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NSG 3160 · Jarvis Ch. 27 & 28 · Quick Reference
Chapters 27 & 28: Female GU · Complete
Assessment
Normal vs. Abnormal Findings
Jarvis & Eckhardt (2024) 9th Ed. · Ch.27 pp.731–767 · Ch.28 pp.769–784 · Unit 9 & 10
n Normal n Abnormal n Rationale n Alert/Refer
n CHAPTER 27 — FEMALE GENITOURINARY SYSTEM
EXTERNAL GENITALIA — INSPECTION
n NORMAL FINDINGS n ABNORMAL FINDINGS
Skin color even. Labia minora darker pink and moist. Labia majora symmetric, plump, well formed; gaping/shriveled after vaginal delivery (normal). Hair in inverted triangle; may trail toward umbilicus. Sebaceous cysts: yellowish, 1 cm, firm, nontender, often multiple (normal).
Pigmented nevus or suspicious lesion → biopsy. Nits or lice at base of pubic hair; excoriated skin. Swelling of labia. Excoriation, nodules, rash, or lesions on labia minora. Delayed puberty: no pubic hair or breast development by age 14–15.
Clitoris: no inflammation. Urethral opening: stellate or slitlike, midline. Vaginal opening: narrow slit or larger. Perineum smooth; well-healed episiotomy scar may be present.
Clitoris: inflammation or lesions. Urethral meatus: polyp, discharge. Foul-smelling, irritating discharge. Markedly enlarged clitoris + fusion of labia = ambiguous genitalia → REFER IMMEDIATELY.
Bartholin area: labia feel soft and homogeneous. Perineum: thick, smooth, muscular (nulliparous); thin and rigid (multiparous). No bulging or urinary incontinence with straining.
Bartholin gland abscess: posterior labia swollen, palpable fluctuant mass, red hot overlying skin, discharge from duct opening → incision and drainage + antibiotics. Cystocele: anterior vaginal wall bulge. Rectocele: posterior vaginal wall bulge. Uterine prolapse: cervix/uterus protruding. Urinary incontinence.
n RATIONALE Bartholin gland ducts open at 5 and 7 o'clock positions. Do NOT palpate clitoris in infants/children (very sensitive). Imperforate hymen = warrants referral. Infants: sanguineous discharge or leukorrhea normal first few weeks (maternal estrogen). Ages 2 months to 7 years: no irritation or foul-smelling discharge is normal.
CERVIX — SPECULUM INSPECTION (Advanced Practice)
n NORMAL FINDINGS n ABNORMAL FINDINGS
Color: pink and even (cervical mucosa). Chadwick sign = blue at 6– weeks pregnancy (normal). After menopause: pale cervix. Transformation zone easy to see in young women; migrates inward with aging; not visible after menopause.
Redness, inflammation. Pallor with anemia. Cyanosis other than pregnancy = heart failure or pelvic tumor. Lateral position = adhesion or tumor. Projection >3 cm = prolapse. Hypertrophy >4 cm = inflammation or tumor.
Os: small and round (nulliparous); horizontal irregular slit with healed lacerations (parous). Nabothian cysts: small, smooth, yellow nodules <1 cm (benign; from obstruction of cervical glands after childbirth). Cervical secretions: odorless and nonirritating; may be clear/thin or thick/opaque depending on cycle.
Reddened, granular, asymmetric surface especially around os. Friable, bleeds easily. White patch on cervix. Strawberry spot. Cervical polyp: bright red soft pedunculated growth from os → biopsy. HPV (condylomata): warty thickened white epithelium, enhanced by acetic acid wash (acetowhitening with irregular borders). Cervical cancer: chronic ulcer, induration, bleeding. ANY suspicious red, white, or pigmented lesion → refer for biopsy.
Cervical eversion (ectropion): red beefy halo inside pink cervix around os — can occur normally after vaginal deliveries.
Cannot always distinguish ectropion from erosion or carcinoma — biopsy may be needed. DES syndrome: daughters of women given DES 1940–1970 have rare tumor and cervical/vaginal abnormalities; even 3rd-generation DES exposure women at increased risk.
n RATIONALE Pap test screening: No Pap under age 25. Ages 25–65: HPV testing alone or co-testing with Pap every 5 years. Pap alone every 3 years ages 30–65. Pap test screens for CERVICAL cancer only — NOT endometrial or ovarian. Goodell sign = cervix softens like velvet at 5– weeks pregnancy.
