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Breast assessment

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  • 1. ASSESSMENT:BREAST & AXILLAE
  • 2. OBJECTIVES: At the end of the lecture-discussion, the students will be able to:• Define related terms in relation to the Breast and axillae;• Discuss the physiology and anatomy of the breast and axillae system;• Identify the purposes of performing breast and axillae assessment;
  • 3. OBJECTIVES:• Discuss the importance of preparing clients prior to breast and axillae examination;• Explain the two methods of examining the breast and axillae examination;• Explain the significance of a selected breast and axillae findings;• Enumerate the steps in performing breast and axillae assessment;
  • 4. OBJECTIVES:• Describe a suggested sequencing to conduct breast and axillae assessment in an orderly or systematic fashion;• State diagnostic procedures being performed to assess breast and axillae;• Discuss variations and special considerations in performing breast and axillae examination techniques appropriate for clients of different age.
  • 5. THE BREAST
  • 6. THE BREAST• It has an important role in modern culture• Often viewed as measures of sexuality , femininity and attractiveness because it is visible for its size and shape.• However, it is a secondary sex characteristic• Its physiologic function is milk secretion to feed infants.
  • 7. THE BREAST: CLINICAL VALUE
  • 8. THE BREAST: CLINICAL VALUE• Experience has verified that 90% of breast cancers are found by women themselves.• When women discover lumps in their breasts at a very early stage, surgery can save 70-80% of proven cases.
  • 9. THE BREAST: ANATOMY & PHYSIOLOGY
  • 10. THE BREAST: ANATOMY & PHYSIOLOGY lies against the anterior thoracic wall, extending from the clavicle and 2nd rib down to the 6th rib, and from the sternum across to the mid-axillary line. Its surface area is generally rectangular rather than round. The breast overlies the pectoralis major and at its inferior margin, the serratus anterior.
  • 11. THE BREAST: ANATOMY & PHYSIOLOGY Divided into four quadrants based on horizontal and vertical lines crossing at the nipple. Axillary tail of breast tissue extends toward the anterior axillary fold. Findings can be localized as the time on the face of a clock (e.g., 3 o’clock) and the distance in centimeters from the nipple.
  • 12. THE BREAST: ANATOMY & PHYSIOLOGY
  • 13. THE BREAST: ANATOMY & PHYSIOLOGY• The breast is hormonally sensitive tissue, responsive to the changes of monthly cycling and aging.GLANDULAR TISSUE: secretory tubualveolar ducts, lobules – drains into the nipples or arreolaFIBROUS CONNECTIVE TISSUE: supportADIPOSE TISSUE: varies with age, the general state of nutrition, pregnancy, exogenous hormone use, and other factor
  • 14. THE BREAST: ANATOMY & PHYSIOLOGY
  • 15. THE ARREOLA & THE NIPPLES: ANATOMY & PHYSIOLOGY Surface has small, rounded elevations formed by sebaceous glands, sweat glands, and accessory areolar glands and with hairs Well supplied with smooth muscle that contracts to express milk from the ductal system during breast- feeding. “Milk letdown” following (neurohormonal stimulation from infant sucking, tactile stimulation of the area, including the breast examination, makes the nipple smaller, firmer, and more erect, while the areola puckers and wrinkles (NORMAL).
  • 16. THE ARREOLA & THE NIPPLES: ANATOMY & PHYSIOLOGY• One or more extra or supernumerary nipples are located along the “milk line,”• Only a small nipple and areola are usually present, often mistaken for a common mole.• There may be underlying glandular tissue.• An extra nipple has no pathologic significance.
  • 17. THE ARREOLA & THE NIPPLES: ANATOMY & PHYSIOLOGY
  • 18. THE BREAST: LYMPHATICS• Drain toward the axilla.• CENTRAL NODES (axillary lymph node) most palpable frequently which lies along the chest wall, usually high in the axilla and mid-way between the anterior and posterior axillary folds.
