Structures and Functions of the Breast

- Breasts are conical in shape and often unequal in size. The primary structures of the breast include
lobes, lobules, milk (lactiferous) ducts, milk (lactiferous) sinuses, acini cells, areola, nipple, ligaments,
blood vessels, lymphatic tissue, and supporting muscular tissue.

- The breast is composed of glandular, connective, and adipose tissues, as well as smooth muscle and
nerve fibers. Men do have few ducts surrounded by breast and other tissue.

- Men, generally, do not secrete the same amounts of hormones(such as estrogen) that cause breasts to
develop. Although incidence is very rare (about 10 in 1 million), men can develop breast cancer.

-The breast contains the mammary glands. Its primary function in female mammals is to produce
nourishment to feed their offspring.

-The breast lies between the second and the sixth ribs and between the sternal edge and the midaxillary
line. The tail of the breast extends into the axilla.

- Approximately 2/3 of the breast lies over the pectoralis major muscle, and the remaining 1/3 is
superficial to the serratus anterior muscle.

Developmental Variations

Infants

- At birth, the infant's nipple is elevated, and a slight secretion of milky material, "witch's milk" may
occur 5 to 7 days after birth.

-Palpable breast tissue is normal in infancy, but not beyond this period.

-Some newborns have supernumerary nipples, a normal finding.

Children and Adolescents

-A female child's breast is underdeveloped compared with an adult's.

- Growth of breast tissue generally begins in the prepubertal period.

-Physical changes occurring in the breasts are the result of growth.

Pregnant Women

- Breasts become fuller and firmer, and the areola and nipples darken and enlarge.

-These changes occur in response to hormones from the corpus luteum and the placenta.

- In the 3rd trimester, colostrum, a yellow secretion, occurs.

-Colostrum continues to be secreted after the birth of a baby until milk is produced.
Older Adults

-As women age, glandular tissue is replaced with adipose tissue and the ducts become more fibrous.
These changes, along with a general reduction of muscle mass and tone, cause breasts to be less firm
and more pendulous.

- Arthritic changes in the joints and hands make BSE a little more challenging.

Helpful Hints

 Pregnancy is not an ideal time for a woman to learn how to do BSE. Getting to know what is
normal for her will be difficult until pregnancy and lactation are completed.
 . Older women may be reluctant to examine their breasts because they have the idea that
"touching yourself" is taboo
 Older women may have trouble assuming some positions necessary for the physical
examination. Besides being sensitive to their needs, adapt technique to meet patient's needs.
 Advise older women to sprinkle talcum powder on their hands so that they will glide more
smoothly durina BSE.

Health History

 Do you have a lump or thickening in or near your breast or under your arm that persists
through the menstrual cycle?
 Is the skin on your breast or nipple red, dimpled, puckered, scaly, or inflamed?
 Do you have nipple changes? For example, a change in the direction in which one nipple
points, inversion, eversion, or discharge?
 Has your breast changed in size, shape, or contour?

Biograhical Data

 Breast development varies with age and various breast problems are age related. - Ex:
The risk for breast cancer increases with age; fibroid adenomas usually occur before age
30.
 The incidence of intraductal papilloma, a benign lesion of the lactiferous duct, peaks at
age 40.
 Fibrocystic breast changes usually occur between ages 35 and 50.
 Ductal ectasia occurs most commonly in perimenopausal women in their 50s.

Current Health Status

 If the patient's chief complaint is about her breast, investigate this first; then perform a
symptom analysis.
  Common chief complaints include lumps or masses, breast pain or tenderness (mastalgia), and
nipple discharge.
 Related complaints are changes in the venous pattern of the breast (increased vascularity),
dimpling or puckering of breast skin, redness or scaliness, and changes in the direction of
nipple.
- Past Health History
- Family History
- Review of Systems
- Psychosocial Profile

Anatomical Landmarks

Breast examination should include the areas above the clavicle to the 6 or 7th rib and from the sternum
to the midaxillary line.

Approach

 Use the techniques of Inspection and Palpation

 Perform the examination in several positions: Sitting, arms at side.

-Sitting, arms over head.

>Sitting, hands on hips. (detect dimpling/retraction)

>Sitting, leaning forward. (assess large, pendulous breast)

> Supine with pillow under shoulder of breast being examined. (pillow helps spread the breast
tissue)

INSPECTING THE BREASTS

1. POSITIONS FOR BREAST EXAMINATION

Assessment Techniques/Normal Variations

 Inspect the breast with the patient in various positions.

 Note color, size, shape, symmetry, lesions, discharge, venous pattern, dimpling or retraction
 Breast conical, symmetrical, or slightly asymmetrical.
 Skin color lighter than in exposed areas; no lesions, redness, or edema; texture even.
 Striae often seen with breast enlargement during pregnancy.
 No dimpling or retraction.
 No increase in venous pattern unless patient is pregnant. Then symmetrical increase is normal.
 Abnormal Findings/Rationale

 Change in symmetry warrants further investigation.

 Edema and peau d'orange (orange skin appearance): May be related to lymphatic
obstruction. (may signal cancer)
 Erythema: Infection, abscess, or inflammatory carcinoma of breast.
 - Dimpling/puckering: Sign of retraction phenomena or abnormal traction on Cooper's
ligaments caused by neoplasm. Attachment of tumor to fascia and pectoralis muscle pulls
on skin and produces dimpling.
 - Lesions/asymmetrical increased venous pattern: Signs of breast cancer.

