HAS - BREAST

• Breast


  A pair of mammary glands located on the anterior chest wall, the milk-producing gland of women
• Anatomic breast landmarks and their position in the thorax

  • Extending vertically from the 2nd to the 6th rib and laterally from the sternal border to the axilla
• How the breasts change with age

  1. Occurs between ages 8-13

  2. Breast and nipple as a single mound

  3. Tender and dull during the reproductive years

  4. During pregnancy: pigmentation and enlargement

  5. Glandular tissue atrophy

  6. Gradual decline of tissues on the mammary glands during menopause
• Functions of the breast

  • Synthesis, secretion, and ejection of milk for nourishment and protection of neonates and infants
  • Breastfeeding
  • Provides sensual pleasure during sexual foreplay
  • Provides some protection on the anterior chest wall
• Nipples (papilla mammary)


  Round, hairless, pigmented protrusion of erectile tissue, approximately 0.5 to 1.5 in diameter, located at the center of the breast, containing 12-20 minute openings on the surface (lactiferous ducts), a cylindrical or conical structure projecting from the center of the areola, containing an elaborate subcutaneous network of smooth muscle cells and elastic fibers
• Areola


  A pigmented area surrounding the nipples, approximately 2.5-10 cm in diameter, containing Montgomery's Tubercles (modified sebaceous glands that help lubricate the nipple and lactation) and a number of subcutaneous glands that enlarge during pregnancy
• Axilla


  The small hollow portion beneath the arm where it joins the body at the shoulders, also called the armpit
• Breast glands


  • Each breast has 8-10 sections (lobes) arranged like the petals of daisies, inside each lobe are many smaller structures called lobules, at the end of each lobule are tiny sacs (bulbs) that can produce milk
• Arterial supply to the breast

  • Lateral Thoracic Branch of the 2nd part of the Axillary Artery
  • Medial Mammary Branches of the Internal Thoracic Artery
  • Superior Thoracic Branch of the Axillary Artery
  • Lateral Branches of the 2nd, 3rd, and 4th Posterior Intercoastal Arteries

  
• Venous drainage of the breast

  Circular Venosus - an anastomosis venous plexus deep to the areola at the base of the nipple, with a superficial set of veins ending in the internal thoracic vein and a deep set ending in the internal thoracic, axillary and post-intercostal veins
• Lymphatic drainage of the breast

  • Anterior (pectoral) set - situated along the lateral thoracic vein under the anterior axillary fold, lying mainly on the 3rd rib
  • Posterior (scapular) set - lies on the post-axillary fold in relation to the subscapular vessels
  • Lateral (axillary vein) set - along the upper part of the humerus in relation to the axillary vein
  • Central set - situated in the fat of the upper axilla
  • Apical or infraclavicular set - lie deep to the clavipectoral fascia along the axillary vessels

  
• Muscles that support the breast

  • Pectoralis Major and Pectoralis Minor
  • Axillary Tail of Spence
  • Lastissimus Dorsi
  • Serratus Anterior
  • Rectus Abdominus
• Supernumerary nipples


  An additional nipple, a minor birth defect, non-functional, without accompanying mammary glands, similar to the location of nipples on mammals that have multiple nipples along the underbelly
• General approach to breast assessment

  1. Prior assessment: Preparation of the nurse, preparation of the patient, explain the procedure, adopt a non-judgmental and supportive approach, be aware of the impact of culture

  2. Positioning: Performed when assessing the breast for retraction and dimpling, the following actions contract the pectoral muscles

  3. Before assessment: Introduce yourself, ask permission, assure privacy, ask for a chaperone, explain what you want to do, expose the patient adequately
• History taking


  • Lump - duration, onset, rate of growth
  • Pain
  • Fever
  • Discharge from nipple
  • Retraction of nipple
  • Trauma
  • Loss of weight/appetite
  • Swelling elsewhere
  • Related to metastasis - bone pain, jaundice, cough with hemoptysis
  • Similar episodes
  • Smoking
  • Alcoholism
  • Diet habits (high-fat diet)
  • Breast feeding
  • Drug intake
• Cancer risk factors


  • Age: Older
  • History: Family
  • Abortion
  • Late menopause
  • Obese
  • Nulliparity
  • Early Menarche
• Breast examination


  1. Expose: Patient removes upper body clothing, inspect the opposite side to compare for asymmetry

  2. Inspection: Position - sitting with arms by side, look for symmetry, any mass, skin changes (lump, pilled in nipple, dimpling, dripping, redness/rash, skin changes)

