Chapter 16
BREASTS AND AXILLAE
KEVIN DOBI, MS, APRN
Anatomy and Physiology

Breasts are paired mammary glands
located within superficial fascia of
anterior chest wall:
Feature of all mammals as milk-producing organs
providing nourishment for offspring.
 During embryologic development, develop along
paired “milk lines,” that extend between limb buds
of what will become axillae and inguinal regions.
 Only one develops on each side in pectoral region.
 Undergo considerable development in females
during adolescence under influence of estrogen
and progesterone.

2
Anatomy and Physiology:
Female Breast

Mature female breast has distinctive
shape but great variation in size and
volume:
Extend vertically from second to sixth ribs; laterally
from sternal margin to midaxillary line.
 Divided into four quadrants by vertical and
horizontal lines intersecting at nipple.


Composed of three types of tissue:



Glandular tissue
Fibrous tissue
Subcutaneous and retromammary fat tissue
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Anatomy and Physiology:
Female Breast (contd.)

Glandular tissue arranged into 15 to 20
lobes radiating around nipple in spokelike pattern:
Each lobe is composed of 20 to 40 lobules (alveoli)
containing milk-producing acini cells.
 During lactation, milk produced by acini cells
empties into lactiferous ducts draining milk from
lobes to surface of nipple.
 Largest amount of glandular tissue lies in upper
outer quadrant of each breast.
 From this quadrant, breast tissue extends into axilla,
forming axillary tail of Spence.

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Anatomy and Physiology:
Female Breast (contd.)

Cooper’s ligaments, subcutaneous
fibrous tissue and multiple fibrous bands
support breasts:
These suspensory ligaments extend from connective
tissue layer through breast attaching to underlying
muscle fascia.
 Subcutaneous and retromammary fat surrounds
glandular tissue and comprise bulk of breast.
 Nipple surrounded by pigmented areola.

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Anatomy and Physiology:
Female Breast (contd.)

Nipples composed of epithelium with
circular and longitudinal smooth muscle
fibers:
Muscle fibers contract in response to sensory,
tactile, or autonomic stimuli, producing erection
and causing lactiferous ducts to empty.
 Montgomery glands, sebaceous glands, located
within areolar surface, aid in lubrication of nipple
during lactation.

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Anatomy and Physiology:
Female Breast (contd.)

Throughout reproductive years, breasts
undergo cyclic pattern of size change,
nodularity, and tenderness in menstrual
cycle:


3 to 4 days before onset of menses, many women
experience breast fullness, tenderness, and pain
from hormonal changes and fluid retention.
Breasts change dramatically during
pregnancy and lactation in response to
luteal and placental hormones:

Increase in number of lactiferous ducts and size and
number of alveoli.
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Anatomy and Physiology:
Lymphatic System

Each breast contains extensive lymphatic
network, which drains into lymph nodes:


More than 75% of lymph drainage is outward
toward axillary lymph nodes, then upward to
subclavicular and supraclavicular nodes.
Other drainage routes flow through:



Anterior axillae (pectoral) nodes above breast.
Internal mammary nodes in thorax.
Subdiaphragmatic nodes toward abdomen and
cross-mammary pathways to opposite breast.
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Anatomy and Physiology:
Male Breast




Male breast undergoes little
development after birth; gland remains
rudimentary.
Consists of thin layer of undeveloped
tissue beneath nipple; areola small
compared with that in female.
During puberty, male breast may
become slightly enlarged, producing
temporary gynecomastia.
Older men may also have gynecomastia
secondary to decrease in testosterone.
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General Health History:
Present Health Status

Do you take any medications?

What medications?

Do you take any vitamin supplements?

How much chocolate and caffeine do you
consume each week?
13
General Health History:
Past Medical History



Have you ever had fibrocystic breast changes?

Fibroadenomas?

Breast cancer?
History of ovarian cancer?

Endometrial cancer?

Colon cancer?
Surgery on breast?


How old were you when you began menstruating?


