Health Assessment: Breast and Axillae Assessment.pptx

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. S t r u c tu r e and Function

4. Breasts 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.

5. 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: T o p r o d u c e and s t o r e mi l k th a t p ro vides nourishment for newborns T o a i d i n s e x u al st im u l at i o n. The male breasts have no functional capability

6. For purposes of describing the location of assessment findings, the breasts are divided into four quad r ants b y d r a w i ng horizontal and vertical imaginary lines that intersect at the nipple.

7. 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. H a i r f ol li cle s c om m o n l y appear a r ou n d t he a r eola. Smooth muscle fibers in the areola cause the nipple to become more erectile during stimulation.

8. 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 e x t ends f r o m ea c h ax i ll ae t o th e g r o i n a r e a . I t g r ad u al l y 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”.

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

10. Lymph Nodes Th e m a j o r ax i ll a r y lymph nodes c o ns i st o f Anterior ( p e c t o r al) Posterior (subs c ap u l a r ) Lateral (brachial) Central (mid- axillary) nodes.

11. 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 chest or abdomen.

12. Physical E x amin a tion

13. Equipment Centimeter ruler Small pillow Gloves Client handout for BSE S l i d e f o r spec im en

14. 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. Th e o l de r cl ient of t en ha s mo r e pendu l o u s , l e s s firm, and saggy breasts. Abnormal Findings A recent increase in the size of one breast may indicate inflammation or an abnormal growth.

15. Inspect C olor a n d T ex t u r e 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 blocked lymphatic drainage.

16. 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 p r o mi ne n t v eno u s p a t t ern m a y o c c u r as a r e s u l t o f increased circulation due to a malignancy. An asymmetric venous pattern may be due to malignancy.

17. 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.

18. 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 evaluation.

19. Supernumerary nipples may appear along the embryonic “milk line.” Th e o l de r clien t m a y have smaller, flatter nipples that are less erectile on stimulation.

20. Inspect for Retraction and Dimpling

21. 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.

22. Palpation P al p a t e T e xtu r e a nd Ela st ici ty As k t h e c lie n t t o lie d o w n and t o p la c e o v e r h e a d th e a r m on th e s ame side as the breast being palpated. P la c e a s mall p ill o w or r ol led to w el u n de r t h e b r ea s t b e i n g p al p a t ed. U s e th e f lat p a d s of th r ee f i n g e r s t o palpate the client’s breasts. P al p a t e e v e r y s q u a r e i n c h of th e breast. Vary the levels of pressure during palpation.

23. Palpate the breasts using one of three different patterns

24. 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.

25. P al p a t e f or T enderness 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. P a i n m a y al s o o c cu r w i t h a m al i gnant tumo r . Heat in the breasts of women who have not just given birth or who are not lactating indicates inflammation.

26. 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.

27. 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 underlying tissues.

28. 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.

29. Fibrocystic breast tissue that feels ropy, lumpy, or bumpy in t ex t u r e i s r e f er r ed t o 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.

30. 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 lum p . 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.

31. Palpate the Nipples

32. Normal Findings The nipple may become erect and the areola may pucker in r e sp o n s e t o s t imul a t io n . A milky discharge is usually normal only during pregnancy and lactation. So m e w o m en m a y n or m al l y h a v e a c lear di s ch a r g e. Abnormal Findings Di sch a r g e m a y b e s e en i n e n do c rin e di s o r de r s and wi t h c e r t ain 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 the nipple.

33. Palpate Mastectomy or Lumpectomy Site

34. Normal Findings Scar is whitish with no redness or swelling. No lesions, lumps, or tenderness noted. Abnormal Findings R edne s s and i n f l a m m at i o n o f th e s c ar a r ea m a y indicate infection. Any lesions, lumps, or tenderness should be referred for further evaluation.

35. 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 indicate an underlying malignancy.

36. Breast Self Examination (BSE)

37. 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.

38. The Male Breasts: Inspection and Palpation Inspect and palpate the breasts, areolas, nipples, and axillae Abnormal Findings So ft , f a t t y e n la r g e m e n t of b r ea s t t i s s u e is seen in obesity. G yn e c om a st i a , a smoot h , f irm , m o v a b le di s c of g la n d u lar t i s s u e, m a y b e s e en i n o n e b r e as t i n males d u r i n g p ub e r t y , usu al l y temporary. I t m a y al s o b e s een i n h orm on al imbalances, drug abuse, cirrhosis, leukemia, and thyrotoxicosis. Irregularly shaped, hard nodules occur in b r e a st c a n c e r .

39. Common Problems and Conditions

40. Fibrocystic Changes to the Breast T he t erm f i b r o c y s ti c cha n g es t o t he b r ea s t r e f ers t o 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 m i d d le-a g e w omen. 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.

41. Breast Cancer Invasive Breast Cancer The most common type of breast cancer is an invasive malignancy arising from the ducts or lobules. B r ea s t c a n c er i s m o s t p r e v ale n t i n w o me n a g es 4 t o 6 y ea r s 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.

42. N oni n v as i v e B r east Can c er Two types of cancers categorized as noninvasive are D uct al c a r c i n o m a i n s i t u (DC I S) L ob u lar c a r c i n o m a i n s i t u ( L CIS) 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 c o n s i de r ed t h e m o r e i m p or t ant of t h e t w o . LCIS is a risk factor for subsequent development of breast cancer. Cli n i c al F i n din g s: Th e m o st c o m m on m an i f e s t a t io n of DC I S or LCIS is an abnormal mammogram. Occasionally DCIS is clinically detected as a lump with well- d e f i n ed ma r gi n s or n i p p le d isch a rg e.

43. Mastitis Mastitis is an inflammatory condition of the breast u s ual l y c a u s ed b y a b a c t e r i a l in f e c t io n . T h e c ond i t io n o c c urs m o s t f r e q ue n t l y i n la c t a t ing w o me n s e c ond a r y t o mi l k st a s i s o r a plug g ed d u c t . The incidence is highest in the first few weeks after delivery and decreases thereafter. In non-lactating women mastitis may also result f r o m f o r ei g n bod ie s s u c h as n ipp l e r ing s a n d b r ea s t implants or from trauma. Clinical Findings: T h e i n f e c t io n g e n e r al l y o c c urs i n on e a r ea o f th e breast, which appears as red, edematous, tender, warm to the touch, and hard. A x i lla r y l ymp h n od es a r e o f t en e n la r g ed a n d t e nd e r . The patient usually has associated fever and chills a n d o f t en e x pe r ien c es g e n e r al mala is e.

44. Galactorrhea 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 or change in vision if caused by a pituitary tumor).

45. Gynecomastia Gynecomastia is a non inflammatory enlargement of one or both male breasts representing the most common breast problem in men. I t ca n o c cu r at a n y a g e. 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.