Assessing Breasts and Lymphatic System - Chapter 20

Chapter 20: Assessing Breasts and Lymphatic System

• This chapter covers assessing breast and lymphatic systems.
• Learning objectives include identifying significant breast anatomy, breast glandular tissue composition, how Cooper's ligaments change with cancer, documenting clinical findings, breast lymphatic system anatomy, and adolescent/pregnant breast development.
• Learning outcomes also include breast self-examination procedure and health promotion concepts.

Breast and Lymphatic System Function

• Function: Produce and store milk nourishing newborns.
• Structure:
  • Paired mammary glands:
    • External anatomy: Nipple for milk passage, areola and Montgomery glands for lactation.
    • Internal anatomy: Glandular tissue, fibrous tissue, fatty tissue.

Anatomy of the Breast

• Diagram of breast anatomy shows locations of:
  • Cooper's ligaments
  • Lactiferous ducts
  • Lactiferous sinuses
  • Montgomery glands
  • Areola
  • Nipple
  • Lobules
  • Lobes
  • Adipose tissue
  • Pectoralis Major muscle
  • Axillary tail of Spence

Embryonic Development

• During embryonic development, a milk line extends from the axilla to the groin.
• Breast development occurs along this ridge.
• If the milk line tissue doesn't atrophy, supernumerary nipples may be present.

Axilla: Tail of Spence

• The axillary area is divided into four quadrants.
• The upper outer quadrant extends into the axillary area and called the Tail of Spence.
• Most breast tumors occur in the upper outer quadrant.

Lymphatics

• Breast has an extensive lymphatic drainage.
• Major axillary lymph nodes:
  • Anterior (pectoral): drains anterior chest and breast.
  • Posterior (subscapular): drains posterior chest and breast.
  • Lateral: drains arms.
  • Central: receives drainage from all other nodes.

Male Breast

• Rudimentary structure (thin disc of undeveloped tissue) under the nipple.
• Male breast exams are abbreviated, but an exam of the anterior thorax, chest wall, nipple, and axillary lymph nodes is required.

Gynecomastia

• Enlargement of breast tissue in males, usually temporary during puberty.
• Can significantly impact self-esteem.
• Can recur with aging and possibly due to testosterone deficiency.

Breast: Subjective Data

• Biographical data, chief complaint (followed by HPI - history of present illness)
• Past history (trauma/injury, lumps/mass)
• Family history (breast disease)
• Functional assessment- lifestyle and health practices.
• Relevant details (breast exam/mammogram, diet, exercise, smoking, alcohol use)

Objective Data- Preparing the Client

• Purpose of examination- identify signs of abnormalities.
• Provide privacy and explanation before examination.
• Positioning: sitting then supine.

Objective Data- Equipment

• Centimeter ruler
• Small pillow
• Gloves

Objective Data- Physical Assessment

• Warm hands, Inspection and palpation.
• Consider males' anatomy during assessment.

Inspection: Breast-Normal Findings

• Normal size variability
• Normal shape (round and pendulous)
• Mild asymmetry

Inspection: Breast-Abnormal Findings

• Sudden increase in size of one breast
• Hyperpigmentation
• Erythema (redness) - inflammation(potential infection)
• Unilateral/one-sided dilated veins
• Edema (swelling) - could indicate cancer

Inspection: Breast-Lymphatic Drainage Areas-Normal Findings

• No bulging
• No discoloration
• No edema

Inspection: Breast-Lymphatic Drainage Areas-Abnormal Findings

• Bulging
• Discoloration
• Edema

Inspection: Breast-Nipples-Normal Findings

• Symmetrically sized
• Normally located
• Everted (straight up position) or slightly inverted.

Inspection: Breast-Nipples-Abnormal Findings

• Deviation in pointing
• Nipple retraction
• Discharge (bleeding)

Inspection: Breast-Supernumerary Nipples

• Not common
• Additional nipples may be detected.

