King Saud University

Collage of Nursing

Medical Surgical Nursing depart

Application of Health Assessment

NUR 225

Module Six

Physical examination of Breast & lymphatic system

Overview of anatomy:

- The breast also called mammary glands in women .lie on anterior chest wall.

- They are located vertically between the second or third and sixth ribs over the pectoralis muscle and

horizontally between the sternal border and the midaxillary line

- Each breast has centrally located nipple of pigmented erectile tissue ringed by an areola that darker

than tissue

Purpose of breast examination:

To early detection and screening of breast cancer

To prevent breast cancer prevalence

To improve prognosis of breast cancer

To evaluate plan of care for breast cancer patient

1-Obtain health history:

Includes breast pain, nipple discharge, rash, lump, masses& other changes

Chief complains

Age, day of menstrual cycle appears symptom, changes in underarm area axilla , tenderness , lump , or swelling , rash

Present history:

LMP( Last menstrual period ) , Delivery and pregnancy, breast feeding, history of breast disease, history of surgery or biopsy

Past history:

Breast cancer, breast disorder , other types of cancer Family history

Oral contraceptive pills Medication

High fat diet , caffeine Nutritional

Smoking, alcohol Habits

Perform breast self examination Self care behavior and psychological status

2- Physical Examination

Equipment needed:

- Small pillow

- Ruler marked in centimeter

- Pamphlet or teaching aid for breast self examination

- Mirror

Prepare Patient:

- Explain procedure

- Provide privacy

- Room well light

- Make her in comfort position

- Keep both breast uncovered

Establish landmark and visualize the anatomy to describe clinical finding :

Method I: Divide the breast into four quadrants by imaginary horizontal and vertical lines

intersecting at the nipple. Describe findings according to:

- Appropriate quadrant

-The distance in centimeters from the nipple

Method II-Think of the breast as a clock with the nipple in the centre. Describe findings

according to:

-Location according to time

- The distance in centimeters from the nipple

Remember: The upper outer quadrant of breast is the site of most breast tumors .

Technique Examination

Normal Finding Abnormal Finding

Inspection of the breast Position the client in sitting position & disrobe to the waist .

1- General appearance: Symmetry of size and shape

It is common to have a slight asymmetry in size, often the left breast is slightly larger than the right

A sudden increase in the size of one breast signifies inflammation or new growth of tissue

2- Skin features for: Color , texture, vascular network, edema and contour

1-The skin is smooth and even color 2-A fine blue vascular network is visible normally during pregnancy 3-No edema 4-Contour: no bulging or dimpling

1-Hyperpigmentation, localized redness and heat with inflammation 2-Unilateral dilated superficial veins in non pregnant women 3-Edema exaggerates the hair follicles giving a pig-skin or orange-pee look(Peau d “orange)

4-Bulging or dimpling

Inspect Nipple & Areola 1- Location

2- Size,Color& skin changes

3- Shape

4- Discharge

5- Compare with other side

-The nipples is located just below the center of the breast -Nipple and areola are symmetrically placed on the same plane on the two breast - The nipple is rough round, wrinkled and intended with tiny openings -Nipples usually protrude, although some are flat and some are inverted Normal nipple inversion may be unilateral or bilateral and usually can be pulled out (not fixed) The areola is circular and surrounds the nipple for 1-2cm,has small elevated glands, nipple and areola are darker in color than the rest of the breast No discharge

Deviation of nipple

-Dry scaling , fissure, ulceration -Recent nipple inversion signifies acquired disease

Bleeding or other discharge Except in pregnancy and lactation If any discharge appears, note its color, odor and consistency

Inspect breast & Nipple for retraction: Instruct client to perform the following maneuvers while you check the breasts for skin retraction signs.

Both breasts should move up symmetrically

Retraction signs are due to fibrosis in the breast tissue, usually caused by growing neoplasm

Positions of patients:

a-sitting position arms at sides

b- sitting position arms raised

overhead

c-sitting position hands pressed on

the hips or push her two palms

together.

d-sitting position and leaning

forward.(For women with large

pendulous breasts )

e- supine with a pillow under the

shoulder of the breast being

examined.

A slight lifting of both breasts will occur Symmetrical free-forward movement of both breasts

Lag in movement of one breast indicates retraction Dimpling indicates retraction

Fixation to chest wall

Inspect the axilla region: Bulging Discoloration Rash Edema

Free from bulging, discoloration, rash and Edema

Bulging ,edema indicate cancer

Palpation of Axilla for Central node or axillary

nodes - Examine the axilla while the women is sitting. - use your right hand to plapate the left axilla and your left hand to palpate the right one. -Ask the client to relax her arm -Lift the arm and support it yourself ,so that her muscles are loose and relaxed. -Cup your fingers and reach high into the axilla downward and inward to chest wall

- Central nodes may or may not be palpable. -One or more may be palpable. Nodes are : - Soft -small(less than 1 cm) -mobile -non tender nodes

Central nodes are enlarged(bigger than 1 cm)firm ,matted together or fixed indicated of cancer breast

Palpate the breast for: 1- Consistency, tenderness and

mass

-Help the woman to a supine position , place a small pillow under the side to be palpated and raise her arm over her head.

