Assessment-breast – Flashcards
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What are the landmarks of the breast?
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nipple, areola, & montgomery's (sebacceous) glands
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What is the most common site of malignancy in the breast?
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Tail of Spence in the upper outer quadrant. 50% incidence of breast cancer
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What is the Tail of Spence?
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part of breast tissue extending into axillae
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What is the incidence of breast cancer in the outer upper quadrant?
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50% incidence of breast cancer
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What is the incidence of breast cancer in the inner upper quadrant?
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15% incidence of breast cancer
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What is the incidence of breast cancer in the outer lower quadrant?
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11% incidence of breast cancer
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What is the incidence of breast cancer in the inner lower quadrant?
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6% incidence of breast cancer
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What is the incidence of breast cancer in the nipple?
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18% incidence of breast cancer
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The amount of breast tissue one has is related to...
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age, nutritional status, pregnancy, lactation & genetics
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Most of the breast tissue consists of...
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Adipose tissue
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What does the glandular tissue of the breast do?
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Secretes milk
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What are Cooper's ligaments?
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fibrous bands that attach breast tissue to chest wall muscles a.k.a. suspensory ligaments
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Cancer may cause the ligaments to contract causing _______ or _______ in the overlying skin
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pits; dimples
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Where are the pectoral lymph nodes located?
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behind anterior axillary fold
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What do the pectoral lymph nodes drain?
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drains anterior chest wall & breast
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Where are the subscapular lymph nodes located?
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located along lateral edge of the scapula just inside posterior axillary fold
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What do the subscapular lymph nodes drain?
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drains posterior chest wall & arm
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Where are the lateral lymph nodes located?
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along the humerus inside the upper arm
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What do the lateral lymph nodes drain?
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drains the arm
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Where are the central axillary lymph nodes located?
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high middle axillae
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What do the central axillary lymph nodes drain?
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receives drainage from all axillary nodes
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Where does 75% of the drainage from the central axillary lymph nodes go?
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75% of drainage will go to infraclavicular & supraclavicular nodes on the same side
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Where does the other 25% of the drainage from the central axillary lymph nodes go?
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25% of drainage will go to the opposite breast, abdomen, or deep into breast (a problem for metastatic disease) - ↑ spread to the other side
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What stimulates adolescent breast development?
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estrogen
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What is the normal age range for breast development to begin?
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8-13 yrs (average 10-11)
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How long does it usually take breasts to develop?
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3 yrs
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If breasts develop before age 8 or after age 13½ what might be going on?
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endocrine disorder - needs evaluation
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Breasts may normally be ________.
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asymmetric (teens may need reassurance)
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What is the MALE lifetime risk of breast cancer?
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1 in 1,000 (females 1 in 8)
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What is gynecomastia?
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nub of breast tissue under areola - feels like a large grape
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Why does gynecomastia sometimes occur in adolescence?
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excess testosterone is converted to estrogen
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Is gynecomastia unilateral or bilateral in adolescence?
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usually unilateral & temporary
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Why does gynecomastia sometimes occur in the older male?
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1. Occurs when testosterone levels drop and estrogen becomes unopposed OR 2. May also be due to medication effects (e.g., Cimetadine) or a pituitary tumor
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Is gynecomastia unilateral or bilateral in the older male?
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unilateral or bilateral
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Why is breast pain always significant?
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Could be cancer, altho not all cancers are painful
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If breast pain is present, you should ask if it is _______ or _______.
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localized; generalized
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What do you want to know about the character of breast pain?
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Is it burning, pulling, and/or a vague discomfort?
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What is significant about cyclic breast pain?
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common with OCs & fibrocystic changes may treat with Vitamin E, 400-800mg
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What are some associated factors that can cause breast pain?
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underwire bras, exercise
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Fibrocystic (noncancerous) lumps may enlarge and be more tender at what time?
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prior to menstrual period
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What effect does caffeine have on fibrocystic lumps?
