Health Assessment: Breast and Axillae Assessment

1. By
Tahira bibi

2. Learning
Objectives
⚫Describe the structure & function of the
breast and major axillary lymph nodes.
⚫Discuss risk factors associated with breast
cancer.
⚫Perform a PE of the breasts and axillary
lymph nodes using correct techniques.
⚫Explain the correct method for teaching a
client how to perform self breast
examination.

3. Structur
e and
Functio
n

4. Breast
s
⚫The breasts are paired mammary glands that
lie over the muscles of the anterior chest wall,
anterior to the pectoralis major and serratus
anterior muscles.
⚫Depending on their size and shape, the breasts
extend vertically from the second to the sixth rib
and horizontally from the sternum to the mid-
axillary line.

6. ⚫The male and female breasts are similar until
puberty.
⚫Female breast tissue enlarges in response
to the hormones estrogen and
progesterone, which are released from the
ovaries.
⚫The female breast is an accessory reproductive
organ with two functions:
1. To produce and store milk that
provides nourishment for
newborns
2. To aid in sexual stimulation.

7. ⚫For purposes of
describing the
location of
assessment
findings, the
breasts are divided
into four
quadrants by
drawing
horizontal and
vertical imaginary
lines that intersect
at the nipple.

8. External Breast
Anatomy
⚫The skin of the breasts is smooth and varies in color
depending on the client’s skin tones.
⚫The nipple is located in the center of the breast,
contains the tiny openings of the lactiferous ducts
through which milk passes.
⚫The areola surrounds the nipple (generally 1 to 2 cm
radius) and contains elevated sebaceous glands
(Montgomery glands) that secrete a protective lipid
substance during lactation.
⚫Hair follicles commonly appear around the areola.
⚫Smooth muscle fibers in the areola cause the
nipple to become more erectile during
stimulation.

9. ⚫The nipple and areola typically have darker
pigment than the surrounding breast.
⚫The amount of pigmentation increases
with pregnancy, then decreases after
lactation.
⚫During embryonic development, a milk line or
ridge extends from each axillae to the groin
area. It gradually atrophies and disappears as
the person grows and develops.
⚫However, in some clients, supernumerary
nipples or other breast tissue may appear
along this “milk line”.

11. Internal Breast
Anatomy
⚫Female breasts consist of three types of
tissue: glandular, fibrous, and fatty
(adipose).
1. Glandular tissue constitutes the functional
part of the breast, allowing for milk
production.
2. The fibrous tissue provides support for the
glandular tissue largely by way of bands called
Cooper’s ligaments (suspensory ligaments).
3. Fatty tissue is the third component of the
breast. The glandular tissue is embedded in the

13. Lymph
Nodes
⚫The major
axillary lymph
nodes consist
of
1. Anterior
(pectora
l)
2. Posterior
(subscapula
r)
3. Lateral
(brachial)

14. ⚫The anterior nodes drain the anterior chest
wall and breasts.
⚫The posterior chest wall and part of the
arms are drained by the posterior nodes.
⚫The lateral nodes drain most of the arms,
and the central nodes receive drainage from
the anterior, posterior, and lateral lymph
nodes.
⚫A small proportion of the lymph also flows
into the infraclavicular or supraclavicular
lymph nodes or deeper into nodes within the

15. Physical
Examinatio
n

16. Equipme
nt
⚫Centimeter ruler
⚫Small pillow
⚫Gloves
⚫Client handout for
BSE
⚫Slide for specimen

17. The Female Breasts:
Inspection
Inspect Size and Symmetry
Normal Findings
⚫Breasts can be a variety of sizes and are
somewhat round and pendulous.
⚫One breast may normally be larger than the
other.
⚫The older client often has more pendulous,
less firm, and saggy breasts.
Abnormal Findings
⚫A recent increase in the size of one breast may
indicate inflammation or an abnormal growth.

18. Inspect Color and
Texture
Normal 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.
Abnormal Findings
⚫Redness is associated with breast
inflammation.
⚫A pigskin-like or orange-peel (peau d’orange)
appearance results from edema, caused by

20. Inspect Superficial Venous
Pattern
Normal Findings
⚫Veins radiate either horizontally and toward the
axillae (transverse) or vertically with a lateral
flare (longitudinal).
⚫Veins are more prominent during pregnancy.
Abnormal Findings
⚫A prominent venous pattern may occur as a
result of increased circulation due to a
malignancy.
⚫An asymmetric venous pattern may be
due to malignancy.

21. Inspect the
Areolas
Normal Findings
⚫Areolas vary from dark pink to dark brown,
depending on the client’s skin tones.
⚫They are round and may vary in size.
⚫Small Montgomery tubercles are present.
Abnormal Findings
⚫Peau d’orange skin, associated with carcinoma,
may be first seen in the areola.
⚫Red, scaly, crusty areas are may appear in
Paget’s disease.

