health

1. Assessment of Breast& Axilla

2. Introduction
The ability to do a complete and accurate breast exam is an important skill
for medical practitioners of all levels and specialties. A clinical breast
exam is an important step in the diagnosis and follow-up of a variety of
benign and malignant breast illnesses. When utilized as part of a
multimodal evaluation, the breast exam gives crucial information that is
used in both the workup and management of various breast illnesses.
Current breast cancer screening intervals and tests vary; nevertheless,
many guidelines agree that a clinical breast exam is necessary with
atypical mammography findings and as part of annual screening for
certain groups of women at increased risk for breast cancer.

3. Anatomy of the breast
• Composed of :
• Muscles
• Ligaments
• Glandular tissue
• Fatty tissue
• Lymphatic tissue

4. • The breast is hormonally sensitive
tissue, responsive to the changes
of monthly cycling and aging.
Glandular tissue, namely
secretory tubuloalveolar glands
and ducts, forms 15 to 20 septated
lobes radiating around the nipple.
Within each lobe are many
smaller lobules. These drain into
milk-producing ducts and sinuses
that open onto the surface of the
areola, or nipple.

5. LYMPHATICS
• Lymphatics from most of the breast drain toward the axilla. The
central nodes are palpable most frequently. They lie along the chest
wall, usually high in the axilla and midway 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, located along the lower border of the
pectoralis major inside the anterior axillary fold.
• Subscapular nodes—posterior, located along the lateral border of the
scapula
• Lateral nodes—located along the upper humerus

6. THE HEALTH HISTORY
Common or Concerning
Symptoms:
•Breast lump or mass
•Breast pain or discomfort
•Nipple discharge
• History of Breast Disease/Surgery
• Lumps or thickening
• Discharge/Rash
• Swelling/Trauma
• Pain
• Does pt. perform SBE monthly?
• Date of last clinical breast exam
CBE
• Date of last mammogram
• Axillary tenderness, lumps swelling,
rash
Assessing: Subjective Data

7. Assessing Breast Cancer Risk
• Examiner must ask focused
questions regarding risk factors:
Family history: 1st degree
relatives
Estrogen exposure: Age onset of
menses / Age menopause
Obstetrichistory / Use of HRT
Personal habits: Alcohol /
Dietary Fat / Exercise
Ever tested for gene mutation:
BRCA1/ BRCA2
Age: Over 50 => risk
• Inspection- patient sitting,
disrobed to waist
• Note symmetry, size and shape
• Skin normally smooth &even in
color.
• Observe the axillary and supra
clavicular areas for any bulging,
discoloration or edema
• Nipples- symmetrical? Flat?
Inverted? Discharge? Bleeding?
Assessing:Objective Data

8. Screen for Retraction
• While patient is sitting
Ask patient to:
• Lift arms slowly above
head. Both breast
should move up
symmetrically
• Push hands into hip.
• Push palms together
• Lean forward.
• While patient is sitting, lift and support
the arm so patient’s muscles are relaxed
• Use the right hand to palpate left axillae
• Reach fingers high into axillae
• Move fingers firmly down in four
directions:
Down the chest wall, along the
anterior and posterior borders of
axillae and around the inner aspect of
the arm
• Move arm through ROM to have access
to areas.
Inspect and Palpate Axillae

9. Breast Palpation
• Supine position with small pad/pillow
under side to be palpated
• Arm raised over head
• Use pads of fingers and make gentle
rotary movement on breast
• Use a pattern of concentric circles or
laterally, like spokes of wheel.
• Palpate all areas of breast, clockwise
fashion

10. Bimanual Breast Palpation
• For pendulous breasts
• Patient sitting, leaning forward
• Support inferior part of breast with
one hand.
• Use other hand to palpate breast
tissue against supporting hand.

11. Examination of Nipples
• Performed after breast palpation.
• Palpate nipple, noting any indurations
or mass.
• Use thumb and forefinger to apply
gentle pressure to note any
discharge.

12. ASSESSMENT of Breast Lumps
• Location- use breast as clock face to
describe distance from nipple in
centimeters (use diagram to locate).
• Size- in centimeters
• Shape
• Consistency
• Movable
• Tenderness

13. Comparison of Breast Lumps
Benign Breast Disease
 Multiple or single
 Rubbery texture
 Mobile / slippery
 Regular borders
 Tenderness (cyclic)
 No retraction
 May increase/decrease
in size rapidly
Cancer
 Unilateral
 Firm texture
 Fixed firmly
 Irregular border
 Usually painless
 Usually retraction
 Grows constantly

14. Teaching BSE
• Assist patient to establish a schedule
• Regular monthly exams
• Majority of women never get breast
cancer, majority of lumps are benign
• Early detection is important.
• In non-invasive cancer, survival is
close to 100%

15. Inspect for:
• Skin changes
• Redness
• Visible bumps
• Nipple crusting
• Symmetry

16. Assessing Breasts and axillae
Assessment Normal findings Deviation from
normal
Inspect the breasts for:
•Size.
•Symmetry.
•Shape.
While the client is in a
sitting position
Female: rounded shape, slightly
unequal in size, generally
symmetric.
Male: breasts even with the
chest wall, if obese may be similar
in shape
to female breasts.
-Recent change in breast
size, swelling, marked
asymmetry.

