormal-masses require further evaluation or may require a mammogram, ultrasound, asipiration, or biopsy. 
o	“Breast tissue is soft and homogeneous. No masses or tenderness. No Lymphadenopathy.”
•	Areolae and nipples
o	Discharge
•	Gently compress the nipple between your thumb and index finger to assess for discarge. 
•	If evident, note color consistency, and amount. 
o	Massage areola  if there is discharge to determine where it originates 
o	“nipples without discharge or masses.”
•	Axillae and lymph nodes-
o	Best performed while patient is sitting. 
o	Instruct patient to raise arm. 
o	Support the arm and wrist to aid in muscle relaxation
o	Use right hand to palpate the left axilla and the left hand to palpate the right axilla
o	Point fingers toward the midclavicle directly behind the pectoral muscle. 
o	Feel for central nodes which are against the chest wall
o	“One of more small, soft, nontender nodes are commone findings.”
o	Assess other axillary lymph nodes
•	More difficult to palpate
•	Pectoral nodes-located insie the border of the pectoral muscle
•	Lateral nodes- located along upper humerous, high in axilla. 
•	Subscapular nodes- examiner standing behind the patient, feeling inside the posterior axillary folds. 
•	Adjust patients arm in various positions incrases the surface area that can be assessed. 
•	Size- measure or judge length x width x depth in centimeters using a ruler as a guide. 
•	Shape- oval, round, lobular, nodular, or distinct?
•	Consistancy-smooth, soft, firm, or hard?
•	Mobility-movable or immobile?
•	Tenderness- tender or not? 
•	Distinctness- one lump or multiple nodules?
•	Skin- dimpled, retracted, erythematous?
•	Nipple-retracted or displaced?
Teach breast self-exam
Cognitive
	Explain
•	Why breasts are examined
o	In the shower
o	Before a mirror
o	Supine with pillow underside of breasts being examined
•	Who should do breast exam
o	Women, starting at mid 20s
•	Frequency of breast exam
o	Once a month
•	Best time of the month to do breast exam and rationale
o	The 4th to 7th day of the menstrual cycle, end of menstrual period. When breasts are least congested. 
•	State the area of the breast where most lumps are found
•	Give two reasons a person may not report significant findings to the health care provider. 
	Performance
•	Explain to woman need for BSE
o	Important for them to be aware of how breasts feel and look so they can immediately detect any changes. 
•	Instructs woman on technique of BSE by:
o	Inspecting and bilaterally comparing breasts in front of mirror. 
o	Palpating in a systemic manner, using pads of three fingers and with woman’s arm raised overhead. 
o	Palpating tail of Spence and axilla
o	Gently compressing nipples
•	Instruct woman to report unusual findings to the physician at once. 
o	Any significant changes-dimpling or bulging of a section fo the breast, a nipple that is inverted when it was previously outward, or rash, sorness, swelling, or redness, then she should call her primary care provider for an appointment. 
o	Many lumps are benign, but that if a lump is cancerous, the survival rate is ver hig if it is detected and treated before it becomes invasive. 
o	
	Any uninary frequency, urgency, or wakening during night to urinate?
	Any pain or burning with urinating?
	Any trouble starting urine stream?
	Urine color cloudy or foul smelling?
•	Red-tinged or bloody?
	Any problems controlling your urine?
	Any pain or sores on penis?
	Any lump in testicles or scrotum?
•	Do you perform testicular self-exam?
	In relationship now involving intercourse?
•	Use a contraceptive? Which one?
	Any contact with partner who has sexually transmitted disease?
	
	Inspect and palpate penis
•	Skin condition-
o	Observe genital hair distribution
o	“skin is clear, intact and smooth. Hair is diamond shaped or in a escutcheon pattern. Hair appears coarser that at the scalp and no parasites.”
o	Color, lesions, and discharge. 
o	Check posterior side
o	“Dorsal vein is apparent on the dorsal surface of the penis. The penis has no edema, lesions, discharge or nodules. “
o	Circumsized penis-gland and corona are visible, lighter in color than shaft. And free of smegma. 
o	“Circumcised penises have varying lengths of foreskin; some have folds of skin, while others have no extra foreskin.”
o	Uncircumcised penis-prepuce covers the glan
•	Ask to retract the prepuce. 
o	“the prepuce retracts easily. Smegma(a white, cheesy substance) may be normally present around corona.”
