Health Assessment Chp 17 Flashcards
The breast is composed of (3 things)
Glandular tissue, fibrous tissue, including suspensory ligaments, and adipose tissue
What is glandular tissue and its purpose?
15-20 lobes radiating from the nipple and these are composed of lobules which contain clusters of alveoli that produce milk.
What is the tail of spence?
Cone shaped breast tissue that projects up into that axilla, close the pectoral group of axillary lymph nodes
The site of most breast tumors?
Upper outer quadrant
Where are the breast located?
Anterior to the Pectoralis major and serratus anterior muscles. Between the 2nd and 6th ribs and extending from the side of the sternum to the midaxillary line.
The breast lymphatic drains ___% of lymph into ____
75%, ipsilateral axillary nodes
Four groups of axillary nodes in the breast?
Central axillary nodes, pectoral (anterior), subscapular (posterior), lateral
Central axillary nodes
High up in the middle of the axilla, over the ribs and serratus anterior muscle. These receive lymph from the other three groups of nodes
Pectoral (anterior)
Along the lateral edge of the pectoralis major muscle, just inside the axillary fold.
Subscapular (posterior)
Along the lateral edge of the scapula, deep in the posterior axillary fold
Lateral group of lymph nodes
Along the humerus, inside the upper arm
From the central axillary nodes, drainage….
Flows up to the infraclavicular, and supraclavicular nodes.
A smaller amount of lymph drainage
Flows directly up to the infraclavicular group, or deep into the chest, or into the abdomen, or directly across the opposite breast
During embryonic life
Epidermal ridges or milk lines are present and curve down from the axilla to the groin bilaterally. The breast develops along the ridge over thorax, and the rest of the ridge atrophies. Occasionally a supernumerary nipple (extra nipple) persists and is visible somewhere along the track of the mammary ridge
At birth only breast structures present are
Lactiferous ducts within the nipple. No alveoli have developed. Little change occurs in puberty.
The onset of breast development occurs at an average age between
8&9 years for African American girls and by 10 in white girls. However, recent evidence shows an earlier onset of breast development in 7 year olds: 10.4% of white girls, 23.4% of non-Hispanic black girls and 15% of Hispanic girls
Early breast development is linked to
Greater body mass (BMI) ratings and reflects the rise in obesity in US children
Is it normal for one breast to grow faster than the other?
Yes, tenderness is common also
Tanner stages
- Preadolescent- only a small elevated nipple
- Breast bud stage- a small mound of breast and nipple develops; the aerial widens
- The breast and areole enlarge; the nipple is flush with the breast surface.
- The aerial and nipple from a secondary mound over the breast.
- Mature breast: only the nipple protrudes; the Areola is flush with the breast contour (the Areola may continue as a secondary mound in some normal women)
Tanner stages 2-5 takes an average of
3 years although the range is 1.5 to 6 years. During this time pubic hair develops, and axillary hair appears 2 years after the onset of pubic hair
The beginning of breast development precedes
Menarche (beginning of menstruation) by about 2 years.
Menarche occurs in breast development stage
3 or 4, usually just after peak of adolescent growth spurt around 12 years of age. This helps to assess the development of adolescent girls and increases their knowledge about their own development.
During pregnancy breast changes start
During the second month and are common early signs of pregnancy. Pregnancy stimulates the expansion of the ducal system and supporting fatty tissue and the development of true secretory alveoli. Thus the breast enlarge and feel more modular.
What happens to the nipples during pregnancy
They grow larger, darker, and more erectile
What happen to the areolae during pregnancy?
They become larger and darker as pregnancy progresses, and the tubercles become more prominent. The brown color fades after lactation, but the areolae never return to the original color
A 5-month pregnant woman comes in and complains of prominent venous patterns over enlarged breasts that are leaking a very thick, yellow fluid. How would you assess/ document this finding?
These are normal findings. (p 389)
During pregnancy, breasts expand the ducts system and supporting fatty tissue and development of the the secretory alveoli. This causes the breasts to be enlarged.
After the 4th month of pregnancy, colostrum (thick yellow precursor for milk) may be expressed.
