BREAST ASSESSMENT

The purpose of breast assessment is to identify signs of breast disease and then to initiate early
treatment. The incidence of breast cancer in women is rising, but early detection and treatment have
resulted in increased survival rates.

It is often convenient to assess the breast immediately after assessment of the thorax and lungs.
Female breast examinations are also performed by the nurse before a mammogram or by the
gynaecologist or nurse practitioner before a pelvic examination. A breast examination should also be
a routine part of the complete male assessment. However, the male breast examination is not as
detailed as the female breast examination.

Keep in mind that breast palpation requires practice and skill because the consistency of the breasts
varies widely from client to client. Some breasts are more difficult to palpate than others. For
example, it is more difficult to palpate and inspect large, pendulous breasts to ensure adequate
evaluation of all breast tissue. It may also be difficult to detect new lumps in women who have
fibrocystic breast disease and who have granular, singular, or multiple mobile, tender lumps in their
breasts.

The actual hands-on physical examination of the breast may create client anxiety. The client may be
embarrassed about exposing his or her breasts and may be anxious about what the assessment will
reveal. Explain in detail what is is happening throughout the assessment and answer any questions
the client might have. In addition, attempt to provide the client with as much privacy as possible
during the examination.

Preparing the client

1. Let the client sit in an upright position. The breasts are first inspected in the sitting position while
the client is asked to hold arms in different positions. The breasts are then palpated while the client
assumes a supine position.
2. Explain that it will be necessary to expose both breasts to compare for symmetry during inspection.
3. One breast may be draped while the other breast is palpated.
4. Be sensitive to the fact that many women may feel embarrassed to have their breasts examined.

***The final part of the examination involves teaching clients how to perform BSE and asking them to
demonstrate what they have learned. If the client states that she or he already knows how to perform
BSE, then ask the client to demonstrate how this is done.

Equipment

 Centimeter ruler
 Small pillow
 Gloves
 Client handout for BSE
 Slide specimen

Physical Assessment

Key points or physical assessment include the following:

 Explain to the client what the steps of the examination are and the rationale for them.
 Warm your hands.
 Observe and inspect breast skin, areolas, and nipples for size, shape, rashes, dimpling,
swelling, discoloration, retraction, asymmetry and other unusual findings.
 Palpate breasts and axillary lymph nodes for swelling, lumps, masses, warmth or inflammation,
tenderness, and other abnormalities. Perform the physical assessment just as carefully on
male clients.
ASSESSMENT OF THE FEMALE BREASTS

Inspect size and symmetry. Have the client disrobe and sit with arms hanging freely.

 Normal Findings:
o Breasts can be a variety of sizes and are somewhat round and pendulous.

J The older client often has more pendulous, less firm, and saggy breasts.

Inspect color and texture. Be sure to note client’s overall skin tone when inspecting the breast skin.
Note any lesions.

 Normal Findings:
o Color varies depending on the client’s skin tone. Texture is smooth with no edema.
o Linear stretch marks may be seen during and after pregnancy or with significant weight
gain or loss.

Inspect superficial venous pattern. Observe visibility and pattern of breast veins.

 Normal Findings:
o Veins radiate either horizontally and toward the axilla (transverse) or vertically with a
lateral flare (longitude). Veins are more prominent during pregnancy.

Inspect the areolas. Note the color, size, shape and texture of the areolas of both breasts

 Normal Findings:
o 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.

Inspect the nipples. Note the size and direction of the nipples of both breasts. Also note any
dryness, lesions, bleeding. Or discharge

 Normal Findings:
o Nipples are early equal bilaterally in size and are in the same location on each breast.
Nipples are usually everted, but they may be inverted or flat. Supernumerary nipples
may appear along the embryonic “milk line.” No discharge should be present.

Inspect for retraction and dimpling. To inspect the breasts accurately for retraction and dimpling,
ask the client to remain seated while performing several different maneuvers. Ask the client to raise
her arms overhead; then press her hands against her hips. Next ask her to press her hands together.
These actions contract the pectoral muscles.

 Normal Findings:
o The client’s breasts should rise symmetrically with no sign of dimpling or retraction.

J Finally ask the client to lean forward from the waist. The nurse should support the client by the
hands or forearms. This is a good position to use in women who have large, pendulous
breasts.

 Normal Findings:
o Breasts should hang freely and symmetrically.

Palpate texture and elasticity (see display 17-2, page 343)

 Normal Findings:
o Smooth, firm, elastic tissue.
J The older the client’s breasts may fell more granular, and the inframammary
ridge maybe more easily palpated as it thickens
Palpate tenderness and temperature (see display 17-2, page 343)
 Normal Findings:
o A generalized increase in nodularity and tenderness may be a normal finding
associated with the menstrual cycle or hormonal medications. Breasts should be a
normal body temperature.

Palpate for masses. Note location, size in centimetres, shape, mobility consistency, and tenderness
(see display 17-2). Also note the condition of skin over the mass.
 Normal Findings:
o No masses should be palpated. However, a firm inframammary transverse ridge may
normally be palpated at the lower base of the breasts.

Guidelines For Palpating The Breasts

1. Ask the client to lie down and to place overhead the arm on the same side as the breast being
palpated. Place a small pillow or rolled towel under the breast being palpated.

