St.

Paul University Philippines

Tuguegarao City, Cagayan 3500
School of Nursing and Allied Health Sciences
COLLEGE OF NURSING

ASSESSING BREASTS AND LYMPHATIC

SYSTEM

A. LEARNING OBJECTIVES:
The students will be able to:
• Evaluate the client’s current physical condition
• Detect early sign of developing health problem
• Establish a baseline for future comparisons
• Evaluate the client’s responses to medical and nursing interventions

B. EQUIPMENT NEEDED:
• Centimeter ruler
• Small pillow
• Gloves
• Client handout for BSE
• Slide for specimen

EVIDENCE TO BE PRODUCED RATIONALE

1. Introduce self to patient
2. Explain what you are going to do, why it Alleviates anxiety of the patient.
is necessary, and how he/ she can
cooperate.
3. Identify client using 2 patient identifiers. Recognizes correct patient.
4. Perform hand hygiene or apply alcohol Reduces transmission of microorganism.
based handrub.
5. Provide client’s privacy.
6. Assembles equipment.
7. Inquire whether she has ever had a
clinical breast exam previously.
8. Inquire if the client has any of the
following:
• History of breast masses and what
was done about them; pain or
tenderness in the breasts & relation
to the woman’s cycle; discharge
from the nipple;
• Medication history (some
medications, e.g. oral
contraceptives, steroids, digitalis &
diuretics, may cause nipple
discharge; estrogen replacement
therapy may be associated with the
development of cysts or cancer)
• Risk factors that may be associated
with the development of breast
cancer.
• Inquire if the client performs breast
self-exam and technique used.
Inspection
9. Inspect breasts for size, symmetry and
contour or shape while client is in a sitting
position.
10. Inspect the skin of the breast for
localized discolorations or
hyperpigmentation, retraction or dimpling,
localized hypervascular areas, swelling or
edema.
11. Emphasize any retraction by having the
client:
• Raise the arms above the head
• Push the hands together, with
elbows flexed
• Press hands down on the hips
12. Inspect the areola area for the size,
shape, symmetry, color, surface,
characteristics and any masses or lesions.
13. Inspect the nipples for size, shape,
position, color, discharge and lesions.
Palpation
14. Palpate the axillary, subclavicular and
superclavicular lymph nodes.
• The client is seated with the arms
abducted and supported on the
nurse’s forearm.
• Use the flat surface of all fingertips
to palpate the four areas of the
axilla:
• The edge of the greater
pectoral muscle along the anterior
axillary line
• The thoracic wall in the
midaxillary area
• The upper part of the
humerus
• The anterior edge of the
latissimus dorsi muscle along the
posterior axillary line
15. Palpate the breast for masses,
tenderness and nay discharge from the
nipples. Position the client in supine.
• If the client reports a breast lump
with the “normal” breast to obtain
baseline data that will serve as a
comparison to reported involved
breast.
• To enhance flattening of the breast,
instruct the client to abduct the arm
and place her hand behind her hear.
Then, place a small pillow or rolled
towel under the client’s shoulder.
• For palpation, use the palmar
surface of the middle three
fingertips (held together) and make
a gentle rotary motion on the
breast.
• Choose one of three patterns for
palpation:
1. Hand of the clock or spokes on
a wheel
2. Concentric circles
3. Vertical strips pattern
• Start at one point for palpation, and
move symmetrically to the end
point to ensure that all breast
surfaces are assessed.
• Pay particular attention to the upper
 quadrant and tale of Spence.
• If you detect a mass, record the
following data:
a. Location. Exact location
relative to the quadrant and
axillary tail or the clock and
the distance from the nipple
in cm
b. Size
c. Shape
d. Consistency
e. Mobility
f. Skin over the lump
g. Nipple
h. Tenderness
16. Palpate the areola and the nipples for
masses.
• Compress each nipple to determine
the presence of any discharge. If
discharge is present, milk the breast
along its radius to identify the
discharge- producing lobe.
• Assess any discharge for amount,
color, consistency, and odor.
• Note any tenderness on palpation
17. Teach the client the technique of breast
self-examination.
18. Document findings in the client record.