Breast & Lymphatics

Learning Objectives

• Anatomy and Physiology: Related to the breast and lymphatic system.

• Assessment Data: Identify objective (observable) and subjective (reported by patient) data.

• Assessment Findings: Differentiate between expected and unexpected physical assessment findings.

• Analysis of Data: Analyze data to determine steps for further assessment.

• Health Promotion Interventions: Identify appropriate health promotion interventions for the client.

• Documentation: Discuss documentation of assessment findings.

Anatomy and Physiology Overview

Breast Anatomy

• Components of the Breast:

  • Tissue

  • Nipple

  • Areola

  • Montgomery Glands

Quadrants of the Breast

• Axillary Tail of Spence

• Upper Inner Quadrant

• Upper Outer Quadrant

• Lower Inner Quadrant

• Lower Outer Quadrant

Lymphatic System

• Nodes: Act as FILTERS

  • Palpable Nodes:

  • Cervical (Neck)

  • Axillary (Armpit)

  • Epitrochlear (Elbow)

  • Inguinal (Groin)

• Groups: Nodes are grouped along lymphatic vessels

• Organs: Lymph

• Fluid: Lymphatic system also consists of lymph fluid.

Physiology of Breasts and Lymphatic System

• Primary Function of Breasts:

  • LACTATION

• Functions of the Lymphatic System:

  • Fights INFECTION

  • Absorbs FATS (from small intestine)

  • Balances FLUIDS (returns extra tissue fluid to blood)

Breast Lymphatics Drainage

• Most lymph from the breast drains to the axilla.

• Breast Cancer Considerations:

  • Node removal may lead to edema on the affected side.

Health History Assessment

Present Health History Questions

• Assess for:

  • Pain or tenderness in breasts or underarms: Where/when?

  • Changes in breast, nipple, or skin appearance?

  • Swelling, lumps, or rashes: Location and timing?

  • Nipple discharge: Timing, color, odor?

  • For menstruating clients: Breast changes with cycle?

  • Swollen or painful lymph nodes: Where?

Past Health History Questions

• History of breast disease (e.g., cancer, fibrocystic changes)?

• Any trauma, surgery, biopsies, breast augmentations, reductions, or mastectomies?

• Routine breast exam by professionals? Self-breast exams frequency?

• Family history of breast cancer: Who? Age at diagnosis?

Steps of Breast and Lymphatics Assessment

Skin Color and Condition

Expected Findings:

• Smooth, similar color to surrounding skin

Expected Variations:

• Visible veins bilaterally

• Striae visible bilaterally

• Inflammation underneath

• Slight asymmetry

Unexpected Findings:

• Thick, rough skin

• Lump

• Unilateral vein dilation

• Dimpling

• Edema

• Inflammation

• Unilateral rash: Peau d'orange (skin appearance resembling an orange peel) indicates concern for malignancy

Assessment Summary Table

C.A.R.E.S. Framework for Assessment

• C = Color change (red, inflamed, unilateral rash)

• A = Asymmetry (unilateral veins, one-sided findings)

• R = Rough/Thickened skin (loss of smooth texture)

• E = Edema/Peau d’orange (orange-peel skin from lymph blockage)

• S = Swelling, heat, tenderness (infection or inflammation)

Detecting Changes Between Mammograms

Changes to Look For:

• Thick area

• Dimpled skin

• Crusting on nipple

• Red or hot areas

• New fluid secretion

• Skin sores

• Bumps or hard lumps

• Growing veins

• Sunken nipple

• New shape/size

• Orange peel appearance of skin

Important Note:

• Changes might be normal; however, consult a doctor if they persist.

Assessment Scenario - Pop Quiz (Case Study)

• Scenario: A nurse is performing a breast assessment on a 48-year-old client.

• Question: Which finding indicates potential breast cancer?