•	Glans
o	“it is glistening pink, smooth in texture, and bulbous. 
•	Urethral meatus
o	“located centrally on the glan. The orifice is slit-like and millimeters from the tip of the penis. The urethral meatus has no discharge, stenosis, or warts.”
o	 The glan can be opened by pressing it between the thumb and forefinger. 
o	Strip or milk the penis from the base toward the glan or head. Note color, consistency, or odor of any discharge.
o	“the glan is smooth and pink with no discharge.”
•	Shaft
o	“it feels smooth without lesions or pain. Normal variations include ectopic sebaceous glands on the shaft that appear as tiny whitish-yellow papules. “
•	Inspect and palpate the scrotum
o	Inspect anterior and posterior for any rashes. 
•	Skin condition- “Darker in pigmentation with a rogous or wrinkled surface.”
o	Testes “Smooth, rubbery consistency of each testicle. No nodules should be felt.”
o	Spermatic cord- “Smooth, non tender”
o	“it is divided into two sacks. The scrotum could hang asymmetrically, with the left side lower than the right. Sebaceous cysts or sebaceous glands may be normally noted on the scrotal sac.”
•	Inspect and palpate for Hernia
o	Instruct patient to stand. 
o	Ask to bear down
o	Inspect the inguinal canal area and femoral area for bulges or masses. 
o	Inguinal canal
o	Femoral area
	Palpate inguinal lymph nodes
•	With patient relaxed, insert finger into scrotal sac and follow it upward along the vas deferens into the inguinal canal. 
o	Palpate the oval external ring
•	If hernia is present you should feel the sudden presence of a viscous agent against your finger. 
•	“Hernias are common but not normal. There is no bulging or pain.”
	Teach testicular self-examination
	Cognitive
	Explain
•	Why testicles are examined
o	Become familiar with what is normal for them. Once normal is established, changes are easier to identify. Testicular cancer can be detected at an early stage. 
•	Who should performTSE
o	Men older than 14
•	Frequency of testicular exam
o	monthly
	Describe the technique
	Performance
•	After warm bath or shower- heart relaxes scrotum
•	Examine each testicle one at a time with both hands. 
•	Index finger and middle finger under the testicle with the thumbs placed on tob. 
•	Roll the testicle gently from side to side. 
•	Should not feel pain. 
	Explain to males need for TSE
	Instruct male on technique of TSE by:
•	Describing method of palpating testicles
•	Describing normal findings
o	One testicle may be larger than other
•	Describing abnormal findings to look for
o	Cancerous lumps are on the sides of the testicle, but can show up on the front. 
o	Epididymis
	Instruct male to report findings promptly
•	If you find any lump or any warning signs-elargement of testes, pain or discomfort, heaviness in scrotum, a dull ache in the groin, significant loss of size of one testicle or a sudden collection of fluid in the scrotum. 
	
	Bowels move regularly? How often?
•	Usual color? Hard or soft?
	Any change in usual bowel habits?
	Ever had black or bloody stool?
	Take any medications?
	Any rectal itching, pain, or hemorrhoids?
	Any family history of colon/rectal polyps or cancer?
	Describe usual amount of high-fiber foods in diet?
	
	Inspect the perianal area
•	Skin conditon- “smooth, darker, darker than surrounding area. No lumps, ulcers, lesions, hymorrhoids, rashes, erythema, or fissures.” 
•	Sacrococcygeal area-“is without edema, erythema, dimpling, or hair.” 