Venous pattern is expected to be prominent over skin surface?
A 6-month pregnant woman is getting a routine breast assessment, what normal findings would you have?
Colostrum expressed
Enlarged nodular breasts
Larger, darker, more erectile nipples
Larger, darker areolae
Prominent tubercles
(p 389)
Describe the components of colostrum
Thick, yellow fluid
Precursor for milk
Same amount of protein and lactose as milk, practically no fat; rich in antibodies
Expected after 4th most until first few days after delivery (until milk is produced aka lactation)
A woman is postpartum and is questioning breastfeeding her new baby. What would you include in your discussion with her?
Since the baby is new born, she may be expelling colostrum for these first few days and that is normal; it is filled with antibodies so encourage breastfeeding
Lactation aka milk production, may take up to 3 days to start (1-3 days after delivery)
When it comes, it may be whitish color because emulsified fat and calcium caseinate
(P 389)
A postmenopausal woman complains of breast changes. Describe normal changed that would be assessed.
Decrease in estrogen and progesterone from ovaries, this causes atrophy in breast glandular tissue.
Fibrous connective tissue replaces the breast glandular tissue
Fat envelope atrophies ( decreases breast size and elasticity) giving the breasts a droopy look which is worsened by kyphosis
Internal structures more prominent and palpable
Decrease in axillary hair
(P 389)
Which spinal disorder affects an aging woman’s breasts?
Kyphosis
Drooping is accentuated by kyphosis in some older women (p 389)
A 49-year-old woman has done a BSE and comes into the hospital complaining of a new lump near her nipple she had not felt before menopause. She is a non-smoker, been losing weight since menopause, and has never had children/breastfed before. She is concerned about breast cancer, what should you tell her.
This is likely a normal finding because as an aging woman, her decreased breast size makes her inner structures more prominent. A breast lump may have been present for years is suddenly palpable.
Around the nipple, the lactiferous ducts more palpable and feel firm and stringy because of fibrosis and calcification.
A 14-year-old male comes in and is self-conscious about removing his clothing. He complains of other male adolescents picking on him during gym class. When assessing his chest-region, the nurse inspects enlarged, underlying tissue. How should she document this finding?
Gynecomastia (p389)
During adolescence, it is common for the male breast tissue to enlarge temporarily, gynecomastia. (Image on P 402)
This condition is usually temporary, but reassurance is necessary for the adolescent male , whose attention is riveted on his body image.
Other than adolescence, when would you see gynecomastia? Likely cause?
Aging male
Testosterone deficiency
What types of factors influence onset of puberty? Which groups would you expect to see it in earlier? Later?
Genetic & environmental (menarche, breast development, obesity, high BMI)
AA girls menstruate 8.5 months earlier (12.16 years old)
White girls (almost 13 years)
AA girls start puberty 1-1.5 years earlier
AA girls breast development at 8.87 years (on average)
White girls (10 years)
Hispanic girls in both groups
Obesity causes early menarche and breast budding
Thus epidemic major determinant of early-age pubertal milestones
What patient would you expect to see a mutation in BRCA1 & BRCA2?
These are tumor suppressor genes.
Women who inherit a mutation on one or both, have significantly increased risk of developing breast or ovarian cancer.
Expected among 1-4% of breast cancer patients of Africa, Asia, White, and Hispanic descent.
Who has the highest incidence of breast cancer?
Before 45: African-American women (also more likely to die)
After 45: Caucasian women (but AA more likely to die)
Which group of women would you LEAST expect to have breast cancer?
Women from Asian-American, Hispanic, and American Indian groups have a lower incidence AND lower death rates from breast cancer than Whites and AA.
What affected the rise and fall of breast cancer rates between 1992-2005?
Reflected the trend in hormone replacement therapy in certain perimenopausal women. In July 2002, the results of the Women’s Health Initiative (WHI) study, confirmed that long term use of combined estrogen and progesterone therapy increased the risk of developing cancer.
Followed by a dramatic reduction in hormone use.
