St.

Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

COLLEGE DEPARMENT

DEPARTMENT OF NURSING

NURSING PROCEDURE

ASSESSING BREASTS AND LYMPHATIC SYSTEM

Name: ___TORRES, TRISHA MAE_ __________________Date:___05/24/23____

Course/Year_________________Clinical Instructor: CLAIRE RIODIL_____Score:_____________

Direction: Rate the procedure base on the rating scale below by putting a check mark on the
column provided beside the steps as follows:

5 The skill was performed very comprehensively.

4 The skill was performed comprehensively.
3 The skill was performed with some minor errors.
2 The skill was performed with major errors.
1 The skill was performed with none of the required features at all.

ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS 5 4 3 2 1

PROCEDURE
Female Breasts
INSPECTION
Inspect size and Breast can be a varied A recent increase in the size
symmetry. Have the client of sizes and are of one breast may indicate
disrobe and sit with arms somewhat round and inflammation or an abnormal
hanging freely. Explain pendulous. One breast growth. √
what you are observing to may normally be larger
help ease client anxiety. than the other.

Inspect color and texture.
Be sure to note client’s
overall skin tone when
inspecting the breast skin.
Note any lesions.
Inspect superficial
venous pattern. Observe
visibility and pattern of
breast veins.
Color varies depending Redness is associated with
on the client’s skin tone. breast inflammation.
Texture is smooth, with
no edema. A pigskin-like or orange peel
(peau d’orange) appearance √
Linear stretch marks results from edema, which is
may be seen during and seen in metastatic disease.
after pregnancy or with The edema is caused by
significant weight gain or blocked lymphatic drainage.
loss.
Veins radiate either A prominent venous pattern
horizontally and toward may occur as a result of
the axilla (transverse) or increased circulation due to a
vertically with a lateral malignancy. An asymmetric
flare (longitudinal). venous pattern may be due √
Veins are more to malignancy.
prominent during
pregnancy.

BREASTS AND LYMPHATIC SYSTEM 1

Inspect the areolas. Note
the color, size, shape, and
texture of the areolas of
both breast.
Inspect the nipples. Note
the size and direction of the
nipples of both breasts.
Also note and dryness,
lesions, bleeding or
discharge.
Inspect for retractions
and dimpling. To inspect
the breasts accurately for
retraction and dimpling, ask
the client to remain seated
while performing several
different maneuvers. Ask
the client to raise her arms
overhead the press her
hands against her hips.
Next ask her to press her
hands together. These
actions contract the
pectoral muscles.
Areolas vary from dark
pink to dark brown,
depending on the client’s
skin tones. They are round
and may vary in size.
Small Montgomery
tubercles 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 along the
embryonic “milk line.”
No discharge should be
present.
The client’s breasts should
rise symmetrically with no
sign of dumpling or
retraction.
Peau d’orange skin,
associated with carcinoma,
may be first seen in the √
areola. Red, scaly, crusty
areas may appear in Paget
disease.
A recently retracted nipple
that was previously everted
suggests malignancy.
√
Any type of spontaneous
discharge should be
referred from the cytologic
study and further
evaluation.
Dimpling or retraction is
caused by a malignant
tumor that has fibrous
strands attached to the
breast tissue and the
fascia of the muscles. As
the muscle contracts, it
draws the breast tissue
and skin with it, causing
dimpling or retraction. √

Finally, ask the client Breasts should hang freely Restricted movement of
learn forward from the and symmetrically. breasts or retractions of
waist. The nurse should the skin or nipple indicates
support the client by the fibrosis and fixation of the
hands or forearms. This is underlying tissues. This is
a good position to use in usually due to an
women who have large, underlying malignant
pendulous breasts. tumor.
PALPATION
Palpate texture and Palpation reveals smooth, Thickening of the tissues
elasticity. firm, elastic tissue. may occur with an
underlying malignant
tumor.
√
Palpate for tenderness A generalized increase in Painful, tender breasts
and temperature. nodularity and tenderness may be indicative of
may be a normal finding fibrocystic breasts,
associated with the especially right before
menstrual cycle or menstruation. √
hormonal medications.