  • 19. THE BREAST: LYMPHATICS• Into them drain channels from three other groups of lymph nodes, which are seldom palpable:• PECTORAL NODES: anterior• SUB-SCAPULAR NODES: posterior• LATERAL NODES: located along the upper humerus.
  • 20. THE BREAST: LYMPHATICS INFRACLAVICULAR NODES• LYMPHATIC • SUPRA- SYSTEM OF CLAVICULAR • CENTRAL NODES NODES THE BREAST • PECTORAL NODES • SUB-SCAPULAR NODES • LATERAL NODES AXILLA DRAIN
  • 21. THE BREAST: LYMPHATICS• Lymph drains from the central axillary nodes to the infraclavicular and supraclavicular nodes.• Not all the lymphatics of the breast drain into the axilla.• Malignant cells from a breast cancer may spread directly to the infraclavicular nodes or into deep channels within the chest.
  • 22. THE BREAST: PURPOSE OF ASSESSMENT (BREAST SELF-EXAMINATION)
  • 23. THE BREAST & AXILLAE: PREPARATION PRIOR TO ASSESSMENT• To identify breast disease• To initiate early treatment.
  • 24. THE BREAST & AXILLAE: ADVANTAGES OF BSE• Women can use BSE to asses their breasts.• When they perform BSE properly and regularly, they can note any changes in their breasts and seek further evaluation.• Examination should be done every month and at the end of menses in all menstruating women.
  • 25. THE BREAST & AXILLAE: BARRIER TO BSE• LACK OF CONFIDENCE
  • 26. THE BREAST & AXILLAE: PREPARATION PRIOR TO ASSESSMENTEQUIPMENT: Ruler (centimetres) Small pillow Gloves Client handout for Self-Breast Examination Slide for specimen (if any)
  • 27. THE BREAST & AXILLAE: PREPARATION PRIOR TO ASSESSMENTPOSITION OF THE CLIENT• Upright position (sitting while the client is asked to hold arms in different position: arms at sides, arms over head, arms pressed against hips, and leaning forward)• Supine/Standing (palpation)
  • 28. THE BREAST & AXILLAE: METHODS OF ASSESSMENTWhen is the best time toperform BREAST-SELF EXAMINATION?
  • 29. THE BREAST & AXILLAE: INSPECTION• 5-7 days after the menstruation or between the fourth or seventh day of the cycle (if the cycle is regular)  Increase estrogen levels before menstruation in effect breasts become more nodular.  Nodules appearing during the premenstrual phase should be re- evaluated at this later time.
  • 30. THE BREAST & AXILLAE: INSPECTION• Assess the breasts immediately after the assessment of the thorax and lungs and before a mammogram or pelvic examination.
  • 31. THE BREAST & AXILLAE: METHODS OF ASSESSMENT• INSPECTION: Requires full exposure of the chest. Inspect skin for changes, symmetry, contours, color, superficial vein patterns, presence of retractions
  • 32. THE BREAST & AXILLAE: METHODS OF ASSESSMENT• Assess also for the size, shape, texture of the arreola• Note also the characteristics of the nipples, including size and shape, direction in which they point, any rashes or ulceration, or any discharge.
  • 33. THE BREAST & AXILLAE: INSPECTION
  • 34. THE BREAST & AXILLAE: INSPECTION
  • 35. THE BREAST & AXILLAE: INSPECTION TO VALIDATE THE PRESENCE OF DIMPLING OR RETRACTIONS
  • 36. THE BREAST & AXILLAE: INSPECTION TO VALIDATE THE PRESENCE OF DIMPLING OR RETRACTIONS
  • 37. THE BREAST & AXILLAE: INSPECTION TO VALIDATE THE PRESENCE OF DIMPLING OR RETRACTIONS
  • 38. THE BREAST & AXILLAE: INSPECTION TO VALIDATE THE PRESENCE OF DIMPLING OR RETRACTIONS• The three maneuvers presented abovecontract the pectoral muscles.• If the breasts are large or pendulous, itmay be useful to have the patient stand andlean forward, supported by the back of thechair or the examiner’s hands.• Inspect the breast contours carefully to ineach position.
