Breast assessment

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;

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;

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.

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.

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.

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.


 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.


• 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
arreola
FIBROUS CONNECTIVE TISSUE: support
ADIPOSE TISSUE: varies with age, the general
state of nutrition, pregnancy, exogenous
hormone use, and other factor

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).

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.

PHYSIOLOGY

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.


• 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.


INFRACLAVICULAR
NODES
• LYMPHATIC • SUPRA-
SYSTEM OF CLAVICULAR
• CENTRAL NODES NODES
THE BREAST • PECTORAL NODES
• SUB-SCAPULAR
NODES
• LATERAL NODES

AXILLA DRAIN


• 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.

THE BREAST: PURPOSE OF ASSESSMENT (BREAST
SELF-EXAMINATION)

THE BREAST & AXILLAE: PREPARATION
PRIOR TO ASSESSMENT

• To identify breast disease
• To initiate early treatment.

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.

THE BREAST & AXILLAE: BARRIER TO
BSE

• LACK OF CONFIDENCE

PRIOR TO ASSESSMENT

EQUIPMENT:
 Ruler (centimetres)
 Small pillow
 Gloves
 Client handout for Self-Breast
Examination
 Slide for specimen (if any)

PRIOR TO ASSESSMENT

POSITION 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)

THE BREAST & AXILLAE: METHODS
OF ASSESSMENT

When is the best time to
perform BREAST-SELF
EXAMINATION?

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.

INSPECTION

• Assess the breasts immediately after
the assessment of the thorax and
lungs and before a mammogram or
pelvic examination.

OF ASSESSMENT

• INSPECTION: Requires full exposure of
the chest. Inspect skin for changes,
symmetry, contours, color, superficial
vein patterns, presence of retractions

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.

INSPECTION

THE BREAST & AXILLAE: INSPECTION
TO VALIDATE THE PRESENCE OF DIMPLING OR
RETRACTIONS

TO VALIDATE THE PRESENCE OF DIMPLING OR
RETRACTIONS

• The three maneuvers presented above
contract the pectoral muscles.
• If the breasts are large or pendulous, it
may be useful to have the patient stand and
lean forward, supported by the back of the
chair or the examiner’s hands.
• Inspect the breast contours carefully to in
each position.

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.


• 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.


• 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.


• 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.


• 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.

INSPECTION ABNORMAL ASSESSMENT
FINDINGS

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.

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)

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.

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.

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.

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

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.

PALPATION

THE BREAST & AXILLAE: PALPATION
FOR THE PRESENCE OF NODULES

FOR THE NIPPLES

FOR THE LUMPECTOMY OR MASTECTOMY

• Mastectomy or lumpectomy scar
• Lymphedema
• Upper outer quadrant
• Lymph nodes
• Signs of inflammation

FOR THE LUMPECTOMY OR MASTECTOMY

OF THE AXILLAE

OF THE AXILLAE

• Sitting position preferable.
• Inspect each skin of the axilla noting
evidence of rash, signs/symptoms of
infection, unusual pigmentation.

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.

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.

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.

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.

THE BREAST & AXILLAE: SIGNS OF
BREAST CANCER

• Elevation
• Asymmetry
• Bleeding
• “Orange Peel” skin
• Nipple Retraction

THE BREAST & AXILLAE: SIGNS OF
BREAST CANCER

THE BREAST & AXILLAE: WHO ARE
AT RISKS OF BREAST CA?

• Altered body structure or function due to
trauma, pregnancy, recent childbirth,
anatomic abnormalities of genitals or
disease
• Physical, psychosocial, emotional, or
sexual abuse; sexual assault
• Disfiguring conditions, such as burns,
skin conditions, birthmarks, scars (e.g.
mastectomy)
• Specific medication therapy that causes
sexual problems

THE BREAST & AXILLAE: WHO ARE
AT RISKS OF BREAST CA?

• Temporary or long term impaired
physical ability to perform grooming and
maintain sexual attractiveness
• Value conflicts between personal
beliefs and religious doctrines
• Loss of partner
• Lack of knowledge or misinformation
about sexual functioning and expression

DIAGNOSTIC EXAMINATIONS

1. Clinical Breast Examination: Clinical breast
exam is an examination by a doctor or nurse,
who uses his or her hands to feel for lumps or
other changes

2. Breast self-exam: A breast self-exam is
when you check your own breasts for lumps,
changes in size or shape of the breast, or any
other changes in the breasts or underarm
(armpit).


1. DIAGNOSTIC MAMMOGRAPHY
• Multiple views are taken to isolate area of
cancer. It differs from a screening
mammogram, which involves only two x-ray
views and costs less.

3 views :
• Craniocaudal
• Mediolateral
• Axillary


2. ULTRASONOGRAPHY
• It is used to distinguish a fluid-filled cyst
from a solid mass.
• However, it can’t detect small small,
non-palpable cancers.
• It can’t also distinguish benign from
malignant lesions.


3. COMPUTED TOMOGRAPHY (CT SCAN)
• It is indicated for any discrete palpable mass,
regardless of mobility of mass, negative
mammogram, age of client, length of time
mass has been present or previous benign
biopsies.


4. 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.


a) 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


b.) 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.

5. STEREOTACTIC BIOPSY
• It is a new technique that is now used in
many centers, it is used for small non-
palpable breast lesions discovered during
mammography.
• The procedure takes an hour and requires
no special preparation. The patient is in
prone position, with breast suspended down
through a hole in examining table.


• A 14-gauge needle in a high speed core
biopsy gun is automatically guided by x-ray
to the suspicious area, where multiple
masses are taken.
• Potential complications are hematoma and
infection. Stereotactic biopsy is faster and
less expensive than needle localization and
outpatient surgical biopsy.

HEALTH PROMOTION AND
COUNSELLING (Abaquin and Kuan, 2005)

• Not delaying pregnancy until after 30 years
of age.
• Follow recommended mammography
screening guidelines for age group. If all
women over 50 years of age had annual
mammograms, breast cancer deaths would
decrease by 30%
• Breastfeeding
• Educate all women of reproductive age to
perform monthly self-breast examination

HEALTH PROMOTION AND
COUNSELLING (Abaquin and Kuan, 2005)

• Get regular breast examination
• Strenuous exercise, especially in youth but
also in adulthood.
• Advice older clients to use well-fitting bra
to reduce discomfort related to sagging of
breasts.
• Encourage healthy lifestyle choices such
as low-fat, high-fiber diet.

ASSESSMENT:
BREASTS & AXILLAE

THANKS!

Breast assessment

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