VAGINAL WALL — INSPECTION
n NORMAL FINDINGS n ABNORMAL FINDINGS
Vaginal wall: pink, deeply rugated, moist and smooth. No inflammation or lesions. Normal discharge: thin and clear or opaque and stringy; always odorless.
Inflammation or lesions. Leukoplakia: spot of dried white paint. Thick white curdlike = candidiasis. Profuse watery gray-green frothy = trichomoniasis. Gray, green-yellow, white, foul-smelling = various infections. Aging: walls look pale pink from thinned epithelium (atrophic vaginitis).
n RATIONALE Slowly withdraw speculum while rotating to fully inspect vaginal wall. Do not pinch mucosa or catch hair as blades close. Turn blades obliquely to avoid stretching opening. Pedersen speculum (narrow blades) preferred for postmenopausal women with vaginal stenosis/dryness.
BIMANUAL EXAMINATION — CERVIX, UTERUS & ADNEXA
n NORMAL FINDINGS n ABNORMAL FINDINGS
Vaginal wall: smooth, no induration or tenderness. Cervix: smooth and firm (like tip of nose). Evenly rounded contour. Freely mobile side to side WITHOUT PAIN.
Vaginal wall: nodule, tenderness. Cervix: hard = malignancy. Nodular, irregular. Immobile = malignancy. PAINFUL with movement = inflammation, PID, ectopic pregnancy (chandelier sign).
Uterus: firm, smooth, fundus rounded. Freely movable and nontender. Positions: anteverted/anteflexed (most common), midposition, retroverted, retroflexed (all can be normal).
Enlarged uterus: pregnancy, fibroids, carcinoma. Lateral displacement. Nodular/irregular/asymmetric = fibroids. Fixed and immobile = endometriosis or PID. Tenderness. Retroverted + FIXED = endometriosis or PID (not just retroverted alone).
Adnexa: ovary smooth, firm, almond-shaped, highly movable, slightly sensitive but NOT painful. Fallopian tube NOT palpable. No mass or pulsation. Secretions on withdrawal: clear or cloudy, odorless.
Enlarged adnexa. Nodules or mass in adnexa. Immobile ovary. MARKEDLY TENDER. Pulsation or palpable fallopian tube = ectopic pregnancy → IMMEDIATE REFERRAL. Any unidentified mass → refer. Postmenopausal: ovaries NOT normally palpable — any palpable ovary = abnormal.
n RATIONALE Hegar sign = isthmus softer, compressible at 10–12 weeks pregnancy. Normal adnexal structures often NOT palpable — consider abnormal any mass you cannot positively identify. Rectovaginal septum (rectovaginal exam): smooth, thin, firm, pliable. Change gloves before rectovaginal exam. Test stool for occult blood.
VAGINITIS DIFFERENTIAL DIAGNOSIS — QUICK COMPARISON (Table 27.5)
Type Discharge Symptoms pH Diagnostic Test Key Notes
Candidiasis Thick, white, curdy ("cottage cheese"); NOT malodorous
Intense pruritus; vulva/vagina RED and edematous
<4.5 KOH wet mount → branched hyphae
NOT an STI. Caused by antibiotics, OCs, DM, pregnancy, douching, tight clothing
Trichomoniasis Frothy, yellow-green, foul-smelling
Pruritus, dysuria, frequency; vagina red/granular with petechiae ("strawberry")
>4.5 Saline wet mount → flagellated trichomonads
STI — sexual transmission. Treat both partners
Bacterial Vaginosis
Thin, creamy, gray-white, malodorous; "foul, fishy, rotten"; may have bubbles
"Constant wetness"; most ASYMPTOMATIC; NO vaginal wall inflammation
>4.5 Saline wet mount → "clue cells." KOH → fishy odor ("whiff test"). = Amsel criteria
STI — highly prevalent. No vaginal/cervical inflammation (surface parasite)
Chlamydia Yellow/green mucopurulent; or NO discharge
Often ASYMPTOMATIC; may have urinary frequency, dysuria, postcoital bleeding; friable cervix; cervical motion tenderness
Varies NAAT — first-void urine or vaginal swab
MOST COMMON STI. If untreated → PID → infertility. Screen all sexually active women ≤24 years annually
Gonorrhea Purulent vaginal discharge; often NONE (95% asymptomatic)
Mostly asymptomatic; may have dysuria, abnormal uterine bleeding, Bartholin/Skene gland abscess
Varies NAAT — co-test with chlamydia
If untreated → acute salpingitis, PID. Treat + retest in 3– months
HPV Genital Warts Painless warty growths; may be unnoticed. Pink or flesh-colored, soft, pointed, moist, warty papules; single or multiple cauliflower-like patch. Around vulva, introitus, anus, vagina, cervix.