22. Inspect the
Nipples
 Normal Findings
⚫Nipples are nearly equal bilaterally in size and are
in the same location on each breast.
⚫Nipples are usually everted, but they may be
inverted or
flat.
⚫No discharge should be present.
 Abnormal Findings
⚫A recently retracted nipple that was previously
everted
suggests malignancy.
⚫Any type of spontaneous discharge should be
referred for cytologic study and further

24. ⚫Supernumerary
nipples may appear
along the embryonic
“milk line.”
⚫The older client may
have smaller, flatter
nipples that are less
erectile on
stimulation.

25. Inspect for Retraction and
Dimpling

27. Normal Findings
⚫The client’s breasts should rise symmetrically,
with no sign of dimpling or retraction.
Abnormal Findings
⚫Dimpling or retraction is usually caused by a
malignant tumor that has fibrous strands
attached to the breast tissue and the fascia of
the muscles.
⚫ As the muscle contracts, it draws the breast
tissue and skin with it, causing dimpling or
retraction.

29. Palpatio
n
Palpate Texture and
Elasticity
⚫ Ask the client to lie down and to
place overhead the arm on the
same side as the breast being
palpated.
⚫ Place a small pillow or rolled
towel
under the breast being palpated.
⚫ Use the flat pads of three
fingers to
palpate the client’s breasts.
⚫ Palpate every square inch of
the
breast.

30. ⚫Palpate the breasts using one of three
different patterns

31. ⚫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.

32. Palpate for Tenderness
and Temperature
 Normal Findings
⚫A generalized increase in nodularity and tenderness
may be a normal finding associated with the
menstrual cycle or hormonal medications.
⚫Breasts should be a normal body temperature.
 Abnormal Findings
⚫Painful, tender breasts may be indicative of
fibrocystic breasts, especially right before
menstruation.
⚫Pain may also occur with a malignant tumor.
⚫Heat in the breasts of women who have not just
given birth or who are not lactating indicates
inflammation.

33. Palpate for
Masses
Normal Findings
⚫No masses should
be palpated.
⚫A firm inframammary
transverse ridge may
normally be palpated at
the lower base of the
breasts.

34. Abnormal Findings
Malignant tumors are
most often found in the
upper outer quadrant of
the breast.
⚫They are usually
unilateral, with
irregular, poorly
delineated borders.
⚫They are hard and non-
tender and fixed to

35. Fibroadenomas are
usually 1–5 cm, round
or oval, mobile, firm,
solid, elastic, non-
tender, single or
multiple benign masses
found in one or both
breasts.

36. Fibrocystic breast tissue
that feels ropy, lumpy, or
bumpy in texture is
referred to as “nodular” or
“glandular” breast tissue.
⚫Benign breast disease
consists of bilateral,
multiple, firm, regular,
rubbery, mobile nodules
with well-demarcated
borders.
⚫Pain and fullness occurs
just before menses.

37. Milk cysts (sacs filled with milk) and infections
(mastitis), may turn into an abscess and occur if
breastfeeding or recently given birth.
If one’s breast is bruised from an injury, there will be
a blood collection that appears as a lump, which goes
away in days or weeks, or the blood may have to be
drained by a health care provider.
Lipomas are a collection of fatty tissue that may also
appear as a lump.
Intraductal papilloma is a small growth inside a
milk duct of the breast, often near the areola. It is
harmless and occurs in women ages 35 to 50.

38. Palpate the
Nipples

39.  Normal Findings
⚫ The nipple may become erect and the areola may pucker
in
response to stimulation.
⚫ A milky discharge is usually normal only during
pregnancy and
lactation.
⚫ Some women may normally have a clear discharge.
 Abnormal Findings
⚫ Discharge may be seen in endocrine disorders and with
certain medications (i.e., antihypertensives, tricyclic
antidepressants, and estrogen).
⚫ Discharge from one breast may indicate benign
intraductal
papilloma, fibrocystic disease, or cancer of the breast.
⚫ Sometimes there is only a watery, pink discharge from

40. Palpate Mastectomy or Lumpectomy
Site

41. Normal Findings
⚫Scar is whitish with no redness or swelling.
⚫No lesions, lumps, or tenderness noted.
Abnormal Findings
⚫Redness and inflammation of the scar
area may indicate infection.
⚫Any lesions, lumps, or tenderness should be
referred for further evaluation.

