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406 PHYSICAL EXAMINATION
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
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Persistent eczematous dermatitis of the areola and nipple region is suggestive
P
of
Paget’s disease, a malignant neoplasm, which is usually unilateral in
its involvement.
UNIT 2
Discharge
Observe for spontaneous discharge from the nipples or other areas of the breast.
E
In the nonpregnant, nonlactating female, there should be no discharge.
N
Duringpregnancy and up through the rst week after birth, there may be a
yellow discharge known as colostrum. During lactation, there is a white
discharge of breast milk.
The presence of a nipple discharge in the nonpregnant, nonlactating woman
A
isabnormal.
Nipple discharge may be caused by the use of medications such as tranquillisers
P
and oral contraceptives, manual stimulation, pituitary tumour or infection.
Itmay also be indicative of malignant or benign breast disease.
CLINICAL REASONING
Practice tip: Examining nipple discharge
If a consumer is found to have abnormal nipple discharge, the nurse should undertake
the following:
1 Don gloves before proceeding with the assessment.
2 Note the colour, odour, consistency, amount of discharge, unilateral or bilateral,
spontaneous or provoked.
3 With a sterile, cotton-tipped swab, obtain a sample of the discharge so that a culture
and sensitivity as well as a Gram stain can be obtained.
4 Consider checking the sample for occult blood.
5 Follow your institution’s guidelines for sample preparation.
FIGURE 12.21 Palpation of
supraclavicular nodes
FIGURE 12.22 Palpation of
infraclavicular nodes
Palpation
Palpation is performed in a sequential manner:
1. Supraclavicular and infraclavicular lymph node areas
2. Breasts, with the consumer in sitting position
a Arms at side
b Arms raised over head
3. Axillary lymph node regions
4. Breasts, with the consumer in supine position.
Supraclavicular and infraclavicular lymph nodes
1. Have the consumer seated and uncovered to the waist.
E
2. Encourage the consumer to relax the muscles of the head and neck because
this pulls the clavicles down and allows a thorough exploration of the
supraclavicular area.
3. Flex the consumer’s head to relax the sternocleidomastoid muscle.
4. Standing in front of the consumer, in a bilateral and simultaneous motion,
place the nger pads over the consumer’s clavicles, lateral to the tendinous
portion of the sternocleidomastoid muscles.
5. Using a rotary motion of the palmar surfaces of the ngers, probe deeply
into the scalene triangles in order to palpate the supraclavicular lymph
nodes(Figure 12.21).
6. Palpate the infraclavicular nodes using the same rotary motion of the palmar
surfaces of the ngers (Figure 12.22).
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Advanced Assessment
BREASTS AND REGIONAL NODES 407
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Palpable lymph nodes less than 1cm in diameter are usually considered normal
N
and clinically insignicant, provided that there are no additional enlarged
lymph nodes found in other regions such as the axilla. Palpation should not
elicit pain.
Fixed, rm, immobile, irregular lymph nodes more than 1cm in diameter are
A
considered abnormal.
These nodes are considered suspicious for metastasis from a variety of sources or
P
primary lymphoma.
Enlarged, painful or tender nodes that are matted together are abnormal.
A
Tender, enlarged nodes may indicate systemic infection or carcinoma.
P
Breasts: consumer in sitting position
1. Place the consumer in a sitting position with arms at sides.
E
2. Stand to the consumer’s right side, facing the consumer.
3. Using the palmar surfaces of the ngers of the dominant hand, begin the
palpation at the outer quadrant of the consumer’s right breast.
4. Use the other hand to support the inferior aspect of the breast.
5. In small-breasted consumers, the dominant hand can palpate the tissue
against the chest wall, but if the breasts are pendulous, use a bimanual
technique of palpation as shown in
6. Palpate in a downwards fashion, sweeping from the outer quadrants to the
sternal border of each breast.
7. Repeat this sequence on the other breast.
8. Repeat the entire assessment with the consumer’s arms raised over her head
to enhance any potential retraction.
