BREAST AND AXILLAE

By:
Arnelle L. Balinao, MAN
Jennifer R. Macagba, MSN
Clinical Instructors
OBJECTIVES:

At the end of the lecture –

discussion, the students will be able
to
Define related terms in relation to
the breast and axillae
Identify the purposes of
performing breast and axillae
assessment
Discuss the importance of
preparing clients prior to
examination
Explain two methods of
examining the breast and axillae
Explain the significance of a
selected breast and axillae
findings
Enumerate the steps in
performing breast and axillae
assessment
State diagnostic procedures
being performed
Discuss variations and special
considerations in performing
examination techniques
appropriate for clients of
different age.
Assessment Techniques Used:

Inspection
Palpation
ANATOMY PHYSIOLOGY
• Divided into four quadrants based
on horizontal and vertical lines
crossing at the nipple

• Axillary tail of breast tissue extends

toward the anterior axillary fold

• Findings can be localized as the

time on the face of a clock (e.g.
3o’clock) and the distance in
centimeters from the nipple
After assessing the breast of a female
client, the nurse should explain to the
client that most breast tumors occurs
in the
• The breast is hormonally sensitive
tissue, responsive to the changes
of monthly cycling and aging.

• Glandular tissue: secretory

tubualveolar ducts, lobules –
drains into the nipples or arreola

• Fibrous connective tissue: support

• Adipose tissue: varies with age,

the general state of nutrition,
pregnancy, exogenous hormone,
ad other factor.
iw
Advantages of BSE:
 Women can use BSE to assess their
breast
 When they perform BSE properly and
regularly, they can note any changes
in their breast and seek further
evaluation
 Examinationshould be done every
month and at the end of menses in all
menstruating women.
However, breast self-exams help
you familiarize yourself with the
shape, size, and texture of your
breasts.
 This is important because it can
help you determine if what you
are feeling is normal or abnormal.
Any time you feel an abnormality
in your breast, tell your doctor.
Barriers to BSE

Lack of confidence
Lack of knowledge and
awareness
Assessment skills:
Preparation prior to assessment

1. Gather equipment:
 Centimeter Ruler
 Small pillow
 Gloves
 Clients
handout for Breast Self-
Examination
 Slide for specimen (if there is any)
2. Explain the procedure to the client
- what the steps of the examinations
are and the rationale for them.
Wash your hands
Warm your hand
Provide privacy.
3. Assist client to put on gown.
 Female Breast:
1. Inspect for
a. size and symmetry
b. color and texture
c. superficial venous patterns
d. areolas e. nipples
f. retraction and dimpling
g. bilaterally, note color, shape &
texture of areolas
g. bilaterally, note size &
direction of nipples
2. Palpates for:
a. texture and elasticity.
b. Tenderness and Temperature
(warmth or inflammation)
c. Masses
Note for location, size in
centimeter, shape mobility,
consistency, and tenderness.
Note the condition of skin over
the mass
 3.
Palpates nipples by compressing
nipple gently between thumb and
index finger; observe for discharge
4. Palpates mastectomy or
lumpectomy site, if applicable
Observing the scar, and any
remaining breast or axillary tissue
for redness, lesion, lumps, swelling
or tenderness.
Women who do not menstruate
should choose a certain day to
perform the exam, such as the
first of each month.

You should also keep a journal of

your self-exams. This will help you
track and record any changes
you have noticed in your breasts.
ASSESSMENT PROCEDURE

FEMALE BREAST
1. Inspects breast for

A. SIZE AND SYMMETRY

Have the client disrobe and sit

with arms hanging freely. Explain
what you are observing to help
ease client anxiety.
Normal Findings:
Breasts can be a variety of sizes
and are somewhat round and
pendulous; one breast may be
larger than the other.
The older client often has more
pendulous, less firm and saggy
breasts.
Abnormal
Findings:
 A recent
increase in the
size of one
breast may
indicate
inflammation or
an abnormal
growth.
A pig skin like or orange peel/ peau
d’orange appearance results from
edema, which is seen in metastatic
breast disease. The edema is caused by
blocked lymphatic drainage.
B. COLOR AND TEXTURE

Normal Findings:
 Color varies depending on the client’s
skin tone. Texture is smooth with no
edema.
 Linear stretch marks may be seen
during and after pregnancy or with
significant weight gain or loss
Abnormal Findings:
Redness is associated with
breast inflammation
C. SUPERFICIAL VENOUS
PATTERNS OBSERVE VISIBILITY
AND PATTERNS OF BREAST VEINS.