42. The Axillae: Inspection and
Palpation
Abnormal Findings
⚫Redness and
inflammation may be
seen with infection of the
sweat gland.
⚫Enlarged (greater than 1
cm) lymph nodes may
indicate infection of the
hand or arm.
⚫Large nodes that are hard
and fixed to the skin may

43. Breast Self Examination
(BSE)

45. ⚫Next, stand in front of a mirror and press hands
firmly down on hips (this contracts chest wall
muscles and emphasizes any breast changes). At
the same time look at breasts for changes in
size, shape, or contour. Note any dimpling,
redness, or scaliness of the nipple or breast skin.
⚫Examine both underarms while sitting up or
standing, with arm slightly raised. Do not raise
arm straight up, because it will tighten the
breast tissue, making it difficult to examine.

46. The Male Breasts:
Inspection and
Palpation
Inspect and palpate the breasts,
areolas,
nipples, and axillae
⚫ Abnormal Findings
⚫ Soft, fatty enlargement of breast tissue
is
seen in obesity.
⚫ Gynecomastia, a smooth, firm,
movable disc of glandular tissue, may
be seen in one breast in males during
puberty, usually temporary.
⚫ It may also be seen in
hormonal imbalances, drug
abuse, cirrhosis, leukemia,
and thyrotoxicosis.
⚫ Irregularly shaped, hard

47. Common
Problems and
Conditions

48. Fibrocystic Changes to the
Breast
⚫The term fibrocystic changes to the breast refers to a
variety of conditions associated with multiple benign
masses within the breast caused by ductal
enlargement and the formation of fluid-filled cysts,
commonly seen among middle-age women.
⚫Clinical Findings:
⚫Typically cysts manifest as one or more palpable
masses that are round, well-delineated, mobile,
and tender.
⚫The degree of discomfort experienced can range
from slightly tender to very painful; the cysts often
fluctuate in size and tenderness with the
menstrual cycle.
⚫Symptoms tend to subside after menopause.

50. Breast
Cancer
Invasive Breast Cancer
⚫ The most common type of breast cancer is an invasive malignancy
arising from the ducts or lobules.
⚫ Breast cancer is most prevalent in women ages 40 to 60 years
⚫ Clinical Findings:
⚫ A breast malignancy usually manifests as a solitary, unilateral, non-
tender
lump, thickening, or mass.
⚫ As the mass grows, there may be breast asymmetry, discoloration
(erythema or ecchymosis), unilateral vein prominence, peau d’orange,
ulceration, dimpling, puckering, or retraction of the skin.
⚫ The lesion is sometimes fixed to underlying tissue. Its borders are
irregular and
poorly delineated. The nipple may be inverted or diverted to one side.
⚫ A serosanguineous or clear nipple discharge may be present.
⚫ There may be crusting around the nipple or erosion of the nipple or
areola.
⚫ Lymph nodes may be palpable in the axilla.

52. Noninvasive Breast
Cancer
⚫ Two types of cancers categorized as noninvasive are
1. Ductal carcinoma in situ (DCIS)
2. Lobular carcinoma in situ (LCIS)
⚫ The term in situ is used to describe an early, noninvasive
stage of
cancer.
⚫ DCIS is a true precursor of invasive ductal carcinoma and
is
considered the more important of the two.
⚫ LCIS is a risk factor for subsequent development of breast
cancer.
⚫ Clinical Findings: The most common manifestation of
DCIS or
LCIS is an abnormal mammogram.

53. Mastiti
s
⚫ Mastitis is an inflammatory condition of the
breast
usually caused by a bacterial infection.
⚫ The condition occurs most frequently in
lactating
women secondary to milk stasis or a plugged
duct.
⚫ The incidence is highest in the first few weeks
after delivery and decreases thereafter.
⚫ In non-lactating women mastitis may also
result from foreign bodies such as nipple
rings and breast implants or from trauma.
⚫ Clinical Findings:
⚫ The infection generally occurs in one area
of the breast, which appears as red,
edematous, tender, warm to the touch, and
hard.
⚫ Axillary lymph nodes are often enlarged
and tender.
⚫ The patient usually has associated fever

54. Galactorrhe
a
⚫The term galactorrhea means inappropriate
lactation.
⚫Causes include endocrine-related disorders such as a
pituitary tumor; systemic diseases such as renal
failure; and adverse effects of many medications,
especially those that interfere with or suppress
dopamine.
⚫Clinical Findings:
⚫The manifestation is milky appearing nipple
discharge.
⚫There are no other specific symptoms because
any additional signs or symptoms are likely
based on the underlying cause (e.g., headache

55. Gynecomasti
a
⚫Gynecomastia is a non inflammatory enlargement of
one or both male breasts representing the most
common breast problem in men.
⚫It can occur at any age.
⚫In neonates the cause is typically associated with
maternal
hormones.
⚫At puberty the condition is idiopathic and transient.
⚫Common causes in adult men include adverse
effects of medications, adrenal or testicular
tumors, liver disease, obesity, or renal disease.
⚫Clinical Findings:
⚫Gynecomastia may be unilateral or bilateral and
manifests as enlargement of the male breast.