The non pregnant female breast is normally firm, smooth and elastic . -From midcycle up to menstruation the breast is : *slightly enlarged , *tender to palpation *generalized nodularity

Signs of inflammation(heat, redness, swelling and tenderness)

-Use superficial then deep palpation using gentle rotator motion - Cover one breast with the gown while examining the other Palpation technique of breast:

1- Parallel line 2- Spokes on a wheel 3- Concentric circle 4- Clock pattern

Remember :

1- Any pattern of palpation you choose , make sure examine every square inch of the breast

2- Move in clockwise direction 3- Don’t forget to palpate the

tail of Spence Palpate Nipple for:

Thickness Elasticity Discharge

By using gently squeezing the nipple between your thumb and index

-During the 3-4 days before menstruation the breast feel full, tight, heavy and occasionally sore -On days 4 to 7 of the menstrual cycle the breast volume is smallest(this is the best time to perform breast examination)

Nipples are : -Soft -Elastic -Not tender -Free of discharge

-If Mass is present must assess the following items:

- Location - Size - Shape - Consistency - Mobility - Number - Tenderness

-Thickening -Loss of elasticity -Tenderness

For the women with pendulous breast palpate using bimanual technique:

Position the client in sitting & leaning forward

Support the inferior part of the breast with one hand

Use your other hand to palpate the breast tissue against your supporting hand

-Bleeding or other discharge

If you feel a lump or mass , not the following characteristics :

1- Location : Using the breast as a clock face , describe the distance in centimeters from the

nipple , e.g. ( 7:00 , 2 cm from the nipple ) Or four quadrant method .

2- Size : judge in centimeters in three dimensions width X Length X thickness

3- Shape : Oval, round , lobulated or indistinct

4- Consistency : if the lump soft, firm or hard

5- Mobility : freely movable or fixed

6- Number : Solitary or multiple

7- Tenderness : tender to palpate

Quick Quiz

True and False:

1- Palpate pendulous breast by using one hand technique:

a-True

b-False

2- Central nodes are palpable one, more soft, small(less than 1 cm)mobile, non tender nodes is

considered abnormal:

a-True

b-False

3- Tail of Spence is located at upper inner quadrant:

a-True

b-False

4- The Most common cancer site on upper inner quadrant breast:

a-True

b-False

5- Lag in movement of one breast ,dimpling and fixation on chest wall are signs of retraction

a-True

b-False

6- From 4-7 days of menstruation is the best time for breast examination :

a-True

b-False

King Saud University

College of Nursing

Medical-Surgical Nursing Application of Health Assessment

NURS 225

Performance Checklist

Brest and axilla assessment

Students Name: ______________________________ Rating:____________________

Student Number: ______________________________ Date Performed:____________

The student nurse should be able to:

Performance criteria Competency level

Technique Trial 1 Trial 2 Comment

Preparation: Done

correctly

(2)

Done with

assistance

(1)

Not

done

Competent Not

Competent

Obtain the health history

Prepare required equipment.

Explain procedure to patient.

Wash hands.

Put the patient in the desired position.

(sitting and supine positions)

Expose body part to be examined and Drape

patient appropriately .

Compare findings of any side of body to the

other .

Follow the inspection & palpation

techniques

Inspection of the breast

1- General appearance: Symmetry of size

and shape

2- Skin features for:

Color , texture, vascular network,

edema and contour

3- Inspect Nipple & Areola

Location Size, Color& skin changes Shape Discharge Compare with other side

4- Inspect breast & Nipple for retraction:

Instruct client to perform the following

maneuvers while you check the breasts for

skin retraction signs

Inspect with patient in these

positions ( maneuvers ):

a-sitting position arms at sides

b- sitting position arms raised overhead

c-sitting position hands pressed on the hips.

d-sitting position and leaning forward.

e- supine with a pillow under the shoulder of

the breast being examined.

5- Inspect the axilla region:

Bulging Discoloration Rash Edema

Palpation of Axilla

Palpation of Axilla for:

Central node or axillary nodes

Examine the axilla while the women is sitting,

use your right hand to palpate the left axilla

and your left hand to palpate the right one

-Ask the client to relax her arm

-Lift the arm and support it yourself ,so that

her muscles are loose and relaxed

-Cup your fingers and reach high into the

axilla downward and inward to chest wall

Palpate the breast for:

2- Consistency, tenderness and mass -Help the woman to a supine position , place a

small pillow under the side to be palpated and

raise her arm over her head.

-Use superficial then deep palpation using

gentle rotator motion

Palpation technique of breast

5- Parallel line 6- Spokes on a wheel 7- Concentric circle 8- Clock pattern

Palpate Nipple for:

Thickness Elasticity Discharge

By using gently squeezing the nipple

between your thumb and index

Evaluated by: ___________________________ Date Evaluated: __________

Name and Signature of Faculty

For the women with pendulous breast

palpate using bimanual technique:

Position the client in sitting & leaning forward

Support the inferior part of the breast with one hand

Use your other hand to palpate the breast tissue against your supporting hand