  • 39. THE BREAST & AXILLAE: INSPECTION ASSESSMENT FINDINGS• Color varies depending on the client’s skin tone. Texture is smooth with no edema.• Linear Stretch marks may be seen during and after pregnancy or with significant weight gain or loss.• Veins radiate either horizontally and toward the axilla (transverse) or vertically with a lateral flare (longitudinal). Veins are more prominent during pregnancy.
  • 40. THE BREAST & AXILLAE: INSPECTION ASSESSMENT FINDINGS• Redness from local infection or inflammatory carcinoma. A pigskin-like or orange-peel appearance results from edema, which is seen in metastatic breast disease.• A prominent venous pattern may occur as result of increased circulation due to malignancy. An asymmetric venous pattern may be due to malignancy.
  • 41. THE BREAST & AXILLAE: INSPECTION ASSESSMENT FINDINGS• Breast symmetrical in size, shape, no prominent pores,• Breasts can be a variety of sizes and are somewhat round and pendulous.• One breast may normally be larger than the other.
  • 42. THE BREAST & AXILLAE: INSPECTION ASSESSMENT FINDINGS• Areolas vary from dark pink to dark brown, depending on the client’s skin tone. They are round and may vary in size. Small Montgomery tubercles are present.• Nipples are nearly equal bilaterally in size and are in the same location on each breast.• Nipples are usually everted, but they may inverted or flat. Supernumerary nipples, may appear along the embryonic “milk-line”.• No discharges should be present.
  • 43. THE BREAST & AXILLAE: INSPECTION ASSESSMENT FINDINGS• When doing the three maneuvers that validate the presence of retractions, the client’s breasts should rise symmetrically with no sign of dimpling or retraction.• Breasts should hang freely and symmetrically.
  • 44. THE BREAST & AXILLAE:INSPECTION ABNORMAL ASSESSMENT FINDINGS
  • 45. THE BREAST & AXILLAE:INSPECTION ABNORMAL ASSESSMENT FINDINGS
  • 46. THE BREAST & AXILLAE:INSPECTION ABNORMAL ASSESSMENT FINDINGS
  • 47. THE BREAST & AXILLAE:INSPECTION ABNORMAL ASSESSMENT FINDINGS
  • 48. THE BREAST & AXILLAE:INSPECTION ABNORMAL ASSESSMENT FINDINGS
  • 49. THE BREAST & AXILLAE:INSPECTION ABNORMAL ASSESSMENT FINDINGS
  • 50. THE BREAST & AXILLAE: INSPECTION-GERIATRIC CONSIDERATIONS• The older client often has more pendulous, less firm, and saggy breasts.• Older clients may have smaller, flatter nipples that are less erectile or stimulation.
  • 51. THE BREAST & AXILLAE: METHODS OF ASSESSMENT• PALPATION: Cover one breast while you are palpating the other. • TEXTURE AND ELASTICITY • CONSISTENCY OF THE TISSUES. • TENDERNESS AND TEMPERATURE (as in pre- menstrual fullness)
  • 52. THE BREAST & AXILLAE: METHODS OF ASSESSMENT• SUPINE: breast tissue is flattened• palpate a rectangular area extending from the clavicle to the inframammary fold or bra line, and from the midsternal line to the posterior axillary line and well into the axilla for the tail of the breast.
  • 53. THE BREAST & AXILLAE: METHODS OF ASSESSMENT• A thorough examination will take 3 minutes for each breast.• Use the fingerpads of the 2nd, 3rd, and 4th fingers, keeping the fingers slightly flexed. It is important to be systematic.