The consistency of the breasts is widely variable, depending on age, time in
N
menstrual cycle, and proportion of adipose tissue. The breasts may have a
nodular or granular consistency that may be enhanced prior to the onset of
menses. The inferior aspect of the breast will be somewhat rmer due to a
transverse inframammary ridge. Palpation should not elicit signicant tenderness,
although the breasts and especially the nipples may become full and slightly
tender premenstrually. Breasts that feel uid-lled or rm throughout with
accompanying inferior suture-line scars are indicative of breast augmentation.
The presence of any lump, mass, thickening or unilateral granulation that is
A
noticeably different from the rest of the breast tissue should be considered
suspicious and abnormal.
For a description of breast masses and their pathologies, see Table 12.4.
P
Signicant breast tenderness is abnormal and may indicate mammary
A
duct ectasia.
This is a benign condition in which lactiferous ducts become inamed.
P
Erythema and swelling of the breast with possible pitting oedema is abnormal
A
and usually indicates mastitis.
This condition is usually seen postpartum and is an inammation of the breast
P
usually caused by Staphylococcus aureus.
Figure 12.23.
FIGURE 12.23 Bimanual palpation of the
breasts while consumer is sitting
CHAPTER 12
Axillary lymph node region
1. Stand at the consumer’s right side, facing the consumer.
E
2. Tell the consumer to take a deep breath and relax the shoulders and arms
(this relaxes the areas to be palpated).
3. Using your left hand, adduct the consumer’s right arm so that it is close to
the chest wall. This manoeuvre relaxes the muscles.
4. Support the consumer’s right arm with your left hand.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Advanced Assessment
408 PHYSICAL EXAMINATION
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UNIT 2
FIGURE 12.24 Palpation of axillary nodes
5. Using the palmar surfaces of the nger pads of your right hand, place your
E
ngers into the apex of the axilla. Your ngers will be positioned behind the
pectoral muscles.
6. Gently roll the tissue against the chest wall and axillary muscles as you
workdownwards.
7. Locate and palpate the four axillary lymph node groups:
a brachial (lateral) at the inner aspect of the upper part of the humerus,
close to the axillary vein
b central axillary (midaxillary) at the thoracic wall of the axilla
c pectoral (anterior) behind the lateral edge of the pectoralis major muscle
d subscapular (posterior) at the anterior edge of the latissimus dorsi muscle.
8. Repeat this method of palpation with the consumer’s arm abducted
(i.e.instruct the consumer to remain in the same position and lift the upper
arm and elbow away from the body). Support the consumer’s abducted arm
on your left shoulder, as shown in
Figure 12.24.
9. Palpate the consumer’s left axilla using the same technique.
URGENT FINDING
Breast mass
Any new breast mass or change in a previously benign known breast mass must be referred
to an appropriate health professional for further assessment.
Palpable lymph nodes less than 1cm in diameter are usually considered normal
N
and clinically insignicant provided that there are no additional enlarged lymph
nodes found in other regions. Palpation should not elicit pain.
Fixed, rm, immobile, irregular lymph nodes more than 1cm in diameter are
A
clinically signicant.
These nodes are considered suggestive of metastasis from a variety of sources or
P
primary lymphoma.
Enlarged, painful or tender nodes that are matted together are abnormal.
A
Tender, enlarged nodes may be indicative of a systemic infection or carcinoma.
P
REFLECTION IN PRACTICE
Attitude and awareness of older women and breast cancer
You are conducting a seminar on female health to residents of an assisted living community.
You review the importance of breast examination and how to be breast aware. Some of the
women start to laugh and you hear comments such as:
> ‘My breasts are so saggy, there’s no need to worry.’
> ‘I had one breast removed for cancer and the other breast is OK.’
> ‘Breast cancer only occurs in young women.’
How might you respond to these comments?
What further breast awareness advice could you provide?
Breasts: consumer in supine position
1. Keep the consumer uncovered to the waist.
E
2. Instruct the consumer to assume a supine position. This position spreads
thebreast tissue thinly and evenly over the chest wall. Palpation is more
accurate when there is the least amount of breast tissue between the skin
andthe chest wall.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Advanced Assessment
BREASTS AND REGIONAL NODES 409
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3. If the breasts are large, place a small towel or folded sheet under the
E
consumer’s right shoulder. This helps to atten the breast more.
