1 Chapter 17

Surface Anatomy

• Breasts lie anterior to pectoralis major and serratus anterior muscles. Chapter 17 •Areola surrounds nipples; contains Breasts and Regional small elevated sebaceous glands, Lymphatics called Montgomery’s glands.

Breast Surface Anatomy Internal Anatomy I Breast is composed of Glandular tissue Fibrous tissue Adipose tissue Glandular tissue contains 15 to 20 lobes Within lobules are clusters of alveoli Lactiferous ducts form collecting duct system converging toward nipple. Ampullae, or lactiferous sinuses, behind nipple, are reservoirs for storing milk.

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1 Internal Anatomy II Internal Anatomy III Breast may be divided into four quadrants by imaginary horizontal and vertical lines Suspensory ligaments, or Cooper’s ligaments intersecting at nipple. Lobes are embedded in adipose tissue. These layers of subcutaneous and retromammary fat actually provide most of bulk of breast. The relative proportion of glandular, fibrous, and fatty tissue varies depending on age, cycle, pregnancy, lactation, and general nutritional state.

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Breast Internal Anatomy Regional Lymphatics

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2 Lymphatics Developmental Competence • During embryonic life, ventral epidermal ridges, or “milk lines,” are present and curve down from axilla to groin bilaterally. Breast has extensive lymphatic drainage. • Breast develops along ridge over thorax, and Four groups of axillary nodes are present rest of the ridge usually atrophies. Central axillary nodes • Occasionally a supernumerary nipple persists Pectoral (anterior) and is visible along track of mammary ridge. Subscapular (posterior) • At birth, the only breast structures present are Lateral lactiferous ducts within nipple From the central axillary nodes, drainage flows up to infraclavicular and supraclavicular nodes.

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Developmental Competence: Pregnant Developmental Competence: Adolescent Woman

At puberty, estrogen stimulates breast Breast changes start during the second changes. month of pregnancy and are an early sign for  Occasionally one breast may grow faster most women. than other, producing a temporary Colostrum may be expressed after fourth asymmetry. month. Five stages of breast development are Lactation, milk production, begins 1 to 3 days correlated with Tanner Staging. postpartum Beginning of breast development precedes menarche by about 2 years.

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3 Developmental Competence: Aging Question Woman

A pregnant woman who has breast implants asks the nurse if she can  After menopause, ovarian secretion of estrogen and progesterone still breastfeed. What is the nurse’s best response? decreases, causing breast glandular tissue to atrophy.  Decreased breast size makes inner structures more prominent. 1. “You should not have any problems breast feeding because your  A breast lump may have been present for years but is suddenly implants do not affect milk production.” palpable. 2. “When the breast implants are inserted they usually affect the  Around nipple, the lactiferous ducts are more palpable and feel firm milk glands, and breastfeeding is not possible.” and stringy because of fibrosis and calcification. 3. “This would depend on which type of implants were placed and  Axillary hair decreases. which procedure was used by the surgeon. Check with your surgeon to see if your milk production will be affected.”

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Male Breast Cultural Competence

Rudimentary structure consisting of a Timing of puberty is influenced by genetic thin disk of undeveloped tissue and environmental factors. underlying nipple. Research data indicate age differences in onset of puberty according to different ethnic Gynecomastia groups. Obesity contributes to the early onset of puberty. Menses began at an average age of 12.16 years for black girls and age 13 for white girls.

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4 Cultural Competence: Breast Cancer I Cultural Competence: Breast Cancer II Incidence of breast cancer varies in cultural Lifestyle risk factors relate to risk. groups. Factors contributing to breast health care Women who inherit mutations of BRCA1 and BRACA2 on one or both sides are at an increased access include: risk for developing breast or ovarian cancer. 1. Different risks are linked to breast cancer related 2. to age and ethnicity variables. 3. Screening mammography annual screening is 4. recommended starting at age 40. 5.

Cultural Competence: Breast Cancer III Breast Cancer: Culture and Women •In Western culture, female breasts signify more than their primary purpose of lactation. “Alcohol/Western” dietary pattern linked to increased risk of breast cancer, especially with estrogen or •A woman who has found a breast lump may progesterone + tumors come to you with fear, anxiety, and panic. “Mediterranean” dietary pattern linked to a modest protective effect against breast cancer

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5 Subjective Data Questions I Subjective Data Questions: Pain Any pain or tenderness in breasts? When did Lump you first notice it? Ever noticed lump or thickening in breast? Where? Where is pain? Localized or all over? When did you first notice it? Changed at all since then? Is painful spot sore to touch? Do you feel a burning or pulling sensation? Does lump have any relation to your menstrual period? Is pain cyclic? Any relation to your menstrual Noticed any change in overlying skin: redness, period? warmth, dimpling, swelling? Is pain brought on by strenuous activity, especially involving one arm; a change in activity; manipulation during sex; part of underwire bra; exercise?

