VII.
BREASTS AND AXILLAE
ASSESSMENT PROCEDURE
1. Inspects breast for
a. Size and symmetry
Have the client disrobe and sit
with arms hanging freely. Explain
what you are observing to help
ease client anxiety.
b. Color and texture
c. Superficial venous patterns
observe visibility and patterns of
breast veins
d. Retraction and dimpling
Ask the client to remain seated
while performing several
different maneuvers. Ask the
client to raise her arms
overhead, and then press her
hands against her hips. Next ask
her to press hands together.
Finally, ask the client to lean
forward from waist. This is a
good position to use in women
who have large pendulous
breasts.
e. Bilaterally, note color, size,
shape, and texture of areolas
FEMALE BREAST
NORMAL FINDINGS
Breasts can be a variety of sizes
and are somewhat round and
pendulous; one breast may be
larger than the other.
The older client often has more
pendulous, less firm and saggy
breasts.
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
Veins radiate either horizontally
or and toward the axilla
(transverse) or vertically with a
lateral flare ( longitudinal)
The client’s breasts should rise
symmetrically with no sign of
dimpling or retraction
Breast should hang freely and
symmetrically.
Areolas very from dark pink to
dark brown depending on the
client’s skin tones. They are
round and may vary in size.
Small Montgomery tubercles
ABNORMAL FINDINGS
A recent increase in the size of
one breast may indicate
inflammation or an abnormal
growth.
A pig skin like or orange peel/
peau d’orange appearance
results from edema, which is
seen in metastatic breast
disease. The edema is caused by
blocked lymphatic drainage.
Redness is associated with
breast inflammation
A prominent venous patter may
occur as a result of increased
circulation due to a malignancy.
An asymmetrical venous patter
may be due to malignancy
Dimpling or retractions is
usually caused by malignant
tumor that has fibrous strands
attached to the breast tissue
and fascia of the muscles. As
muscles contracts, it draws the
breast tissue and skin with it,
causing dimpling and retraction.
Restricted movement of breast
or retraction of the skin or
nipple indicates fibrosis and
fixation of the underlying
tissues. This is usually due to an
underlying malignant tumor.
Peau d’orange skin, associated
with carcinoma
Red, scaly crusty areas

