When the patient has a specific breast complaint and as part of an overall annual well person examination
When is the breast examination typically performed?
Examination of the axillae
Relevant lymph node chains
An examination of the breasts includes...
Breast masses, skin, or vascular changes that could indicate malignancy
Major focus of breasts and axillae examination in adults is identification of....
African American
What race has earlier and faster breast development
Inspect with patient seated. Compare breasts for:
Size
Symmetry
Contour
Retractions or dimpling
Skin color and texture
Venous patterns
Lesions
Supernumerary nipples
Inspect both areolae and nipples and compare for:
Shape
Symmetry
Color
Smoothness
Size
Nip
You should inspect female patients while being.....
Compare breasts for....
-Arms extended over head or flexed behind the neck
-Hands pressed on hips with shoulder rolled forward
-Seated and leaning over
-Recumbent position
You should reinspect breasts with the patient in which positions?
Perform a chest wall sweep.
Perform bimanual digital palpation.
Palpate for lymph nodes in the axilla, down the arm to the elbow, and in the supraclavicular and infraclavicular areas.
Palpate breast tissue with patient supine, using light, medium, and dee
When performing your female examination what are some things you should include?
Symmetry
Enlargement
Surface characteristics
Inspect both areolae and nipples and compare for:
Shape
Symmetry
Color
Smoothness
Size
Nipple inversion, eversion, or retraction
Palpate breasts and over areolae for lumps or nodules.
Palpate for lymph nodes in
Inspect male breasts for....
breasts
Paired mammary glands on anterior chest wall, superficial to the pectoralis major and serratus anterior muscles
small nipple and areola
thin layer of breast tissue
Male Breast consists of...
-Nipple and areola
-Glandular tissue
-Fibrous tissue
-Subcutaneous tissue
-Retromammary fat
Female breast consist of....
Upper outer quadrant
What quadrant of the breasts has the most tissue?
15-20 lobes
20-40 lobules
The glandular tissue has how many lobes per breasts radiate about nipple?
Lobes are composed of how many lobules?
Lobules
Consist of milk-producing acini cells
Lactiferous
drain milk form each lobe into nipple surface
Fibrous tissue
Subcutaneos
Provides breast support
Suspensory Ligaments
Suspensory Ligaments (Cooper ligaments)
Extend from connective tissue layer through the breast and attach to the underlying muscle fascia providing further supports
Muscles forming floor of breast
Pectoralis major and minor
Serratus anterior
Latissimus dorsi
Subscapularis
External oblique
Rectus abdominis
Vascular supply
Internal mammary artery
Lateral thoracic artery
Subcutaneoous and retromammary fat
Supplies bulk of breast
Varies with age, pregnancy, lactation, and genetics
Upper outer quadrant: greatest amount of glandular tissue
Upper inner quadrant
Lower inner quadrant
Lower outer quadrant
Tail of Spence
Five segments (for examination purposes): four quadrants and tail
nipple
Located centrally on the breast and surrounded by the pigmented areola
Epithelium infiltrated with smooth muscle fibers
Lactiferous ducts empty onto nipple
Contraction of the smooth muscle, induced by tactile, sensory, or autonomic stimuli, produces erect
Lymphatic network
Drains breast radially and deeply to underlying lymphatics
Superficial lymphatics drain skin
Deep lymphatics drain mammary lobules
Complex of axillary lymph nodes
Latent phase in children and preadolescence
Thelarche (Breast development) early sign of puberty in adolescent girls
Tanner's 5 stages of developing sexual maturity
Breast development in children and adolescents
Stage 1 preadolescent
There is only a small elevated nipple
Stage 2 Breast bud stage
A small mound of breast and nipple develops; the areola widens
Stage 3
The breast and areola enlarge; the nipple is flush with the breast surface, no contour separation
Stage 4
The areola and nipple form a secondary mound over the breast. Increasing fat deposits
Occurs in approx half of all girls and in some cases persists in adulthood
Stage 5 Mature breast
Only the nipple protrudes; the areola is flush with the breast contour (the areola may continue as a secondary mound in some normal women)
Areola is usually part of general breast contour and is strongly pigmented
Lactiferous ducts proliferate.
Alveoli increase in size and number.
Breasts enlarge 2- to 3-fold.
Colostrum is produced.
Areolar pigment increases.
Areolae become more erect.
Vascularization increases.
What are some characteristics of the breasts in pregnant women?
Colostrum secreted in the first few days after delivery
(More protein and minerals than does mature milk
Contains antibodies and other host resistance factors)
Milk produced 2-4 days after delivery
Breasts full and tense
Involution period over a period of
When does lactating start in woman?
Decrease in glandular tissue is replaced by fat.
Inframammary ridge thickens.
Breasts hang loosely.
Result of the tissue changes and relaxation of the suspensory ligaments
Nipples are smaller and flatter.
