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ASSESSMENT:

BREAST &
AXILLAE

OBJECTIVES:
At the end of the lecture-discussion,
the students will be able to:
Define related terms in relation to
the Breast and axillae;
Discuss the physiology and
anatomy of the breast and axillae
system;
Identify the purposes of performing
breast and axillae assessment;

OBJECTIVES:
Discuss the importance of preparing
clients prior to breast and axillae
examination;
Explain the two methods of examining
the breast and axillae examination;
Explain the significance of a selected
breast and axillae findings;
Enumerate the steps in performing
breast and axillae assessment;

OBJECTIVES:
Describe a suggested sequencing to
conduct breast and axillae assessment
in an orderly or systematic fashion;
State diagnostic procedures being
performed to assess breast and axillae;
Discuss variations and special
considerations in performing breast and
axillae examination techniques
appropriate for clients of different age.

THE BREAST

THE BREAST
It has an important role in modern
culture
Often viewed as measures of sexuality ,
femininity and attractiveness because
it is visible for its size and shape.
However, it is a secondary sex
characteristic
Its physiologic function is milk secretion
to feed infants.

THE BREAST: CLINICAL VALUE

THE BREAST: CLINICAL VALUE


Experience has verified that
90% of breast cancers are
found by women themselves.
When women discover lumps
in their breasts at a very early
stage, surgery can save 7080% of proven cases.

THE BREAST: ANATOMY & PHYSIOLOGY

THE BREAST: ANATOMY & PHYSIOLOGY


lies against the anterior thoracic
wall, extending from the clavicle
and 2nd rib down to the 6th rib,
and from the sternum across to the
mid-axillary line.
Its surface area is generally
rectangular rather than round.
The breast overlies the pectoralis
major and at its inferior margin,
the serratus anterior.

THE BREAST: ANATOMY & PHYSIOLOGY


Divided into four quadrants based
on horizontal and vertical lines
crossing at the nipple.
Axillary tail of breast tissue
extends toward the anterior
axillary fold.
Findings can be localized as the
time on the face of a clock (e.g., 3
oclock) and the distance in
centimeters from the nipple.

THE BREAST: ANATOMY & PHYSIOLOGY

THE BREAST: ANATOMY & PHYSIOLOGY


The breast is hormonally sensitive
tissue, responsive to the changes of
monthly cycling and aging.
GLANDULAR TISSUE: secretory
tubualveolar ducts, lobules drains
into the nipples or arreola
FIBROUS CONNECTIVE TISSUE: support
ADIPOSE TISSUE: varies with age, the
general state of nutrition, pregnancy,
exogenous hormone use, and other
factor

THE BREAST: ANATOMY & PHYSIOLOGY

THE ARREOLA & THE NIPPLES: ANATOMY &


PHYSIOLOGY

Surface has small, rounded elevations


formed by sebaceous glands, sweat glands,
and accessory areolar glands and with
hairs
Well supplied with smooth muscle that
contracts to express milk from the ductal
system during breast-feeding.
Milk letdown following (neurohormonal
stimulation from infant sucking, tactile
stimulation of the area, including the
breast examination, makes the nipple
smaller, firmer, and more erect, while the
areola puckers and wrinkles (NORMAL).

THE ARREOLA & THE NIPPLES: ANATOMY &


PHYSIOLOGY

One
or
more
extra
or
supernumerary nipples are located
along the milk line,
Only a small nipple and areola are
usually present, often mistaken for
a common mole.
There may be underlying glandular
tissue.
An extra nipple has no pathologic
significance.

THE ARREOLA & THE NIPPLES: ANATOMY &


PHYSIOLOGY

THE BREAST: LYMPHATICS


Drain toward the axilla.
CENTRAL
NODES
(axillary
lymph node) most palpable
frequently which lies along the
chest wall, usually high in the
axilla and mid-way between
the anterior and posterior
axillary folds.

THE BREAST: LYMPHATICS


Into them drain channels from
three other groups of lymph
nodes, which are seldom
palpable:
PECTORAL NODES: anterior
SUB-SCAPULAR NODES:
posterior
LATERAL NODES: located along
the upper humerus.

THE BREAST: LYMPHATICS


LYMPHATIC SYSTEM OF THE BREAST

THE BREAST: LYMPHATICS


Lymph drains from the central
axillary nodes to the infraclavicular
and supraclavicular nodes.
Not all the lymphatics of the breast
drain into the axilla.
Malignant cells from a breast
cancer may spread directly to the
infraclavicular nodes or into deep
channels within the chest.

