Assessment of Breast& Axilla Present by: Dr.Amira Yahia

Introduction 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.

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

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.

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

THE HEALTH HISTORY Common or Concerning Symptoms: Breast lump or mass Breast pain or discomfort Nipple discharge

Assessing: Subjective Data 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 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

Assessing:Objective Data 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?

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.

Inspect and Palpate Axillae 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.

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

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.

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.

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

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

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%

Inspect for: Skin changes Redness Visible bumps Nipple crusting Symmetry Look for any dimpling or unusual skin changes. There should be no visible bumps or bulges of the breast beyond the normal contour. The skin should be a uniform color and not have areas of redness suggesting increased blood flow. The nipples should have no visible secretions or crusting.

Assessing Breasts and axillae Deviation from normal Normal findings Assessment -Recent change in breast size, swelling, marked asymmetry. 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. Inspect the breasts for: Size. Symmetry. Shape. While the client is in a sitting position

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.

Assessing Breasts and axillae Deviation from normal Normal findings Assessment Breasts should rise evenly Watch for dimpling or retraction *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.

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

Assessing Breasts and axillae Deviation from normal Normal findings Assessment -A symmetrical size and color. -Presence of discharge, crusts, or cracks. -Recent inversion of one or both nipples. -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. Inspect the nipples for size, shape, position, color, discharge, and lesions.

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.

Assessing Breasts and axillae Deviation from normal Normal findings Assessment -Tenderness, masses, nodules, or nipple discharge. If a mass was detected, record the following data: A-Location and distance from the nipple in cm. No tenderness, masses, nodules, or nipple discharge. 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

Feel for Lumps Raise the arm Feel with opposite hand Feel for a “marble in a bag of rice” With one arm raised begin feeling for lumps or masses with the opposite hand. Raising the arm is helpful because it stretches the pectoralis major muscle (the large muscle under the breast) and lifts the breast up, creating a more solid, smooth surface on which to examine the breast. All breasts feel a little "lumpy," but remember that you are not feeling for tiny nodules, but rather for larger lumps. You are feeling for "a marble in a bag of rice."

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 Don't use your fingertips...they are too sensitive and you will end up focusing on all the tiny irregularities and nodules that are present in everyone's breasts. Don't use the palms of your hand...they are too insensitive and you can miss something important. Use the middle portions of your fingers...they have just the right sensitivity for finding the lumps or masses you are seeking.

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 Move your hand in small circles while feeling for lumps

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. Using the same circular motions, examine the armpit, feeling for any lumps in the "tail" of the breast or any lymph nodes. Lymph nodes are normally so small they cannot be felt. If enlarged due to infection or inflammation, they grow to about the size of a pencil eraser but are long and narrow rather than round.

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. Using the thumb and fingers, squeeze the breast toward the nipple to try to express any discharge. This stripping of the milk ducts can be useful in identifying early problems with the ducts. You should squeeze not only from side to side, but also from top to bottom and at an angle. In normal breasts, you can, with effort, usually produce a drop or two of clear, milky, or slightly green-tinged discharge. Abnormal findings would be a bloody discharge, or so much discharge that it squirts across the room or consistently stains the inside of your bra.

Assessing Breasts and axillae Deviation from normal Normal findings Assessment 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. 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.

Assessing Breasts and axillae Deviation from normal Normal findings Assessment 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. 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.

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

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.

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.

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

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