Breast Assessment

Breast Structure and Functions:

The breasts are paired mammary glands that lie over the muscles of the anterior chest wall,
anterior to the pectoralis major and serratus anterior muscles. Depending on their size and
shape, the breasts extend vertically from the second to the sixth rib and horizontally from the
sternum to the midaxillary line.

The male and female breasts are similar until puberty, when female breast tissue enlarges in
response to the hormones estrogen and progesterone released from the ovaries. The female breast
is an accessory reproductive organ with two functions: to produce and store milk that provides
nourishment for newborns and to aid in sexual stimulation. The male breasts have no functional
capability.

For purposes of describing the location of assessment findings, the breasts are divided into four
quadrants by drawing horizontal and vertical imaginary lines that intersect at the nipple.
The upper outer quadrant, which extends into the axillary area, is referred to as the tail of
Spence. Most breast tumors occur in this quadrant (Fig. 19-2).

EXTERNAL ANATOMY

The skin of the breasts is smooth and varies in color depending on the client’s skin tones. The
nipple, which is located in the center of the breast, contains the tiny openings of the lactiferous
ducts through which milk passes.
The areola surrounds the nipple (generally 1 to 2 cm radius) and contains elevated sebaceous
glands (Montgomery glands) that secrete a protective lipid substance during lactation. Hair
follicles commonly appear around the areola. Smooth muscle fibers in the areola cause the nipple
to become more erectile during stimulation.
The nipple and areola typically have darker pigment than the surrounding breast. Their color
ranges from dark pink to dark brown, depending on the person’s skin color. The amount of
pigmentation increases with pregnancy then decreases after lactation. It does not, however,
entirely return to its original coloration.

LYMPH NODES

Lymph nodes are present in both male and female breasts. These structures drain lymph from
the breasts to filter out microorganisms and return water and protein to the blood.

The major axillary lymph nodes consist of the anterior (pectoral), posterior (subscapular), lateral
(brachial), and central (midaxillary) nodes. The anterior nodes drain the anterior chest wall and
breasts. The posterior chest wall and part of the arms are drained by the posterior nodes. The
lateral nodes drain most of the arms, and the central nodes receive drainage from the anterior,
posterior, and lateral lymph nodes. A small proportion of the lymph also flows into the
infraclavicular or supraclavicular lymph nodes or deeper into nodes within the chest or abdomen.
 Breast Assessment Procedure

Assessment Procedure Normal Findings Abnormal Findings

1.Inspect the breast with the client Breasts can be a variety of A recent increase in the size
in sitting position with arms at sizes and are somewhat of one breast may indicate
sides, arms overhead, hands round and pendulous. One inflammation or an
pressed on hips, palms pressed breast may normally be abnormal growth.
together and arms extended larger than the other.
straight as client leans forward. A pigskin-like or orange-
The older client often has peel (peau d’orange)
2.Observe the breast for Size & more pendulous, less firm, appearance results from
symmetry. and saggy breasts. edema, which is seen in
metastatic breast disease
(Fig. 19-7). The edema is
caused by blocked
lymphatic drainage.

2. Inspect color and texture. Be Color varies depending on Redness is associated with
sure to note client’s overall skin the client’s skin tone. breast inflammation.
tone when inspecting the breast Texture is smooth with no
skin. Note any lesions. edema.
Linear stretch marks may
be seen during and after
pregnancy or with
significant
weight gain or loss.
Inspect superficial venous pattern Veins radiate either A prominent venous pattern
Observe visibility and pattern of horizontally and toward may occur as a result of
breast veins. the axilla (transverse) or increased circulation due to
vertically with a lateral a malignancy. An
flare (longitudinal). Veins asymmetric
are more prominent during venous pattern may be due
pregnancy. to
malignancy.
3. Observe areola both breast for Areolas vary from dark Peau d’orange skin (Fig. 19-
size, color, shape, discharge and pink to dark brown, 7), associated with
texture. depending on the client’s carcinoma, may be first seen
skin tones. They are round in the areola, whereas red,
and may vary in scaly, crusty areas are
size. Small Montgomery indicative of Paget’s disease
tubercles are present. (Fig. 19-8).
3. Inspect the nipples. Note the Nipples are nearly equal Dimpling or retraction (Fig.
size and direction of the nipples bilaterally in size and are 19-12) is usually caused by
of both breasts. Also note any in the same location on a malignant tumor that has
dryness, lesions, bleeding, or each fibrous strands attached to
discharge. breast. Nipples are usually the
everted, but they may be breast tissue and the fascia
inverted or flat. of the muscles. As the
Supernumerary nipples muscle contracts, it draws
(Fig. 19-9) may appear the breast tissue and skin
along the embryonic “milk with it, causing
line.” dimpling or retraction.
No discharge should be
present.

4. Palpate the breast for Smooth, firm, elastic Thickening of the tissues
temperature, elasticity, tissue. may occur with an
tenderness. A generalized increase in underlying malignant tumor.
nodularity and tenderness
may be a normal finding Painful breasts may be
associated with the indicative of benign breast
menstrual cycle or disease but can also occur
hormonal medications. with a malignant tumor. The
Breasts should be a normal client should be referred for
body temperature. further evaluation. Heat in
the breasts of women who
have not just given birth or
who are not lactating
indicates inflammation.
4. Palpate for masses (note size, No masses should be Malignant tumors are most
shape, mobility, consistency, palpated. However, a firm often found
location/quadrant) inframammary transverse in the upper outer quadrant
ridge may normally be of the breast. They are
palpated at the lower base usually unilateral with
of the breasts. irregular, poorly delineated
borders.
If you detect any lump, They are hard and nontender
refer the client for further and fixed to underlying
evaluation. tissues.

5.Palpate nipple gently for The nipple may become Discharge may be seen in
discharges. Wear gloves to erect and the areola may endocrine disorders and with
compress the nipple gently with pucker in response to certain medications (i.e.,
your thumb and index finger (Fig. stimulation. A milky antihypertensives, tricyclic
19-15). discharge is usually antidepressants, and
Note any discharge. normal only during estrogen). Discharge from
pregnancy and lactation. one breast may indicate
However, some women benign intraductal
may normally papilloma, fibrocystic
have a clear discharge disease,
or cancer of the breast.

Bimanual Technique. If a patient

has pendulous breasts, use the
bimanual technique. The patient
should sit upright, leaning slightly
forward. Place one hand
underneath the breast
(on the inferior surface) while
palpating with the other hand.

If spontaneous discharge occurs

from the nipples, a specimen must
be applied
to a slide and the smear sent to the
laboratory for cytologic
evaluation.
6. Palpate lymph nodes in the Firm, hard, enlarged nodes
following areas: Supraclavicular, (>1 cm) fixed to underlying
subclavian, intermediate, brachial, tissues or skin suggest
scapular, mammary & internal malignancy.
mammary. Tender, warm, enlarged
nodes
suggest infection of the
breast, arm, or hand.

The Male Breast: No swelling, nodules, or Soft, fatty enlargement of

Inspect and palpate the breasts, ulceration should be breast tissue
areolas, nipples, and axillae. Note detected. is seen in obesity.
any swelling, nodules, or Gynecomastia, a
ulceration. Palpate the flat disc of smooth, firm, movable disc
undeveloped breast tissue under of glandular tissue, may be
the nipple. seen in one breast in males
during puberty for a
temporary time
(Fig. 19-18). However, it
may also be seen in
hormonal imbalances, drug
abuse, cirrhosis, leukemia,
and thyrotoxicosis.
Irregularly shaped, hard
nodules occur in breast
cancer.