17. Assessing Breasts and axillae
Deviation from
normal
Normal findings
Assessment
-Localized
discolorations or
hyperpigmentation.
-Retraction or
dimpling.
-Unilateral localized
hypervascular areas.
-Swelling or edema
appearing as pig skin
or orange peel due
to exaggeration of
the pores
Skin : uniform in
color and skin is
smooth and intact.
Striae, moles and
nevi.
*Inspect the skin for
localized
hyperpigmentation,
retraction or
dimpling, localized
hypervascular
areas, swelling or
edema.

18. Assessing Breasts and axillae
Assessment Normal
findings
Deviation from
normal
*Emphasize any
retraction by having the
client:
-Raise the arms above
the head.
-Push the hands together,
with elbows flexed.
-Press the hands down
on the hips.
Breasts should rise
evenly Watch for
dimpling or retraction

19. Assessing Breasts and axillae
Assessment Normal findings Deviation from
normal
Inspect the areola
area for size, shape,
symmetry, color,
surface
characteristics, and
any masses or
lesions.
-Rounded or oval
bilaterally the same,
--Color varies from
light pink to dark
brown.
-Irregular
placement of
sebaceous glands
on the surface of
areola.
Any a symmetry,
mass, or lesion.

20. Assessing Breasts and axillae
Assessment Normal findings Deviation from
normal
Inspect the nipples
for size, shape,
position, color,
discharge, and
lesions.
-Rounded, everted and
equal in size.
-Similar in color, smooth,
soft, both nipples point in
same direction.
- No discharge, except
from pregnant or breast
feeding females.
-Inversion of one or both
nipples that is present
from puberty.
-A symmetrical size
and color.
-Presence of
discharge, crusts, or
cracks.
-Recent inversion of
one or both nipples.

21. Assessing Breasts and axillae
Assessment
*Palpate the axillary, subclavicular, and supraclavicular lymph nodes.
Client position: sits with arms abducted and supported on the nurse’s forearm.
Use the flat surfaces of all fingertips to palpate the four areas of axilla:
• The edge of the greater pectoral muscle.
• The thoracic wall in the midaxillary area.
• The upper art of the humerus.
• The anterior edge of the latissimus dorsi muscle along the posterior axillary
line.

22. Assessing Breasts and axillae
Assessment Normal
findings
Deviation from
normal
Palpate the breasts for masses,
tenderness, and any discharge
from the nipples.
Client position: supine
Rationale: The breasts flatten
evenly against the chest wall,
facilitating palpation
No
tenderness,
masses,
nodules, or
nipple
discharge.
-Tenderness, masses,
nodules, or nipple
discharge.
If a mass was detected,
record the following data:
A-Location and distance
from the nipple in cm.

24. Feel for Lumps
• Raise the arm
• Feel with opposite
hand
• Feel for a “marble in a
bag of rice”

25. 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

26. Move your hand in small
circles
• Stay in one place
• Press in while circling
with your hand
• Feel for thickenings
the size of a marble

27. Feel the Armpit
• Use the same circular
motions.
• Feel for breast lumps
and lymph nodes.
• Normal lymph nodes
cannot be felt.
• Enlarged lymph nodes
are about the size of a
pencil eraser, but
longer and thinner.

28. Try to Express Nipple Discharge
• Strip the ducts towards the
nipple.
• Normally, one or two drops
of clear, milky or green-
tinged secretions.
• Should not be bloody or in
large quantity, squirting out
or staining the inside of a
breast.

29. Assessing Breasts and axillae
Assessment Normal
findings
Deviation from normal
For client’s who have
a past history of
breast masses, who
are at high risk for
breast cancer,
examination in both a
Supine and a Setting
position is
recommended.
B-Size: the length, width,
and thickness of the
mass in cm.
C-Shape: round, oval,
lobulated, indistinct, or
irregular.
D-Consistency: hard or
soft mass.

30. Assessing Breasts and axillae
Assessment Normal
findings
Deviation from normal
If the client reports a
breast lamp, start with the
“normal” breast to
obtain baseline ass.
For palpation choose one
of three patterns:
1- Concentric circles.
E- Mobility: movable or fixed.
F-Skin over the lump: is
reddened, dimpled, or
retracted.
G-Nipple: whether it is
displaced or retracted.
H-Tenderness: whether
palpation is painful.

31. Self Breast Exam
Teaching positions:
1. Standing in front of mirror
2. In the shower – soap and water
assist palpation
3. Supine
Keep teaching simple
Demonstrate to patient and use return
demonstration

32. The Male Breast
• Examination can be abbreviated but
not omitted.
• Inspect the chest wall noting skin
surface and any lumps or swelling.
• Palpate nipple area for lumps or
enlargement.
• Normal male breast has a flat disc of
undeveloped breast tissue beneath
the nipple. Should be even with no
nodules.

33. Documentation: Female
• S- Denies breast pain, lump,
discharge, rash, swelling, trauma.
Denies past history of breast disease
or surgery. States performs monthly
breast exams.
• O- Inspection: Breasts symmetric.
Skin smooth with even color. No
dimpling or retraction elicited. No
nipple discharge. No lesions.

34. Documentation: Female
• A- Healthy breasts bilaterally with no
S/S of abnormalities
• P- Reinforce BSE (patient performs
BSE monthly), follow up with MD for
CBE & mammogram

35. 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

36. 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