4. Stand at the right side of the consumer. Palpation can be performed with the
consumer’s arms at her sides or with her right arm above her head.
5. Using the palmar surfaces of the ngers, palpate the right breast by
compressing the mammary tissues gently against the chest wall. Do not press
too hard. You may mistake a rib for a hard breast mass. Palpation maybe
performed in wedge sections, concentric circles or parallel lines (
Figure 12.25).
Using two out of the three palpation methods is acceptable, in order to
ensure thoroughness of palpation.
CHAPTER 12
A. Wedge
FIGURE 12.25 Breast palpation methods
6. Palpation must include the tail of Spence, periphery (Figure 12.26A) and
E
areola(
Figure 12.26B).
B. Concentric circles
7. Finally, don gloves and compress the nipple to express any discharge, as
shown in
Figure 12.26C. If discharge is noted, palpate the breast along the
wedge radii to determine from which lobe the discharge is originating.
8. Repeat procedure on opposite breast.
See previous section on normal breast tissue ndings upon palpation. The nipple
N
should be elastic and return readily to its previous shape. No discharge should be
expressed in the nonpregnant, nonlactating consumer.
C. Parallel lines
A. Palpation of the glandular tissue
FIGURE 12.26 Palpation of the breasts while consumer is supine
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
B. Palpation of the areola
C. Compression of the nipple
410 PHYSICAL EXAMINATION
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HEALTH EDUCATION
UNIT 2
Breast awareness and mammography
Your mother states that she questions the value of breast awareness and serial mammography
in light of recent publicity. What health education do you think is appropriate?
You might consider explaining that it is always good to have a discussion related to
health, as this enables correct facts to be shared.
In relation to breast cancer, most women do not experience any symptoms. This is why
they are encouraged to be breast aware, to become familiar with the normal look andfeel,
so if any changes are identied, they can seek medical advice early. Regular breast
screening should be encouraged, including mammography, which simply detects suspicious
areas in the breast where cancer could be present. Provide facts, such as the following:
> There is overwhelming evidence (multiple robust research) that supports early detection,
with reduced deaths attributed to breast cancer.
> Mammograms can assist in detecting small breast cancers, before they have had a
chance to metastasise.
> Early detection allows for less toxic therapies and less extensive surgical intervention.
For further information, see:
> Australia: Breast Cancer Network Australia https://www.bcna.org.au/
> New Zealand: Breast Cancer Foundation New Zealand https://www.
breastcancerfoundation.org.nz/
Refer to Table 12.4 for a description of breast masses. Table 12.5 offers a list of breast
mass characteristics that are used to evaluate abnormal ndings.
TABLE 12.5 Evaluation of breast mass characteristics
If a mass is noted during palpation, the following information should be obtained regarding the mass.
Alwaysnote if one or both breasts are involved.
Location Identify the quadrant involved or visualise the breast with the face of a clock
superimposed upon it. The nipple represents the centre of the clock. Note where the
mass lies in relation to the nipple (e.g. 3 cm from the nipple in the 3 o’clock position).
Size
Shape Masses may be round, ovoid, matted or irregular.
Number Note if mass is singular or multiple. Note if one or both breasts are involved.
Consistency Masses may be rm, hard, soft, uid or cystic.
Denition Note if the mass borders are discrete or irregular.
Mobility
Tenderness Note if palpation elicits pain.
Erythema Note any redness over involved area.
Dimpling or
retraction
Lymphadenopathy Note if the mass involves any of the regional lymph nodes, and indicate whether
Loss of nipple elasticity or nipple thickening is abnormal.
A
P
Loss of elasticity in the nipple may indicate tumour formation.
Milky-white discharge in a nonpregnant, nonlactating consumer may be
A
Determine size in centimetres in all three planes (height, width and depth).
Determine if the mass is xed or freely movable in relation to the chest wall.
Observe for dimpling or retraction as the consumer raises arms overhead and
presses her hands into her hips.
there is associated lymphadenopathy.
nonpuerperal galactorrhea.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
BREASTS AND REGIONAL NODES 411
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Nonpuerperal galactorrhea is either hormonally induced from lesions of the
P
anterior pituitary gland or drug induced.