f. Bilaterally, note size and
direction of nipples
2. Palpates breast for
a. Texture and elasticity
b. Tenderness and temperature
c. Masses: noting location, size in
centimeters, shape, mobility,
consistency, and tenderness
3. Palpates nipples by
compressing nipple gently
between thumb and index
finger; observe for discharge.
Ask client to lie down, raise right
arm and check the right breast,
repeat procedure to the left
breast.
Wear gloves to compress the
nipple gently with your thumb
and index finger. Note any
discharge.
If spontaneous discharge occurs
are present.
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.
Supernumerary nipples may
appear
The older client may have
smaller, flatter nipples that are
less erectile on stimulation
Smooth, firm , elastic tissue
A generalized increase in
nodularity and tenderness may
be normal findings associated
with menstrual cycle or
hormonal medications. Breasts
should be a normal body
temperature.
No masses
The nipple may become erect
A milky discharge is usually
present only during pregnancy
and lactation.
A recently retracted nipple that
was previously everted suggests
malignancy. Discharges should
be referred for cystologic study
and further evaluation
Thickening of the tissues may
occur with an underlying
malignant tumor.
Painful breast may be indicative
of benign breast disease but can
also occur in malignant tumor
Heat in the breasts of women
who have not just given birth or
who are not lactating indicates
inflammation.
Malignant tumors are most
often found in the upper outer
quadrant of the breast. They
are unilateral, with irregular,
poorly delineated borders. Hard
and non-tender and fixed to
underlying tissue
Benign breasts disease consists
of bilateral, multiple, firm,
regular, rubbery, mobile
nodules with well demarcated
borders. Pain and fullness
occurs just before menses.
Discharge may be seen in
endocrine disorders and with
certain medications ( anti
hypertension, estrogen)
Cancer of the breast, fibrocystic
disease
from the nipples, a specimen
must be applied to a slide and
the smear sent to the laboratory
for cytologic evaluation
4. Palpates mastectomy site/
lumpectomy site, if applicable,
observing the scar and any
remaining breast or axillary
tissue for redness, lesions,
lumps, swelling, or tenderness
Ask client to sit down then
palpate
1. Inspects the breasts, areolas,
and nipples for swelling,
nodules, or ulcerations.
2. Palpates the breasts, areolas,
and nipples for swelling,
nodules, or ulcerations.
3. Palpate the flat disc of
underdeveloped breast tissue
under the nipple.
1. Inspects the axillary skin for
rashes and infection.
Ask the client to sit up.
2. Palpates the axillary skin for
rashes and infection.
3. Holds the elbow with one
hand and use the three finger
pads of your other hand to
palpate firmly the axillary lymph
nodes.
4. Palpates high into the axillae,
moving downward against the
ribs to feel for the central nodes.
Continue down the posterior
axillae to feel for the posterior
nodes.
5. Use bimanual palpation to feel
Scar is whitish with no redness
or swelling. No lesions, lumps or
tenderness noted
MALE BREAST
No swelling or ulcerations
No swelling , nodules/
ulceration
No palpable nodes
AXILLAE
No rash or infection noted
No palpable nodes or one to
two small (less than 1 cm)
discrete, non-tender, movable
nodes in the central area.
Redness, inflammation of the
scar may indicate infection
Any lesions, lumps or
tenderness should be referred
for further evaluation.
Soft, fatty enlargement of the
breast tissue is seen in obesity.
Gynecomastia, a smooth firm
movable disc of glandular tissue
may be seen in one breast in
males during puberty for a
temporary at a time. Also seen
in hormonal imbalance, drug
abuse, leukemia
Irregularly shaped, hard nodules
occur in the breast
Hard nodules, swelling,
presence of ulcerations/ lesions
Hard nodules
Redness and inflammation may
be seen in infection of the
sweat gland.
Dark, velvety pigmentation of
the axillae –acanthosis
nigricans, may indicate an
underlying malignancy
Enlarged greater than 1 cm
lymph nodes may indicate
infection of the hand or arm.
Large nodes that are hard and
well-fixed to the skin may
indicate malignancy
for the anterior axillary nodes.
If the client has large breast.
Support breast with your non
dominant hand, and use your
dominant hand to palpate.
6. Palpates down the inner
aspect of the upper arm.
7. Assist client to demonstrate Ask the client to lie down and to
how she performs Breast Self- place overhead the arm on the
Examination (BSE). (This should same side as the breast being
be offered as an option and the palpated. Place a small pillow or
client’s choice) rolled towel under the breast
being palpated.

Use the flat pads of three

fingers to palpate the client’s
breast.
Palpate the breast using one of
three different patterns.
Circular/ clockwise
Wedge
Vertical strip

Be sure to palpate every square

inch of the breast from the
nipple to areola to the periphery
of the breast tissue and up into
the tail of Spence. Vary the
levels of pressure as you palpate
Light- superficial
Medium- mid level tissue
Firm- to the ribs

NURSING DIAGNOSES
Opportunity to enhance health management of Breast
Health Seeking behavior; Requests Information on Breast Self-Examination (BSE)
Ineffective Individual Coping R/t diagnosis of breast cancer
Body image Disturbance r/t Mastectomy
Anticipatory Grieving r/t anticipation 0f poor outcome of breast biopsy.
COLLABORATIVE PROBLEMS- cannot be prevented by nursing interventions; these are physiologic
complications of medical conditions and can be detected and monitored by the nurse.
PC ( Potential Complications): infection ( abscess) PC: Hematoma PC: Benign Breast disease
Example of Subjective Data:
No history of breast disease, biopsies or surgery in self or family. Takes hormone replacement therapy
for early onset of menopause. Performs monthly BSE, Reports no breast lesions, lumps swelling, pain,
rashes, or discharge. Has yearly mammogram and breast examination by gynecologist. Eats a low fat
diet. Does not drink alcohol. Exercises four times a week wearing supportive firm bra. Menstruation
started at age 14. Has one adopted child. Comfortable with discussing condition of breast.
Example of Objective Data:
Bilateral breast moderate in size, pendulant, and symmetric. Breast skin pale pink with light brown
areola. Montgomery tubercles present. Nipples everted bilaterally. Free movement of breasts with
position changes of arms and hands. No dimpling, retraction, lesions or inflammation noted. Axillae
free of rashes or inflammation. No masses or tenderness palpated. Bilaterally mammary ridge present.
No discharge from nipples. Axillary (central, anterior or posterior) and lateral arm lymph nodes non
palpable. Demonstrates appropriate technique for BSE.
VIII. HEART AND NECK VESSELS