When, and for what reason?
How old were you at menopause (if appropriate)?
Have you ever been pregnant?

At what age did you have your children?
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General Health History:
Family History

Is there a history of breast cancer or
breast disease in your family?
If so, in whom?
 At what age did this relative have breast cancer or
disease?
 Did it affect one or both breasts?

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General Health History:
Personal and Psychosocial
History

Do you perform breast self-examination
(BSE)?


How often?
Do you have regular breast examination
by a health care professional?
Have you ever had a mammogram?
When?
 How often?


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Problem-Based History


Most commonly reported problems
related to breasts are pain or tenderness,
lump, nipple discharge, and pain or
lumps in axillae.
A symptom analysis is completed, which
includes onset, location, duration,
characteristics, aggravating and
alleviating factors, related symptoms,
and treatments.
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Problem-Based History:
Breast Pain or Tenderness

Where does it hurt?
One breast or both?
 Specific location or generalized?
 When did it first begin?

Describe pain.
Does pain or tenderness prevent you
from carrying out routine activities?
 Have you noticed specific activities that
bring on pain?


Do you experience pain during sexual activity or
when you exercise?
 When wearing bra, or not wearing bra?

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Problem-Based History:
Breast Pain or Tenderness
(contd.)


Have you noted recent changes in your
breasts, such as changes in size, shape,
tenderness, lumps, or discharge?
Is breast tenderness associated with
swollen feeling to breasts? When do you
notice swelling? Is swelling related to
menstrual cycle?
19
Problem-Based History:
Breast Lump

When did you first notice lump in your breast?


Is lump always present, or does it come and
go?


Does severity of tenderness change related to
menstruation?
Recently injured breast?


Is it related to menstrual cycle?
Is lump tender?


Where is lump?
Did lump develop after injury?
Other symptoms?

Redness, swelling, or dimpling associated with this
lump?
20
Problem-Based History:
Nipple Discharge




When did you notice discharge from
nipple?


Ever noticed before?
One or both nipples?



Color?
Thick or thin?
Odor?


Breast pain or breast lump?
Headaches or changes in vision?
Describe discharge:
Occur spontaneously or when
expressed?
Other symptoms?
21
Problem-Based History:
Axillary Lumps or
Tenderness


When did you first notice lumps or
tenderness under your arms?
Where?
One or both arms?
 Come and go, or constant?
 Has it gotten worse?


Shave underarms?



Relationship to shaving and tenderness?
Use deodorant or antiperspirant?
What have you done to treat this?
22
Problem-Based History:
Breast Swelling or
Enlargement (Men)

Describe change to your breast.
When did you first notice it?
Have changes occurred on one or both sides?
(Gynecomastia is enlargement of one or both
breasts in men.)
 Although breast cancer in men is rare, the most
common initial symptom is a breast mass.



Have you experienced any other
symptoms such as pain or discharge?
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Female Breast
Examination:
Routine Techniques

Female examination: Always explain
procedure before you begin.



Let patient know you will be touching her breasts,
and obtain permission before beginning.
Position patient so she is sitting on exam table
facing you, sitting erect with gown dropped to
waist.
Following inspection, assist patient into
supine position so that breasts and
nipples may be palpated.
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Female Breast
Examination:
Routine Techniques
(contd.)




Inspect both breasts: Note size, shape,
contour, and symmetry.
Inspect skin for color, pigmentation,
vascularity, surface characteristics, and
lesions.
Inspect areolae for color and surface
characteristics.
Inspect nipples for position, symmetry,
surface characteristics, lesions, bleeding,
and discharge.
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Male Breast Examination



Inspect breasts and nipples.
Palpate breasts and nipples.
Palpate axilla.
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Age-Related Variations:
Infants and Children
Breast assessment among infants and
children only requires inspection.
 Neonates of both genders may have
slightly enlarged breast secondary to
mother’s estrogen.
 Maternal hormones are also responsible
for a small watery whitish discharge
referred to as “witch’s milk” seen in small
percent of newborns during first few
weeks of life.