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Caffeine intake may increase size and tenderness of cystic lumps
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What might lumps that are associated with redness and warmth indicate?
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pt could have mastitis
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What might lumps that are associated with dimpling and swelling indicate?
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pt could have cancer
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Also ask about ______ if lumps are found on exam
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history of breast trauma
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What can cause clear discharge of the nipple?
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may be due to meds (OCs, phenothiazides [thorazine], diuretics, digitalis, steroids,Tricyclic antidepressants [amitriptyline], reserpine, & aldomet) or a pituitary tumor
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What can cause a milky discharge of the nipple? (hint: not breastfeeding :)
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Galactorrhea associated with a pituitary tumor
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What can cause a bloody or yellow/bloody discharge of the nipple?
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may indicate ductal cancer always significant, especially when associated with a lump
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What might a rash on the breasts indicate?
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Paget's disease (advanced ductal CA) - starts as a small crust on the nipple with surrounding erythema
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When is the best time to do self breast exams (SBE)?
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Perform SBE 5 - 7 days after onset of menses due to (decreased nodularity) note: increased nodularity midcycle to last ½ of cycle
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How often should women in their 20s and 30s have clinical breast exams done?
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every 3 years
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How often should women in their 40s and older have clinical breast exams done?
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yearly
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Per the American Cancer Society, how often should women have mammograms done?
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Yearly starting at age 40
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Per the United States Preventive Services Task Force Recommendations, how often should women have mammograms done?
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Biennial (every 2-years) between ages 50 - 74
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Can women with breast implants have mammograms done?
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Yes
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Can men have mammograms done?
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Yes
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Breast cancer is the _______ major cause of cancer death in women
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2nd (lung cancer is #1)
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What percentage of breast cancer occurs after age 40?
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80%
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1 in _____ women before age 45 will develop breast cancer
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8
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Positive outcomes in breast cancer rely on...
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early identification, early treatment
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Which gender is at higher risk for breast cancer?
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Women
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How does age affect one's risk for breast cancer?
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progressively increases with age
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How does a history of breast cancer in one breast affect the risk of developing breast cancer in the other breast?
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the other breast is 3-4 times more likely to get breast cancer
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What effect does family history of breast cancer have on developing breast cancer yourself?
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20-30% of women with breast cancer will have a family history; 70% will not
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What gene mutations are associated with higher risk for breast cancer?
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BRACA 1 or BRACA 2 (also applies to men)
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What affect does race have on developing breast cancer?
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higher in caucasians
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What affect does having children have on developing breast cancer?
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you are at higher risk if your first child was born after you were 30-35 yrs old OR you are at higher risk if you've never had a child and never breastfed
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What affect does menarche have on developing breast cancer?
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menarche before age 12 is higher risk
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What affect does menopause have on developing breast cancer?
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menopause after age 55 is higher risk
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What affect does weight have on developing breast cancer?
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overweight/obese is higher risk
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What affect does activity level have on developing breast cancer?
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sedentary is higher risk
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What affect does alcohol have on developing breast cancer?
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more than one drink per day increases risk 1 - 1.5 times
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What affect does DES exposure (diethylstilbesterol) have on developing breast cancer?
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risk is higher in persons taking it & their daughters (this is a hormone that was given in the 1940s -1950s to prevent miscarriage)
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What are some other risk factors of breast cancer?
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• Abnormal breast cells on previous biopsy • Radiation to chest (especially if before age 30) • Current use of oral contraceptives • Hormone replacement therapy (HRT) - estrogen & progesterone • Mammograms showing dense tissue (more glandular, less fat)
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What are you noting when you inspect the breasts?
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Note size & shape (often slight asymmetry) - left breast is usually larger than right breast
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What are you noting when you inspect the skin of the breasts?
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Normally smooth & even color Note any localized areas of redness, bulging, dimpling, edema
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What might redness of the skin and warmth indicate?
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mastitis
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What might peau d'orange (orange peal skin) indicate?