ASSESSMENT PROCEDURE
1. Inspects jugular venous pulse.
Inspect the jugular venous
pressure pulse by standing on
the right side of the client. The
client should be in supine
position with the torso elevated
30-45 degrees. Make sure the
head and torso are on the same
plane. Ask the client to turn the
head slightly to the left. Shine a
tangential light source onto the
neck to increase visualization of
pulsations.
The jugular veins return blood to
the heart from the head and
neck by way of superior vena
cava.
2. Evaluates jugular venous
pressure.
Evaluate jugular venous pressure
by watching for distention of the
jugular vein. It is normal for the
jugular veins to be visible when
the client is supine s to evaluate
jugular vein distention, position
the client in a supine position
with the head of the bed
elevated 30, 45, 60 and 90
degrees. At each increase of the
elevation, have the client’s head
turned slightly away from the
side being evaluated. Using a
tangential lighting, observe for
distention, protrusion or bulging.
3. Auscultates carotid arteries for
bruits.
Auscultate the carotid arteries if
you suspect cardiovascular
disease or if the client is middle
aged or older
Place the bell of the stethoscope
over the carotid artery and ask
the client to hold his/ her breath
NECK VESSELS
NORMAL FINDINGS
The jugular venous pulse is not
normally visible with the client
sitting upright. This position fully
distends the vein and pulsations
may or may not be discernible.
Assessment of jugular venous
pulse is important for
determining the hemodynamics
of the right side of the heart.
The level of jugular venous
pressure reflects right atrial
(central venous) pressure and,
usually right diastolic filling
pressure.
The jugular vein should not be
distended, bulging, or
protruding at 45 degrees
No blowing or swishing or other
sounds heard
ABNORMAL FINDINGS
Fully distended jugular veins
with client’s torso elevated
more than 45 degrees indicate
increased intracranial pressure.
Right sided heart failure raises
pressure thus raising jugular
venous pressure
Distention, bulging, or
protrusion at 45, 60 or 90
degrees may indicate right
sided heart failure. Document
at which positions you observe
distention (45, 60 or 90
degrees)
Client with obstructive
pulmonary disease
A bruit, a blowing or swishing
sound caused by turbulent
blood flow through a narrowed
vessel is indicative of occlusive
arterial disease.
for a moment so breath sounds
do not conceal any vascular
sounds.
Always auscultate the carotid
arteries before palpating.
4. Palpates each carotid artery
for amplitude and contour of the
pulse, elasticity of the vessel,
and thrills.
Palpate each carotid artery by
placing the pads of the index and
middle fingers medial to the
sternocleidomastoid muscle on
the neck.
1. Inspects for visible pulsations
(note if apical or other).
Assist the client with the head of
the bed elevated between 30
and 45 degrees. Stand on the
client’s right side and look for
the apical impulse and any
abnormal pulsations.
2. Palpates apical impulse for
location, size, strength and
duration of pulsation.
The apical pulse was originally
called the point of maximal
impulse (PMI). However the
term is not used anymore
because a maximal impulse may
occur in other areas of the
precordium as a result of
abnormal conditions.
If the pulsation cannot be
palpated, have the client assume
a left lateral chest wall and
relocates the apical impulse
farther to the left.
Remain on the client’s right side
and ask the client to remain
supine. Use the palmar surfaces
of your hand to palpate the
apical pulse in the mitral area
(fourth or fifth intercostal space
Pulses equally strong
A 2+ or normal with no variation
from beat to beat. Arteries are
elastic and no thrills are noted.
Contour is normally smooth
The strength of the pulse is
evaluated on a scale from 0-4 as
follows
Pulse Amplitude Scale
0 Absent
1+ Weak
2+ Normal
3+ Increased
4+ Bounding
HEART /PRECORDIUM
The apical pulse may or may not
be visible. if apparent, it would