Inspection: Breast - Retraction and Dimpling

• Normal finding: Breasts rise when arms are raised.
• Abnormal finding: Dimpling, retraction

Inspection: Breast - Forward Movement of Breasts

• Normal finding: Symmetrical free-forward movement of breasts during exams.
• Abnormal finding: Restricted movement (could indicate cancer)
• Client's arms are supported while she leans forward.

Inspection and Palpation: Axillae

• Normal finding: No rash/infection, less than 1 cm nodes that are discrete, movable, and nontender.
• Abnormal finding: Rash, infection, inflammation, abnormal lymph node findings, hard/fixed lymph nodes (could indicate cancer)
• Lymph nodes are palpated for rashes, infection, or abnormalities in the axilla.

Breast Palpation

• Positioning: supine with a pillow under the examination side.
• Arm overhead
• Palpation using different touch strengths (light, medium, deep)-vertical and rotary motion.
• Palpating entire breast, including the tail of Spence.

Palpation: Breast-Texture & Elasticity

• Normal finding: Firm, smooth, elastic tissue.
• Abnormal finding: Erythema, heat, and swelling. Tissue thickening, suggestive of a malignant tumor.

Palpation: Breast - Tenderness

• Normal finding: Possible tenderness associated with menstrual cycles, varying intensity and location.
• Abnormal finding: persistent, excessive tenderness.

Palpation: Breast-Masses

• Normal findings: No masses.
• Abnormal findings: Masses, specifically hard, immobile, and fixed. Location, size, shape, consistency, mobility, distinctness, skin over the lump, and tenderness assessed for characteristics.

Abnormal Breast Masses

• Fibroadenomas: Benign masses (1-5cm, solid, firm, rubbery, elastic, nontender, round or oval shape, clear margins, mobile).
• Fibrocystic breast disease: Benign multiple tender lumps, nodularity, dominant lumps, nipple discharge, and other symptoms that reflect infections and inflammation (could be a secondary infection to a disorder).
• Breast abscess: complication of infection. (pus pocket that feels hard, looks erythematous, with tenderness and heat).
• Intraductal papilloma: benign tumors in ducts. (palpable nodule underlying the affected duct and potential for serous to serosanguineous discharge).

Palpation: Nipples- Normal Findings

• Physiologic (benign) discharge, usually bilateral, (white, milky and present during pregnancy, breastfeeding, within 1 year of weaning.)

Palpation: Nipples- Abnormal Findings

• Pathologic discharge (Spontaneous, unilateral, and blood).

Examining a Woman with a Healed Mastectomy

• Inspection and palpation of the intact breast and mastectomy area, incisional site, and axilla.
• Observe for erythema, swelling, and skin lesions.

The Male Breast Palpation

• Inspection of the chest wall to note presence of any lumps or swellings.
• Checking the nipple area for similar abnormalities, along with tissue enlargement
• Axillary lymph nodes are assessed.

Breast Self-Exam

• Positioning: Lie down, sit up, mirror review.
• Technique: Circular motions, different pressure levels, up-and-down patterns, hands on hips/shoulders.
• Timing: post-menstrual cycle.

Expected Changes in Aging Female Breasts

• Breasts may appear pendulous (sagging), and flattened (slight downward shift).
• Nipples may be retracted.
• Breasts may feel granular on palpation.
• Decreased firmness.

American Cancer Society Recommendations for Early Detection

• Ages 40-44: Women should have the option to start screening with mammograms yearly.
• Ages 45-54: Women should get mammograms yearly.
• Age 55+: Women can switch to mammograms every other year or continue yearly if in good health and expected to live 10+ years.

Breast Cancer Risk Factors

• Non-modifiable: Gender, age, genetics (BRCA1/2), family/personal history of breast cancer, high breast density/consistency, early menstruation/late menopause, previous chest radiation.
• Modifiable: Hormone replacement therapy, never been pregnant, alcohol consumption, excessive night shift work, excessive weight gain, recent use of oral contraceptives, no breast-feeding history.