  • A. Symmetric visible veins during pregnancy

  • B. Pale striae on both breasts

  • C. Rough, thickened skin with orange-peel appearance on one breast

  • D. Redness and tenderness of both breasts while breastfeeding

• Correct Answer: C. Rough, thickened skin with orange-peel appearance.

Additional Assessment Steps

Shape and Size of Breasts

Expected Findings:

• Similar in size

• Smooth contour

Expected Variations:

• Scars

• Gynecomastia in males

• Atrophy

Unexpected Findings:

• Significant size or contour differences

• Dimpling or retraction of skin

• Bulging

Memory Hook for Assessment

• S = Symmetry, Smooth, Stable → Normal

• C = Change in contour → Cancer concern

Assessment of Nipples and Areola

Skin Condition

Expected Findings:

• Round, oval structure

• Visible Montgomery glands

• Smooth without open areas, crusting, rash, or drainage

Unexpected Findings:

• Dry scaling

• Discharge

Symmetry, Alignment, Orientation

Expected Findings:

• Symmetrical with alignment

• Nipples point in the same direction

Expected Variations:

• Supernumerary nipple

Unexpected Findings:

• Nipple inversion or direction change

Characteristics of Breast Lump/Mass Assessment

• Location: Describe distance in cm from the nipple (analogous to a clock face)

• Size: Measure in cm (width, length, thickness)

• Shape: Note if the lump is oval, round, lobulated, or indistinct

• Consistency: Soft, firm, or hard

• Movability: Determine if it is freely movable or fixed during palpation

• Distinctness: Solitary or multiple lumps

• Nipple displacement or retraction: Any skin changes over the lump (e.g., erythematous, dimpled, retracted)

• Tenderness: Tender to palpation?

• Lymphadenopathy: Are any regional lymph nodes palpable?

Lymph Node Assessment

Normal Lymph Nodes

• Feel mobile, discrete, soft, nontender, and less than 1 cm

• If nodes are palpable: Note location, size, shape, delimitation (discrete or matted), mobility, consistency, tenderness

Lymphadenopathy

• Definition: Enlargement of lymph nodes greater than $1 ext{ cm}$

• Causes: Infection, allergy, neoplasm.

Interventions for Unexpected Findings

Assessment: RED FLAGS

• Changes in breast size, shape, contour

• Unilateral superficial vein dilation, inflammation, edema

• Nipple drainage

• Enlarged lymph nodes

• Changes in presentation or orientation of nipple

• Rash on nipple or areola

• Dimpled or retracted area

• Visible or palpable lump

Follow-Up Questions for Unexpected Findings

For Nipple Discharge:

• When did it start?

• Are you pregnant, breastfeeding, or recently stopped?

• Is it one or both nipples?

• Describe discharge: color, consistency, odor, location, staining?

• Any breast pain or lumps?

For Axillary/Arm Edema:

• When did the swelling begin?

• Relevant history: Pregnancy, breastfeeding or recent cessation?

• History of breast cancer or surgery?

• Recent trauma to breast/nipple?

• Other accompanying symptoms: fever, chills, pain?

Observational Framework for Assessment

• Observe: Look for red flags.

• Ask: Targeted follow-up questions.

• Document: Accurate and thorough documentation.

• Report: Communicate findings to the provider.

Health Promotion: Breast Self-Exam (BSE)

Expected Findings During BSE:

• Similar size and shape

• Smooth contour

• No dimpling, rashes, edema, lumps, or tenderness

• Normal inframammary ridge

Unexpected Findings:

• Variations in size

• Asymmetry

• Inflammation, warmth

• Tenderness

• Changes in texture or appearance

• Lumps

• Any drainage noted

BSE Steps:

1. Lie down: Use three middle fingers in a circular motion with three levels of pressure.

2. Follow an up-and-down pattern across the breast.

3. Sit up: Examine the underarm with the arm slightly raised.

4. Note surface changes with hands pushed on hips or shoulders hunched into a ball to observe any abnormalities.