Non-milky discharge from the nipple, which may be green, brown, straw
A
coloured or grey, is abnormal.
Non-milky discharge may be indicative of benign or malignant breast disease
P
such as duct ectasia.
Bleeding from the nipple is abnormal.
A
Bleeding from the nipple is often seen in the benign condition of
P
intraductal papilloma.
CLINICAL REASONING
Practice tip: The consumer who has had a mastectomy
Assessment of the mastectomy consumer will be guided by the type of mastectomy and
the presence or absence of reconstructive surgery. Follow the standard assessment
procedures and modify your technique to suit the amount of breast tissue and the
presence, if any, of a nipple. Always begin the assessment on the unaffected breast.
Women who have had a mastectomy should continue to do their monthly breast awareness
examinations to detect any changes, such as a mass in the excised area. Annual clinical
assessment and mammography are also recommended. The types of mastectomy
procedures are as follows:
> Partial – Lumpectomy or wide local incision (also referred to as breast conserving surgery),
involves removing the breast cancer as well as a small amount of surrounding tissue.
> Simple – Only the breast is removed.
> Modied radical – The breast and lymph nodes from the axilla are removed
(Figure 12.27A).
> Radical – The breast, lymph nodes from the axilla, and pectoral muscles are removed
(
Figure 12.27B). This procedure is rarely performed.
> Subcutaneous – The skin and nipple are left intact, but the underlying breast tissue and
lymph nodes are removed.
Which procedure the woman has will depend on the stage of her breast cancer and
whether it involves the lymph nodes.
Reconstruction techniques include:
> synthetic implants
> tissue expansion techniques (in which a temporary device is placed in a subpectoralis-
subserratus position between the anterior chest wall and skin and is then inated with
saline over a period of weeks)
> latissimus dorsi myocutaneous ap breast reconstruction. A myocutaneous ap
reconstruction involves transferring skin from the back or the abdomen to the
anteriorchest wall.
CHAPTER 12
COUR TESY OF ST EVEN M. LYN CH, M.D.
A. Modied radical
FIGURE 12.27 Mastectomy consumers
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
D.
COUR TESY OF ST EVEN M. LYN CH, M.
B. Radical
412 PHYSICAL EXAMINATION
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UNIT 2
CLINICAL REASONING
Breast augmentation and reduction
> Breast augmentation, or augmentation mammoplasty, is a popular surgical procedure in
Australia and New Zealand. There are two main types of synthetic implants: the saline
implant, which is a silicone envelope lled with normal saline; and the silicon implant,
a silicon envelope that is lled with an elastic gel. When assessing a consumer, ask if
the breasts have been augmented and what type of implant was used. Incision sites
can be found in the axillae, circumareolar areas and inframammary creases. Potential
complications from augmentation include haematoma, infection, scarring, loss of nipple
or skin sensation, pain from engorgement, asymmetry and malpositioning. Another rare
complication is breakage of the implant, which can lead to
in thebreasts, where small, nodular, inammatory lesions develop, and a capsular
membrane forms over the breasts. The augmented breast will feel rmer upon palpation
and remain more erect when the consumer is supine.
> Breast reduction is usually performed for women who suffer from back, neck or shoulder
pain caused by breast hypertrophy. Two types of procedures may be performed to
reduce the breasts: free nipple graft and dermal pedicles. The type of procedure can
beascertained from the postoperative scarring. A free nipple graft leaves scars around
the nipple and at the inferior mammary fold. A dermal pedicles procedure leaves
‘keyhole’ scars over the breasts. Recently, breast liposuction has become popular.
Potential complications from these breast reduction procedures include haematoma,
infection, nipple or skin necrosis, fat necrosis, and asymmetry. Palpation results will
depend on the type of procedure performed and the amount of scar tissue formed.