be in the mitral area, left
midclavicular line , fourth or
fifth intercostal space. The
apical impulse is a result of the
left ventricle moving outward
during systole
The apical impulse is palpated in
the mitral area and may be the
size of a nickel. 1-2 cm
Amplitude is usually small-like a
gentle tap. The duration is brief,
lasting through the first two
thirds of systole and often less.
In obese clients the apical pulse
may be un palpable.
In older clients apical pulse may
be difficult to palpate because
of the increased anteroposterior
chest diameter.
Pulse inequality may indicate
arterial constriction or occlusion
in one carotid
Weak pulse may indicate
hypovolemia, decreased cardiac
output
A bounding firm pulse may
indicate hypervolemia and
increased cardiac output
Thrills may indicate narrowing
of artery.
Pulsations which msy also be
called heaves or lifts , other
than the apical pulsation are
considered abnormal and
should be evaluated. A heave or
lift may occur as the result of an
enlarged ventricle from an
overload of work.
The apical impulse may be
impossible to palpate in clients
with pulmonary emphysema. If
the apical pulse is larger than 1-
2 cm, displaced, more forceful
or of longer duration, suspect
cardiac enlargement.
at midclavicular line.) After
locating the pulse use one finger
for more accurate palpation
If this pulsation cannot be
palpated, have the client assume
a left lateral position. This
displaces the heart toward the
left chest wall and relocates the
apical impulse further to the left.
3. Palpates for abnormal
pulsation or vibrations at apex,
left sternal border and base.
Use your palmar surfaces to
palpate the apex, left sternal
border and base
4. Auscultates to identify heart
sounds for rate and rhythm
(apical and radial pulses, pulse
rate deficit, s1 and s2).
Place the diaphragm of the
stethoscope at the apex and
listen closely to the rate and
rhythm of the apical impulse.
If you detect an irregular rhythm,
auscultate for a pulse rate
deficit. This is done by palpating
the radial pulse while you
auscultate the apical pulse.
Count for a full minute.
5. Auscultates s1 and s2 heart
sounds for sound location and
strength pattern (louder/softer
at locations and with respiration,
splitting of s2).
Auscultate the first sound s1 or
lub and the second heart sound
s2 or dub. These 2 sounds make
up the cardiac cycle of systole
and diastole. S1 starts systole
and s2 starts diastole. The space
or systolic pause between s1 and
s2vis of short duration thus s1
No pulsations/ vibrations
palpated in the areas of apex,
left sternal border or base
Rate 60-100 beats per minute
with regular rhythm. A regularly
irregular rhythm, such as sinus
arrhythmia when the heart
increases with inspiration and
decreases with expiration, may
be normal in young adults.
Normally the pulse rate in
females is 5 to 15 beats per
minute faster than in males.
Pulse rate do not differ by race
or age in adults.
Apical pulse and radial pulse
should be identical.
S1 corresponds with each
carotid pulsation and loudest at
the apex of the heart. S2
immediately follows after s1 and
is the loudest at the base of the
heart
A thrill, which feels similar to a
purring cat or a pulsation is
usually associated with grade IV
or higher murmur.
Bradycardia- less than 60
beats/min or tachycardia- more
than 100 beats per minute may
result in decreased cardiac
output.
Clients with regular irregular
rhythm like premature atrial
contraction or premature
ventricular contractions and
regular irregular rhythms like
atrial fibrillation and atrial
flutter with varying block should
be referred for evaluation.
These patterns may result to
decreased Cardiac Output ,
heart failure or emboli.
A pulse deficit may indicate
(difference between the apical
and peripheral / radial pulse)
may indicate atrial flutter, atrial
fibrillation, premature
ventricular contractions, and
varying degrees of heart block.
and s2 occur very close together.
Whereas, the space or diastolic
pause, between s2 and the start
of another s1 is of longer
duration.

