Health Assessment

1. Assessment of Breast, Axilla & Genitalia
Ms. Gulshan Umbreen
Lecturer, SNC
PhD Scholar (Epidemiology & Public Health)

2. Objectives:
By the end of the unit, learners will be able to:
• Discuss the history questions pertaining to male
and female breast and Genitalia assessment.
• Perform a breast examination including axillary
nodes and interpret findings.
• Discuss components of a genital exam on a male
or female.
• Document findings.
List the changes in breast, male & female genitalia
that are characteristics of aging process.

3. Female Reproductive System
• External genitalia: vulva, labia majora, labia
minora, clitoris, vestibule, perineum
• Internal genitalia: vagina, uterus, corpus,
cervix, fallopian tubes, ovaries
• Breasts
• Menstruation and menopause.
Bickly, L. S. (2013).

4. Male Reproductive System
• External genitalia:
• Penis, scrotum
• Internal genitalia:
• Testes and spermatic cord,
• Epididymis, vas deferens, seminal vesicles,
• Ejaculatory ducts, prostate gland
• Inguinal area.
Bickly, L. S. (2013).

5. History questions:
• Subjective Data Collection:
• History:
• Demographic data:
• The nurse uses data about client’s age, sex, and
culture to assess the risk for certain diseases.
• The nurse considers the client’s age in evaluating
the reproductive system.
Bickly, L. S. (2013).

6. Common Chief Complaints
• Rectal bleeding
• Rectal pain
• Anal incontinence
• Constipation
• Diarrhea
• Pruritis
• Palpable mass
Bickly, L. S. (2013).

7. • Family history helps to determine the client’s risk for
conditions that affects reproductive system
functioning.
– Is there family history of breast cancer?
– Is there family history of benign breast disease?
– Is there family history of rectal polyps?
– Is there family history of rectal cancer?
– Is there family history of prostate cancer?

8. Past Health History:
• Do you have the following problems in the past?
• Medical history:
– Anorectal specific
– Systemic
• Surgical history:
– Anorectal specific
– Prostate
• Medications:

9. Cont…
• Communicable diseases
• Allergies
• Injuries/accidents
• Childhood illnesses
– Anal stenosis

10. Cont….
• Social history
– Alcohol use
– Tobacco use
– Work environment
– Home environment
– Economic status
– Ethnic background

11. Cont…
– Substance use
– Work environment
– Hobbies/leisure
– Stress.

12. Cont…
• Personal history:
• Do you have diabetes, hypertension, neurologic
impairment, asthma, chronic obstructive
pulmonary disease (COPD), chronic bronchitis,
or cardiovascular disease?
• Was surgery ever performed on your penis,
scrotum, or rectum?
• • What type of procedure, year/ date?
• • How has this procedure affected you?

13. Cont…
• Have you ever been treated for a sexually
transmitted infection (STI)?
• • Where and when?
• • What type of STI?
• • How was it treated?
• • Did you have a test of cure afterward?
• Have you ever had an injury to or other
problems with your scrotum, penis, or testes?

14. Cont…
• Examples include testicular torsion, hydrocele,
spermatocele, and varicocele.
• Have you had benign prostatic hyperplasia or
prostatitis?
• Do you have a history of cancer?
• When was the diagnosis?
• What treatment did you have?

15. Cont…
• Health maintenance activities:
– Diet
– Exercise
– Breast self-exam
– Mammogram
– Sleep
– Safety devices
– Health checkups.

16. Subjective Data Collection: Female
• Family History:
• Tell me about your family history (two generations)
of diabetes, heart disease, cancer, thyroid problems,
gynecologic conditions, asthma, hypertension,
allergies, multiple pregnancy, and congenital
anomalies.
• Menstrual History:
• How old were you when you got your first period?
• What was the 1st day of the last period?

17. Cont…
• What is your flow like?
• For how many days do you experience flow?
• • How many pads or tampons do you use per
day?
• For how many days is there heavy, moderate,
or light flow?
• Obstetrical History:
• Have you ever been pregnant?
• If so, how many times?