  • 54. THE BREAST & AXILLAE: METHODS OF ASSESSMENT• Palpate the breasts using one of the three different patterns ( circular or clockwise, wedge, vertical strip). Choose one that is most comfortable for you, but be consistent and thorough with the method chosen.• Start at one point for palpation and move systematically to the end-point to ensure that all breast surfaces are assessed.
  • 55. THE BREAST & AXILLAE: METHODS OF ASSESSMENT• Be sure to palpate every square inch of the breast from the nipple and areola to the periphery of the breast tissue and up to into the tail of Spence.• Vary the levels of pressure as you press. • LIGHT – superficial • MEDIUM – mid-level tissue • Firm – to the ribs
  • 56. THE BREAST & AXILLAE: METHODS OF ASSESSMENT• Use the bimanual technique if the client has large breasts.• Support the breast with your non- dominant hand and use your dominant hand to palpate.
  • 57. THE BREAST & AXILLAE: PALPATION
  • 58. THE BREAST & AXILLAE: PALPATION
  • 59. THE BREAST & AXILLAE: PALPATION FOR THE PRESENCE OF NODULES
  • 60. THE BREAST & AXILLAE: PALPATION FOR THE PRESENCE OF NODULES
  • 61. THE BREAST & AXILLAE: PALPATION FOR THE NIPPLES
  • 62. THE BREAST & AXILLAE: PALPATION FOR THE NIPPLES
  • 63. THE BREAST & AXILLAE: PALPATION FOR THE NIPPLES
  • 64. THE BREAST & AXILLAE: PALPATION FOR THE LUMPECTOMY OR MASTECTOMY• Mastectomy or lumpectomy scar• Lymphedema• Upper outer quadrant• Lymph nodes• Signs of inflammation
  • 65. THE BREAST & AXILLAE: PALPATION FOR THE LUMPECTOMY OR MASTECTOMY
  • 66. THE BREAST & AXILLAE: PALPATION FOR THE LUMPECTOMY OR MASTECTOMY
  • 67. THE BREAST & AXILLAE: INSPECTION OF THE AXILLAE
  • 68. THE BREAST & AXILLAE: INSPECTION OF THE AXILLAE• Sitting position preferable.• Inspect each skin of the axilla noting evidence of rash, signs/symptoms of infection, unusual pigmentation.
  • 69. THE BREAST & AXILLAE: INSPECTION OF THE AXILLAE• To examine the left axilla, ask the patient to relax with the left arm down.• Help by supporting the left wrist or hand with your left hand.• Cup together the fingers of your right hand and reach as high as you can toward the apex of the axilla.• Warn the patient that this may feel uncomfortable. Your fingers should lie directly behind the pectoral muscles, pointing toward the midclavicle.
  • 70. THE BREAST & AXILLAE: INSPECTION OF THE AXILLAE• Now press your fingers in toward the chest wall and slide them downward, trying to feel the central nodes against the chest wall.
  • 71. THE BREAST & AXILLAE: INSPECTION OF THE AXILLAE• PECTORAL NODES: grasp the anterior axillary fold between your thumb and fingers, and with your fingers palpate inside the border of the pectoral muscle.• LATERAL NODES: from high in the axilla, feel along the upper humerus.
  • 72. THE BREAST & AXILLAE: INSPECTION OF THE AXILLAE• SUB-SCAPULAR NODES: step behind the patient and with your fingers feel inside the muscle of the posterior axillary fold.• Feel for infraclavicular nodes and re- examine the supraclavicular nodes.