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Subjective Data Questions I Subjective Data Questions II Discharge Swelling Any discharge from nipple? When did you first Any swelling in breasts? In one spot or all over? notice this? Related to your menstrual period, pregnancy, or What color is discharge? breastfeeding? Is consistency thick or runny? Odor? Any change in bra size? Rash History of breast disease Any rash on breast? Any history of breast disease yourself? When did you first notice this? What type? How was this diagnosed? Where did it start? On the nipple, areola, or When did this occur? How is it being treated? surrounding skin? Any breast cancer in your family? Who? Sister, mother, maternal grandmother, maternal aunts, daughter? At what age did this relative have breast cancer?

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6 Trauma Self-care behaviors Any trauma or injury to the breasts? Have you ever been taught breast self- Did it result in any swelling, lump, or break in skin? examination? Surgery or radiation • (If the answer is yes) How often do you perform it? Ever had surgery on the breasts? Was this a biopsy? What helps you remember? It is an excellent way What were the biopsy results? to be in charge of your own health; I would like you Mastectomy? Mammoplasty, augmentation, or to show me your technique after we do your reduction? examination. Ever had mammography, a screening x-ray • (If the answer is no) This will be an excellent way examination of breasts? When was last x-ray? that you can take charge of your own health; you Medications can make breast self-examination a very routine Have you taken oral contraceptives? How long? health habit, just like brushing your teeth; I will teach you the technique after we do your Have you been on HRT? How long? examination. Types of medications

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•Axilla • Tenderness, lump, or swelling Additional History for • Any tenderness or lump in the underarm Preadolescent Girl area? • Where? When did you first notice this? Have you noticed your breasts changing? How long has this been happening? • Rash • Any axillary rash? Please describe it. Many girls notice other changes in their bodies, too, that come with growing up. • Does it seem to be a reaction to deodorant? What have you noticed? What do you think about all this?

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7 Additional History for Menopausal Additional History for Pregnant Woman Woman

Have you noticed any enlargement or Have you noticed any change in breast fullness in the breasts? contour, size, or firmness? Is there any tenderness or tingling? Change may not be as apparent to obese Do you have a history of inverted nipples? woman or to woman whose earlier Are you planning to breastfeed your baby? pregnancies have already produced breast changes.

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Risk Profile for Breast Cancer Objective Data • Preparation Breast cancer is second major cause of death • Woman sitting up facing examiner from cancer in women. • An alternative draping method is to use a short However, early detection and improved gown, open at back, and lift it up to woman’s treatment have increased survival rates. shoulders during inspection. • During palpation when woman is supine, cover one breast with gown while examining other. • Be aware that many women are embarrassed to have their breasts examined; use a sensitive but matter-of-fact approach. • After examination, be prepared to teach woman breast self-examination.

8 Inspection of the Breast I

General appearance Note symmetry of size and shape; common to have a •Equipment slight asymmetry in size; often left breast is slightly •Small pillow larger than right. Skin •Ruler marked in centimeters Normally smooth and of even color •Pamphlet or teaching aid for breast self- examination (BSE) Note any localized areas of redness, bulging, or dimpling; also any skin lesions or focal vascular pattern. Fine blue vascular network visible during pregnancy; pale linear striae, or stretch marks, follow pregnancy. Normally no edema is present.

Inspection of the Breast II General Appearance of Breasts Lymphatic drainage areas Note: B ______, D______, E ______Nipple Symmetrical Typically protrude Normal nipple inversion Note 1. 2. 3. 4.

9 Maneuvers to Screen for Retraction Inspection and Palpation of the Axillae Direct woman to change position to check breasts for skin retraction signs; first ask her to lift arms slowly • Examine axillae while woman is sitting. over head; both breasts should move up • Inspect skin; lift woman’s arm and support it, so symmetrically. that her muscles are loose and relaxed; use Next ask her to push her hands onto her hips and then right hand to palpate left axilla. to push her two palms together; these maneuvers • Reach fingers high into axilla contract pectoralis major muscle; slight lifting of both • Move woman’s arm through range-of-motion to breasts will occur. increase surface area you can reach. Ask woman with large pendulous breasts to lean forward while you support her forearms; note • Usually nodes are not palpable symmetric free-forward movement of both breasts. • Note any enlarged and tender lymph nodes.