•	Note Skin integrity while patient performs valsalva maneuver
	Palpate anus and rectum
•	Apply lubricant to index finger of gloved hand
•	Explain he might feel like he will habe a bowel movement 
•	Have patient take a deep breath while inserting finger into rectum.
o	Anal sphincter-“full closure around the finger is palpable” Rotate index finger around anal ring- “it feels smooth without nodules, masses or irregularities.”
o	Anal canal- advance finger into the anal canal
•	“lateral and posterior rectal walls feel smooth and uninterrupted. Internal hemorrhoids are usually not felt.”
o	Rectal wall- rotate finger to palpate. 
•	“there are no nodules, masses, irregularities, or polyps.”
•	Prostate gland-for males
o	Size- diameter is approximately 4cm; <1cm protrudes into the rectum. 
o	Shape-
o	Surface-firm, smooth.
o	Consistency-rubber ball. 
o	Mobility-slightly movable. 
o	Any tenderness-non tender.
•	“The normal prostate gland had a consistency of a rubber bal. it is nontender, firm, smooth, and slightly moveable. The diameter is approximately 4cm; <1 cm protrudes into the rectum.”
	Prostate enlargement is classified by the amount of projection into the rectum. If the prostate feels hard, may indicate carcinoma, prostatic calculi, or chronic fribrosis. 
	A rubber or boggy glandular consistency may suggest BPH, a common finding in men older than 60. The gland may feel soft, tender, and boggy from infection. 
•	Signs and symptoms of BPH are urine retention, hesitancy, urgency, dribbling, nocturia, and straining to void. 
	Examination of stool
•	Visual inspection
o	Inspect gloved finger for consistency and color of stool
o	“the stool is brown and soft”
•	Test for occult blood
o	3 days prior to examination- patient should have refrained from eating red meat and ingesting vitamin c supplements.
o	Obtain guaic developer and slide
o	Open the flap of the cardboard guaiac slide
o	Dab stool on the paper. 
o	Close the flap and remove gloves
o	With clean gloves on, reverse the slide and open the flap
o	Apply two drops of developing solution to each box of guaiac paper
•	Wait 30 to 60 seconds and note color of paper. 
•	Bluish discoloration- positive result- occult blood is present
•	Warning sign for colorectal disease.
•	False positive guaiac results may occur from a diet of red or rare meats. 
•	Vitamin c may cause false negative results
o	FOBT
o	OBS
•	
	Date of last menstrual period?
•	Age at first period? Usual cycle?
•	Duration? Usual amount of flow?
•	Any pain or cramps with period?
	Every been pregnant? #times? 
•	Describe pregnancy
•	Any complications?
	Periods slowed down or stopped?
	How often has gynecologic checkup?
•	Date of last pap test? Results?
	Any problems with urinating
	Any unusual vaginal discharge? 
	Sores or lesions in genitals?
	In relationship now involving intercourse?
	Use a contraceptive? Which one?
	Any contact with partner who has sexually transmitted disease?
	Any precautions to reduce risk of STDs?
	Taking any medications?
•	Any hormone therapy?
	
	Inspect external genitalia
•	Skin color and characteristics
o	Inspect skin for any redness, breakdown, papules, or vesicles. 
o	Bilaterally observe the inguinal area for erythema, fissures, or englarge inguinal lymph nodes. 
•	Hair distribution
o	Inspect mons pubis. Inspect pubic hair for amount and distribution. 
o	“Hair is evenly distributed and growing in a downward direction. No lice or nits are seen.”
•	Symmetry
o	Inspect the labia major for size and symmetry
•	Clitoris
o	Note size and shape. 
o	“ the clitoris is 1-1.5cm long.”
•	Labia
o	Look for symmetry
o	Redness or swelling
o	Both labia majora and minora are composed of sebaceous and apocrine glands, prone to small inclusion cysts. 
•	Urethral opening
o	Inspect for swelling or redness
o	“no protrustions are seen from the vagina”
•	perineum
“the area between the introitus and anus is smooth with no lesions or tears. Scars from any episiotomies are healed. The anus is intact with no swelling, lacerations, or protrusions.”
o