Normal Findings:
Veins radiate either
horizontally or and toward the
axilla (transverse) or vertically
with a lateral flare
(longitudinal)
Abnormal Findings:
 A prominent venous pattern may
occur as a result of increased
circulation due to a malignancy. An
asymmetrical venous pattern may
be due to malignancy
D. RETRACTION AND DIMPLING
 Askthe 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 hands together.
Normal Findings:
 The
client’s breasts should rise
symmetrically with no sign of
dimpling or retraction
Abnormal Findings:
 Dimpling or retractions is usually caused
by malignant tumor that has fibrous
strands attached to the breast tissue
and fascia of the muscles. As muscles
contracts, it draws the breast tissue and
skin with it, causing dimpling and
D. RETRACTION AND DIMPLING
(CONT..)
 Finally,ask
the client to
lean forward
from waist.
This is a good
position to
use in women
who have
large
Normal Findings:
 Breast should hang freely
and symmetrically.
Abnormal Findings:
 Restricted movement of
breast or retraction of the
skin or nipple indicates
fibrosis and fixation of the
underlying tissues. This is
usually due to an
underlying malignant
tumor.
D. Areolas
E. Nipples
F. Retraction and Dimpling
G. BILATERALLY, NOTE
COLOR, SIZE, SHAPE, AND
TEXTURE OF AREOLAS
Normal Findings:
 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.
Abnormal Findings:
 Peau d’orange skin, associated with
carcinoma
 Red, scaly crusty areas
H. BILATERALLY, NOTE SIZE AND
DIRECTION OF NIPPLES
Normal Findings:
 Nipples are nearly 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
 The older client may have smaller,
flatter nipples that are less erectile
on stimulation
Example of Supernumerary Nipple
Abnormal Findings:
A recently retracted nipple
that was previously everted
suggests malignancy.
Discharges should be referred
for cystologic study and further
evaluation
 GUIDELINES FOR PALPATING THE
BREAST
 Askthe 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.
◼ Usethe flat pads of three fingers to
palpate the client’s breast.
Palpate the breast using one of
three different patterns.
Circular/ clockwise
Wedge
Vertical strip
 Be sure to palpate
every square inch of
the breast from the
nipple to areola to
the periphery of 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
2. Palpates breast for

A. TEXTURE AND ELASTICITY

Normal Findings:
 Smooth, firm , elastic tissue

Abnormal Findings:
 Thickening of the tissues may occur
with an underlying malignant tumor.
B. TENDERNESS AND TEMPERATURE

Normal Findings:
A generalized increase in
nodularity and tenderness may
be normal findings associated
with menstrual cycle or
hormonal medications. Breasts
should be a normal body
temperature.
Abnormal Findings:
Painful breast may be indicative
of benign breast disease but can
also occur in malignant tumor
Heat in the breasts of women
who have not just given birth or
who are not lactating indicates
inflammation.
C. MASSES: NOTING LOCATION, SIZE IN
CENTIMETERS, SHAPE, MOBILITY,
CONSISTENCY, AND TENDERNESS.

Normal Findings:
 No masses
Abnormal Findings:

 Malignant tumors are most often found

in the upper outer quadrant of the
breast. They are unilateral, with irregular,
poorly delineated borders. Hard and
non-tender and fixed to underlying tissue
3. PALPATES NIPPLES BY COMPRESSING
NIPPLE GENTLY BETWEEN THUMB AND
INDEX FINGER; OBSERVE FOR DISCHARGE
 Ask client to lie down, raise right arm
and check the right breast, repeat
procedure to the left breast.
 Wear gloves to compress the nipple
gently with your thumb and index finger.
Note any discharge.
 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
Normal Findings:
 The nipple may become erect
 A milky discharge is usually present
only during pregnancy and lactation.

