Breasts and Axillae Kevin Dobi, MS, APRN Chapter 16 Breasts and Axillae Kevin Dobi, MS, APRN Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Anatomy and Physiology Breasts are paired mammary glands located within superficial fascia of anterior chest wall: Feature of all mammals as milk-producing organs providing nourishment for offspring. During embryologic development, develop along paired “milk lines,” that extend between limb buds of what will become axillae and inguinal regions. Only one develops on each side in pectoral region. Undergo considerable development in females during adolescence under influence of estrogen and progesterone. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Anatomy and Physiology: Female Breast Mature female breast has distinctive shape but great variation in size and volume: Extend vertically from second to sixth ribs; laterally from sternal margin to midaxillary line. Divided into four quadrants by vertical and horizontal lines intersecting at nipple. Composed of three types of tissue: Glandular tissue Fibrous tissue Subcutaneous and retromammary fat tissue Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Anatomy and Physiology: Female Breast (contd.) Glandular tissue arranged into 15 to 20 lobes radiating around nipple in spoke-like pattern: Each lobe is composed of 20 to 40 lobules (alveoli) containing milk-producing acini cells. During lactation, milk produced by acini cells empties into lactiferous ducts draining milk from lobes to surface of nipple. Largest amount of glandular tissue lies in upper outer quadrant of each breast. From this quadrant, breast tissue extends into axilla, forming axillary tail of Spence. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Anatomy and Physiology: Female Breast (contd.) Cooper’s ligaments, subcutaneous fibrous tissue and multiple fibrous bands support breasts: These suspensory ligaments extend from connective tissue layer through breast attaching to underlying muscle fascia. Subcutaneous and retromammary fat surrounds glandular tissue and comprise bulk of breast. Nipple surrounded by pigmented areola. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Anatomy and Physiology: Female Breast (contd.) Nipples composed of epithelium with circular and longitudinal smooth muscle fibers: Muscle fibers contract in response to sensory, tactile, or autonomic stimuli, producing erection and causing lactiferous ducts to empty. Montgomery glands, sebaceous glands, located within areolar surface, aid in lubrication of nipple during lactation. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Anatomy and Physiology: Female Breast (contd.) Throughout reproductive years, breasts undergo cyclic pattern of size change, nodularity, and tenderness in menstrual cycle: 3 to 4 days before onset of menses, many women experience breast fullness, tenderness, and pain from hormonal changes and fluid retention. Breasts change dramatically during pregnancy and lactation in response to luteal and placental hormones: Increase in number of lactiferous ducts and size and number of alveoli. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Anatomy and Physiology: Lymphatic System Each breast contains extensive lymphatic network, which drains into lymph nodes: More than 75% of lymph drainage is outward toward axillary lymph nodes, then upward to subclavicular and supraclavicular nodes. Other drainage routes flow through: Anterior axillae (pectoral) nodes above breast. Internal mammary nodes in thorax. Subdiaphragmatic nodes toward abdomen and cross-mammary pathways to opposite breast. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Anatomy and Physiology: Male Breast Male breast undergoes little development after birth; gland remains rudimentary. Consists of thin layer of undeveloped tissue beneath nipple; areola small compared with that in female. During puberty, male breast may become slightly enlarged, producing temporary gynecomastia. Older men may also have gynecomastia secondary to decrease in testosterone. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

General Health History: Present Health Status Do you take any medications? What medications? Do you take any vitamin supplements? How much chocolate and caffeine do you consume each week? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

General Health History: Past Medical History Have you ever had fibrocystic breast changes? Fibroadenomas? Breast cancer? History of ovarian cancer? Endometrial cancer? Colon cancer? Surgery on breast? When, and for what reason? How old were you when you began menstruating? How old were you at menopause (if appropriate)? Have you ever been pregnant? At what age did you have your children? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

General Health History: Family History Is there a history of breast cancer or breast disease in your family? If so, in whom? At what age did this relative have breast cancer or disease? Did it affect one or both breasts? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