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• Caused by blocked lymph ducts • Common with CA • Edema may exaggerate hair follicles causing bumpy texture & large pores appearing like an orange peel
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What position should the pt be in when you examine the axillae?
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Sitting with arms relaxed at side
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Palpating high into the axillae will allow you to palpate the ______ lymph nodes.
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central
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Palpating the anterior axillae will allow you to palpate the ______ lymph nodes.
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pectoral
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Palpating the posterior axillae will allow you to palpate the ______ lymph nodes.
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subscapular
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What three other areas must you palpate for lymph nodes?
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Down chest wall Supraclavicular Infraclavicular
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A deviation in a nipple may indicate...
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cancer
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Nipples may be _______, _______, or _______
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everted, flat, inverted
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What are some variations on the nipple that you want to note?
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dry scaling, fissures, ulceration, or bleeding
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What is a supernumerary nipple?
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-an extra nipple along the mammary ridge at the midclavicular line -occurs in 1% of men and women -may appear like a nevus (mole) or a fully developed nipple
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What are the retraction maneuvers?
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• Observe breasts with hands at sides • Lift arms overhead • Push hands on hips • Push palms together • Lean forward (to see underside of large breasts)
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Why do the retraction maneuvers?
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observe changes in contour, symmetry, retraction, & dimpling associated with CA
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Begin breast palpation with the pt in what position?
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Sitting up
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What is the best technique for palpating breasts?
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use a bimanual technique especially for women with larger breasts
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When the pt lies down, what should you place beneath the shoulder of side to be examined?
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pillow or towel roll
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How should the pt position their arm during the lying down portion of the exam?
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Have patient place hand behind head on side to be examined
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What is the best pattern to use when palpating the breasts per the American Cancer Society?
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-Palpate vertically using pads of 3 fingers (never raise fingers; may miss a spot) -palpate in strips from mid axillary line to sternal border (include Tail of Spence)
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What might you notice when palpating breasts during the premenstrual portion of the cycle?
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breasts are engorged due to estrogen - feel fuller, more nodular
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How should you alter your technique s/p mastectomy or with breast augmentation?
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Trick question! You do not alter your technique in these situations.
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What are you noting when palpating the nipple?
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- assess for lumps & discharge - note color & consistency of discharge
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What should you note about the location of a lump?
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quadrant, cm from nipple, clock position (e.g., 3 o'clock)
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What should you note about the size of a lump?
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length, width, depth
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What should you note about the shape of a lump?
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round, oval, indistinct
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What should you note about the consistency of a lump?
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soft, hard, firm
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What should you note about the tenderness of a lump?
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present or absent
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What should you note about the borders of a lump?
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defined, irregular
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What should you note about the retraction/dimpling of a lump?
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present or absent
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What should you know about the mobility of a lump?
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• Mobile = fibrocystic • Fixed = CA
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What are common characteristics of a cancerous lump?
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painless lump, ulceration, retraction, nipple discharge
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What pt education do you want to provide about breast care?
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• Educate during or after completing the exam • Examine 5 to 7 days after 1st day of menses • Postmenopausal (examine at same time each month) • Emphasize the importance of early detection • Watch her demonstrate
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What is unique about the breasts of a newborn?
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estrogen causes white nipple fluid in either sex - resolves in few days to few weeks
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What is unique about the breasts of a pregnant woman?
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• Nipples enlarge, darken & become more erect • Increased venous pattern over skin (superficial vessels) • Note elevated Montgomery glands • Colostrum forms in the 4th month (precursor to milk) - thick yellow fluid
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What is unique about the breasts of a lactating woman?
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• Colostrum changes to milk 3 days postpartum • Frequent nursing relieves sensation of tenderness, engorgement • Mastitis (inflammation or infection of breast tissue after childbirth) - red, swollen, hot, painful breasts
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What is unique about the breasts of an aging woman?
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• Menopause (glandular tissue atrophies) - decreased breast size • Decreased elasticity (r/t decreased adipose) - pendulous, flattened, sagging breasts • Axillary hair decreases