Abnormal Findings:
 Discharge may be seen in endocrine
disorders and with certain medications
( anti hypertension, estrogen)
 Cancer of the breast, fibrocystic
disease
4. PALPATES MASTECTOMY SITE /
LUMPECTOMY SITE, IF APPLICABLE,
OBSERVINGTHE SCAR AND ANY
REMAINING BREAST OR AXILLARY
TISSUE FOR REDNESS, LESIONS,
LUMPS, SWELLING, OR TENDERNESS

 Ask client to sit down then

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

Abnormal Findings:
 Redness, inflammation of the scar
may indicate infection
 Any lesions, lumps or tenderness
should be referred for further
evaluation.
MALE BREAST

1. INSPECT THE BREASTS, AREOLAS,

AND NIPPLE FOR SWELLING,
NODULES, OR ULCERATIONS

Normal Findings:
No swelling or ulcerations
Abnormal Findings:

 Soft, fatty enlargement of the breast

tissue is seen in obesity. Gynecomastia,
a smooth firm movable disc of glandular
tissue may be seen in one breast in
males during puberty for a temporary at
a time. Also seen in hormonal
imbalance, drug abuse, leukemia
 Irregularly shaped, hard nodules occur
in the breast
2. PALPATES THE BREAST, AREOLAS,
AND NIPPLES FOR SWELLING,
NODULES, OR ULCERATIONS

Normal Findings:
 No swelling , nodules/ ulceration

Abnormal Findings:
 Hardnodules, swelling, presence of
ulcerations/ lesions
ASSESSMENT PROCEDURE

AXILLAE
1. INSPECT THE AXILLARY SKIN
FOR RASHES AND INFECTION.

Ask the client to sit up.

Normal Findings:
 No rash or infection noted

Abnormal Findings:
 Redness and inflammation may be
seen in infection of the sweat
gland.
 Dark, velvety pigmentation of the
axillae –acanthosis nigricans, may
indicate an underlying malignancy
2. HOLDS THE ELBOW WITH ONE HAND
AND USE THE THREE FINGER PADS OF
YOUR OTHER HAND TO PALPATE FIRMLY
THE AXILLARY LYMPH NODES.
Normal Findings:
 No palpable nodes or one to two small
(less than 1 cm) discrete, non-tender,
movable nodes in the central area.
Abnormal Findings:
 Enlarged greater than 1 cm lymph nodes
may indicate infection of the hand or
arm.
 Large nodes that are hard and well-fixed
to the skin may indicate malignancy
3. Palpates high into the axillae,
moving downward against the
ribs to feel for the central nodes.
Continue down the posterior
axillae to feel for the posterior
nodes.
USE BIMANUAL PALPATION TO FEEL FOR THE
ANTERIOR AXILLARY NODES. Palpate down
The inner aspect of the upper arm.
If the client has large breast, support breast with
your non dominant hand, and use your
dominant hand to palpate.
4. Ask the client to demonstrate
how she performs breast self-
examination (BSE). (This should
be offered as an option and the
client’s choice)
BREAST SELF-EXAMINATION
 Lie
down and place your right arm
behind the 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 much easier to feel all
breast tissue.
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
 Use 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 your 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
 Move 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
ribs and up to the neck or collar bone
(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 hand.
While standing in front of the 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 breasts 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
THANK YOU! ☺
 QUIZ
1. While Student Nurse inspects the breast for size and symmetry, she
observed a pig skin or orange peel appearance of the breast which
is caused by
A. obesity.
B. infection.
C. malignancy.
D. blocked lymphatic drainage.
2.When assessing the Tail of Spence in a client’s breast, the nurse is
palpating

A. in the lower quadrant, close to the ribs.

B. above the nipple at the midclavicular line.
C. in the upper inner quadrant, near the sternum.
D. in the upper outer quadrant, toward the axilla.
3. Nurse Densio asks a 47 year old client to remain seated while
performing several different maneuvers. He asked client to raise his
arms overhead, press hands against her hips and press hand together.
The nurse is inspecting for

A. Size and shape of areolas.

B. Retraction and dimpling.
C. Direction of nipples
D. Texture and elasticity.
4.During the breast exam, the nurse palpates a series of lymph nodes.
Why is this a part of the breast exam?