Risk: early age at menarche, multiple sex partners. Gardasil vaccine prevents majority of HPV-related diseases. HPV = 90% cervical/anal, 70% oropharyngeal, 60% penile cancers.
Pediculosis Pubis (Crab Lice)
Severe perineal itching. Excoriations and erythematous areas. Little dark spots/nits adherent to pubic hair near roots; look like brown hemorrhagic crusts.
Usually sexually transmitted; occasionally contaminated clothing or bedding. May occasionally be in eyebrows or eyelashes.
DEVELOPMENTAL FINDINGS — CHAPTER 27
n NORMAL FINDINGS n ABNORMAL FINDINGS
NEWBORNS — Normal: Genitalia somewhat engorged (maternal estrogen). Labia majora swollen. Clitoris relatively large. Hymen appears thick. Sanguineous vaginal discharge or leukorrhea normal in first few weeks. Engorgement resolves within weeks; labia minora remain small until puberty.
NEWBORNS — Abnormal: Ambiguous genitalia (enlarged clitoris, fused labia, palpable mass in fused labia) → REFER immediately. Imperforate hymen → warrants referral. Lesions, rash.
CHILDREN — Normal (2 months to 7 yrs): Labia majora flat, labia minora thin, clitoris relatively small, hymen tissue-paper thin. No irritation or discharge. Ages 7–10: structures thicken slightly. Pubic hair around age 11 (sparse may start age 8). Menarche follows adolescent growth spurt.
CHILDREN — Abnormal: Poor perineal hygiene. Foul-smelling discharge = foreign body, pinworms, or infection. Absence of pubic hair by age 13 = delayed puberty. Amenorrhea in adolescent + bluish bulging hymen = imperforate hymen → REFER. Screen for sexual abuse directly and age-appropriately.
PREGNANCY — Normal: Chadwick sign = blue vaginal walls and cervix from hyperemia. Hegar sign = isthmus softer, compressible between hands. Vaginal walls deeply rugated; mucosa thickens. Cervix looks blue, feels velvety.
PREGNANCY — Abnormal: Palpable adnexal structures in early pregnancy = ectopic pregnancy → IMMEDIATE referral. Any adnexal mass warrants immediate evaluation.
AGING ADULTS — Normal: Pubic hair grays and becomes sparse. Labia flatter. Clitoris size decreases after 60. Vaginal walls pale pink, rugae decrease. Cervix shrinks, pale, glistening; may retract flush with vaginal wall. Ovaries NOT palpable. Uterus smaller, firmer.
AGING ADULTS — Abnormal: Any palpable ovary in postmenopausal woman = ABNORMAL → refer for prompt evaluation. Postmenopausal bleeding → pelvic exam, transvaginal ultrasonography, referral. Vaginal atrophy increases risk for infection and trauma. Suspicious lesions → biopsy.
n CHAPTER 28 — COMPLETE HEALTH ASSESSMENT: ADULT
Chapter 28 describes the SEQUENCE and INTEGRATION of all system assessments into one complete head-to-toe examination. No new normal/abnormal findings are introduced — it applies the findings from all previous chapters in a systematic order to minimize patient position changes. Performed at a patient's FIRST entry into outpatient setting or initial hospital admission.
COMPLETE ADULT EXAM — ORDERED SEQUENCE & KEY POINTS
Phase / Position Assessment Steps Key Notes
Seated in street clothes
History; General appearance (LOC, skin color, nutritional status, posture, mobility, gait, facial expression, mood, speech, hearing, hygiene); Measurements (weight, height, waist circumference, BMI, Snellen vision)
Note general appearance THROUGHOUT the exam. BP requires 5 min rest before measurement. Have patient empty bladder (save specimen if needed).
Seated, gowned (legs dangling)
Vital signs (pulse, respirations, BP, temp); Skin; Head & face; Eyes (acuity, fields, EOMs, funduscopic); Ears (canals, TM, whisper test); Nose; Mouth & throat; Neck (ROM, lymph nodes, thyroid, carotid); Upper extremities (ROM, pulses, strength)
Examiner stands in front of patient for most steps. Assess skin throughout. Cranial nerves integrated into relevant system exams.
Sitting, leaning forward (posterior thorax)
Posterior thorax: inspect, palpate (tactile fremitus, symmetric expansion), percuss, auscultate; Spine and back; CVA tenderness
Compare side to side. Dullness = consolidation/fluid; hyperresonance = air. Posterior chest: auscultate from top to bottom, side to side.
