Health Assessment NUR 103

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Health AssessmentNUR 103

• Physical Assessment of the Reproductive System

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Objectives

• Define terminology.
• Describe anatomy and physiology.
• Identify equipment.
• Identify positioning.
• Identify techniques.
• Explain process of performing assessment of male
  and female reproductive systems.
• Recognize normal and abnormal data.
• Differentiate between normal and abnormal
  assessment data.

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TerminologyThe External Female Genitalia

• Vulva- (or pudendum) The external genitalia.
• Mons pubis- A round, firm pad of adipose tissue
  covering the symphysis pubis.
• Labia majora- Two rounded folds of adipose tissue
  extending from the mons pubis down and around to
  the perineum.
• Labia minora- Two smaller, darker folds of skin
  inside the labia majora.
• Frenulum- A transverse fold which joins the labia
  minora poseriorly.
• Clitoris- A small, pea shaped erectile body,
  homologous with the male penis and highly
  sensitive to tactile stimulation.
• The labial structures encircle a boat-shaped
  space termed the Vestible.
• Urethral meatus- A dimple 2.5 cm posterior
  opening posterior to the clitoris.

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Terminology The Internal Female Genitalia

• Vagina- A flattened, tubular canal extending from
  the orifice up and backward into the pelvis.
  Leads into the female reproductive tract.
• Rugae- Thick transverse folds which enable the
  vagina to dilate widely during childbirth.
• Cervix- A smooth doughnut-shaped area with a
  small circular hole or os, found at the end of
  the canal that leads into the uterus.
• Anterior fornix- A continuous recess, present in
  front of the cervix.
• Posterior fornix- Continuous recess found in back
  of cervix.
• Rectouterine pouch, or cul-de-sac of Douglas-
  Found behind the posterior fornix, a deep recess,
  formed by the peritoneum, dips down between the
  rectum and cervix.
• Uterus- A pear-shaped, thick walled, muscular
  organ which a fetus develops. Flattened
  anteroposteriorly, measuring 5.5 to 8 cm by 3.5-4
  cm wide, and 2-2.5 cm thick.
• Fallopian tubes- Two pliable, trumpet-shaped
  tubes, 10 cm long, extending from the uterine
  fundus laterally to the brim of the pelvis.
  Transports an egg cell from the region of the
  ovary to the uterus.
• Ovaries- The primary reproductive organ of the
  female An egg-cell producing organ which is oval
  shaped, 3 cm long by 2 cm wide.

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EquipmentFor Female Examination

• Gloves
• Protective clothing
• Vaginal Speculum
• Of appropriate size
• Large cotton-tipped applicators (rectal swabs)

• Materials for cytologic study
• Glass slide with frosted end
• Sterile Cytobrush or cotton-tipped applicator
• Ayres spatula
• Spray fixative
• Specimen container for gonorrhea Cx/chlamidia
• Small bottle of normal saline, potassium
  hydroxide, and acetic acid (white vinagar)
• Lubricant

Pederson Speculum
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Positioning forFemale Examination

• Begin with woman in sitting position to
• establish equal status and trust.
• Place woman in lithotomy position, with
• the examiner sitting on a stool.
• Help the woman into position, feet
• in stirrups, knees apart, and buttocks
• at edge of examination table.
• Arms should be at the womans sides,
• not across chest or over the head.
• Drape the woman fully, covering the stomach,
• and legs, exposing only the vulva to your
• view.

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Techniques

• Have woman empty bladder.
• Position the exam table so her perineum is not
  exposed to inadvertent open door.
• Ask if she would like a friend, family member
  present.
• Elevate her head and shoulders to a semi-sitting
  position to maintain eye contact

• Place stirrups so the legs are not abducted too
  far.
• Explain each step in the exam before you do it.
• Assure the woman she can stop the exam at any
  point she should feel uncomfortable.
• Use a gentle, firm, touch, and gradual movements.
• Communicate throughout the exam. Maintain
  dialogue to share information.

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Assessment of theFemale Genitalia

• Abnormal Findings
• Inspection
• Note
• Refer any suspicious lesion for biopsy
• Consider delayed puberty if no pubic
• hair or breast development has occurred
• by age of 13.
• Nits, or lice at base of pubic hair
• Swelling

• Normal Findings
• Inspection
• Note
• Hair distribution- usual pattern
• Skin color, no lesions
• of inverted triangle.
• Labia Majora symmetric, plump,
• and well formed. Nulliparous woman,
• labia meet in midline following
• vaginal delivery, labia are gaping and
• slightly shriveled.