Skin may take on a relatively dry, thin texture.
H
The breasts in older adults...
Breast discomfort
Breast mass or lump
Nipple discharge
Breast enlargement in men
History of present illness of breasts
Question medications, drugs, and steroids.
History of hyperthyroidism, testicular tumor, Klinefelter syndrome
Medications: cimetidine, omeprazole, spironolactone, finasteride, some antihypertensives, some antipsychotics
Treatment for prostate cancer: andr
If a mans breasts are enlarged what should you consider?
40, unless there is family history or concern
What is the recommended age for a mammogram
Previous breast disease: cancer, fibroadenomas, fibrocystic changes
Known BRCA1 or BRCA2 mutation; other known hereditary cancer syndromes
Previous other related cancers: ovarian, colorectal, endometrial
Surgeries: breast biopsies, aspirations, implants,
Past medical history
Breast cancer: primary relatives, secondary relatives; type of cancer; age at time of occurrence; treatment and results; known BRCA1, BRCA2, or other mutation
Other cancers: ovarian, colorectal known hereditary cancer syndromes
Other breast disease in fem
Family History
Age
Breast support used with strenuous exercise or sports activities
Amount of caffeine intake; impact on breast tissue
Breast self-awareness/self-examination: frequency; at what time in the menstrual cycle
Use of alcohol; daily amounts
Use of anabolic st
Personal and Social history
Sensations: fullness, tingling, tenderness
Presence of colostrum and knowledge about how to care for breasts and nipples during pregnancy
Use of supportive brassiere
Knowledge and information about breast-feeding
Plans to breastfeed, experience, expectati
What to ask Pregnant women
Breast cleaning procedures
Nursing bra
Nipples: tenderness, pain, or related problems
Associated problems
Nursing routine
Breast milk-pumping device and frequency of use
Cultural beliefs about nursing
Food and environmental agents that affect milk
Medicat
What to discuss with lactating women
Skin irritation under pendulous breasts from tissue-to-tissue contact or from rubbing of brassiere; treatment
Hormone therapy during or since menopause: name and dosage of medication; duration of therapy
Use baby powder for irritation under breasts
What to consider with older adults
Breast Self-Examination (BSE)
Women should be told about the benefits and limitations of BSE
Every woman should be familiar with her own breasts and report any breast change to her health care provider
Remains an important tool in the detection of breast cancer
20s
As you discuss BSE, it would be an appropriate time to review the accepted recommendations for early breast cancer detection and to discuss the issues related to breast cancer screening
The american cancer society recommends BSE as an option for women beginning in their _____
Inspect the breasts with patient seated and arms hanging loosely at the sides. Inspect both breasts and compare the following:
Size, symmetry, and contour
Retractions or dimpling
Skin color and texture
Venous patterns
Lesions
Supernumerary nipples
Reinspe
When inspecting the breasts what should you inspect?
Shape
Symmetry
Color
Smoothness
Size
Nipple inversion, eversion, or retraction
Inspect both areolae and nipples, compare for the following:
Arms extended overhead
Hands pressed against hips
Pressing hands together (an alternative way to flex the pectoral muscles)
Leaning forward from the waist
Inspect breasts in what 4 positions?
Peau d'orange
______________ appearance indicates edema of the breast caused by blocked lymph drainage.
Discharge
Depression or inversion
Discoloration
Dermatologic changes
Deviation
The 5 D's in nipple and areola
Montgomery tubercles
Normal finding, round bumps found on areola and on nipple itself. More apparent when stimulated. More prominent during pregnancy.
Nipple inversion
When nipple is pulled inward into the breast instead of pointing outward
Nipple retraction
Appears flat and broad
Patient is seating position
Chest wall sweep
Nodes should not be palpable
Palpation of the axillae and infraclavicular areas
Bimanual digital palpation
Lymph node palpation
Breast palpation is done when....
With the palm of your hand, sweep from the clavicle to the nipple, covering the area from the sternum to the midaxillary line
Chest wall sweep
All areas of breast tissue for lumps or nodules
If a breast mass is felt, note characteristics and palpate its dimensions, consistency, and mobility
Palpation when patient is in supine position
Location
Size and shape
Consistency
Tenderness
Mobility
Borders
Retraction
Document masses found
Tail of Spence
Both axillae
Masses
Nipples
Depression into well behind the areola
Discharge (if present)
Note if spontaneous, unilateral, from a single duct
Palpate
tail of spence
Nipples
Discharge
Consistency of breast lesion
Palpating for delineation of borders of breast mass
Palpating for mobility of breast mass
Palpate for...
Supernumerary nipples and tissue may arise along the "milk line", an embroyonic ridge
Supernumerary nipples
Expect to feel a thin layer of fatty tissue overlying muscle.
Obese men may have a somewhat thicker fatty layer, giving the appearance of breast enlargement.
