Assessment of Breast and Axillary Nodes

1. PHYSICAL ASSESSMENT OF
BREASTS AND AXILLA

2. Breasts And Axilla
The female breast lie against the anterior thoracic wall,
extending from the clavicle and 2nd rib down to the 6th
rib, and from the sternum across the midaxillary line.
The superior lateral corner of the breast tissue, called the
axillary tail of Spence, projects up and laterally into the
axilla.

4. The nipple is just below the center of the breast. It is
rough, round, and usually protuberant. It’s surface looks
like wrinkled and indented with tiny milk duct openings.

5. The areola surrounds the nipple for a 1 to 2 cm radius. In the
areola are small elevated sebaceous gland, called Montgomery’s
gland. These secrete a protective lipid material during lactation.
The areola has a smooth muscle fibers that cause nipple erection
when stimulated. A few hairs are often seen on it.

6. Both the nipple and the areola are more darkly pigmented
than the rest of the breast surface. The color varies from
pink to brown depending on the person’s skin color and
parity.

7. The breast is hormonally sensitive tissue, responsive to
the changes of monthly cycle and aging and of touch.

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

11. Male Breast
• These consists chiefly of a small nipple and areola which
overlie on a thin disc of undeveloped breast tissue that
may not be distinguishable clinically from the
surrounding tissues.

12. Lymphatics
The breast has extensive lymphatic drainage. Most
of the lymph ( more than 75 percent ) drains into
the ipsilateral axillary nodes.

13. There are Four Groups of Axillary Nodes:
1.Central Axillary Nodes
It is located high up in the middle of the axilla, over
the ribs and serratus anterior muscle. It receive lymph
from the other three groups of nodes.

15. 2. Pectoral (Anterior) Nodes
It is located along the lateral edge of the pectoralis
major muscle, just inside the anterior axillary fold.
These nodes drain to the anterior chest wall and much of
the breast.

16. 3. Subscapular (Posterior) Nodes
It is located along the lateral border of the scapula:
palpated deep in the posterior axillary fold. They drain
to the posterior chest wall and portion of the arm.

18. 4. Lateral Nodes
They are located along the upper humerus, inside the
upper arm. They drain most of the arm.

20. Clinical Importance of Breast Examination
Breast cancer is the second major cause of death from
cancer in women. However, early detection and
improved treatment have increased survival rates. If the
cancer has spread regionally, the survival rate is 76- 88
percent. The 5-years survival rate for localized breast CA
has increased from 78 percent in the1940’s to 98 percent
today. (ACS, 2002 )

23. ASSESSMENT OF FEMALE BREASTS

24. Instructions
Tell the client that you are going to examine her/his
breast and explain the procedure properly and as to how
he/she can cooperate.
Ask if she noted any lumps or other problems or whether
she does BSE (Breast Self-Exam)

25. An adequate inspection requires full exposure of the chest;
but cover one breast while palpating the other.
Be aware that some women feel embarrassed to have their
breast examined; try to be gentle, courteous and use a
matter-of-fact approach to help the client relax.
Adopt your approach to the client’s comfort and
psychological readiness.

26. For purposes of
description, the breast
may be divided into four
quadrants by horizontal
and vertical lines crossing
at the nipple.

27. EQUIPMENT
• Drapes
• Small pillow
• Ruler marked in centimeters

28. Draping: expose breast area only
Position:
• Client in sitting position with arms at the sides
• Palms of hands pressed firmly on the hips
• Arms raised and hands pressed together behind the head
• Torso leaning forward

30. INSPECTION
Inspect the Breasts
Note for: size, symmetry, and contour or shape while
the client is in a sitting position.
Inspect the Skin
Note for: localized discolorations or hyper pigmentation,
retraction or dimpling, localized hyper vascular areas,
swelling or edema, rashes, lesions/ulcerations

31. NORMAL FINDINGS
• Females: Rounded shape, conical, pendulous; slightly
unequal in size; generally symmetrical
• Males: breasts are even with the chest wall; if obese, may
be similar in shape to female breasts

32. • Skin is uniform in color (same in appearance as skin of
abdomen or back)
• The nipple and the areola are more darkly pigmented than
the rest of the breast surface; color varies from pink to brown
depending on the skin color and parity.

33. • Skin smooth and intact
• Diffuse symmetric horizontal or vertical vascular pattern
in light-skinned people. A fine vascular network is visible
normally during pregnancy.
• Pale linear striae, or stretch marks, often follow
pregnancy or with significant weight gain or loss

34. ABNORMAL FINDINGS:
• Recent change in breast size; swellings; marked asymmetry
• Localized discolorations or hyper pigmentation
• Retraction or dimpling (result or scar tissue or an invasive
tumor)
• Unilateral, localized hyper vascular areas (associated with
increased blood flow)

35. • Swelling or edema appearing as pig skin or orange peel
due to exaggeration of the pores
• Any asymmetry, mass or lesion.

36. • Emphasize any retraction by having the client:
• Raise the arms above the head
• Push the hands together, with elbows flexed (pushing the
hands together to accentuate retractions of breast tissue).
• Press the hands down on the hips to accentuate retraction of
breast tissue.