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• Normal Findings
• No lesions, except for
• occ. Sebaceous cysts.
• (with gloved hand sep-
• arate labia majora to inspect).
• Clitoris
• Labia minora- dark pink, and moist, usually
  symmetric.
• Urethral opening appears
• stellate or slitlike, midline.
• Vaginal opening (introits) may appear as narrow,
  vertical slit or as a larger opening.
• Perineum-smooth. A well-healed episiotomy scar,
  midline or mediolateral following vaginal birth.
• Anus- course skin of increased pigmentation.

• Abnormal findings
• Excoriation, nodules,
• rash, or lesions.
• Inflammation or lesions.
• Polyp
• Foul-smelling, irritating discharge.

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Palpation

• Abnormal Findings
• Tenderness
• Induration along urethra, pain, urethral
  discharge
• Swelling, induration, pain with palpation,
  erythema around or discharge from duct opening
• Tenderness, paper thin perineum, absent or
  decreased tone may diminish sexual satisfaction.
• Bulging of vaginal walls indicates cystocele,
  rectocele, or uterine prolapses.
• Urinary incontincence

• Normal Findings
• Assess the urethra
• Skenes glands with gloved finger.
• Asses vagina, gently milk the urethra by applying
  pressure up and out.
• Assess Bartholins glands, post. Of labia majora
  with index finger inside and thumb outside.
• Should feel soft and homogeneous.
• Assess pelvic musc. by
• 1. Palpate perineum, should feel thick,
  smooth, and musc. In nulliparous, thin and rigid
  in multi-parous.
• 2. Ask woman to squeeze vaginal opening
  around fingers, should feel tight in nulliparous.
• 3. Separate the vaginal orifice and ask pt.
  to strain down. No bulging of vaginal walls or
  urinary incontinence.

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Internal Genitalia

• Speculum Examination
• Select proper-sized speculum
• Graves Speculum

Pederson Speculum
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Speculum Examination

• Warm and lubricate speculum under warm running
  water.
• Avoid gel lubricant bacteriostatic, distorts
  cell in cytology specimen collected.
• Insert by asking woman to bear down. Relaxes
  perineal muscles and opens introitus.
• Insert speculum at 45-degree angle downward
  toward the small of womans back.
• After blades are fully inserted, open them by
  squeezing handles together.
• Cervix should be in full view.
• Try closing blades by tightening the thumbscrew.

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Inspect the cervix and its os

• Abnormal Findings
• Redness, inflammation
• Pallor wit anemia, cyanotic other than with
  pregnancy.
• Lateral position- adhesion or tumor. Projection
  gt3 cm may be prolapse.
• Hypertrophy gt 4 cm occurs with inflammation or
  tumor.

• Normal Findings
• Color normally pink,even 2nd month preg. Blue
  (Chadwicks sign) past menopause-pale.
• Position midline,anterior or post. Projects 1-3
  cm into vagina.
• Size Diameter-2.5 cm (1).
• OS Small, round in nulliparous, horizontal
  irreg. slit, may show healed laceration on sides.

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• Surface Smooth, eversion, or ectropion, past
  vaginal delivery
• Endocervial canal everted or rolled out. Red,
  beefy halo inside the pink cervix surrounding os.

• Surface reddened, granular, asymmetric, around
  os.
• Friable, bleeds easily.
• Any lesions white patch on cervix, strawberry
  spot.
• Refer any suspicious, red, white, or pigmented
  lesion for biopsy.

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Inspect the Vaginal Wall

• Abnormal Findings
• Inflammation, lesions.
• Leukoplakia, appears as spot of dried paint.
• Vaginal discharge thick, white, curdlike with
  candidiasis, profuse, watery, gray-green, frothy
  with trich. or gray, green-yellow, white, or
  foul odorous discharge.

• Normal Findings
• As you remove the speculum, inspect vaginal wall.
  Pink, deeply rugated, moist, smooth, normal
  discharge thin, clear, opaque, stringy, odorless.

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Bimanual Exam
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Bimanual Exam

• Technique of exam
• 1.Lithotomy position,
• 2.lubricate fingers of gloved hand.
• 3. Insert fingers into vagina posteriorly.
• 4. Use both hands to palpate internal genitalia
  to assess location, size, mobility, screen for
  tenderness or mass.
• 5. One hand is on the abdomen, the other into the
  vagina.
• 6. Palpate the vaginal wall. Should feel smooth,
  no area of induration or tenderness.
• 7. Locate cervix in midline. Palpate using palmar
  surface of fingers. Note consistancy.