For both breast augmentation and breast reduction, a baseline mammogram should be
performed to provide a reference for future mammography. Otherwise, the guidelines for
breast awareness, clinical assessment and mammography are the same as for women
whohave not undergone breast surgeries.
granulomatous reaction
HEALTH EDUCATION
Breast awareness
Early detection of breast cancer increases the chances of successful treatment and, ultimately, survival. Everyone is different, and
breasts continually change as individuals go through the different stages of life. It is important to be familiar with the normal look,
feeland shape of one’s breast so that abnormal changes can be recognised. Women should be encouraged to examine their breasts
at regular intervals and, if they notice a change, they should see a health professional without delay. Changes may include pain,
lumpsor lumpiness, size and shape changes, skin changes such as puckering or dimpling on the breast, thickened breast tissue,
anyarea that feels different from the rest and changes to nipples such as discharge or inversion (pulling in).
Teaching breast awareness
Before you commence, reiterate that there is no right or wrong way to check one’s breasts for any changes. It is important that they
develop a routine and a place and time that feels comfortable to look at and feel their own breast regularly. It is also important that
they check all parts of the breast, including up to the collarbone and the armpits. The following is a guide:
> The woman should examine her breasts for symmetry, retractions, dimpling, inverted nipples or nipple deviation (as shown
inFigure 12.28). She may nd it easier to do this in the shower, while getting dressed or lying on the bed (Figure 12.28A).
> She should stand in front of a mirror with her arms at her sides (see Figure 12.28C), then with her arms raised over her head
(seeFigure 12.28D), and nally with her hands pressed into her hips (see Figure 12.28E).
> She should also be instructed to become familiar with the normal feel of her breasts at different times of the month. She should
feel all the breast tissue from the collarbone to below the bra line and the axilla area.
> Also instruct her to squeeze the nipple to examine for discharge (as shown in Figure 12.28F).
>>
BREASTS AND REGIONAL NODES 413
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>>
CHAPTER 12
A. In bed B. Standing
D. Before a mirror: arms overhead E. Before a mirror: hands pressed into hips F. Compression of the nipple
FIGURE 12.28 Breast self-examination for breast awareness
C. Before a mirror: arms at side
Examination of the male breasts
Inspection and palpation
Assessment of the male breasts is completed in essentially the same manner as that of the
female breast. Modify your technique for a smaller breast with less tissue bulk. Having
the consumer lean forwards is usually not necessary unless gynaecomastia is present.
Males should be encouraged to be breast aware and have clinical examinations of the
breast every 1 to 3 years, if identied as being at high risk, because a small percentage
of all breast cancer is found in men (National Breast Cancer Foundation, 2022).
Diagnostic techniques
Aetiologic determination of breast or lymphatic masses can be accurately assessed
only via a combination of the diagnostic techniques listed below.
1. Mammography is the roentgenographic examination of the breasts by means
of X-rays, ultrasound or magnetic resonance imaging (MRI). Refer to Table 12.6
for information related to the national breast screening programs in Australia
and New Zealand.
414 PHYSICAL EXAMINATION
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UNIT 2
2. Ultrasonography is used to determine the location, measurement
and delineation of deep structures by measuring the reection of
ultrasonic waves.
3. Needle aspiration involves the withdrawal of uid or tissue from a cavity
viaa hollow needle with an aspirator tube attached to one end.
4. Biopsy is the process of removing tissue from a suspicious area for
examination. Methods include needle biopsy, punch biopsy, excisional
biopsy, core biopsy and stereotactic biopsy.
5. Thermography measures the regional temperature of a body part or organ.
Malignant lesions are often warmer than non-malignant areas and are
called‘hot spots’.
6. Ductal lavage is a method of rinsing the milk duct to obtain cells for analysis
of atypia.
TABLE 12.6 National breast screening programs in Australia and New Zealand
BREASTSCREEN AUSTRALIA BREASTSCREEN AOTEAROA (NEW ZEALAND)
> Free mammogram for ages 50–74 years
> Women in their 40s or over 74 are able to have a
free screening mammogram through BreastScreen
Australia if they wish. However, they are not
specically targeted to attend.
Why are women under 40 years not included in
the free screening program?
> The tissue of younger women’s breasts is usually
more dense than that of older women; this makes
breast lumps/changes difcult to detect. Also,
the risk of breast cancer in younger women is
lowcompared to that for older women.
Younger women who notice any unusual breast lumps, pain or nipple discharge should see their
doctor immediately.