Use the diaphragm of the Accentuated, diminished ,

stethoscope to best hear S1 Distinct sound in each area but varying or split
loudest at the apex. May
become softer with inspiration.
A split may be heard normally in
young adults at the lateral
sternal border.
Use the diaphragm of the Any split heard on expiration is
stethoscope to best hear S2. Ask Distinct sound in each area but abnormal. This can be one of
the client to breath normally. Do loudest at the base. A split S2 three types wide, fixed, or
not ask the client to hold his or (into two distinct sounds of its reversed.
her breath. Breath holding will components –A2 and P2 is
cause any normal or abnormal normal and termed physiologic
split to subside. splitting. It is usually heard late
inspiration at the second or
If you are experiencing difficulty third left interspaces.
differentiating s1 from s2 palpate
the carotid pulse; the harsh
sound that occurs with the
carotid pulse is S1.
6. Auscultates for extra heart Normally no sound are heard Ejection sounds/ clicks like a
sounds (clicks, rubs) and mild-systolic click associated
murmurs (systolic or diastolic, with mitral valve prolapse. A
intensity grade, pitch, quality, friction rub may also be heard
shape or pattern, location, during the systolic pause.
transmission, effect of
ventilation and position).
Use the diaphragm first then the
bell to auscultate the entire area.
Note the characteristics like
location, timing of any extra
sound heard.
Auscultate during the diastolic
pause ( space heard between
end of S2 and the next S1

While auscultating keep in mind Normally no sounds are heard. Pathologic S3/ ventricular
that development of a gallop may be heard with
pathologic S3 may be the earliest ischemic heart disease,
sign of heart failure myocardial disease.

Auscultate for murmurs. Normally no murmurs are Pathologic midsystolic,

A swishing sound caused by heard. pansystolic and diastolic
turbulent blood flow through the murmurs
heart valves or great vessels.
Auscultate for murmurs across
the entire heart area. Use the
diaphragm and the bell of the
stethoscope in all areas of
auscultation because murmurs
have a variety of pitches. Also
auscultate in different positions
because some murmurs occur or
subside according to client’s
position.
7. Auscultates with the client in S1 and S2 heart sounds are An S3 and S4 heart sounds or a
the left lateral position and with normally present murmur of mitral stenosis that
the client sitting up, leaning was not detected with the
forward, and exhaling. client in the supine position
Position changes for auscultation may be revealed when the
Ask the client to assume a left client assumes the left lateral
lateral position. Use the bell of position.
the stethoscope and listen at the
apex of the heart.
Ask the client to sit up , lean
forward and exhale. Use the
diaphragm of the stethoscope
and listen over the apex and
along the sternal border.

Nursing Diagnoses
Opportunity to Enhance Cardiac Output
Health Seeking Behavior: desired information on exercise and low fat diet
Risk for Ineffective Denial r/t smoking and obesity
Fatigue r/t decreased cardiac output
Activity Intolerance r/t compromised oxygen transport secondary to heart failure
Acute Pain: Cardiac r/t inequality between oxygen supply and demand
Ineffective Tissue Perfusion: Cardiac r/t impaired circulation
Collaborative Problems
PC: Decreased Cardiac Output, PC: Hypertension, PC: Angina
PC: Cerebral Hemorrhage, , PC: Renal Failure, PC: CHF, PC: CVA

Example of Subjective Data:

No chest pain, no dyspnea, dizziness or palpitation, No previous history of cardiovascular disease,
Denies Rheumatic fever, No current medication treatment, Denies family history of hypertension,
myocardial infarction, coronary heart disease, high cholesterol levels, or Diabetes Mellitus. Client has
never had an ECG. States he needs to exercise more and consumes less fat. Client does not monitor
own pulse, or Blood pressure. Denies use of tobacco, Sleeps 6-8 hours per night. Feels rested after
sleep, States that job can be somewhat stressful.

Example of Objective Data:

Carotid pulse equal bilaterally, 2+, elastic. No bruits auscultated over carotids, jugular venous pulsation
disappears when upright. Jugular venous pulsation disappears when upright. Jugular venous pressure x
2cm . No visible pulsations, heaves, lifts on precordium. Apical impulse palpated in the fifth ICS at the
left MCI, approximately the size of a nickel, with no thrill, Apical heart rate auscultated 70 beats/ min,
regular rhythm, S1 heard best at apex, S2 heard best at base, No S3 or S4 auscultated, No splitting of
heart sounds, snaps , clicks or murmurs noted.