THE BREAST: PURPOSE OF ASSESSMENT


(BREAST SELF-EXAMINATION)

THE BREAST & AXILLAE: PREPARATION


PRIOR TO ASSESSMENT

To identify breast
disease
To initiate early
treatment.

THE BREAST & AXILLAE:


ADVANTAGES OF BSE

Women can use BSE to asses


their breasts.
When they perform BSE properly
and regularly, they can note any
changes in their breasts and
seek further evaluation.
Examination should be done
every month and at the end of
menses in all menstruating

THE BREAST & AXILLAE: BARRIER


TO BSE

LACK OF CONFIDENCE

THE BREAST & AXILLAE: PREPARATION


PRIOR TO ASSESSMENT

EQUIPMENT:
Ruler (centimetres)
Small pillow
Gloves
Client handout for Self-Breast
Examination
Slide for specimen (if any)

THE BREAST & AXILLAE: PREPARATION


PRIOR TO ASSESSMENT

POSITION OF THE CLIENT


Upright position (sitting while the
client is asked to hold arms in
different position: arms at sides,
arms over head, arms pressed
against hips, and leaning forward)
Supine/Standing (palpation)

THE BREAST & AXILLAE: METHODS


OF ASSESSMENT

When is the best time to


perform BREAST-SELF
EXAMINATION?

THE BREAST & AXILLAE:


INSPECTION

5-7 days after the menstruation or


between the fourth or seventh day of
the cycle (if the cycle is regular)
Increase estrogen levels before
menstruation in effect breasts
become more nodular.
Nodules appearing during the
premenstrual phase should be reevaluated at this later time.

THE BREAST & AXILLAE:


INSPECTION

Assess
the
breasts
immediately
after
the
assessment of the thorax and
lungs
and
before
a
mammogram
or
pelvic
examination.

THE BREAST & AXILLAE: METHODS


OF ASSESSMENT

INSPECTION: Requires full exposure


of the chest. Inspect skin for
changes, symmetry, contours,
color, superficial vein patterns,
presence of retractions

THE BREAST & AXILLAE: METHODS


OF ASSESSMENT

Assess also for the size, shape,


texture of the arreola
Note also the characteristics of the
nipples, including size and shape,
direction in which they point, any
rashes or ulceration, or any
discharge.

THE BREAST & AXILLAE:


INSPECTION

THE BREAST & AXILLAE:


INSPECTION

THE BREAST & AXILLAE:


INSPECTION TO VALIDATE THE PRESENCE OF
DIMPLING OR RETRACTIONS

THE BREAST & AXILLAE:


INSPECTION TO VALIDATE THE PRESENCE OF
DIMPLING OR RETRACTIONS

THE BREAST & AXILLAE:


INSPECTION TO VALIDATE THE PRESENCE OF
DIMPLING OR RETRACTIONS

THE BREAST & AXILLAE:


INSPECTION TO VALIDATE THE PRESENCE OF
DIMPLING OR RETRACTIONS

The three maneuvers presented


above contract the pectoral
muscles.
If the breasts are large or
pendulous, it may be useful to have
the patient stand and lean forward,
supported by the back of the chair
or the examiners hands.
Inspect the breast contours
carefully to in each position.

THE BREAST & AXILLAE:


INSPECTION ASSESSMENT FINDINGS

Color varies depending on the


clients 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 and
toward the axilla (transverse) or
vertically with a lateral flare
(longitudinal). Veins are more
prominent during pregnancy.

THE BREAST & AXILLAE:


INSPECTION ASSESSMENT FINDINGS

Redness from local infection or


inflammatory carcinoma. A pigskinlike or orange-peel appearance
results from edema, which is seen
in metastatic breast disease.
A prominent venous pattern may
occur as result of increased
circulation due to malignancy. An
asymmetric venous pattern may be
due to malignancy.

THE BREAST & AXILLAE:


INSPECTION ASSESSMENT FINDINGS

Breast symmetrical in size, shape,


no prominent pores,
Breasts can be a variety of sizes
and are somewhat round and
pendulous.
One breast may normally be larger
than the other.

THE BREAST & AXILLAE:


INSPECTION ASSESSMENT FINDINGS
Areolas vary from dark pink to dark brown,
depending on the clients skin tone. 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
inverted or flat. Supernumerary nipples, may
appear along the embryonic milk-line.
No discharges should be present.

THE BREAST & AXILLAE:


INSPECTION ASSESSMENT FINDINGS

When doing the three maneuvers


that validate the presence of
retractions, the clients breasts
should rise symmetrically with no
sign of dimpling or retraction.
Breasts should hang freely and
symmetrically.