ADAP TED FRO M BREAS TSCREEN A USTRA LIA PROG RAM (20 22) AND BRE ASTSC REEN AOT EAROA (2 022)
> Free mammogram for ages 45–69 years
> Women younger than 45 or older than 69 who wish
to have a mammogram need to be referred by their
GP to a private radiologist.
Why are women under 45 years not included in
thefree screening program?
> The tissue of younger women’s breasts is usually
more dense than that of older women; this makes
breast lumps/changes difcult to detect. Also,
the risk of breast cancer in younger women is low
compared to that for older women.
EVALUATION OF HEALTH ASSESSMENT AND PHYSICAL
EXAMINATION FINDINGS
In the evaluation phase of a health assessment, the focus is on ensuring the data
gathered is complete, accurate and documented appropriately (see case study as
an example of the focused assessment; see Chapter 22 for a comprehensive health
assessment). In evaluating the data you should:
> draw on your critical thinking and problem-solving skills to make sound
clinical decisions
> act on abnormal data (include communicating ndings to other
health professionals)
> ensure documentation reects the outcomes of the clinical decisions/actions
taken (refer to Chapter 3, which discusses in detail why documentation is
so important and how this may be undertaken in different health settings).
The case study that follows steps you through this process.
BREASTS AND REGIONAL NODES 415
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THE CONSUMER WITH FIBROCYSTIC BREAST CHANGES
This case study illustrates the application and objective
documentation of the breasts and regional nodes assessment.
Ms Holly Hastings has been admitted for an excisional biopsy of a
lump in her left breast.
Thesetting is a short-stay ward for day surgery.
HEALTH HISTORY
CONSUMER PROFILE 34-year-old, single woman
CHIEF COMPLAINT ‘I’m scared I have cancer. A friend was diagnosed last year with breast cancer and I can’t afford to be seriously ill.’
HISTORY OF THE
PRESENT ILLNESS
PAST HEALTH HISTORY MEDICAL HISTORY History of brotic breast disease, denies broadenomas, breast cancer, endometrial
Holly Hastings states that she has discovered a lump in the upper outer quadrant of her right breast. She
reports that she has frequent breast tenderness, lumpiness and swelling prior to menses. She denies any nipple
discharge or any other breast changes noted. She states her doctor informed her she has brocystic disease;
however, the new lump feels different and harder than the lumpiness she usually experiences.
or ovarian cancer. Denies hypertension, dyslipidaemia, thyroid disease, exposure
tochest radiation.
Her onset of menarche was age 12, suffers from severe dysmenorrhea,
hasnever been pregnant.
SURGICAL HISTORY Wisdom teeth removed at 23 years of age, rhinoplasty at 26 years of age
ALLERGIES Penicillin and tetracycline (rash and throat swelling)
MEDICATIONS Levlen (contraception)
Takes a multivitamin daily
COMMUNICABLE
DISEASES
Hepatitis A as a child
CHAPTER 12
CASE STUDY
INJURIES AND
ACCIDENTS
SPECIAL NEEDS Nil identied
BLOOD TRANSFUSIONS States nil
CHILDHOOD ILLNESSES Mumps, age 5; chickenpox, age 5
IMMUNISATIONS Flu vaccine annually
FAMILY HEALTH HISTORY Holly has 2 sisters; denies family history of breast disease
SOCIAL HISTORY ALCOHOL USE 2–3 glasses wine per week
TOBACCO USE Quit smoking 7 years ago; previously 1 pack per day for 10 years
DRUG USE Denies experimentation as a teenager
DOMESTIC AND
INTIMATE PARTNER
VIOLENCE
SEXUAL PRACTICE Heterosexual, sexually active; 3 lifetime partners, no one at present
TRAVEL HISTORY Travels regularly interstate
WORK ENVIRONMENT Works in social media marketing
HOME ENVIRONMENT 5-year-old brick low-set house
Fractured wrist at age 18
Does not have a partner at the moment, denies any history of abuse
Taking contraceptive pill to assist with dysmenorrhea
HOBBIES AND
LEISURE ACTIVITIES
Reading and bushwalking
>>
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