  3. Tenderness: Ask the patient if tenderness before touching, warm hands

  4. Skin: Inspect for skin retraction, dimpling, raise the breast to inspect the undermined skin

  5. Nipples: Inspect for redness, bleeding, discharge, ask the patient to raise arms and place hands behind head to check for changes in mass position, nipple or skin tethering

  6. Color: Note normal variations and deviations (redness, peau d'orange)

  7. Venous pattern/vascularity: Observe for visibility and pattern, normal is diffuse and symmetrical, deviations may indicate malignancy

  8. Thickening or edema: Normal is no thickening or edema, deviations indicate edema

  9. Size and symmetry: Normal variations, deviations include retracted nipple, retracted breast tissue, dimpling

  10. Lesions/masses: Normal is no masses, tumors or lesions, deviations include cancerous tumors (irregular, firm, hard, not tender, usually after age 50) and fibroadenomas (lobular, ovoid-shaped, round, firm, well-defined, seldom tender, singular and mobile, usually between puberty)
• Asymmetric venous pattern


  • May be due to malignancy
• Thickening of edema


  • There should be no thickening or edema
• Normal breast characteristics


  • Variety of sizes
  • Somewhat pendulous
  • Larger than the other
  • Nipple inversion during puberty
  • Nipples point upward and laterally or outward or downward
• Contour


  • Normally convex, without flattening
  • No retractions of dimpling
• Deviations from normal breast contour

  • Retracted Nipple
  • Retracted Breast Tissue
  • Dimpling
• Normal breast findings


  • Breasts, areolas, nipples, axilla are free from masses, tumors, and primary and secondary lesions
• Deviations from normal breast lesions/masses

  • Cancerous Tumors
  • Fibroadenomas
  • Fibrocystic Breast Disease
• Cancerous tumors


  • Irregular, firm, hard
  • Not usually tender
  • Usually occur after age 50
  • The most common symptom of breast cancer is a new lump or mass
• Fibroadenomas


  • Lobular, ovoid-shaped, round
  • Firm, well-defined, seldom tender
  • Singular and mobile
  • Usually occur between puberty and menopause
  • Non-cancerous breast lumps

  
• Fibrocystic Breast Disease


  • Round, elastic, defined, tender, mobile cysts
  • Common from age 30 to menopause
• Normal breast discharge


  • No discharge (non-pregnant, non-lactating)
  • Yellow discharge (Colostrum)
  • White discharge of breast milk
• Things to assess when examining the breast

  • Discharge
  • Inversion
  • Skin changes
  • Compare with the other side
• Things to examine in the axilla

  • Axillary tail
  • Axillary lymph nodes
  • Edema, nodules
  • Cancer en cuirase

  
• Palpation technique


  1. Use finger pads of the 2nd, 3rd, and 4th fingers, keeping the fingers slightly flexed

  2. Circular or Clockwise

  3. Spiral or Concentric Circles

  4. Wedge or Spokes of a Wheel

  5. Vertical Strip
• Bimanual palpation technique


  • Use this technique if the client has large breasts
  • Support the breast with your non-dominant hand and use your dominant hand to palpate
• Choose one palpation method that is most comfortable for you and be consistent and thorough with the method chosen
• Sequence of palpation


  1. Supraclavicular and infraclavicular lymph node areas

  2. Axillary lymph node regions

  3. Breasts, with patient in supine position

  
• Checking for nipple discharge

  1. Don gloves

  2. Compress the nipple using your thumb and index finger to express any discharge

  3. Watch out for discharge appearing through one of the duct openings on the nipple's surface

  4. Note the color, consistency, and quantity of any discharge and the exact location where it appeared
• Normal nipple discharge


  • Nipple may become erect and the areola may pucker in response to stimulation
  • Milky discharge is usually normal only during pregnancy and lactation
• Deviations from normal nipple discharge

  • Discharge may be seen in endocrine disorder and with certain medications
  • Discharge from one breast may indicate Benign Intraductal Papilloma, Fibrocystic Disease, or Cancer of the Breast
• Inspection and palpation of the male breast is done essentially in the same manner as that of the female breast
• Every month, every 1-3 years, 1% of all breast cancer is found in men
• Gynecomastia


  An overdevelopment or enlargement of the breast tissue in men or boys