18. Cont…
• How many living children do you have?
• Were births vaginal or cesarean?
• Were there any complications?
• Have you ever had a miscarriage?
• Have you ever had an abortion?
• Was it elective, spontaneous, or incomplete?

19. Cont…
• Menopause:
• Have you stopped having periods?
• Are menstrual cycles irregular?
• Do you experience any irregularity or absence of
• menses?
• Gynecologic History:
• Have you ever had a Papanicolaou (Pap) smear?
When?

20. Cont…
• Have Pap results been normal? If not, did you
receive treatment? When?
• Have you had previous surgeries?
• Have you been treated for vaginal infection?
• Do you have frequent vaginal infections?
• Do you use over-the-counter (OTC) vaginal
medication?
• Have you ever had pelvic infections?

21. Breast examination:
Assessment:
• Assess the following characteristics:
– Color
– Vascularity
– Thickening/edema
– Size and symmetry
– Contour
– Lesions/masses
– Discharge.

22. Cont….
Palpation:
• Sequential manner
• Supraclavicular and infraclavicular nodes
• Breasts, arms at side, arms raised
• Axillary nodes
• Breasts, supine position.

23. Evaluation of Breast Mass Characteristics:
• Location
• Size
• Shape
• Number
• Consistency
• Mobility
• Tenderness
• Erythema
• Dimpling or retraction

24. Palpating the Axillary Nodes:
• Instruct the patient to drop the shoulder and take
a deep breath to facilitate relaxation.
• Support the patient’s arm and elbow with the
non-examining hand to maintain optimal
relaxation.
• Axillary nodes are palpated at deep pressure
using a circular motion with the pads of the three
middle fingers of the examining hand, in all four
aspects of the axilla. Note that this pattern
resembles a diamond.

25. Cont….
1. Start palpating the central nodes deep in the apex
of the axilla. The hand is straight up, deep in the
underarm.
2. Proceeding down the mid -Axillary chest wall, lift
the tissue with the examining hand and gently
move the pads of the fingers medially and inside
the border of the pectoral muscle and the pectoral
node chain.
3. Continue by palpating the subscapular nodes.
Sweep back up and return to the axilla with the
palm facing laterally, feeling inside the muscle of
the posterior Axillary fold.

26. Cont…
4. Check the lateral nodes with the palm of the hand
facing the humeral head.

27. Normal Findings:
• Breast and axillae are flesh colored
• Areolar areas and nipples are darker in
pigmentation
• Moles and nevi are normal variants
• No thickening or edema
• Minor size variation in the breasts and areolar
areas
• Usually breast on dominant side is larger
• Nipples should point upward and outward, may
point outward and downward

28. Cont…
• Breasts, areolar areas, nipples should be
symmetrical
• Breasts are convex, without flattening, retractions,
or dimpling
• Free from masses, tumors, primary or secondary
lesions.
• No discharge from nipples in nonpregnant,
nonlactating female
• Usually, palpable lymph nodes less than 1 cm in
diameter are clinically insignificant
• Palpation should not elicit pain

29. Cont…
• Consistency of breast tissue is highly variable
depending upon age, time in menstrual cycle,
and proportion of adipose tissue
• Breasts are usually nodular or granular prior to
menses
• Variation with breast augmentation— breasts
feel fluid filled or firm throughout.

30. Abnormal Findings.
• Nodes that suggest inflammation or infection, or
are fixed, matted or persistent, should be
considered a suspicious finding.
• Note the size, shape, firmness and mobility.
Appropriate follow-up may include
mammography, ultrasound or other tests as
indicated by history and clinical findings.

31. Components of a genital exam on a male or
female.
Components of male genitalia Includes:
• Testes
• Seminal vesicles
• Bulbourethral glands
• Epididymis
• Ductus deferens.