Since 2016, Us, Europe, and Australia show annual decline of ~10% in White women, high incomes, estrogen-receptor positive tumors, 50 years or older. (reflective of social pattern of hormone use)
Describe the normal male breast
Rudimentary structure consisting of a thin disk of underlying tissue underlying the nipple.
Areolae is well developed. Although the nipple is relatively very small.
Which patient would you recommend annual breast screening to? Why?
Reason: discover small, potentially curable, breast cancers
Who: American Cancer Society recommends yearly screenings starting at 40 years. (only 66.5% went in past 2 years). Higher rates of cancer screening for women of color in recent years.
Which patient would likely not get appropriate, recommended, breast screenings?
Less than high school education
No health insurance
Recent Immigrants
**Low income (lack of insurance coverage, lack of access to care, not having regular health care provider, lack of breast care knowledge & screening awareness)
Name LIFESTYLE factors related to breast cancer RISK
Alcohol-use (3-6 drinks per week)
Alcohol/Western (processed foods and heavy starches) has a modest positive association with breast cancer
Name LIFESTYLE factors related to REDUCING breast cancer
Recreational physical activity (at any intensity level), especially during reproductive years and after menopause
(however, postmenopausal weight gain eliminates these benefits)
healthy/Mediterranean diet (veggies, fruit, olive oil, sunflower oil, seafood) has a modest protective effect
When is mastalgia an abnormal sign? a normal sign?
Mastalgia is pain or tenderness in the breasts. Occurs with trauma, inflammation, infection, and benign breast disease
Cyclic Pain is common & normal. Related to menstrual period, oral contraceptives, and benign (fibrocystic) disease
A 27-year-old female patient comes in with a lump in her breast. the patient says “oh, that’s been there forever” what should you do/say/document?
A lump present for years and exhibiting no changes may not be serious but should be explored.
What is galactorrhea? When is it significant?
Discharge from the nipple
Clear discharge can be caused by medications such as oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, and calcium-channel blockers.
Bloody/ blood-tinged discharge is ALWAYS significant.
A patient comes in with a rash on her breast. It began at the nipple and has spread. What questions would you ask the patient for further subjective data?
When did you first notice this? where did it start?
Paget disease - starts with a small crust on the nipple apex and spreads to areola.
Dermatitis usually starts on the areola, or surrounding skin, and then spreads to the nipple. Eczema or other forms of dermatitis rarely start at nipple (unless caused by breastfeeding)
A patient has come in after a car accident and had a direct blow in her chest. what might you assess?
a lump, caused by local hematoma, or edema, and should resolve shortly.
Mastalgia, or pain
Name some non-lifestyle factors that affect the assessment of the breasts.
The presence of benign breast disease makes the breasts harder to examine. General lumpiness conceals a new lump.
What are some uncontrollable risk factors that increase the risk for breast cancer?
Self: Past breast/ovarian/endometrial/colon cancer (and early onset, 30), late menopause, no full-term pregnancies.
Family: Breast cancer occuring before menopause in certain family members (sister, mother, maternal grandmother, maternal aunt, daughter)
A patient has come in after a mammoplasty. What might you assess?
Significantly larger (augmentation) or smaller (rrduction) breasts from cosmetic surgery
You are explaining to a patient that she her procedure was a biopsy-confirmed atypical hyperplasia. What does this mean for the patient?
Invreased breast cancer risk
A 22-year old comes in with fibrocystic breast disease. How might you expect the doctor to treat her?
Fibrocystic = BENIGN
Oral contraceptives may be prescribed to control the symptoms
A 47-year-old woman has been using hormone therapy. What is it’s significance?
After menopause:
2 years or more of combined estrogen and progesterone increases breast cancer risk (higher risk to current/recent users)
Though…Estrogen alone causes no increase in risk for brrast cancer
Explaon thw importance of cheat radiation anf age administered?
Between ages 10-30, chest radiation exposure has greatest risk of breast cancer later in life
Patient feels “lumps in their underarms” what are they likely feeling?
Breast tissue extends up into the Axilla. The axilla also contains many lymph nodes.
What is the most obvious sign of puberty?
