Nursing practice

1. Salale University College of Health Sciences Department of
Adult Health Nursing
Presentation On : Assessment of Breast and Axila
Submitted to Taddala Assistant Professor
June 2/06/ 2023
Fiche

2. Learning out come
At the end of this Lesson the study participants will be able
to:
 Describe the anatomy & physiology of the breasts and
axilla (regional lymphatics), including age related
variations.
 Demonstrate assessment techniques for the evaluation of
the breasts and Axilla (lymphatics).
 Perform a breast and axilla hysical assessment.
 Differentiate between normal and abnormal findings.
 Discuss methods of teaching breast self-examination to
patients.
 Understand normal breast change during developmental
care

3. Breast
Breasts are paired mammary glands located within
superficial fascia of anterior chest wall
The female breast 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 midaxillary line.
The breast is made up of three types of tissue:
Glandular: Also called lobules, glandular tissue produces
milk.
Fatty: This tissue determines breast size
Connective or fibrous: This tissue holds glandular and fatty
breast tissue in place.
Male breast has no lobes and located in 4th intercostal
space in mid clavicle.

4. Breast Anatomy
 There are many different parts of female breast
anatomy, including:
 Lobes and lobules : Composed of 15-25 radially
arranged lobes of parenchyma and Contain alveoli
cells that produce milk
 Milk (mammary) ducts: These small tubes, or ducts,
carry milk from glandular tissue (lobules) to nipples.
 Nipples: The nipple is in the center of the areola.

5. Breast Anatomy
 Areolae: Dark tissue surrounding nipple and have glands
called Montgomery’s glands that secrete a lubricating
oil.
 Blood vessels: circulate blood throughout the breasts,
chest and body.
 Nerves: Nipples have hundreds of nerve endings, which
makes them extremely sensitive to touch and arousal.
 Limph vessel-are connected to lymph nodes under the
arms that help fight infections.

6. Breast anatomy

7. Breast anatomy
• Divided into four quadrants by vertical and horizontal
lines intersecting at nipple.

8. Breast physiology
 Breasts are part of the female and male sexual anatomy. For
females, breasts are both functional (for breastfeeding) and sexual
(bringing pleasure). Male breasts don’t have a function.
 Breasts size change dramatically during pregnancy and lactation in
response to luteal and placental hormones:
 Nipples enlarged, Visible veins, Soreness, tenderness Enlarged,
darker Montgomery tuberclles and colostrum
 Breast changes during lactation in response to luteal hormones:
Increase size, Increase weight
 Male breast undergoes little development after birth; gland
remains rudimentary.

9. Axilla
 A pyramid-shaped space between the upper part of the
arm and the side of the chest
 The axillary walls are used as landmarks by surgeons to
prevent damage to the neurovascular structures within
the axilla during surgery.
 The overall 3D shape of the axilla looks slightly like a
pyramid. It consists of four sides, an open apex and base:
 Apex – also known as the axillary inlet, it is formed by
lateral border of the first rib, superior border of scapula,
and the posterior border of the clavicle.
 Medially - serratus anterior, thoracic wall
 Laterally - intertubercular sulcus of the humerus
 Anteriorly - pectoralis major and minor
 Posteriorly - subscapularis, latissimus dorsi, teres major
muscles


10. AXILLA
 The contents of the axilla region include:
 Muscles - coracobrachialis, pectoralis minor, and the biceps brachii
 Blood vessels - axillary artery and vein
 Nerves - brachial plexus
 Lymphatics - axillary lymph nodes (pectoral, subscapular, lateral,
central, infraclavicular groups)

11. Clinical Examination
Include :
• Explain to your patient
• Patient’s permission
• Privacy
• palpation of both breasts, armpits and
root of the neck
• Done before biopsy by
• Semi-recumbent position (45°) ,
supine, sitting
• Expose upper half of the patient, both breasts exposed
• Arms by the sides
• educating women on breast self-examination and awareness,
particularly on breast lumps.