A. It's not. It's done because the chest area is exposed.

B. To review the integrity of the skin.
C. To assess the deep lymph nodes which drain the mammary lobules.
D. To assess shoulder range of motion.
5. When examining the breast, palpation should be done using one
of the three different patterns except

A. circular/clockwise.
B. wedge.
C. horizontal strip.
D. vertical strip
6. A 58-year-old client says to the nurse, "My saggy breasts embarrass
me!" What can the nurse say to this client in response?

A. Maybe you can have breast augmentation surgery?

B. Wearing a good bra will help.
C. Don't be silly.
D. Breasts sag because of declining estrogen levels.
7. A client comes into the clinic for a routine breast and axilla exam.
Which assessment technique does the nurse use first during this
examination?

A. Inspection
B. Auscultation
C. Palpation
D. Percussion
8. A 32-week-pregnant client is upset and thinks she has breast
disease because she has a yellowish discharge coming from her
breasts. What can the nurse say or do for this client?

A. This is normal toward the end of pregnancy and is called

colostrum.
B. Refer the client for a mammogram.
C. Notify the health care provider.
D. Ask history questions about previous breast infections.
9.The client tells the nurse, "At times I have discharge from my right
breast." What should the nurse do with this information?

A. Write it in the medical record and say nothing to the client.

B. Phone for a mammogram for the client immediately.
C. Explain that this could be benign or it could mean something else.
It needs to be further investigated.
D. Nothing. It doesn't mean a thing
10. During inspection of the
breast, nurse Tanya will assess
the breast for the following
except
A. symmetry of the breast.
B. superficial venous patterns.
C. size and direction of nipple.
D. tenderness and
temperature.
 TRUE/FALSE

11._____________The client’s breasts should rise symmetrically

with no sign of dimpling or retraction
12._____________Discharges should be referred for
cystologic study and further evaluation
13._____________Use bimanual palpation to feel for
the anterior axillary nodes.
14.____________Be sure to palpate every square inch of the
breast from the nipple to areola to the periphery of the breast
tissue and up to four quadrants of the breast only.
15. _________ Breast self examination should be done
7-10 days before menstrual period
16.________The older client may have smaller, flatter nipples
that are less erectile on stimulation
17. __________ A recent increase in the size of one breast may
indicate inflammation or an abnormal growth.
 IDENTIFICATION

18. A smooth firm movable disc of

glandular tissue may be seen in one
breast in males during puberty for a
temporary at a time IS CALLED?
__________________.
19. It is called the dark, velvety
pigmentation of the axillae
which may indicate an
underlying malignancy.
20. This is a screening method used
in an attempt to detect early breast
cancer. The method involves the
woman herself looking at and
feeling each breast for possible
lumps, distortions or swelling.
 QUIZ answers
1. While Student Nurse inspects the breast for size and symmetry, she
observed a pig skin or orange peel appearance of the breast which
is caused by
A. obesity.
B. infection.
C. malignancy.
D. blocked lymphatic drainage.
2.When assessing the Tail of Spence in a client’s breast, the nurse is
palpating

A. in the lower quadrant, close to the ribs.

B. above the nipple at the midclavicular line.
C. in the upper inner quadrant, near the sternum.
D. in the upper outer quadrant, toward the axilla.
3. Nurse Densio asks a 47 year old client to remain seated while
performing several different maneuvers. He asked client to raise his
arms overhead, press hands against her hips and press hand together.
The nurse is inspecting for

A. Size and shape of areolas.

B. Retraction and dimpling.
C. Direction of nipples
D. Texture and elasticity.
4.During the breast exam, the nurse palpates a series of lymph nodes.
Why is this a part of the breast exam?