2. Use the flat pads of three fingers to palpate the client’s breasts

3. Palpate the breasts using one of three different patterns. Choose one that is most comfortable for
you, but be consistent and thorough with the method chosen.

4. Be sure to palpate every square inch of the breast, from the nipple and areola to the periphery o
the breast tissue and up into the tail of Spence. Vary the levels of pressure as you palpate.

Light – superficial
Medium – mid-level tissue
Firm – to the ribs

***either Circular or clockwise, Wedged, or Vertical strip

5. Use the bimanual technique if the client has large breasts. Support the breast with your non-
dominant hand and use your dominant hand to palpate.

Palpate the nipples. Wear gloves to compress the nipple gently with your thumb and index finger.
Note any discharge
J If spontaneous discharge occurs from the nipples, a specimen must be applied to a slide ang
the smear sent to the laboratory for cytologic evaluation.

 Normal Findings:
o 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. However, some
women may normally have a clear discharge.

Palpate Mastectomy or Lumpectomy site. If the client has had a mastectomy or lumpectomy, it is
still important to perform thorough examination. Palpate the scar and any remaining breast or axillary
tissue for redness, lesion, lumps, swelling or tenderness

 Normal Findings:
o Scar is whitish with no redness or swelling. No lesions, lumps, or tenderness noted.

ASSESSMENT OF THE AXILLA

Inspect and palpate the axillae. Ask the client to sit up. Inspect the axillary skin for rashes or
infection. Hold the client’s elbow with one hands, and use the three finger pads of you other hand to
palpate firmly the axillary lymph nodes.
J 1st palpate high into the axillae, moving downward against the ribs to fell for the central nodes.
Continue to move down the posterior axillae to feel for the posterior nodes. Finally palpate
down the inner aspect of the upper arm.
 J Finally ask the client to demonstrate how she performs BSE if she chooses to receive
feedback on her technique and method. This should be offered as an option and the client’s
choice accepted. This time offer the nurse an opportunity to teach BSE.
 Normal Findings:
o No rash or infection noted.
o No palpable nodes or one to two small (less than 1cm), discrete, nontender, movable
nodes in the central area.

ASSESSMENT OF THE MALE BREASTS

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

 Normal Findings:
o No swelling, nodules, or ulceration should be detected.

Breast Self-Examination (BSE)

Instructions

1. Lie down and place your right arm behind your head. The exam is done while lying down, and not
standing up, because when lying down the breast tissue spreads evenly over the chest wall as thinly
as possible, making it much easier to feel all the breast tissue.

2. Use the finger pads of the three middle fingers on your left hand to feel for lumps in the right
breast. Use overlapping dime-sized circular motions of the finger pads to feel the breast tissue.

3. Use the three different levels of pressure to feel all the breast tissue. Light pressure is needed to
feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel the
tissue closest to the chest and ribs. A firm ridge in the lower curve of each breast is normal. If you’re
not sure how hard to press, talk with your doctor or nurse. Use each pressure level to feel the breast
tissue before moving on to the next spot.

 Moving around the breast in an up-and-down pattern starting at an imaginary line drawn
straight down your side from the underarm and moving across the breast to the middle of the
chest bone (sternum or breastbone). Be sure to check the entire breast area going down until
you feel only rise and up to the neck or collar (clavicle).

 There is some evidence to suggest that the up-and-down pattern (sometimes called the
vertical pattern) is the most effective pattern for covering the entire breast and not missing any
breast tissue.

 Repeat the exam on your left breast, using the finger pads of the right hand. While standing in
front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any
changes of size, shape, contour, or dimpling. (The pressing down on the hips position
contracts the chest wall muscles and enhances any breast changes.)

 Examine each underarm while sitting up or standing and with your arm only slightly raised so
you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and
makes it very difficult to examine.

 This procedure for doing breast self-exam represents changes in previous procedure
recommendations. These changes represent an extensive review of the medical literature and
input from an expert advisory group. There is evidence that the woman’s position (lying down),
area felt, pattern of coverage of the breast , and use of different amounts of pressure increase
the sensitivity of BSE as measured with silicon models for CBE using patient models with
known small noncancerous lumps in their breasts.
DOCUMENTATION

Objective Data

Inspection
 Bilateral breast moderate in size, pendulant, and symmetric.
 Breast skin pale pink with light brown areola
 Montgomery tubercles present
 Nipple everted bilaterally
 Free movement of breast with position changes of arms and hands
 No dimpling, retraction, lesions. Or inflammation noted
 Axillae free of rashes or inflammation
Palpation
 No masses or tenderness palpated
 Bilateral mammary ridge present
 No discharge from nipple.
 Axillary (central, anterior, or posterior) and lateral arm lymph nodes non-palpable
 Demonstrates appropriate technique for BSE

Nursing Diagnoses

Wellness Diagnoses
 Readiness for enhanced health management of breast
 Health seeking behaviour: request information on BSE

Risk Diagnoses
 Risk for ineffective management of therapeutic regimen related to busy lifestyle and lack of
knowledge of monthly BSE

Actual Diagnoses
 Fear of breast cancer related to increased risk factors
 Ineffective individual coping related to diagnoses of breast cancer
 Disturbed body image related to mastectomy
 Anticipatory grieving related to anticipation of poor outcome of breast biopsy
 Ineffective management of therapeutic regimen related to lack of knowledge of BSE