2. NIPPLES AND AREOLAE

Assessment Techniques/Normal Variations

 Inspect position, direction, discharge, or lesions.

 Note presence of supernumerary nipples.

Nipples everted, pointing in the same direction, no discharge or lesions.

 Spontaneous discharge normal during pregnancy and lactation.

 Areola and nipple darker than breast tissue. Become even darker during pregnancy.
 Supernumerary breasts or nipples are congenital anomalies in which small, palpable masses or
nipples are present among milk lines, embryonic ridges that extend from axilla to groin. They
usually atrophy during fetal development, except where the breasts develop. Cracks, redness of
nipple can occur with nursing.
 Lesions/erosion/ulceration of areola and nipple: Paget's disease.
 Discoloration of areola and nipple that is not associated with pregnancy warrants follow-up

3. AXILLAE

Assessment Technique/Normal Variations

 Inspect color, lesions

 Skin Intact. No Rashes or lesions.

Abnormal Findings/Rationale

 Rashes/redness/unusual pigmentation: infection, allergy.

 Dark pigmentation/velvety skin texture of axilla: Malignant acanthosis nigricans, a rare cancer.

PALPATING THE BREAST

1. Vertical strip method

You start at the sternal edge and palpate the breast in parallel lines until you reach the
midaxillary line. This is like “mowing the grass” in which you go up one area and down the
 adjacent strip. Be sure to palpate the tail of Spence as well. End by examining and palpating
the nipple. Note its elasticity, and squeeze in between it between your thumb and your
index finger to see if there is discharge. Because of the possibility of discharge be sure to
wear nonsterile gloves when palpating the nipple. If the patient is supine, shift the pillow or
rolled towel to the opposite side and repeat the procedure with the other breast.

2. Pie Wedge Method

This method (Fig. 16.7) examines the breast in wedges or "pie slices." Once one wedge is
examined, move to the adjacent wedge until you examine the entire breast and the tail of
Spence. Then examine the nipple as you did in the vertical strip method. Repeat with the
opposite breast.
3. Concentric Circles Method
This method (Fig. 16.8) uses concentric circles to examine the entire breast area. Start in the
outermost area (or largest circle) at 12 o'clock; then move to 1 o'clock, 2 o'clock, and so on
until the first circle is completed. When you complete the circle and return to 12 o'clock,
move your fingers two fingerbreadths inward and examine another concentric circle. Repeat
this procedure until you reach the nipple area. Examine the nipple in the same fashion as
the previous two methods. Also examine the tail of Spence. Repeat with the other breast.

PALPATING THE BREASTS, AXILLAE, AND LYMPH NODES

1. BREASTS
Assessment Techniques/Normal Variations
 Position patient supine with arm overhead and small pillow under shoulder of
breast being examined.
 Use three levels of palpation: light, medium, and deeper.
 Using your finger pads, move in circular fashion across breast using vertical strip
method, pie wedge method, or concentric circle method.
 Be sure to cover entire breast area from the sternum to the midaxillary line and
from the clavicle to the sixth or seventh intercostal space.
 Wear gloves if open lesions or discharge present.
 Breast soft, nontender.
 Consistency is age dependent: More firm and elastic in premenopausal women; less
firm and elastic with ducts that may feel stringy or cordlike in postmenopausal
women.

Palpating the breast

 Use your three middle fingers to palpate the patient's breasts systematically. Rotate
your fingers gently against the chest wall. Make sure you include the tail of Spence in
your examination.
Abnormal Findings/Rationale

Benign Lumps

 Fibro adenoma: Smooth, firm, round, movable, nontender, 1 to 5cm in size.

 Fibrocystic breast disease: Nodular, tender, movable, soft to firm, in postmenopausal
women.

Malignant Breast Lumps

 Breast cancer: Irregular shape; irregular, poorly defined borders; nontender;

immovable; increase in size as disease progresses.
 Breast warm and indurated (hard): Mastitis; Staphylococcus aureuss most common.
2. NIPPLES
Assessment Techniques/Normal Variations
Gently palpate the nipple.
Note elasticity, tenderness, discharge.
Nipples elastic, nontender. No discharge or white, sebaceous secretion.

Examining the areola and nipple

 After palpating the breasts, palpate the areola and nipple. Gently squeeze the nipple between
your thumb and index finger to check for discharge.

Abnormal Findings/Rationale

 Loss of elasticity may indicate underlying malignancy.

 Bloody, purulent discharge: Infection.
 Serous, serosanguineous, or bloody drainage: Intraductal papilloma.
 Thick, gray drainage, fixation of nipple: Ductal ectasia

3. AXILLA AND CLAVICULAR NODES

Assessment Techniques/Normal Variations
 If nodes palpable, note size, shape, tenderness, mobility, consistency.
 Nonpalpable.
  Palpable nodes: Infection or metastatic disease.
 Enlarged lymph nodes caused by infection are usually tender; those caused by malignancy
are nontender.

Document Your Findings

 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 of the clock face (e.g. 2 o'clock), and measure the distance
in cm from the nipple.
SAMPLE DOCUMENTATION OF BREAST
 Right breast slightly larger than left.
 Uniform and symmetrical.
 Ovoid in shape
 No redness or dimpling.
 Small, pea-sized (0.5 cm), easily movable, rubbery,
 smooth-edged lesion palpated in right breast at 2
 o'clock; 4cm from areola in the upper outer quadrant.
 No lesions palpated in left breast.