Client Assessment

Breast Self examination

Before, during, and after performing a breast examination, the provider must be considerate of the woman's feelings and concerns. Because she will have to expose her breasts during the examination, she might feel uncomfortable or decide against having it. The medical professional might initially feel uneasy as well. The woman will feel more at ease if you act calmly and sympathetically.

Preparation

• Inform her that you will be looking at her breasts.
• Have the woman sit on the exam table with her arms at her sides while she gets undressed up to her waist.
• This is a good time to inquire about whether she performs monthly breast self-examinations and whether she has noticed any changes in her breasts. Before she leaves, assure the woman that you will demonstrate breast self-examination to her.
• Put fresh examination or highly disinfected surgical gloves on both hands if there are open sores or nipple discharge.

Procedure

Inspection

• Examine the breasts' size and form. Keep track of any variations in nipple size, shape, or skin puckering or dimpling. Even though there may be some variation in breast size, abnormalities or differences in size and form may point to masses. Particularly if the woman is breastfeeding, swelling, increased warmth, or soreness in either breast may indicate infection.
• Look at the nipples and observe their size, shape, and direction (do her breasts hang evenly, for example) Additionally, look for any breast discharge, rashes, or blisters.
• Ask the woman to extend her arms above her head before contracting her pectoral (chest wall) muscles by placing her hands on her hips. Check the for each position the breast's size, shape, and symmetry, as well as any skin puckering or dimpling around the nipple. (In these poses, I'll also demonstrate skin puckering or dimpling, if any.) The woman should then lean forward to check to see if her breasts hang uniformly.

Palpation

• On the examination table, have the woman lie down.
• The breast tissue will be fanned out by placing a pillow beneath her shoulder on the side being checked, which may aid in breast examination.
• A cloth sheet or drape should be placed over the breast that is not being examined.
• The woman should cross her left arm across her chest. Check the left breast for puckering or dimpling to check if it resembles the right breast in appearance.
• Use the spiral technique to palpate the breast using the pads of your three fingers. Start at the breast's topmost outer edge. As you finish each spiral, press the breast tissue firmly against the ribs and glide your fingers slowly toward the areola. Continue this until you have examined every part of the breast. Note any lumps or tenderness.
• You can find it useful to locate little lumps or axillary's nodes by wetting your fingertips with diluted soap solution or betadine.
• Squeeze the breast's nipple gently with the thumb and index finger. Note any discharge, whether it is clear, cloudy, or bloody. It is important to document any hazy or bloody discharge that comes from the woman's nipple in her medical history. Although some cloudy discharge from one or both breasts is common for up to a year after giving birth or ceasing breastfeeding, it is rare that it is caused by cancer, an infection, a benign tumor, or a cyst.
• Repeat the procedure with the woman sitting with her arms at her sides if you are unsure of your findings (such as whether there is a lump).
• The woman should sit up and her left arm should be raised to shoulder level in order to palpate the region of breast tissue known as the "tail of the breast" that extends into or towards the axilla. Have her put her hand on your shoulder if she needs to. To check for swollen lymph nodes or pain, press along the pectoral muscle's outside edge while gently advancing your fingers up into the axilla. Since the majority of cancers are found in the breast's tail, it is crucial to include it in the palpation.
• For the right side, repeat this procedure.
• Have the woman cover her after the examination is finished. Describe any unusual findings and any action that could be required. Tell her everything is fine and healthy and when she should come back for another exam if the examination is completely normal.
• Record your discoveries.

Instructions for BSE

• When to examine your breasts
  • The optimal time to check your breasts is seven to ten days after the first day of your menstruation. (At this time, there is less chance that the breasts would be swollen and sensitive.) Even when your period has permanently ceased, you should check your breasts once a month. You should choose the same day each month (for example, the first of the month) to check your breasts if you are no longer menstruation.
  • BSE may be carried out at any time of the day. Your hands will be able to simply glide over your wet skin while you examine your breasts after a bath.
• How to perform a breast exam Look at your breasts first.
  • Look for any changes in your breasts while standing in front of a mirror with your arms at your sides. Keep track of any modifications to their size, shape, or skin tone, as well as any puckering or dimpling.
  • Once your arms are raised over your head and your hands are put firmly into your hips to tense your chest muscles, take another look at both breasts. To check if both breasts hang equally, bend forward.
  • With your thumb and index finger, gently pinch each nipple to check for any discharge.
  • Afterward, feel your breasts.
  • Put your left arm up in the air. The flat surfaces (fat pads) of your three middle fingers from your right hand should be used to exert firm pressure on your left breast. Start at the top of the left breast and move your fingers in a broad spiral or circular motion all the way around the breast. Check for lumps or thickening by feeling. Until you reach the nipple, keep moving in a spiral motion around the breast and inward toward it.
• Check the spaces between the breast and the collarbone as well as the spaces between the breast and the underarm.
• Repeat the examination for the right breast while raising your right arm above your head.