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Palpation of the Breasts I Palpation of the Breasts II Help woman to a supine position In nulliparous women, normal breast tissue Tuck a small pad under side to be palpated feels firm, smooth, and elastic and raise her arm over her head to flatten After pregnancy, tissue feels softer and looser. breast tissue and displace it medially Premenstrual engorgement is normal from Use pads of your first three fingers and make increasing progesterone. a gentle rotary motion on breast Vertical strip pattern currently recommended to detect a breast mass

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10 Palpation of the Breasts III Characteristics of Lump or Mass I Normally you may feel a firm transverse ridge of Location: as with clock face, describe distance compressed tissue in lower quadrants. in centimeters from nipple; or diagram breast in Palpate nipple; note any induration or subareolar woman’s record and mark in location of lump. mass. Size: judge in centimeters in three dimensions: Gently depress nipple tissue into well behind areola; width, length, and thickness. tissue should move inward easily. Shape: state whether lump is oval, round, If woman reports spontaneous nipple discharge, press areola inward with your index finger; repeat from a few lobulated, or indistinct. different directions Consistency: state whether lump is soft, firm, or If woman mentions a breast lump that she has hard. discovered herself, examine unaffected breast first to Movability: is lump freely movable or fixed when learn a baseline of normal consistency for this woman. you try to slide it over chest wall?

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Characteristics of Lump or Mass II Palpation: Breast Premenopausal women mid-cycle have tissue Distinctness: is lump solitary or multiple? edema and mastalgia (pain) that make it hard Nipple: is it displaced or retracted? to detect lesions. Note skin over lump: is it erythematous, If your findings are in question, consider asking dimpled, or retracted? woman to return for follow-up examination first Tenderness: is lump tender to palpation? week after menses when hormone levels are Lymphadenopathy: are any regional lymph lower and edema is not present. nodes palpable?

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11 Teach Breast Self-Examination (BSE) BSE: Teaching Methods Help each woman establish regular schedule of self-care. Many examiners use a simulated breast Avoid citing frightening mortality statistics about model so that woman can palpate a “lump.” breast cancer and generating excessive fear Pamphlets are helpful reinforcers; give and denial that actually obstructs a woman’s woman two pamphlets to take home and self-care action. encourage her to give one to a relative or friend; this may promote discussion, which is reinforcing.

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Question Male Breast I Examination of male breast can be The nurse is teaching a woman how to perform breast self- abbreviated, but do not omit it. examination (BSE). Which statement by the patient would indicate a Normal male breast has flat disk of need for further teaching? undeveloped breast tissue beneath nipple. 1. “The best time to check my breasts is a week before my cycle.” 2. “I will check my breasts in the shower one week after my cycle.” 3. “I will exam my breast in a clock-like sequence so that I don’t miss any surface area.” 4. “I will be sure to check my arm pits.”

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12 Developmental Competence I Developmental Competence II • Adolescent girl • Infants and children •Breast development usually begins on an • In neonate, breasts may be enlarged and average between 8 and 10 years. visible due to maternal estrogen crossing placenta. • Note position of nipples on prepubertal child.

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Developmental Competence III Developmental Competence V

• Pregnant woman • Aging woman • Breasts increase in size, as do nipples. • On inspection, breasts look pendulous, flat, • Lactating woman and sagging. • Colostrum changes to milk production around the third postpartum day.

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13 Abnormal Findings: Abnormal Findings: Retraction and Inflammation Breast Lump

• Dimpling • Benign breast disease (formerly fibrocystic breast disease) • Nipple retraction • Cancer • Fixation • Fibroadenoma • Edema (peau d’orange) • Deviation in nipple pointing

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Abnormal Findings: Abnormal Findings: Abnormal Nipple Discharge Disorders During Lactation

• Mammary duct ectasia • Plugged duct • Carcinoma • Breast abscess • Intraductal papilloma • Mastitis • Paget disease (intraductal carcinoma)

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14 Abnormal Findings: Male Breast

• Gynecomastia • Male breast cancer