THE BREAST & AXILLAE:


INSPECTION ABNORMAL ASSESSMENT
FINDINGS

THE BREAST & AXILLAE:


INSPECTION ABNORMAL ASSESSMENT
FINDINGS

THE BREAST & AXILLAE:


INSPECTION ABNORMAL ASSESSMENT
FINDINGS

THE BREAST & AXILLAE:


INSPECTION ABNORMAL ASSESSMENT
FINDINGS

THE BREAST & AXILLAE:


INSPECTION ABNORMAL ASSESSMENT
FINDINGS

THE BREAST & AXILLAE:


INSPECTION ABNORMAL ASSESSMENT
FINDINGS

THE BREAST & AXILLAE:


INSPECTION-GERIATRIC
CONSIDERATIONS

The older client often has more


pendulous, less firm, and saggy
breasts.
Older clients may have smaller,
flatter nipples that are less
erectile or stimulation.

THE BREAST & AXILLAE: METHODS


OF ASSESSMENT

PALPATION: Cover one breast


while you are palpating the other.

TEXTURE AND ELASTICITY


CONSISTENCY OF THE
TISSUES.
TENDERNESS AND
TEMPERATURE (as in premenstrual fullness)

THE BREAST & AXILLAE: METHODS


OF ASSESSMENT

SUPINE: breast tissue is flattened


palpate a rectangular area
extending from the clavicle to the
inframammary fold or bra line, and
from the midsternal line to the
posterior axillary line and well into
the axilla for the tail of the breast.

THE BREAST & AXILLAE: METHODS


OF ASSESSMENT

A thorough examination will


take 3 minutes for each breast.
Use the fingerpads of the 2nd,
3rd, and 4th fingers, keeping
the fingers slightly flexed. It is
important to be systematic.

THE BREAST & AXILLAE: METHODS


OF ASSESSMENT

Palpate the breasts using one of the


three different patterns ( circular or
clockwise, wedge, vertical strip).
Choose one that is most comfortable
for you, but be consistent and thorough
with the method chosen.
Start at one point for palpation and
move systematically to the end-point to
ensure that all breast surfaces are
assessed.

THE BREAST & AXILLAE: METHODS


OF ASSESSMENT

Be sure to palpate every square inch of


the breast from the nipple and areola to
the periphery of the breast tissue and
up to into the tail of Spence.
Vary the levels of pressure as you
press.
LIGHT superficial
MEDIUM mid-level tissue
Firm to the ribs

THE BREAST & AXILLAE: METHODS


OF ASSESSMENT

Use the bimanual technique if the


client has large breasts.
Support the breast with your nondominant hand and use your
dominant hand to palpate.

THE BREAST & AXILLAE:


PALPATION

THE BREAST & AXILLAE:


PALPATION

THE BREAST & AXILLAE: PALPATION


FOR THE PRESENCE OF NODULES

THE BREAST & AXILLAE: PALPATION


FOR THE PRESENCE OF NODULES

THE BREAST & AXILLAE: PALPATION


FOR THE NIPPLES

THE BREAST & AXILLAE: PALPATION


FOR THE NIPPLES

THE BREAST & AXILLAE: PALPATION


FOR THE NIPPLES

THE BREAST & AXILLAE: PALPATION


FOR THE LUMPECTOMY OR MASTECTOMY

Mastectomy or lumpectomy
scar
Lymphedema
Upper outer quadrant
Lymph nodes
Signs of inflammation

THE BREAST & AXILLAE: PALPATION


FOR THE LUMPECTOMY OR MASTECTOMY

THE BREAST & AXILLAE: PALPATION


FOR THE LUMPECTOMY OR MASTECTOMY

THE BREAST & AXILLAE:


INSPECTION OF THE AXILLAE

THE BREAST & AXILLAE:


INSPECTION OF THE AXILLAE

Sitting position preferable.


Inspect each skin of the axilla
noting evidence of rash,
signs/symptoms of infection,
unusual pigmentation.

THE BREAST & AXILLAE:


INSPECTION OF THE AXILLAE

To examine the left axilla, ask the patient to


relax with the left arm down.
Help by supporting the left wrist or hand with
your left hand.
Cup together the fingers of your right hand
and reach as high as you can toward the
apex of the axilla.
Warn the patient that this may feel
uncomfortable. Your fingers should lie directly
behind the pectoral muscles, pointing toward
the midclavicle.

THE BREAST & AXILLAE:


INSPECTION OF THE AXILLAE

Now press your fingers in toward


the chest wall and slide them
downward, trying to feel the
central nodes against the chest
wall.

THE BREAST & AXILLAE:


INSPECTION OF THE AXILLAE

PECTORAL NODES: grasp the


anterior axillary fold between your
thumb and fingers, and with your
fingers palpate inside the border of
the pectoral muscle.
LATERAL NODES: from high in the
axilla, feel along the upper
humerus.

