ASSESSMENT OF THE BREAST

SUBJECTIVE DATA

Obtain a nursing history about specific breast complaints and general health
information from the patient to plan care and appropriate patient teaching.

Breast Manifestations

 Palpable lumps—date noted; affected by menstruation; changes noted since

detection.
 Nipple discharge—date of onset, color, unilateral or bilateral, spontaneous or
provoked.
 Pain or tenderness—localized or diffuse, cyclic or constant, unilateral or
bilateral.
 Date of last mammogram and result.
 Patient's practice of breast self-examination (BSE).

History

General Information

 Age.
 Past medical-surgical history; injuries; bleeding tendencies.
 Medications, including current or prior use of hormonal contraceptives and
hormones, over-the-counter (OTC) products, vitamins, and herbal
supplements.

Gynecologic and Obstetric History

 Menarche.
 Date of last menses.
 Pregnancies, miscarriages, abortions, deliveries.
 Lactation history.
 Prior breast history, including previous history of irradiation involving breast
region.
 Family history of breast cancer.

PHYSICAL EXAMINATION

Perform a breast examination, as outlined in Procedure Guidelines 23-1. Remind all

women of the importance of routine checkups with breast examination. Although BSE
is a first step in prevention of breast cancer, it has not been shown to be effective in
reducing mortality. However, it does allow women to become more comfortable and
familiar with their own bodies.
Guidelines for Early Detection

Women at Average Risk

 Begin annual mammography at age 40. Annual clinical breast examination

should be performed prior to mammography.
 For women in their 20s and 30s, it is recommended that clinical breast
examination be part of a periodic health examination, preferably at least every
3 years. Asymptomatic women age 40 and older should continue to receive a
clinical breast examination as part of a periodic health examination, preferably
annually.
 Beginning in their 20s, women should be told about the benefits and
limitations of BSE. The importance of prompt reporting of any new breast
symptoms to a health care professional should be emphasized. Women who
choose to do BSE should receive instruction and have their technique
reviewed on the occasion of a periodic health examination. It is acceptable for
women to choose not to do BSE or to do BSE irregularly.