A. It's not. It's done because the chest area is exposed.

B. To review the integrity of the skin.
C. To assess the deep lymph nodes which drain the mammary lobules.
D. To assess shoulder range of motion.
5. When examining the breast, palpation should be done using one
of the three different patterns except

A. circular/clockwise.
B. wedge.
C. horizontal strip.
D. vertical strip
6. A 58-year-old client says to the nurse, "My saggy breasts embarrass
me!" What can the nurse say to this client in response?

A. Maybe you can have breast augmentation surgery?

B. Wearing a good bra will help.
C. Don't be silly.
D. Breasts sag because of declining estrogen levels.
7. A client comes into the clinic for a routine breast and axilla exam.
Which assessment technique does the nurse use first during this
examination?

A. Inspection
B. Auscultation
C. Palpation
D. Percussion
8. A 32-week-pregnant client is upset and thinks she has breast
disease because she has a yellowish discharge coming from her
breasts. What can the nurse say or do for this client?

A. This is normal toward the end of pregnancy and is called

colostrum.
B. Refer the client for a mammogram.
C. Notify the health care provider.
D. Ask history questions about previous breast infections.
9.The client tells the nurse, "At times I have discharge from my right
breast." What should the nurse do with this information?

A. Write it in the medical record and say nothing to the client.

B. Phone for a mammogram for the client immediately.
C. Explain that this could be benign or it could mean something else.
It needs to be further investigated.
D. Nothing. It doesn't mean a thing
10. During inspection of the
breast, nurse Tanya will assess
the breast for the following
except
A. symmetry of the breast.
B. superficial venous patterns.
C. size and direction of nipple.
D. tenderness and
temperature.
11.After assessing the breast of a
female client, the nurse should
explain to the client that most
breast tumors occurs in the
A. upper inner quadrant
B. lower inner quadrant
C. upper outer quadrant
D. lower outer quadrant
12. A female client tells the nurse that her breasts become lumpy
and sore before menstruation but get better at the end of the
menstrual cycle. The nurse should explain to the client that these
symptoms are often associated with

A. malignant tumors.
B. fibroadenoma.
C. fibrocystic breast disease.
D. increased estrogen production.
 TRUE/FALSE

13._____________The client’s breasts should rise symmetrically

with no sign of dimpling or retraction

Ans: TRUE
14._____________Discharges should be referred for
cystologic study and further evaluation

Ans: TRUE
15._____________Use bimanual palpation to feel for
the anterior axillary nodes.

 Ans: TRUE
16.____________Be sure to palpate every square inch of the
breast from the nipple to areola to the periphery of the breast
tissue and up to four quadrants of the breast only.

Ans: FALSE. Should be until TAIL OF SPENCE

17. _________ Breast self examination should be done
7-10 days before menstrual period.

Ans: FALSE. It should be after

18.________The older client may have smaller, flatter nipples
that are less erectile on stimulation

Ans: TRUE
19. __________ A recent increase in the size of one breast may
indicate inflammation or an abnormal growth.

Ans: TRUE
 IDENTIFICATION

20. A smooth firm movable disc of

glandular tissue may be seen in one
breast in males during puberty for a
temporary at a time IS CALLED?
__________________.
Answer: GYNECOMASTIA
21. Why does gynecomastia occur?

A. deficiency of estrogen.
B. deficiency of aldosterone.
C. deficiency of Follicular
Stimulating Hormone
D. deficiency of testosterone,
changing hormone level.
22. It is called the dark, velvety
pigmentation of the axillae
which may indicate an
underlying malignancy.

Answer: ACANTHOSIS
NIGRICANS
23. This is a screening method used
in an attempt to detect early breast
cancer. The method involves the
woman herself looking at and
feeling each breast for possible
lumps, distortions or swelling.

Answer:
BREAST SELF EXAMINATIONS
24. What breast is larger than the
other?____________
Ans:left larger than right
 What technique should be used
25.

when the client has large breasts?

_____________________________________
Ans: bimanual breasts