General Health History: Personal and Psychosocial History 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? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Problem-Based History Most commonly reported problems related to breasts are pain or tenderness, lump, nipple discharge, and pain or lumps in axillae. A symptom analysis is completed, which includes onset, location, duration, characteristics, aggravating and alleviating factors, related symptoms, and treatments. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Problem-Based History: Breast Pain or Tenderness Where does it hurt? One breast or both? Specific location or generalized? When did it first begin? Describe pain. Does pain or tenderness prevent you from carrying out routine activities? Have you noticed specific activities that bring on pain? Do you experience pain during sexual activity or when you exercise? When wearing bra, or not wearing bra? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Problem-Based History: Breast Pain or Tenderness (contd.) Have you noted recent changes in your breasts, such as changes in size, shape, tenderness, lumps, or discharge? Is breast tenderness associated with swollen feeling to breasts? When do you notice swelling? Is swelling related to menstrual cycle? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Problem-Based History: Breast 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? Other symptoms? Redness, swelling, or dimpling associated with this lump? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Problem-Based History: 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 or when expressed? Other symptoms? Breast pain or breast lump? Headaches or changes in vision? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Problem-Based History: Axillary Lumps or Tenderness 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? Relationship to shaving and tenderness? Use deodorant or antiperspirant? What have you done to treat this? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Problem-Based History: Breast Swelling or Enlargement (Men) Describe change to your breast. When did you first notice it? Have changes occurred on one or both sides? (Gynecomastia is enlargement of one or both breasts in men.) Although breast cancer in men is rare, the most common initial symptom is a breast mass. Have you experienced any other symptoms such as pain or discharge? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Female Breast Examination: Routine Techniques Female examination: Always explain procedure before you begin. Let patient know you will be touching her breasts, and obtain permission before beginning. 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. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Female Breast Examination: Routine Techniques (contd.) Inspect both breasts: Note size, shape, contour, and symmetry. Inspect skin for color, pigmentation, vascularity, surface characteristics, and lesions. Inspect areolae for color and surface characteristics. Inspect nipples for position, symmetry, surface characteristics, lesions, bleeding, and discharge. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Male Breast Examination Inspect breasts and nipples. Palpate breasts and nipples. Palpate axilla. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Age-Related Variations: Infants and Children Breast assessment among infants and children only requires inspection. Neonates of both genders may have slightly enlarged breast secondary to mother’s estrogen. Maternal hormones are also responsible for a small watery whitish discharge referred to as “witch’s milk” seen in small percent of newborns during first few weeks of life. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Age-Related Variations: Adolescents Breast development, thelarche, begins in preadolescence and continues through adolescence. Girls are often sensitive about having breasts exposed for examination; must take time to reassure patient and ensure privacy. Boys may experience an unexpected enlargement of breasts (gynecomastia) as result of obesity or body change transition during early puberty. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Age-Related Variations: Older Adults Atrophic changes to female breasts begins by age 40 years and continues through menopause. As glandular tissue atrophies, breast tissue is replaced with fat and connective tissue. Postmenopausal women should continue to have regular breast examinations because of increased risk of breast cancer with age. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Patients with Situational Variations: Mastectomy Women who have mastectomy require same breast assessment as all other women. Many experience anxiety or fear as they worry about recurrence of cancer or metastasis. Some women may also have personal issues regarding body image and may feel self-conscious about exposing chest. Nurse should be sensitive and reassure patient it is necessary to have comprehensive examination. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Patients with Situational Variations: Mastectomy (contd.) In addition to examining remaining breast, nurse should assess mastectomy site and scar because malignancy recurrence is possible at scar site. Mastectomy site and axilla should be inspected for color changes, redness, rash, irritation, and visible signs of edema, thickening, or lumps. Note areas that may have had muscle resection; also any signs of lymphedema in affected upper extremity. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Patients with Situational Variations: Mastectomy (contd.) Using finger pads of examining hand, palpate side with mastectomy, especially around area of scar; use small circular motion, assessing for thickening, lumps, edema, or tenderness. Palpate entire chest area on affected side to ensure that nothing has been missed. Finally, palpate axillary and supraclavicular areas for lymph nodes. If patient had breast reconstruction or augmentation, examination in usual manner, paying particular attention to scars. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Common Problems and Conditions: Benign Breast Disease Noncancerous breast conditions account for 90% of clinical breast problems. Benign breast disease is term that represents a number of breast-related problems, including breast pain or tenderness, swelling, lumps, discharge, and inflammation. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Common Problems and Conditions: Fibrocystic Changes to the Breast Fibrocystic changes to breast refers to variety of conditions associated with multiple benign masses within breast caused by ductal enlargement and formation of fluid-filled cysts. Clinical findings: Typically, cysts manifest as one or more palpable masses that are round, well-delineated, mobile, and tender. Degree of discomfort ranges from slightly tender to very painful; cysts often fluctuate in size and tenderness with menstrual cycle. Symptoms tend to subside after menopause. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Common Problems and Conditions: Fibroadenoma Common benign breast tumor among young women that consists of glandular and fibrous tissue. Clinical findings: Fibroadenoma usually manifests unilaterally as small, solitary, firm, rubbery, nontender lump. Generally mobile and well-delineated. This tumor does not change premenstrually. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Common Problems and Conditions: Ductal Ectasia Benign breast disease characterized by inflammation and dilation involving one or multiple subareolar ducts. Clinical findings: Initial symptom is a sticky nipple discharge commonly dark green or black. With progression, woman may experience burning or itching of nipple and edema in areolar area. Discharge may become purulent or sanguineous. Complication can be breast abscess. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Common Problems and Conditions: Intraductal Papilloma Small, benign, wartlike tumor in major ducts usually within 1 to 2 cm of areolar edge; one or more ducts may be affected. Most commonly occurs in women 40 to 60 years. Clinical findings: Clinical presentation is spontaneous bloody discharge from nipple; occasionally a mass is palpated. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Breast Cancer Breast cancer is major health problem for women. It is most common non–skin-related malignancy in American women. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Breast Cancer: Invasive Breast Cancer Most common breast cancer is invasive malignancy arising from ducts or lobules. Clinical findings: Breast malignancy usually manifests as solitary, unilateral, nontender lump, thickening, or mass. As mass grows, there may be breast asymmetry, discoloration (erythema or ecchymosis), unilateral vein prominence, peau d’orange, ulceration, dimpling, puckering, or retraction of skin. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Breast Cancer: Invasive Breast Cancer (contd.) Clinical findings: Invasive breast cancer: Lesion sometimes fixed to underlying tissue. Borders irregular and poorly delineated. Nipple may be inverted or diverted to one side. Serosanguineous or clear nipple discharge may be present. May be crusting around nipple or erosion of nipple or areola. Lymph nodes may be palpable in axilla. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Breast Cancer: Noninvasive Breast Cancer Two types categorized as noninvasive are ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS). DCIS is true precursor of invasive ductal carcinoma and considered more significant. LCIS is risk factor for subsequent development of breast cancer. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Breast Cancer: Noninvasive Breast Cancer (contd.) Clinical findings: Noninvasive breast cancer: Most common manifestation of DCIS or LCIS is an abnormal mammogram. Occasionally, DCIS is clinically detected as lump with well-defined margins or nipple discharge. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Common Problems and Conditions: Other Breast Conditions – Mastitis Mastitis is inflammatory condition of breast usually caused by a bacterial infection: Occurs most frequently in lactating women secondary to milk stasis or a plugged duct. Incidence highest in first few weeks postpartum and decreases thereafter. In nonlactating women, mastitis may also result from foreign bodies (such as nipple rings and breast implants) or from trauma. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Common Problems and Conditions: Other Breast Conditions – Mastitis (contd.) Clinical findings: Infection generally occurs in one area of breast, which appears as red, edematous, tender, warm to touch, and hard. Axillary lymph nodes are often enlarged and tender. Patient usually has associated fever and chills, and experiences general malaise. Copyright © 213 by Mosby, an imprint of Elsevier Inc.