12. Physical Assessment of Breast and
Axilla
 Involve :
 Breast history
 Inspection
 Palpation
 Documentation

13. Breast History
Detailed history analysis of :
 Biographical data(Age,Gender,Race)
 Current health status(change in size,Pain, axillary and
breast tenderness, ,skin lesion, redness, nipple inversion,
trauma,thickining, discharge)
 History of BSE
 History of hospitalization and medication

14. Breast History
 History of mammogram
 History of menstrual , pregnancy, lactation, family,
previous breast,problems
 History of Breast Disease/Surgery

15. History of pain
• Site, Duration, Onset and severity
• Relationship to menstrual cycle (cyclical or non-
cyclical)
• Aggravating factors and Relieving factors

16. Menstrual History
• Age of menarche
• Age at menopause:
early menarche (<12 year),
late menopause (>55 year)- increases risk for
carcinoma
• Last menstrual period
• Regularity of menstrual cycle
• Breast changes during menstrual cycle

17. History of nipple discharge
• When did you notice discharge from nipple?
• Ever noticed before?
• One or both nipples?
• Describe discharge:
• Color? ,Thick or thin? ,Odor?
• Occur spontaneously?

18. Hx oof Breast and xillary Lumps
• When did you first notice lumps or tenderness
under your arms?
• Where?
• One or both arms?
• Come and go, or constant?
• Has it gotten worse?
• Shave underarms?
• What have you done to treat this?

19. Hx of pregnancy
• Age at 1st pregnancy :
- younger age (<18) is protective
- >30 years- increased risk
• Number of pregnancy- protective
• Lactational history- protective

20. Family Hx
• At least two generations
• Breast, gynecologic, colon, prostate, gastric, or
pancreatic cancer
• Age at diagnosis of these tumours.

21. Past Medical/Surgical Hx
• Breast problem
• Mammogram
• Breast biopsy
• Obesity (BMI >25) - risk factor
• Exposure to radiation (face, chest)- risk factor
• Other medical /surgical history

22. Hx of Breast and Axilla Swelling
lump
• When did you first notice lump in your breast?
• Where is lump?
• Is lump always present, or does it come and go?
• Is it related to menstrual cycle? Is lump tender?
• Does severity of tenderness change related to
menstruation?
• Recently injured breast? Did lump develop after injury?

23. Hx of Breast and Axilla Swelling /lump
• Redness, swelling, or dimpling associated with this
lump?
• Other symptoms?

24. Hx of BSE
• Do you perform breast self-examination (BSE)?
• How often?
• Do you have regular breast examination by a health
care professional?
• Have you ever had a mammogram?
• When?
• How often?

25. Physical Assessment
• Anatomical landmarks: quadrants of the
breast, include Tail of Spence

26. Principles of physical assessment
• Wash hands
• Always explain procedure before you begin.
• Bring appropriate equipment to bedside(Towel,
drape, centimeter ruler, teaching aid for BSE)
• Introduce self
• Verify correct patient
• Ensure privacy and Ensure comfort
• Obtain consent

27. Principles of physical assessment
• Position patient so she is sitting on exam table facing you,
sitting erect with gown dropped to waist.
• Following inspection, assist patient into supine position so
that breasts and nipples may be palpated.
• Patient positions
• Assess the following areas :
 Breasts,Areolar areas, Nipples, Axillae
• Expose only area needed
 Stand in front of the patient

28. Physical Examination
• Include:
Inspection
Palpation
Documentation

29. Inspection
• Stand in front of the patient
• Position patient so she is sitting arms at sides
• on exam table facing you, sitting erect with gown dropped
to waist.
• Inspect from 3 directions :Front,Left sides and Right side
• Inspect both breasts & axillae at (relaxed, arms raised,
hands on hips, leaning forward and note shape, and
symmetry, Skin changes (dimpling, retraction), ulceration,
edema, redness, vascularity.

30. Inspection
• Raise arms above the head-Inspect supraclavicular
area
• Inspect nipples for position, symmetry,
characteristics, lesions, bleeding, and discharge.
• Location of concern and abnormality
• Documentation

31. Breast Palpation
 Supine position with small pad/pillow under side to
be palpated
 Arm raised over head
 Normal side first
 Use pads of fingers and make gentle rotary movement
on breast
 Use a pattern of concentric circles or laterally, like
spokes of wheel.

