10chapter

ASSESSMENT OFtheBREASTS andAXILLAE

ANATOMY AND PHYSIOLOGY

THE FEMALE BREAST

THE FEMALE BREAST

THE FEMALE BREAST

THE FEMALE BREAST

THE FEMALE BREAST GLANDULAR TISSUES – forms 15 to 20 septated lobes radiating around the nipple- drain into milk producing ducts and sinuses that open onto the surface of the areola

FIBROUS CONNECTIVE TISSUE provides structural support in the form of fibrous bands or suspensory ligaments (Cooper’s ligaments)

ADIPOSE TISSUE – fat; surrounds the breast, predominantly in the superficial and peripheral areas

THE FEMALE BREASTS

THE FEMALE BREASTS

Milk Line or Ectodermal galactic band

THE FEMALE BREASTS

LYMPHATICS Central nodes Pectoral nodes Subscapular nodes

Lateral nodes Infraclavicular and supraclavicular nodes

HEALTHHISTORY

TECHNIQUES OF EXAMINATION

5 TO 7 DAYSafter the ONSET of menstruation

GENERAL APPROACHBEFORE If possible, instruct the patient to neither use creams, lotions or powders, nor shave the underarms 24 to 48 hours before the scheduled examination

Encourage patient to express any anxieties and concerns about the assessment

Inform patient that examination should not be painful but may be uncomfortable at times

Adopt a nonjudgmental and supportive attitude Instruct patient to remove any jewelry that might interfere with assessment

Ensure that the room is in a comfortable temperature

Warm hands Ensure privacy

GENERAL APPROACHDURING Inform patient of what you are going to do before you do it

Use this time to educate the patient about her body

Offer the patient the opportunity to ask questions about her body and sexuality

Keep areas not being assessed appropriately draped

Always compare right and left breasts Wear gloves if the patient has any discharge from the breast

GENERAL APPROACHAFTER Assess whether the patient needs assistance in dressing

After the patient is dressed, discuss the experience with her, invite questions and comments, listen carefully and provide her with information regarding the examination

THE FEMALE BREASTS

INSPECTION Positions of patient

Arms at side

Arms overhead

Hands pressed against hips

Leaning forward

INSPECTION Inspect the breasts, areolar areas and nipples for:

Color Vascularity Thickening or Edema Size and Symmetry Contour Lesions and Masses Discharges

INSPECTIONCOLOR Normal Findings:The breasts and are flesh-colored and the areolar areas and nipples are darker in pigmentation.

Abnormal Findings Reddened areas Striae

INSPECTIONVASCULARITY Normal Findings:Normal superficial vascular patterns are diffuse and symmetrical

Abnormal Findings Focal or unilateral superficial vascular patterns

INSPECTIONTHICKENING OR EDEMA Normal Findings: Normally, thickening or edema should not be found Abnormal Findings Peau d’ orange

INSPECTIONSIZE and SYMMETRY Normal Findings: Difference in the size of the breasts and areolar areas

Nipple inversion Nipples pointing upward and laterally, or outward and downward

Supernumerary nipples Abnormal Findings Asymmetrical nipple direction Significant differences in the size and symmetry Sudden onset of nipple inversion, flattening or depression

Additional broadening or thickening of a previously inverted nipple

Unilateral reduction of breast tissue

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INSPECTIONCONTOUR Normal Findings: Convex No flattening No retractions No dimpling Abnormal Findings Dimpling Retractions Flattening

INSPECTIONLESIONS or MASSES Normal Findings:Free of masses, tumors, and primary or secondary lesions

Abnormal Findings Breast masses, tumors, nodules or cysts of any kind

Persistent eczematous dermatitis of the areola and nipple region

INSPECTIONDISCHARGE Normal Findings No discharge for nonpregnant and nonlactating womanAbnormal Findings

Nipple discharge

PALPATION Ask the client to assume a supine position and to place arm overhead

Be systematic

PALPATION Use the finger pads of the three fingers

PALPATION Palpate the breasts using one of three different patterns

PALPATION Be sure to palpate every square inch of the breast, from the nipple and areola to the periphery and up into the tail of Spence.

PALPATION Vary the levels of pressure:

Light – superficial

Medium – midlevel tissue

Deep – to the ribs

PALPATIONPalpate the breast tissue for: Consistency Tenderness and temperature Nodules/lumps/masses

PALPATIONCONSISTENCY Normal Findings The consistency of the breasts is widely variable, depending on age, time in menstrual cycle, and proportion of adipose tissue Abnormal Findings Thickening of the tissues may occur with an underlying malignant tumor

PALPATIONTENDERNESS and TEMPERATURE Normal Findings Generalized tenderness associated with menstrual cycle or hormonal medications

Normal body temperature Abnormal Findings Painful breasts Heat in the breasts

PALPATIONNODULES Normal Findings No lumps or masses Abnormal Findings Presence of mass/lumps

PALPATIONIf a mass is noted, the following information should be obtained: Location Size Shape Number Consistency Definition Mobility Tenderness

PALPATION Palpate each nipple for elasticity Compress the nipple to express any discharge

Normal Findings: Elastic No discharge in nonpregnant and nonlactating women

Abnormal Findings Loss of elasticity Discharges and bleeding

THE AXILLAE

INSPECTION Inspect for: Rash Infection Unusual pigmentation Normal Findings No rash or infection Abnormal Findings Redness and Inflammation Dark, velvety pigmentation

PALPATION Ask patient to relax shoulders and arms.

Support the client’s arm and use the three fingers of your other hand to palpate firmly the following axillary lymph nodes

Central nodes Pectoral nodes Lateral nodes Subscapular nodes

PALPATION Normal findingsNo palpable nodes or one or two <1cm nontender nodes in the central area Abnormal findings

Enlarged (>1cm) lymph nodes

THE MALE BREASTS

INSPECTION AND PALPATION Inspect the nipple and areola for nodules, swelling or ulceration

Palpate the areola and breast tissue for nodules

Abnormal Finding: Gynecomastia

Gynecomastia

BREASTSELFEXAMINATION

BSE should be performed once a month, 5 to 7 days after the onset of menses

Advise patient to avoid the time when her breasts might be tender due to menstruation or ovulation

ED

BED (lying supine)1. Lie down with a pillow under right shoulder.

Place your right arm behind your head2. Use the finger pads of the three middle fingers

on your left hand to feel for lumps in the right breast.

3. Press firmly enough to know how your breasts feels, using firmer pressure for tissue closest to the chest and ribs

4. Press firmly on the breast in a vertical strip pattern. You can also use a circular or wedge pattern, but be sure to use the same pattern everytime.

5. Check the entire breast area, from the underarm to the sternum and from the collarbone to the ribs below the breast. Remember how your breast feels from month to month

6. Repeat the examination on the left breast, using the fingerpads of the right hand

TANDING

STANDING1. While standing in front of a mirror

with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin

XAMINE

EXAMINE1. Examine each underarm while sitting

up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it harder to examine