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• Normal findings of cervix
• Consistency smooth, firm, tip of nose. Softens,
  feels velvety at 5-6 wks gest. (Goodells sign).
• Contour Evenly rounded.
• Mobility With finger on either side, move cervix
  gently from side to side. No pain.

• Abnormal findings of cervix
• Nodule, Tenderness.
• Hard with malignancy, Nodular, Irregular,
  Immobile with malignancy.

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Palpation of pelvic organs

• Palpate Uterus with intravaginal fingers in ant.
  fornix. Palpate with abdom. Hand midway between
  umb. And sympthysis.
• Palpate uterine wall with fingers in fornices,
  firm, smooth, with contour of fundus rounded,
  freely movable, nontender.
• Palpate Adnexa on lower quadrant inside ant.
  Illiac spine with intravaginal fingers in lateral
  fornix.
• May not be palpable.

• Abnormal findings
• Painful with inflammation or ectopic pregnancy.
• Enlarged uterus, lateral displacement, nodular
  mass, irregular, asymmetric uterus, fixed,
  immobile, tenderness.
• Enlarged adnexa, nodules or mass. Immobile,
  marked tenderness, pulsation, palpable fallopian
  tube.

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Retrovaginal Exam

• Technique
• Use this tech. when assessing rectovaginal
  septum, post. Uterine wall, cul-de-sac, and
  rectum.
• Change gloves- avoids spreading poss. Infection.
• Lubricate first two fingers.
• Instruct pt. poss. Feeling of discomfort.
• Ask pt. to bear down as fingers are inserted into
  vagina, middle finger is gently inserted into
  rectum, while pushing with abdominal hand.
• Note Rectovaginal spetum-smooth, thin, firm,
  pliable.
• Rectovaginal pouch, or cul-de-sac- not palpated.
• Uterine wall and fundus feel firm, smooh.
• Rotate intrarectal finger to check rectal wall
  and anal sphincter tone.
• Give pt. tissue to wipe area, help her up. Remind
  her to slide hips back from edge before sitting
  up.

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Abnormal Findings of External Genitalia

• Pediculosis Pubis (Crab Lice)
• Severe perineal itching, excoriations,
  erythematous areas. May see little dark spots,
  nits (eggs) adherent to pubic hair near roots.

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Syphilitic Chancre

• Begins as small, solitary silvery papule, erodes
  to red, round
• or oval, superficial ulcer with yellowish serous
  discharge.
• Palpation- nontender indurated base can be
  lifted like button
• between thumb and finger.

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Herpes Simplex Virus- Type 2

• Episodes of local pain,
• dysuria, fever.
• Clusters of small, shallow
• vesicles with surrounding
• erythema, erupt on genital
• areas, inner thigh.
• Vesicles on labia rupture in
• 1-7 days, leaving painful ulcurs.
• Initial infection lasts 7-10 days.
• Virus remains dormant indefinitely
• recurrent infections last 3-10 days
• with milder symptoms.

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Red Rash- Contact Dermatitis

• History of skin contact with allergenic
• substance in environment, intense
• pruritus.
• Primary lesion- red, swollen, vesicles.
• May have weeping of lesions, crusts,
• scales, thickening of skin, excoriations
• from scratching. May result from reaction
• to feminine hygiene spray, synthetic
• underclothing.

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Genital Human Papillomavirus (HPV, Condylomata
Acuminata, Genital Warts

• Painless warty growths, may
• Be unnoticed by woman.
• Pink or flesh-colored, soft,
• pointed, moist, warty papules.
• Single or multiple in cauli-
• flowerlike patch. Occur around
• vulva, introitus, anus, vagina,
• cervix.

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Terminology related to assessment of male
reproductive systems

• Penis External reproductive organ of the male
  through which the urethra passes. Composed of
  three cylindrical columns of erectile tissue two
  corpora cavernosa on dorsal side, one corpus
  spongiosum ventrally.
• Glans (Corpus spongiosum) Cone of erectile
  tissue, found at the distal end of shaft.
• Urethra Tube leading from urinary bladder to
  outside of body, transverses the corpus spong.,
  and its meatus forms a slit at the glans tip.
• Frenulum A fold of forskin extending from
  urethral meatus ventrally.
• Scrotum A loose, protective sac, encloses
  testes.
• Epididymis Highly coiled tubule that leads from
  the seminiferous tubules of the testis to the vas
  deferens. Main storage site of sperm.