THE BREAST & AXILLAE:


INSPECTION OF THE AXILLAE

SUB-SCAPULAR NODES: step


behind the patient and with your
fingers feel inside the muscle of
the posterior axillary fold.
Feel for infraclavicular nodes
and
re-examine
the
supraclavicular nodes.

THE BREAST & AXILLAE: SIGNS OF


BREAST CANCER

Elevation
Asymmetry
Bleeding
Orange Peel skin
Nipple Retraction

THE BREAST & AXILLAE: SIGNS OF


BREAST CANCER

THE BREAST & AXILLAE: WHO ARE


AT RISKS OF BREAST CA?

Altered body structure or function


due to trauma, pregnancy, recent
childbirth, anatomic abnormalities
of genitals or disease
Physical, psychosocial, emotional,
or sexual abuse; sexual assault
Disfiguring conditions, such as
burns, skin conditions, birthmarks,
scars (e.g. mastectomy)
Specific medication therapy that
causes sexual problems

THE BREAST & AXILLAE: WHO ARE


AT RISKS OF BREAST CA?

Temporary or long term impaired


physical ability to perform
grooming and maintain sexual
attractiveness
Value conflicts between personal
beliefs and religious doctrines
Loss of partner
Lack of knowledge or
misinformation about sexual
functioning and expression

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

1. Clinical Breast Examination: Clinical


breast exam is an examination by a
doctor or nurse, who uses his or her
hands to feel for lumps or other changes
2. Breast self-exam: A breast self-exam is
when you check your own breasts for
lumps, changes in size or shape of the
breast, or any other changes in the
breasts or underarm (armpit).

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

1. DIAGNOSTIC MAMMOGRAPHY
Multiple views are taken to isolate area
of cancer. It differs from a screening
mammogram, which involves only two
x-ray views and costs less.
3

views :
Craniocaudal
Mediolateral
Axillary

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

2. ULTRASONOGRAPHY
It is used to distinguish a fluidfilled cyst from a solid mass.
However, it cant detect small
small, non-palpable cancers.
It cant also distinguish benign
from malignant lesions.

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

3. COMPUTED TOMOGRAPHY (CT SCAN)


It is indicated for any discrete palpable
mass, regardless of mobility of mass,
negative mammogram, age of client,
length of time mass has been present or
previous benign biopsies.

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

4. BIOPSY is a medical test involving


removal of cells or tissues for
examination.
It is done under local anesthesia and
occasionally under general
anesthesia, include fine needle
aspiration, needle core biopsy, open
biopsy, and needle localization.

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

a) Aspiration Biopsy a syringe and


g 18 needle is used to aspirate
tissue from the site which is under
local anesthesia.
) The specimen is spread on a
glass slide, fixed, stained and sent
to the laboratory

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

b.) Incisional Biopsy a piece of


tissue is obtained in the
operating room, sent to the
laboratory fro frozen section
which is the stained and
examined under the
microscope.

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

5. STEREOTACTIC BIOPSY
It is a new technique that is now
used in many centers, it is used for
small non-palpable breast lesions
discovered during mammography.
The procedure takes an hour and
requires no special preparation. The
patient is in prone position, with
breast suspended down through a
hole in examining table.

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

A 14-gauge needle in a high speed


core biopsy gun is automatically
guided by x-ray to the suspicious area,
where multiple masses are taken.
Potential complications are
hematoma and infection. Stereotactic
biopsy is faster and less expensive
than needle localization and
outpatient surgical biopsy.

THE BREAST & AXILLAE:


DIAGNOSTIC EXAMINATIONS

HEALTH PROMOTION AND


COUNSELLING (Abaquin and Kuan,
2005)

Not delaying pregnancy until after


30 years of age.
Follow recommended
mammography screening guidelines
for age group. If all women over 50
years of age had annual
mammograms, breast cancer deaths
would decrease by 30%
Breastfeeding
Educate all women of reproductive
age to perform monthly self-breast

HEALTH PROMOTION AND


COUNSELLING (Abaquin and Kuan,
2005)

Get regular breast examination


Strenuous exercise, especially in
youth but also in adulthood.
Advice older clients to use wellfitting bra to reduce discomfort
related to sagging of breasts.
Encourage healthy lifestyle choices
such as low-fat, high-fiber diet.

ASSESSMENT:
BREASTS & AXILLAE

ASSESSMENT:
BREASTS & AXILLAE

THANKS
!

ASSESSMENT:
BREASTS & AXILLAE

FIN