Common Problems and Conditions: Other Breast Conditions – Galactorrhea Galactorrhea means inappropriate lactation. Causes include endocrine-related disorders (such as a pituitary tumor), systemic diseases (such as renal failure), and side effect of medications (that interfere or suppress dopamine: codeine, morphine, metoclopramide, phenothiazines, reserpine) Clinical findings: The manifestation is milky-appearing nipple discharge. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Common Problems and Conditions: Other Breast Conditions – Gynecomastia Gynecomastia is noninflammatory enlargement of one or both male breasts. Can occur at any age; in neonates, cause is typically associated with maternal hormones. At puberty, condition is idiopathic and transient. Common causes in adult men include side effect of medications, adrenal or testicular tumors, liver disease, or renal disease. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Common Problems and Conditions: Other Breast Conditions – Gynecomastia (contd.) Clinical findings: Gynecomastia: May be unilateral or bilateral and manifests as enlargement of male breast. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Question 1 Nurses teaching patients about breast self-examination (BSE) need to understand the important issues related to this important self-care behavior. Patients should understand that: Mammography is indicated in all women older than 30. BSE is used so that women will need to make fewer health care visits. BSE is used so that women will be able to identify changes in their breast tissue. Mammography is indicated primarily for women who do not perform BSE. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Correct Answer: C Rationale: Mammography is indicated for women over the age of 40 years. Health care providers need to assess for patient understanding of mammography and BSE. 51

Question 2 During a breast examination, the nurse should be cognizant of patient comfort and any questions she may have. Understanding breast shape means that: The patient should report recent changes. The patient should be concerned if one breast is slightly larger than the other breast. Dimples may be a normal variation. Retractions are considered normal unless there is exudate. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Correct Answer: A Rationale: Recent changes in symmetry, shape, or discovery of dimples and retractions should be discussed with a health care provider. Dimples and retractions should always be investigated. Slight asymmetries that are not new findings are usually considered normal. 52

The End Copyright © 2013 by Mosby, an imprint of Elsevier Inc.