It will be more comfortable to place a folded towel or cushion under the shoulder of the breast you are examining if you are lying down to examine your breasts.

• A redness, dimpling, or puckering of the breast skin.
• A growth or lump in the breast, underarm, or nearby area. Do not be concerned if the lump is smooth or rubbery and moves under the skin when you push it with your fingers. The lump should be reported to your doctor if it is hard, unevenly shaped, painless, and only affects one breast. It should also not move even when you push on it.
• If your breasts typically have lumps, you should keep track of how many and where they are. You should keep track of any changes in size or shape for the next month (smooth or irregular). Utilizing the same method each month will allow you to detect any changes.
• You should notify your doctor of any nipple discharge that resembles blood or pus, especially if you are not breastfeeding.

After having a baby or ceasing breastfeeding, one or both breasts may discharge occasionally for up to a year.

Pelvic exam

The function of pelvic exams in family planning

Even though there are other reasons to perform a pelvic examination, in family planning services, these ones include:

• To evaluate the internal and exterior reproductive health of women.
• To examine the uterus's size, shape, location, and consistency, especially if pregnancy is suspected.
• To identify any external or internal genitalia conditions that might call for caution, such as additional testing, more frequent follow-up, or consideration of an alternative method of birth control (like detecting cervical infection or active pelvic inflammatory disease (PID) in a candidate for an IUD).
• to recognize any abnormal condition that might have developed accidentally or as a side effect of any form of contraception.
• to help identify the cause of unexplained vaginal bleeding, which in women of reproductive age is typically functional (such as an ovulation) but may also be caused by vaginal or cervical infections, incomplete abortions, ectopic pregnancies, or, in rare cases, cancer.

A clean, well-lit (light), private exam or procedure room with access to clean water should be used for pelvic exams. These things are required:

• Examining the table while draping a cloth over the woman
• Good source of light (lamp)
• Soap and a towel to clean and dry her genital and abdominal regions (if necessary)
• Place a rubber mat underneath the woman (optional)
• Clean surgical gloves or brand-new examination gloves (sterile gloves are not necessary)
• Bivalve vaginal speculum of the right size, thoroughly sterile or disinfected.
• Fabric swabs (for wiping discharge of mucus form the cervix or for specimen collection)
• Disposable and washable gloves, as well as a container with 0.5% chlorine solution for decontaminating the vaginal speculum.
• Use a plastic bag or a leak-proof container to dispose of garbage.
• For cervical or genital samples (optional)
• Dacron or cotton swabs (wire-handlefor urethral smears)
• Small test tube (5 to 10 ml)
• Glass slides with cover slips
• Wooden or plastic spatula  
• PH paper

Preparation

• Maintaining privacy is a must.
• Female aides are typically present for male clinicians. Female doctors may work with a female assistant, particularly if the client requests it or if it helps the client feel more at ease.
• Always speak in a soothing, relaxed tone, and let the client know that she is free to ask questions at any moment.
• Make sure the woman has let her bladder empty.
• If she has poor hygiene, make sure she has thoroughly cleaned and rinsed her vaginal area with soap and water.
• Asking the client to change (some wome may prefer to have privacy at th time). Help her get comfortable by helping her sit at the table. If necessary, ask her to take a few slow, deep breaths to help her unwind.
• Observe the client's discretion. Close the door to the examination room and/or draw the drapes around the examination table. Cover the client's knees by covering her with a sheet or drape. (If a sheet is not available, ask her to loosen her clothing and take off her clothes and/or underwear rather than completely undress her.)
• If you haven't done so already, wash your hands thoroughly with soap and water and dry them with a soft, dry cloth or by letting them air dry.
• On the examination table, have the patient lie on her back with her arms by her sides.
• Describe the purpose of the examination and the steps involved in it in brief (e.g., show the client the speculum and explain its use). Unless she requests otherwise, tell her what you are doing and how your examination is going. Utilize this chance to inform the woman about her own body.
• Light should be turned on and pointed toward genital region.
• Don both hands with fresh examination or highly sterile surgical gloves.
• Take a seat comfortably so you can readily view the external genitalia.
• Recognize any anxiety the client may be experiencing. Assure her that you will try your best to make the examination comfortable, and allow her to let you know if anything about it bothers her.