BREASTS AND LYMPHATIC SYSTEM 2


Palpate for masses.
Note location, size in
centimeters, shape,
mobility, consistency and
tenderness. Also note the
condition of the skin over
the mass.
If you detect any lump,
refer the client for further
evaluation.
Palpate the nipples. Wear
gloves to compress the
nipple gently with your
thumb and index finger.
Note any discharge. If
spontaneous discharge
occurs from the nipples, a
specimen must be applied
to a slide and the smear
sent to the laboratory for
cytologic evaluation.
Breast should be a normal
body temperature.
No masses should be
palpated. However, a firm
inframammary transverse
ridge may normally be
palpated at the lower base
of the breasts.
Fibrocystic breast tissue
that feels ropy, lumpy, or
bumpy in the texture is
referred to as “nodular” or
“glandular” breast tissue.
Benign breast tissue
disease consists of
bilateral, multiple, firm,
regular, rubbery, mobile
nodules with well-
demarcated borders. Pain
and fullness, occurs just
before menses.
The nipple may become
erect and the areola may
pucker in response to
stimulation. A milky
discharge is usually
normal only during
pregnancy and lactation.
However, some women
may normally have a clear
discharge.
However, pain may also
occur with a malignant
tumor. Therefore, refer the
client for further evaluation.
Heat in the breasts of
women who have not just
given birth or who are not
lactating indicates
inflammation.
Malignant masses or
tumors are most often
found in the upper outer
quadrant of the breast.
These masses generally √
are hard, immobile, and
fixed to surrounding skin
and soft tissues, with
poorly defined or irregular
margins.
Fibroadenomas are
usually 1-5 cm, round, or
oval, mobile, firm, solid,
elastic, non-tender, single
or multiple benign masses
found in one or both
breasts.
Milk cysts (sacs-filled with
milk) and infectious
(mastitis), may turn into an
abscess and occur if
breastfeeding or recently
given birth.
Lipomas are a collection
of fatty tissue that may also
appear as a lump.
Intraductal papilloma is a
small growth inside a milk
duct of the breast, often
near the areola. It is
harmless and occurs in
women ages 30-50.
Common causes of nipple
discharge in addition to
pregnancy, include
lactation, hypothyroidism,
pituitary adenoma, oral √
contraceptives,
antihypertensive and
tranquilizers.
Nipple discharge may be
BREASTS AND LYMPHATIC SYSTEM 3
 bloody (possibly from
papilloma in the duct)
greenish (often from a
drainage breast cyst); or
clear (more likely
associated with cancer
unless from both nipples).

Palpate mastectomy or Scar is whitish with no Redness and inflammation

lumpectomy site. If the redness or swelling. No of the scar area may
client has had a lesions, lumps, or indicate infection. Any
mastectomy or tenderness noted. lesions, lumps, or
lumpectomy, it is still tenderness should be √
important to perform a referred for further
thorough examination. evaluation.
Palpate the scar and any
remaining breasts or
axillary tissue for redness,
lesions, lumps, swelling, or
tenderness.
THE AXILLAE
INSPECTION AND
PALPATION
Inspect and palpate the No rash or infection noted. Redness and inflammation
axillae. Ask the client to sit may be seen with infection
up. Inspect the axillary skin of the sweat gland. Dark,
for rashes or infection. velvety pigmentation of the
axillae (acanthosis √
nigricans) may indicate an
underlying malignancy.

No palpable nodes or one

Hold the client’s elbow with to two small (less than 1 Enlarged (greater than 1
one hand and use three cm), discrete, non-tender, cm) lymph nodes may
finger pads of your other movable nodes in the indicate infection of the
hand to palpate firmly the central area. hand or arm. Large nodes
axillary lymph nodes. that are hard and fixed to
the skin may indicate an
First palpate high into the underlying malignancy.
axillae, moving downward
against the ribs to feel for
the central nodes. Continue
to move down the posterior
axillae to feel for the
posterior nodes. Use bi
manual palpation to feel for
anterior axillary nodes.
Finally palpate down the
inner aspect of the upper
arm.
Breast Self-Examination Client may request
Ask the client who instructions on how to
performs BSE to perform the examination
demonstrate how she or choose not to learn how
does so, if she chooses to perform the √
BREASTS AND LYMPHATIC SYSTEM 4
to receive feedback on examination. Either choice
her technique and needs to be accepted by
method. This should be the examiner.
offered as an option and
the client’s choice
accepted. This offers the
nurse can opportunity to
teach BSE. Give clients
printed instructions.
The Male Breasts
INSPECTION AND
PALPATION
Inspect and palpate the No swelling, nodules, or Soft, fatty enlargement of
breasts, areolas, nipples ulceration should be breast tissue is seen in
and axillae. Note any detected. obesity. Gynecomastia, a
swelling, nodules, or smooth, firm, movable disc
ulceration. Palpate the flat males during puberty, √
disc of undeveloped breast usually temporary.
tissue under the nipples. However, it may also be
seen in hormonal
imbalances, drug abuse,
cirrhosis, leukemia, and
thyrotoxicosis. Irregularly
shaped, hard nodules
occur in breast cancer.
Total: ______________

STUDENT LEARNING

Student’s Significant Learning

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Problems Encountered
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Students Signature
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BREASTS AND LYMPHATIC SYSTEM 5