38. • NORMAL FINDINGS:
• The client’s breasts should rise symmetrically, with no sign
of dimpling or retraction.

39. • ABNORMAL FINDINGS:
• Dimpling or retraction is
usually 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.

41. Inspect the Areola
Note for: area for size, shape, symmetry, color, surface
characteristics, and any masses or lesions.

42. NORMAL FINDINGS:
Round or oval and bilaterally the same. 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.
ABNORMAL FINDINGS:
Peau d’orange skin, associated with carcinoma, may be first
seen in the areola.
Red, scaly, crusty areas are may appear in Paget’s disease

44. Peau d’orange skin

45. Inspect the Nipples
Note for: size, shape, position, color, discharge, and lesions.

46. NORMAL FINDINGS:
• Round, everted, and equal in size; similar in color; soft
and smooth; both nipples point in same direction.
• Absence of discharges, except from pregnant or breast-
feeding females.
• Inversion of one or both nipples that is present from
puberty is normal.

47. PALPATION
• Have client lie supine
• To enhance flattening of the breast, instruct the client to
abduct the arm and place her hand behind her head.
Then place a small pillow or rolled towel under the
client’s shoulder.

48. Palpate the Breast
Note for: masses, tenderness, nodules, and temperature
NORMAL FINDINGS:
• Absence of tenderness, masses, nodules, breasts should
be a normal body temperature.

49. • For palpation, use the palmar surface of the middle
three fingertips (held together) and make a gentle rotary
motion on the breast.
• If the client reports a breast lump, start with the
“normal” breast to obtain baseline data that will serve
as a comparison to the reportedly involved breast.

50. • Start at one point for palpation, and move systematically
to the end point to ensure that all breast surfaces are
assessed.
• Pay particular attention to the upper outer quadrant
area and the Tail of Spence

51. • Choose one of the Three Patterns Of Palpation:
1. Hands-of-the-clock Or Spokes-on-a-wheel
2. Concentric Circles
3. Vertical Strips Pattern

52. Concentric Circles Hands-of-the-clock or
Spokes-on-a-wheel
Vertical Strips Pattern

53. Palpate the Areola and the
Nipples.
• Compress each nipple to
determine the presence of any
discharge.
• Note for: tenderness, and
discharges (assess for amount,
color, consistency, and odor)

55. NORMAL FINDINGS:
• Absence of tenderness, masses, nodules, or nipple discharges
• 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.
ABNORMAL FINDINGS:
Tenderness, masses, nodules, or nipple discharges

56. • If you detect a mass, record the following data:
a. Location: the exact location relative to the quadrants and
the tail of Spence, or the clock, and the distance from the
nipple in centimeters.
b. Size: the length, width, and thickness of the mass in
centimeters. If you are to determine the discrete edges,
record this fact.

57. c. Shape: whether the mass is round, oval, lobulated, indistinct,
or irregular.
d. Consistency: whether the mass is hard or soft.
e. Mobility: whether the mass is movable or fixed.
f. Skin over the lump: whether it is reddened, dimpled, or
retracted.
g. Tenderness: whether palpation is painful.

58. PALPATION
• Palpate the lymph nodes (Central axillary, Pectoral,
Lateral, Subclavicular, and Supraclavicular), while the
client sits with the arms abducted and supported on the
nurse’s forearm.

59. For palpation of clavicular lymph nodes use the flat surface
of all fingertips to palpate the four areas of the axilla:
1. The edge of the greater pectoral muscle along the
anterior axillary line.
2. The thoracic wall in the midaxillary area
3. The upper part of the humerus, and
4. The anterior edge of the latissimus dorsi muscle along the
posterior axillary line
Note for: tenderness, masses, and nodules

61. NORMAL FINDINGS:
• Normally there is absence of tenderness, or masses.
• No palpable nodes or one to two small nodes (less than 1
cm), discrete, nontender, movable nodes in the central area.
ABNORMAL FINDINGS:
• Presence of tenderness and masses
• Enlarged (greater than 1 cm) lymph nodes may indicate
infection of the hand or arm. Large nodes that are hard and
fixed to the skin may indicate an underlying malignancy

62. • If you palpate a mass or lump,
describe its size, shape, symmetry,
mobility, delimitation, tenderness,
consistency, temperature, and
degree of redness.
• To document the location of breast
masses, divide the breast into four
quadrants by horizontal and vertical
lines. Then visualize the breast as a
clock face with the nipple as the
center. Locate the pain or lump by
the time on the clock (e.g., 2
o’clock),and measure the distance in
centimeters from the nipple

63. ASSESSMENT OF MALE BREASTS

64. INSPECT AND PALPATE
• Inspect the breasts, areolas, nipples, and axillae. Note
any swelling, nodules, or ulceration.
• Palpate the flat disc of undeveloped breast tissue
under the nipple.

65. NORMAL FINDINGS
• Males: breasts are even with the chest wall; if obese, may be
similar in shape to female breasts
• No swelling, nodules, or ulceration should be detected.
ABNORMAL FINDINGS
• Soft, fatty enlargement of 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,
usually temporary. However, it may also be seen in hormonal
imbalances, drug abuse, cirrhosis, leukemia, and
thyrotoxicosis. Irregularly shaped, hard nodules occur in
breast cancer