Procedure

• "Now I'm going to touch the inner of your leg," you should say to the customer before touching their privates. Use language she will comprehend, please.
• Before making any genital contact, lightly touch the inner of her thigh to avoid startling her.
• Talking to the client will help her unwind, which will make it easier for you to properly and rapidly palpate her internal organs. She needs to know what you plan to do.
• Typically, a right-handed individual will place their right hand in their vagina.
• With clean water or a small amount of vaginal secretions, moisten the index and middle finger of the pelvic hand.
• It is uncomfortable for the woman if you put your thumb on her clitoris.
• Inquire of the patient if she has any discomfort or pain while being examined. Additionally, look for signs of discomfort in her body language and facial expressions.
• When you feel the cervix, follow the anterior vaginal mucosa and start gently palpating it.
  • Your nose's tips will feel like your cervix when you are not pregnant. The cervix feels like your lip and is softer and bigger during pregnancy.
  • Feel the cervix's size, length, and contour.
  • Note its uniformity and location.
  • The location of the cervix frequently reveals the location of the uterus corpus. When the cervix is pointing up, the uterine body is typically directed posteriorly (retroverted), and when it is pointing down, the uterus is typically directed anteriorly (anteverted)
  • Between your fingertips, gently rock the cervix from side to side. It should be able to move 1-2 cm in each direction without irritating or hurting the client.
• If the client experiences pain with cervical motion, this may be a sign of uterine or adnexal infection. Ask the patient to indicate where the pain is located.
• Place your fingers behind the cervix with your palm facing up to feel the uterus' body. Then, place your second flat hand on the abdomen, in the middle, between the pubic bone and the umbilicus.
• Pressing downward and forward (toward the uterus) with the flat part of your fingers, slowly slide your abdominal hand toward the symphysis pubis. Try to trap the uterus between the fingers of your two hands by simultaneously pushing inside and upward with the fingers of one hand in the vagina. You will know if the uterus is anteverted feel the fundus between the fingers of your two hands, about 2-4 cm above the level of the pubic bone.
• The client might contract their buttocks and abdomen muscles. It will be easier for you to feel the uterus if you ask her to take a deep breath, blow it out, and relax the muscles in her buttocks.
  The uterus may be horizontally directed or, most likely, retroverted if you cannot feel it.
• To check this, you will need either to:
  • Place your fingers under the cervix and gently lift it up (posteriorly) to raise the uterus.
  • With the fingers of your abdominal hand, press down more forcefully.

Once found, there are six characteristics of the uterus to take note of:

• Size: The uterus should be between 5.5 and 8 cm (2 and 3 inches) length when not pregnant. Consider fibroids if swollen (smooth muscle pregnancy or fibroids tumors).
• Shape: The uterus should have a pear-shaped, rounded body. Suspect fibroids if it is irregular; if it is heart-shaped or "wide shouldered," consider atypical uterine structure (such as a "double" uterus).
• Position: The uterus should be in the midline, regardless of where it is. Deviation to the right or left may indicate pelvic tumors, ectopic pregnancy, or scar tissue (adhesions).
• Consistency: Pregnancy should be suspected if the uterine walls feel soft rather than smooth and firm.
• Mobility: If the uterus is fixed (not mobile), there may be adhesions or other issues. The uterus should be simple to move up or down in the anterioposterior plane.
• Tenderness: Infection should be suspected if the uterus is sore to pressure or movement in the normal course of things (endometritis). During the examination, inquire if the patient feels any soreness or pain. Additionally, keep an eye out for other signs of pain in her body and face; the kind of pain that matters will be clear from the woman's reaction to your actions.

Completing the examination

• Submerge both gloved hands in a 0.5% chlorine solution after the examination. Turn the gloves inside out to remove them.
  • Put the gloves in a leak-proof container or plastic bag before throwing them away.
  • If you plan to reuse the gloves, decontaminate them for 10 minutes in the 0.5% chlorine solution.
• Use soap and water to thoroughly clean your hands, then pat them dry with a soft cloth or let them air dry.
• Request that she move toward the head of the table so that you can assist her in assuming a sitting position.
• Offer the woman a tissue or "napkin" to wipe off her external genitalia before she puts on her clothes when lubrication is used for the bimanual examinations or if she is having her period or discharge. She needs to be shown where to throw the tissue.
• Once the patient is dressed, if the examination was normal, inform her that everything is fine and healthy and let her know when to come back for another checkup. If any abnormal findings were discovered, go over them with her and decide what, if anything, needs to be done.
• Use a 0.5% chlorine solution to clean any rubber sheet that was utilized.
• Record your findings.
  For instance
  Normal uterus dimensions, form, and consistency. midline, anteriorly oriented, freely mobile, and not tender
  No masses or tenderness exist in the adnexa (cervix).
  Ovaries: Clearly healthy