Supine (anterior thorax)
Anterior thorax and lungs; Female breasts (inspect 3 positions, palpate with arm raised, palpate nipple, axillary nodes, teach BSE); Neck vessels (JVD); Heart (inspect, palpate apical impulse, auscultate "Z" pattern — diaphragm then bell, left lateral for apex with bell)
Male breasts: inspect and palpate while palpating anterior chest wall. Heart: auscultate all 5 areas (aortic, pulmonic, Erb's point, tricuspid, mitral). Z-pattern from apex to base or base to apex.
Supine (abdomen) Abdomen: Inspect → Auscultate (bowel sounds + vascular) → Percuss all quadrants → Palpate (light then deep, all quadrants) → Liver, spleen, kidneys → Aorta pulsation if indicated; Inguinal area: femoral pulse + inguinal nodes; Lower extremities: skin, hair, pulses (popliteal, post tibial, dorsalis pedis), temp, edema, toes, ROM + muscle strength
ABDOMEN EXAM ORDER: Inspect FIRST, then Auscultate BEFORE percussing/palpating (percussion/palpation can increase peristalsis → falsify bowel sounds). Lift drape to expose legs after abdomen.
Sitting (legs dangling) Neurologic: sensation (superficial pain, light touch, vibration), position sense, stereognosis; Cerebellar (finger-to-nose, rapid alternating movements, heel-shin test); DTRs (biceps, triceps, brachioradialis, patellar, Achilles); Babinski reflex; Note muscle strength as person sits up
DTRs: graded 0-4+. 2+ = normal. Babinski = abnormal in adults (normal in infants <2 years). Romberg tested when standing.
Standing Lower extremities: inspect for varicose veins; Gait (walk across room, turn, heel-toe, toe walk, heel walk, Romberg sign, shallow knee bend); Spine ROM (hyperextension, rotation, lateral bending, scoliosis check with forward bend)
Stand close to patient for safety during Romberg and balance tests. Stabilize pelvis when testing spine ROM.
Male (standing/standing over table)
Male genitalia: inspect/palpate penis, scrotum; transilluminate if mass; check inguinal hernia; teach TSE; Male rectum: perianal inspection, rectal/prostate palpation, stool occult blood
Position: standing (genitalia) → bent over table or left lateral (rectum). NAVEL for femoral landmarks. Use lubricated gloved finger toward umbilicus for rectal exam — never at right angles.
Female (lithotomy) Female genitalia: perineal and perianal inspection; speculum exam (cervix, vaginal walls, specimens); bimanual exam (cervix, uterus, adnexa); rectovaginal exam if indicated; stool occult blood
Elevate head 30–40 degrees. Arms at sides (not overhead). Have chaperone present. Warm speculum. Explain each step. Patient can say "stop" at any time. Offer mirror pelvic exam.
n CPE CRITICAL ELEMENTS — FEMALE GU & COMPREHENSIVE ASSESSMENT
- Inquire frequency, urgency, hesitancy, straining, dysuria, and other changes or abnormalities.
- Palpate bladder for distention and tenderness.
- Inspect urine for color, amount, clarity, odor, particulate matter.
- Female — inquire frequency, duration, and onset of last menstrual cycle.
- (From comprehensive CPE) All body systems assessed in sequence as listed in Jarvis Chapter 28 complete adult exam.
n CANCER SCREENING SUMMARY — Chapter 27 Key Screening Guidelines
CERVICAL CANCER SCREENING: No Pap test under age 25 (even if sexually active). Ages 25–65: HPV testing alone or co-testing with Pap every 5 years. Pap alone every 3 years ages 30–65. Women ≥65 may choose to stop. STI SCREENING: Screen ALL sexually active women ≤24 years for chlamydia annually. Also screen those ≥25 with new/multiple partners. HPV VACCINE: All girls and boys by age 13 (used ages 9–26). 2 doses if 1st dose before 15 years; 3 doses if 15–45 years. POSTMENOPAUSAL BLEEDING: Warrants pelvic exam + transvaginal ultrasonography + referral. INTIMATE PARTNER VIOLENCE: Document all injuries objectively, provide resources, do not confront perpetrator in patient's presence.
NSG 3160 · Galen College of Nursing · Jarvis & Eckhardt (2024) · Ch.27 pp.731–767 · Ch.28 pp.769–784 · Unit 9 & 10 USLOs 1–