  • 73. THE BREAST & AXILLAE: SIGNS OF BREAST CANCER• Elevation• Asymmetry• Bleeding• “Orange Peel” skin• Nipple Retraction
  • 74. THE BREAST & AXILLAE: SIGNS OF BREAST CANCER
  • 75. THE BREAST & AXILLAE: WHO ARE AT RISKS OF BREAST CA?• Altered body structure or function due totrauma, pregnancy, recent childbirth,anatomic abnormalities of genitals ordisease• Physical, psychosocial, emotional, orsexual abuse; sexual assault• Disfiguring conditions, such as burns,skin conditions, birthmarks, scars (e.g.mastectomy)• Specific medication therapy that causessexual problems
  • 76. THE BREAST & AXILLAE: WHO ARE AT RISKS OF BREAST CA?• Temporary or long term impairedphysical ability to perform grooming andmaintain sexual attractiveness• Value conflicts between personalbeliefs and religious doctrines• Loss of partner• Lack of knowledge or misinformationabout sexual functioning and expression
  • 77. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONS1. Clinical Breast Examination: Clinical breastexam is an examination by a doctor or nurse,who uses his or her hands to feel for lumps orother changes2. Breast self-exam: A breast self-exam iswhen you check your own breasts for lumps,changes in size or shape of the breast, or anyother changes in the breasts or underarm(armpit).
  • 78. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONS1. DIAGNOSTIC MAMMOGRAPHY• Multiple views are taken to isolate area ofcancer. It differs from a screeningmammogram, which involves only two x-rayviews and costs less.3 views :• Craniocaudal• Mediolateral• Axillary
  • 79. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONS
  • 80. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONS2. ULTRASONOGRAPHY• It is used to distinguish a fluid-filled cystfrom a solid mass.• However, it can’t detect small small,non-palpable cancers.• It can’t also distinguish benign frommalignant lesions.
  • 81. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONS
  • 82. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONS3. COMPUTED TOMOGRAPHY (CT SCAN)• It is indicated for any discrete palpable mass,regardless of mobility of mass, negativemammogram, age of client, length of timemass has been present or previous benignbiopsies.
  • 83. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONS
  • 84. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONS4. BIOPSY – is a medical test involving removal of cells or tissues for examination.• It is done under local anesthesia and occasionally under general anesthesia, include fine needle aspiration, needle core biopsy, open biopsy, and needle localization.
  • 85. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONSa) Aspiration Biopsy – a syringe and g 18 needle is used to aspirate tissue from the site which is under local anesthesia.• The specimen is spread on a glass slide, fixed, stained and sent to the laboratory
  • 86. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONS
  • 87. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONSb.) Incisional Biopsy – a piece of tissue is obtained in the operating room, sent to the laboratory fro frozen section which is the stained and examined under the microscope.
  • 88. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONS
  • 89. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONS5. STEREOTACTIC BIOPSY• It is a new technique that is now used inmany centers, it is used for small non-palpable breast lesions discovered duringmammography.• The procedure takes an hour and requiresno special preparation. The patient is inprone position, with breast suspended downthrough a hole in examining table.
  • 90. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONS• A 14-gauge needle in a high speed corebiopsy gun is automatically guided by x-rayto the suspicious area, where multiplemasses are taken.• Potential complications are hematoma andinfection. Stereotactic biopsy is faster andless expensive than needle localization andoutpatient surgical biopsy.
  • 91. THE BREAST & AXILLAE: DIAGNOSTIC EXAMINATIONS
  • 92. HEALTH PROMOTION AND COUNSELLING (Abaquin and Kuan, 2005)• Not delaying pregnancy until after 30 yearsof age.• Follow recommended mammographyscreening guidelines for age group. If allwomen over 50 years of age had annualmammograms, breast cancer deaths woulddecrease by 30%• Breastfeeding• Educate all women of reproductive age toperform monthly self-breast examination
  • 93. HEALTH PROMOTION AND COUNSELLING (Abaquin and Kuan, 2005)• Get regular breast examination• Strenuous exercise, especially in youth butalso in adulthood.• Advice older clients to use well-fitting brato reduce discomfort related to sagging ofbreasts.• Encourage healthy lifestyle choices suchas low-fat, high-fiber diet.
  • 94. ASSESSMENT:BREASTS & AXILLAE
  • 95. ASSESSMENT: BREASTS & AXILLAETHANKS!
  • 96. ASSESSMENT:BREASTS & AXILLAE