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• Vas Deferns A muscular duct or tube that leads
  from the epididymis to the urethra of the male
  reproductive tract.
• Spermatic cord Ascends along the posterior
  border of the testes and runs through the tunnel
  of the inguinal canal into the abdomen.
• Ejaculatory duct A duct of the seminal vesicle
  behind the bladder which empties into the
  urethra.
• Lymphatics Where the penis and scrotal surface
  drain into the inguinal lymph nodes, those of
  testes drain into the abdomen.

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Examination Equipment Needed for Male Anatomy

• Gloves- Wear gloves during every male genitalia
  exam.
• Occasionally glass slide for urethral specimen
• Materials for cytology
• Flashlight

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Positioning for Male Examination

• Position male standing with undershorts down,
  with appropriate draping.
• Examiner should be sitting. (Male may be supine
  for first part of exam, standing for hernia
  check.
• 3. Take time for pt. to discuss genitourinary
  history.

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Inspection and palpation of male reproductive
system

• Normal Findings
• Penis skin wrinkled, hairless, no lesions.
• Glans smooth, no lesions. Retract uncircumcised
  forskin. Cheesy smegma uncer foreskin may be
  noted.
• Always slide foreskin back to original
  position.

• Abnormal Findings
• Inflammation, solitary ulcer, grouped vesicles,
  superficial ulcers, wartlike papules.
• Inflammation, lesions on glans or corona.
• Phimosis- unable to retract foreskin.
• Paraphimosis- unable to return forskin to
  original pos.
• Hypospadias- ventral location of meatus.
• Epispadias- dorsal location of meatus
• Pubic lice or nits- excoriated skin
• Stricture- narrowed opening
• Edges that are red, everted, edematous, purulent
  discharge (urethritis).
• Nodule, induration, tenderness

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Inspection and palpation of scrotum

• Normal Findings
• Inspect scrotum as male holds penis.
• Scrotal size varies with room temp.
• Should be asymmetrical with left scrotal half
  lower than right.
• Spread rugae out between fingers, Inspect post.
  surface.
• Palpate gently ea. Half between thumb and first
  two fingers. Contents should easily slide. Testes
  palpable, oval, firm, rubbery, smooth, equal
  bilat. Freely movable.
• Epididymis feels discrete, softer than testis,
  smooth, nontender

• Abnormal Findings
• Scrotal swelling (edema)
• taut and pitting. (Heart failure, renal
  failure, local inflammation. Lesions
• Inflammation
• Absent testes, temporary migration, true
  cryptorchidism
• Atrophied testes-small, soft
• Fixed testes
• Nodules on testes or epididymides
• Marked tenderness
• Indurated, swollen, tender epididymis
  (epididymitis)

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• Inspect each spermatic cord between thumb and
  forefinger, along its length from epidiymis to
  external inguinal ring. Should feel smooth,
  nontender cord.
• Any mass? Note tenderness, distal or proximal to
  testes, can you place finger over it?, does it
  reduce when pt. lies down, can you auscultate
  bowel sounds over it.
• Transillumination Perform this maneuver if you
  note swelling or mass. Darken room, shine
  flashlight from behind scrotal contents, normal
  scrotal contents do not illuminate.

• Abnormal findings
• Thickened cord, soft, swollen, tortuous.
• Abnormalities in scrotum hernia, tumor,
  orchitis, epididymitis, hydrocele, spermaatocele,
  varicocele.
• Serous fluid does trasilluinate and shows red
  glow, e.g., hydrocele, or spermatocele. Solid
  tissue and blood do not transilluminate, e.g.,
  hernia, epidiymitiis, or tumor.

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Inspect for hernia

• Normal Findings
• Technique-
• 1. Inspect inquinal region for bulge as pt.
  stands and strains.
• Normally, none is present.
• 2.Palpate right side of inquinal canal by asking
  pt. to shift wt. onto left leg. Place right index
  finger low in the right scrotal half. Palpate up
  length of spermatic cord, invaginating scrotal
  skin as you go, to external inguinal ring. Feels
  like triangular slitlike opening, may go easier
  if you ask pt. to bear down.
• Normally, there is no change. Repeat
  procedure to left side.
• 3. Palpate inguinal lymph nodes by palpating
  horizontal chain along groin inferior to ligament
  and vertical chain along inner thigh. Normal-
  feels small, soft, discrete, and movable.

• Abnormal Findings
• Bulge at external inguinal ring or femoral canal
  (hernia may be present but easily reduced and may
  appear only intermittently with increase in
  intraabdominal pressure.)
• Palpable herniating mass bumps your fingertip or
  pushes against the side of your finger.
• Enlarged, hard, matted, fixed nodes.

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Always encourage self care by

• Teaching every male from 13-14 years old through
  adulthood to perform testicular self-examination
  (TSE).