32. Cont…
• Ejaculatory ducts
• Urethra
• Scrotum
• Penis
• Glans penis
• Spermatic cord.

33. Cont…
• Spermatogenesis
• Male sexual function
– Erection
– Lubrication
– Emission
– Ejaculation.

34. Cont…
Components of Female genitalia Includes:
• External genitalia: vulva, labia majora, labia
minora, clitoris, vestibule, perineum
• Internal genitalia: vagina, uterus, corpus,
cervix, fallopian tubes, ovaries
• Breasts
• Menstruation and menopause

35. Document Normal findings: Male
• The patient denies pain, discomfort, and
problems with urination.
• States that he has no premature ejaculation,
erectile dysfunction, low libido, delayed orgasm,
or physical abnormalities of the penis.
• No lesions, discharge, or scrotal enlargement.
Skin is clear, intact, and smooth.
• No masses or lesions noted. Foreskin intact.

36. Cont…
• No phimosis or paraphimosis.
• Penis size is appropriate to age and smooth
without lesions or pain.
• No discharge, edema, or redness.

37. Document abnormal findings:
• Acute infection of the epididymis, commonly
by Chlamydia, gonorrhea, or other bacterial
infection, is often linked to prostatitis,
especially after surgical intervention/urethral
instrumentation.
• Scrotal pain is severe, accompanied by
swelling and fever.

38. Cont…
• This benign scrotal mass or cyst develops on the
• head of the epididymis or testicular adnexa.
Patients may report a lump in the scrotal sac or
edema.
• Upon palpation a mobile, cystic nodule usually
less than 1 cm is noted superior and posterior to
the testis.
• The mass will transilluminate with a pink or red
glow.

39. Document Normal findings: Female
• External genitalia: Even hair distribution; no
lesions present.
• Bartholin’s glands, urethral glands, and Skene’s
glands (BUS): with no erythema, edema, or
discharge. Vaginal introitus and walls: pink, moist
with normal rugae, good anterior and posterior
wall support, and no discharge present.
• Cervix: smooth round with no lesions and no
tenderness upon movement.
• Uterus: normal size, shape, midposition, and
freely mobile.

40. Cont…
• Adnexa: No palpable masses and no tenderness
to examination.
• Perineum: smooth. Anal area: pink, with no
hemorrhoids, fissures, or bleeding.
• Rectal wall: smooth without masses or nodules,
and good sphincter control.

41. Female Reproductive System
• External genitalia: vulva, labia majora, labia
minora,clitoris, vestibule, perineum
• Internal genitalia: vagina, uterus, corpus, cervix,
fallopian tubes, ovaries, Breasts, menstruation and
menopause.

42. Male Reproductive System
• External genitalia: penis, scrotum
• Internal genitalia: testes and spermatic cord,
epididymis, vas deferens, seminal vesicles and
ejaculatory ducts, prostate gland Inguinal area.

43. Characteristics of aging process
Changes in Female Breast
• Pregnant Women:
• Women experience breast changes as early as the
first 2 months of pregnancy, stimulated by
placental hormones. Breasts enlarge, feeling
tender and nodular.
• Nipples darken, enlarge, and become more erect.
• As pregnancy progresses, areola also become
larger, darker, and more prominent. Stretch marks
(striae) may be evident; these disappear
completely when breasts return to the pre-pregnant
size.

44. Cont…
• Small, scattered Montgomery’s glands develop
within the areolae. Because of increased blood
flow, a bluish venous pattern is often evident on
the breast tissue.
• Breasts may begin to express colostrum (milk
precursor) during the 4th month of pregnancy.
Women continue to produce colostrum through
the first few days postpartum.
• Actual milk replaces colostrum if breast-feeding
occurs. During breast-feeding, smooth muscle in
the nipple and areola contracts to express milk.

45. • Breasts may become larger, reddened, warm, and
engorged, especially at this time. Frequent breast-
feeding will stimulate milk production, drain the
sinuses, and resolve the symptoms.
• Newborns and Infants:
• Enlarged breast tissue and white discharge (“witch’s
milk”) in newborns of either gender may occur for
the first few weeks of life, secondary to the effects
of maternal estrogens. If breast enlargement, witch’s
milk, or both are present, reassure the newborn’s
parents/ caregivers that nothing is wrong and the
conditions will resolve spontaneously.

46. • At birth, the lactiferous ducts are present in
females within the nipples, but alveoli do not
develop in females until puberty.
• Children and Adolescents:
• On inspection, the symmetrical nipples of
prepubescent children lie between the fourth and
fifth ribs just lateral to the mid-clavicular line.
The nipples and areolae are flat and darker than
the rest of the breast tissue.