Firm disk of glandular tissue can be felt in some men
Palpation on males
Breasts of many well newborns, male and female, are enlarged for a relatively brief time.
Result of passively transferred maternal estrogen
Small amount of clear or milky white fluid, commonly called "witch's milk," is sometimes expressed.
Breast enlargem
Infant breasts
The right and left breasts of the adolescent female may not develop at the same rate.
Reassurance
Breast tissue of the adolescent female feels homogeneous, dense, firm, and elastic.
Start BSE early.
Provides opportunity for reassurance and education
Adolescent breasts
Transient unilateral or bilateral subareolar masses in males
Firm, sometimes tender, and often a source of great concern to the patient and his parents
Disappear, usually within a year
Gynecomastia in males
Unusual and unexpected enlargement that is readi
Adolescent breasts in males
Inspection:
Increase in size
Tenderness and tingling
Enlarged erect nipples
Vascular spiders and striae
Palpation:
Colostrum
Coarse nodularity of breast tissue
Dilated subcutaneous veins
Inspection and palpation in pregnant women
Palpate breasts.
Engorgement
Clogged milk ducts
Examine nipples.
Irritation or blisters
Petechiae
Cracking
Lactating women
Inspection:
Elongation or flattening
Hanging tissue
Smaller nipple size
Palpation:
Fine granular glandular tissue
Thickened inframammary ridge
Fluid-filled cysts
older adults
galactorrhea
abnormalities in breasts, lactation not associated with childbearing
Paget disease
surface manifestation of underlying ductal cancer
mastitis
inflammation and infection of the breast tissue
Gynecomastia
breast enlargement in men
Fibrocystic changes
breast lumps, benign fluid-filled cyst formation caused by ductal enlargement
fibroadenoma
benign tumors composed of stromal and epithelial elements that represent a hyperplastic or proliferative process in a single terminal ductal unit
Malignant breast tumors
Ductal cancer arises from the epithelial lining of ducts
Lobular cancer originates in the glandular tissue of the lobules
Fat necrosis
Benign breast lump that occurs as an inflammatory response to local injury
Intraductal papillomas and papillomatosis
Benign tumors of the subareolar ducts produce nipple discharge
Duct ectasia
Benign condition of the subareolar ducts that produces nipple discharge
Premature thelarche
Breast enlargement in girls before onset of puberty
Cause unknown
Breasts continue to enlarge slowly throughout childhood until full development reached during adolescence
The greatest amount of glandular tissue lies in the upper outer quadrant of the breast.
The greatest amount of glandular tissue of the breast lies in which of the following:
Inspection begins with the patient in a sitting position with arms hanging loosely at the sides.
Inspection of the breasts usually begins with the patient in which position?
The anterior axillary lymph nodes are located along the lower border of the pectoralis major, inside the lateral axillary fold.
The anterior axillary lymph nodes would best be palpated at the:
Montgomery's tubercles are the tiny bumps scattered around the areola and are regarded as an expected finding when they are nontender and have no purulent drainage.
A peppering of nontender, nonsuppurative Montgomery tubercles is considered to be a:
Lactiferous sinuses
The reservoirs for storing milk in the breast are:
Upper outer quadrant
What are the most common site of breast tumors?
One breast normally may grow faster than the other during development.
During a visit for a school physical, the 13-year-old girl being examined questions the asymmetry of her breasts. What is the nurse's best response?
On the 4th to 7th day of the cycle
When teaching the breast self-examination, you would inform the woman that the best time to conduct breast self-examination is:
Every year
You are providing health promotion teaching for a 40-year-old woman. What is the current recommendation for women 40 years of age and older for breast cancer screening with mammography?
sitting with hand pushing onto hips
you are going to inspect a female patient's breasts for retraction. The best position for this part of the examination is
with pendulous breasts
A bimanual technique may be the preferred approach for a woman:
Review the medications for drugs that have gynecomastia as a side effect
During the examination of a 70-year-old man, you note gynecomastia. You would:
Irregular, poorly defined, fixed
During a breast examination you detect a mass. Which of the following is most consistent with cancer rather than benign breast disease?
blue vascular pattern over both breasts
During the examination of the breasts of a pregnant woman, you would expect to find:
a 25 year old with asymmetric breasts and inversion of nipples since adolescence
Which woman should not be referred to a physician for further evaluation?
Irregular shape
Any lump found in the breasts should be referred for further evaluation. A benign lesion will usually have 3 of the following characteristics. Which one is characteristic of a malignant lesion?
Enlargement of the male breast
Gynecomastia is:
Breast bud development
Which is the first physical change associated with puberty in girls?
this is a normal finding of supernumerary nipples that are not developed.
During the examination of a 30 year old woman, she asks about "the 12 large moles" that are below her left breast. After examining the area, how do you respond?