Developing breasr are the most obvious sign of puberty
Breast development is often a focus of attention, esp in comparison eith peers. Make sure to assrss girl’s perception of her own development and provide traching and reassurance
What is the importance of inverted nipples in a pregnant woman?
Invetyed nipplrd need special care in preparation for breastfeeding
How long should a woman breast feed? Why?
Breastfeeding alone for 6 months
Provide food Antibodies Reduce risk for ear infection Promotes bonfing Provides relaxation
Protects mom against breast cancer
What causes the breast changes in menopausal women?
Decreased firmness because of decreased estrogen
Shrinkage because of rapid decrease in estrogen
Most breastcancers occur in women with which two identifiable factors?
Sex and age
A sudden increase in the size of one breast signifies______________?
Inflammation or new growth
It is common yo have a slight asymmetry in size (often left is bigger than right)
Inflammation of the breasts
Redness and heat
esp in non-lactating and postpartum
Skin of pregnant breast
A fine blue vascular network is visible
Pale, linear straie (stretch marks)
Edema in breasts
Normally not present
Edema exaggerates hair follicles giving “pigskin” or “orange peel” look
Aka peau d’ orange
A patient comes in and you notice a recently retractes nipple. What might this signify?
A recently retracted nipple, that had been introverted for many years, sugnifues acquired disease
A patient has one nipple that is introverted and one thatbis not. What might this signify? What if the patient has bilateral inversion?
Both unilaterl AND bilqteral nipple inversion is normal and is usually not fixed (ie- can be pulled out)
Supernumerary nipple
Normal and common variation
Extra nipple along embryonic “milk line” on thorax or abdomen
Congenital finding
Usually 5-6cm below breast near midline and no associated grandular tissue.
Looks like a mole (closely resembles little nipple and areola)
Supernumerary breast
Rare
Like supernumerary nipple, but glandular breast tissue is present
List some things that can cause retraction signs
Fibrosis in the breast tissue (which is caused by growing neoplasms)
The fibrosis shortens with time, causing contrasting signs with the normally loose breast tissue.
Dimpling or a pucker
Fixation to chest wall
Note a lag in the movement of one breast by asking the patient to do the retraction maneuver (hands up, behind head)
Why might axillary nodes be palpable?
Nodes enlarge with any local infection of the breast, arm, or hand with breast cancer mestastases.
How do you assess the axillae?
With patient sitting, lift her arm and support is yourself. Use your right hand to palpate the left axilla. Reach your hands into the axilla. move in 4 directions ( down the chest wall in a line from the middle of the axilla - along the anterior border of the axilla - along the posterior border - along the inner aspect of the upper arm.
Describe a CBE
Clinical breast exam
3 fingers; light/medium/deep tissue
Vertical strip pattern (nipple to periphery like a wheel and concentric circles out to periphery)
inframmamary ridge
firm, transverse ride of compressed tissue in the lower quadrants; esp noticeable in large breasts (normal)
Assessing discharge
Abnormal (except in pregnancy and lactation)
note # of droplets, quadrants producing it, color, and test for blood
A patient has large breasts, what techniques might you use?
bimanual technique
sitting, leaning forward, support inferior and palpate with other hand
What characteristics do you need to note about a lump in the breast?
Location; Size(3); Shape; Consistency; Movable; Distinctiveness; Nipple; Skin over lump; Tenderness; Lymphadenopathy
A patient has had a mastectomy, what would you assess?
Gentle around scar; lymphedema of upper arms
Male breast cancer
Rare (1% of breast cancers); usually presents with painless, firm, irregular, fixed, retroareolar lump (less frequently with **nipple discharge, ulceration, retraction, axillary lymphadenopathy,)
no standard screening (detected by clinical symptoms)-diagnosed 10 years after women (60-70) and later stages- stage indicates survival
early spread to axillary lymph nodes because of minimal breast tissue.
gynecomastia
benign growth of flat disk, undeveloped breast tissue beneath nipple; distinguishable from other tissues in the chest wall. feels like smooth, firm, moveable disk; occurs in 1/2 adolescent boys at 13-14; bilateral or unilateral; temporary
Also with anabolic steroids, cirrhosis, other diseases, and meds
