Skin and breast assessment 1
MENNONITE COLLEGE OF NURSING
AT ILLINOIS STATE UNIVERSITY
Diagnostic Reasoning for Advanced Practice Nursing 431
Skin and Breast Assessment
Skin Assessment
Anatomy and Physiology of the Skin, Hair, & Nails review
 Major function – body homeostasis
o Protects underlying structures
o Modulates temperature
o Synthesized vitamin D
 Largest and heaviest (16% of body weight) organ of the body
 3 layers (contain sebaceous and sweat glands)
o Epidermis
o Dermis
o Hypodermis
 Hair
 Nails
 Sebaceous glands
o On all surfaces except palms/soles
o Secrete fatty substance through hair follicles
 Sweat glands
o Eccrine – widely distributed, open onto skin surface, control body temp
o Apocrine – in axilla & groin, stimulated by emotion
Age Changes
 Infant
 Adolescents
 Pregnancy
 Adult
 Older adults
Skin Lesions: Primary
 Flat
o macule (freckle)
o patch (vitiligo)

Elevated
o papule (<0.5 cm)
o plaque (> 0.5 cm)
o nodule
o tumor
o wheal
o keloid (scars, piercings)

Elevated, containing free fluid
Skin and breast assessment 2
o
o
o
vesicle (< 0.5 cm)
bulla (> 0.5 cm)
pustule
Skin Lesions: Secondary
 Loss of Skin Surface
o erosion
o ulcer
o fissure
 Material on the Skin Surface
o Crust
o Scale
Skin Cancers
 Basal cell – shiny, translucent, slow growing, rarely metastasize, 80%
 Squamous cell – crusted, scaly, ulcerated, can metastasize, 16%
 Melanoma – 4% and rising
o Screen using ABCDE (asymmetry, borders irregular, color change/variation, diameter ≥6
mm, elevated/enlargement
o Risk factors – previous melanoma, age > 50, male, mole change, light eye/skin/hair color,
sun exposure, family history
Subjective; History
 CC – common concerns rash, hair loss, moles
 HPI
 PMH – skin cancer (most common cancer in U.S.)
 FH - melanoma
 SH – sun exposure (hands, neck, head)
 ROS – rashes, lumps, size/color/location of moles; changes in hair, skin, moles, new moles
 Prevention – regular self-exam, reporting changes in moles, moisturizing, use of sun
screen/hats/sunglasses
Objective; Physical Exam
 Examination begins with General survey (hair and nails discussed previously)
 Inspection and Palpation
o Best done in gown with good light
o Note characteristics – color, moisture, temperature, texture, turgor
o Describe lesions
 color
 location
 pattern (arrangement)
 shape
 type
o Use proper terminology! See Dains, chapter 25.
 Buy a good book and use in clinic.
 Example: Skin – warm, moist; no rashes, suspicious nevi, petechiae or ecchymoses. Nails-no
clubbing or cyanosis. Hair – normal distribution, moderate (fine or thick) texture, no scalp scaling
or nevi.
Article – Lyons, F. (2012). Solving skin rash in primary care. Advance for NPs & PAs; April 2012: 30-33.
Skin and breast assessment 3
Breast Assessment
Anatomy
 Breast tissue made up of:
o glandular tissue
o fibrous tissue
o subcutaneous tissue
o fatty tissue
 Most concerned with glandular tissue
Glandular tissue
 There are 15-20 lobes/breast
 Each lobe has 20-40 lobules
 Each lobule has milk-producing acini cells that lead to the lactiferous ducts that lead to the nipple
Breast Anatomy
 Each breast has
o 4 quadrants; UOQ, UIQ, LIQ, LOQ
o Tail of Spence
o Nipple

Lymph nodes
o Central (deep in axilla)
o Pectoral (anterior)
o Subscapular (posterior; lateral border of scapula)
o Lateral (upper humerus; flow into infraclavicular and supraclavicular)
Breast Cancer
 12.28% lifetime risk of breast cancer in women
 Risk increases with aging
 Cure rate = 90% when nonpalpable, but found on mammography
 Most tumors in upper outer quadrant and Tail of Spence
Breast Cancer: Risk Factors
 Age
 First degree relative
 Personal history of GYN, colon or thyroid cancer
 Early menarche (<12)
 Late menopause (>55)
 Nulliparity
 First child after age 30
Age Changes
 Tanner changes
 Adult female
 Pregnancy
 Menopause and after
 Male breast - gynecomastia
Male breast cancer (ACS website)
Skin and breast assessment 4



1/1000 lifetime risk, 1% of all breast cancers
S/S – commonly a firm, non-painful mass below nipple, nipple change/discharge
Increased risk with increased by elevated levels of estrogen, previous radiation exposure, and a
family history
Subjective; History
 CC – common concerns lump or mass, breast pain, nipple discharge
 HPI
 PMH – hormonal drugs, history of breast cancer, calcifications on mammograms, menstrual
history, breast feeding, HRT, LMP
 FH – 1st degree relatives, early age
 SH – alcohol, diet/exercise, caffeine, tobacco
 ROS – breast pain/discomfort, lumps, nipple changes/discharge, self-exam, clinical exam,
mammograms
 Prevention- reduce modifiable risk factors
Objective; Physical Exam
 Inspection
o Positions – arms at side, overhead, pressed on hips, leaning forward
o Breast and nipple; skin color, size, shape, symmetry, discharge (drug related?)
 Palpation
o Position – supine, arm above shoulder, position roll to flatten breast tissue; sittingmales
o Systematic pattern – vertical strip or concentric circles
o Nodules – describe
o Nipple
o Axilla nodes – sitting
Breast Care (Controversy exists on the appropriate intervals for screening due to the evidence; consider
guidelines below, patient desires and your assessment from H&P)
 Self-breast examination
o Not recommended (ACS)
o Advises against (USPSTF)
 Clinical exam
o Ages 20-39, every 3 years; ages 40+, yearly; no upper age limit (ACS)
o Ages 20-39, insufficient evidence; age 40+ consider (USPSTF)
 Mammogram
o 40+ and no upper limit, annually (ACS)
o 40-59 biannually (individual basis), 50-75 biannually, >75 insufficient evidence
(USPSTF)
 Ultrasound
 Biopsy
Case study-Lump, 2 Multiple Choice Questions & 4 Matching to be done in groups.
Demonstration & practice of physical examination on model.