47. Male Breast changes
• Male breasts are immature structures with well-
developed areolae and small nipples. During
midpuberty, one or both male breasts commonly
and temporarily enlarge as a result of changing
hormone levels, a condition referred to as
gynecomastia.
• Pubescent males also may develop breast buds or
tenderness, which also is usually temporary.
• Gynecomastia is physically benign but can cause
emotional distress. Reassurance that this is
temporary and normal may help alleviate the
distress.

48. Cont…
• As males age, gynecomastia may recur
from decreases in testosterone.

49. Male genitalia characteristics of aging process
• Adolescents:
• With puberty, testicular growth begins. Scrotal
skin thins and becomes pendulous. Testes
become active and begin to secrete testosterone,
which promotes bone maturation and
epiphyseal closure.
• Genital hair appears at the base of the penis,
darkens, and extends over the entire pubic area;
at this time, the prostate gland enlarges.

50. Cont…
• When maturation is complete, genital hair is curly,
dense, and coarse, with a diamond shape from
umbilicus to anus.
• Growth and development of the scrotum and testes
are complete and the length and width of the penis
are increased.

51. Cont…
• Older Adults:
• Pubic hair may be thin and gray. Testes may be
smaller and softer.
• The scrotal sac has less ruggae and appears to
droop.
• Rectal tone is intact, but strength of the rectal
reflex may be reduced slightly.

52. • Older men may have rectal distention from
degeneration of afferent neurons. This may
contribute to fecal incontinence.
• Testosterone levels decline with aging, which
may affect both libido and sexual function.
Erection becomes more dependent on tactile
stimulation and less responsive to erotic cues.
The penis may decrease in size.
• Fibromuscular prostate structures atrophy.
Ironically, benign hyperplasia of the glandular
tissue often obscures the atrophy of aging.

53. Female genitalia characteristics of aging process
Newborns and Infants:
• On assessment of the newborn, it is no uncommon to
see some pink discharge at the opening of the
vagina. This is most often a result of maternal
estrogen.
• In the female child the genitalia continues growing,
except for the clitoris. Ambiguou genitalia is a
congenital anomaly found in some newborns.
• This emergent condition requires referral for
diagnostic evaluation.

54. Cont…
• Child and Adolescent:
• To conduct a genital examination on a young
female child, allow the parent to hold her and have
the child place her feet together like a frog. Allow
the child to participate. Have the parent let the
child know that it is OK to allow this examination,
especially if she has been taught not to allow
anyone to touch her genitals.
• Age of onset of puberty in girls has continued to
decline. Budding of the breast occurs first,
followed by pubic hair, and finally onset of
menses.

55. • Genital assessment of the adolescent is not required
unless there has been initiation of sexual activity or
there are genital tract problems. The opportunity for
nurse education is greatest at this time, however.
• The adolescent is experiencing body changes, self-
identity exploration, and relationship questions. The
nurse should be direct and honest with the teen.
Establishment of a trusting and confidential nurse–
patient relationship is vital.

56. Cont…
• Older Adults:
• As women age, they experience many changes in
the genitourinary tract related to limited or absent
estrogen in the system. Menopause is 12
consecutive months without menses and usually
occurs between 48 and 51 years. As estrogen levels
decrease the uterus becomes smaller, the ovaries
shrink, the normal vaginal rugae flatten, and the
epithelium atrophies.
• These normal changes may lead to problems such
as vaginal infections, urinary tract infections,
dyspareunia, and lowered libido.

57. Cont…
• Older women are at increased risk for endometrial
cancers and need education regarding abnormal
signs and symptoms.

58. Reference
• Bickly, L. S. (2017). Bates’Guide to Physical
Examination and History Taking (12th ed).
Philadelphia: J. B. Lippincott.
• Weber, J. R. (2001). Nurses handbook of health
assessment (4th ed). Philadelphia: J. B.
Lippincott.
• Wilson, S. F; Giddens J. F. (2001). Health
assessment for nursing practice (2nd ed). St.
Louis: Mosby.