32. Palpation
Use the Middle of Your Fingers
• Fingertips are too sensitive (all breasts are
somewhat lumpy)
• Palm is too insensitive
• Middle portion of fingers is just right

33. Palpation
 Bimanual Breast PalpationFor pendulous breasts/Large
Breasts
 Support inferior part of breast with one hand.
 Use other hand to palpate breast tissue against
supporting hand.
 Ask for any painful area
 Palpate beast with palmer surface of the fingers for
presence of lump

34. Palpation
• Lump characteristics: site, size, shape, surface,
mobility, temperature, tenderness, texture, edge,
attachment to skin or deep tissue
• While you are palpating note skin Thickening, mass,
tenderness.
• Nipple:Performed after breast palpation for
elasticity, masses, tenderness, Any retraction/
ulceration,discharge milky and Pathological (blood,
serum, pus)
• Palpate nipple, noting any indurations or mass.
• Use thumb and forefinger to apply gentle pressure
to note any discharge.

35. Palpation
Palpate axilla(Feel armpit)
• Use the same circular motions.
• Feel for breast lumps and lymph nodes.
• Normal lymph nodes cannot be felt.

36. Palpation of axilla
• Palpate Lymph nodes: axillary, clavicular node
while sitting.

38. • Supine with shoulder support –Use pads of
fingers of dominant hand

39. Normal finding
 Breast and axillae are flesh colored
 Areolar areas and nipples are darker in pigmentation
 Breasts, areolar areas, nipples should be symmetrical
 No thickening or edema and No dimpling, retraction
 Free from masses, tumors, lesions
 Right breast larger than left
 movable
 No discharge from nipples in nonpregnant, nonlactating
female

40. Abnormal finding
• Palpable mass(Benign(mobile)-cyst,Fibro adenoma,
lipoma,malignant(immobile)-carcinoma))
• Thickening, tenderness
• Mass or pain in the axilla
• Nipple discharge
• Oedema or
• erythema of the skin
• Ulcer(Paget’s disease)

41. Gerontological Variations
• Breast tissue atrophy
• Decreased glandular tissue, resulting in
granular feeling
• Breasts become smaller, pendulous, and
flatter
• Ductal tissue becomes more palpable. Stringy
feeling

42. BSE
• Performed once a month
• Performed on a fixed date each month, or
eight days after menses
• Avoid completing during menstruation or
ovulation
• Use calendar for monthly reminder
• Include significant other in examination
process
• Early detection is important.

43. BSE
• Steps of self-breast examination:
• Two components:
• 1. Inspection (Preferably in standing position)
• 2. Palpation (Either lying down, sitting, standing)
Inspection
• 1.Standin: front of the mirror exposing the chest up
to the waist, look at the breasts through the mirror,
while keeping the arms in positions.
• Look at the size and shapesymmetry, retractions,
dimpling, inverted nipples, or nipple deviation of
each breast and nipple.
• Check for swelling, lumps, scaly skin, or other skin
changes.

44. BSE
• You may sit or stand to check your breasts in the following three ways. Look at
your breasts with:
• o Your arms hanging down at your sides.
• o Your hands raised and joined behind your head.
• o Your hands placed firmly on your hips and bent slightly forward
• 2 LYING DOWN
• • When you lie down, your breast tissue spreads out
• evenly over your chest. This makes it easier for you to feel
• for lumps and any changes in your breasts.
• • Place a small pillow or towel under your left
• shoulder. Put your left arm behind your head.

45. Summary
• Assessing the breast includes:
• Take into account developmental level
• Remembering to assess both females and
males
• Inspecting & palpating breasts,nipples, lymph
nodes and axillary
• Teaching BSE

46. REFERENCES
References
1. Bickley, L. S., Szilagyi, P. G., & Bates, B. (2007). Bates' guide to
physical examination and history taking (11th Edi). Philadelphia:
Lippincott Williams & Wilkins. Chapter No.06 & 07 p.n 171-250
2. Weber, Kelley's. (2007). Health Assessment in Nursing, 3rd Ed: North
American Edition. Lippincott Williams & Wilkins. Chapter
No.14 &15 p.n 239-294