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Age-Related Variations:
Adolescents


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Breast development, thelarche, begins in
preadolescence and continues through
adolescence.
Girls are often sensitive about having
breasts exposed for examination; must
take time to reassure patient and ensure
privacy.
Boys may experience an unexpected
enlargement of breasts (gynecomastia)
as result of obesity or body change
transition during early puberty.
28
Age-Related Variations:
Older Adults



Atrophic changes to female breasts
begins by age 40 years and continues
through menopause.
As glandular tissue atrophies, breast tissue
is replaced with fat and connective
tissue.
Postmenopausal women should continue
to have regular breast examinations
because of increased risk of breast
cancer with age.
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Patients with Situational
Variations:
Mastectomy
Women who have mastectomy require same
breast assessment as all other women.
 Many experience anxiety or fear as they
worry about recurrence of cancer or
metastasis.
 Some women may also have personal issues
regarding body image and may feel selfconscious about exposing chest.
 Nurse should be sensitive and reassure
patient it is necessary to have
comprehensive examination.

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Patients with Situational
Variations:
Mastectomy (contd.)

In addition to examining remaining
breast, nurse should assess mastectomy
site and scar because malignancy
recurrence is possible at scar site.


Mastectomy site and axilla should be inspected for
color changes, redness, rash, irritation, and visible
signs of edema, thickening, or lumps.
Note areas that may have had muscle
resection; also any signs of lymphedema
in affected upper extremity.
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Patients with Situational
Variations:
Mastectomy (contd.)
Using finger pads of examining hand, palpate
side with mastectomy, especially around
area of scar; use small circular motion,
assessing for thickening, lumps, edema, or
tenderness.
 Palpate entire chest area on affected side to
ensure that nothing has been missed.
 Finally, palpate axillary and supraclavicular
areas for lymph nodes.
 If patient had breast reconstruction or
augmentation, examination in usual manner,
paying particular attention to scars.

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Common Problems and
Conditions: Benign Breast
Disease


Noncancerous breast conditions account
for 90% of clinical breast problems.
Benign breast disease is term that
represents a number of breast-related
problems, including breast pain or
tenderness, swelling, lumps, discharge,
and inflammation.
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Common Problems and
Conditions: Fibrocystic Changes
to the Breast
34


Fibrocystic changes to breast refers to variety of
conditions associated with multiple benign masses
within breast caused by ductal enlargement and
formation of fluid-filled cysts.
Clinical findings:
Typically, cysts manifest as one or more palpable masses that are
round, well-delineated, mobile, and tender.
 Degree of discomfort ranges from slightly tender to very painful;
cysts often fluctuate in size and tenderness with menstrual cycle.
 Symptoms tend to subside after menopause.

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Common Problems and
Conditions:
Fibroadenoma


Common benign breast tumor among
young women that consists of glandular
and fibrous tissue.
Clinical findings:
Fibroadenoma usually manifests unilaterally as
small, solitary, firm, rubbery, nontender lump.
 Generally mobile and well-delineated.
 This tumor does not change premenstrually.

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Common Problems and
Conditions: Ductal Ectasia


Benign breast disease characterized by
inflammation and dilation involving one
or multiple subareolar ducts.
Clinical findings:
Initial symptom is a sticky nipple discharge
commonly dark green or black.
 With progression, woman may experience burning
or itching of nipple and edema in areolar area.
 Discharge may become purulent or sanguineous.
 Complication can be breast abscess.

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Common Problems and
Conditions: Intraductal
Papilloma



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Small, benign, wartlike tumor in major ducts usually
within 1 to 2 cm of areolar edge; one or more ducts
may be affected.
Most commonly occurs in women 40 to 60 years.
Clinical findings:

Clinical presentation is spontaneous bloody discharge from
nipple; occasionally a mass is palpated.
Breast Cancer
Breast cancer is major health problem for
women.
 It is most common non–skin-related
malignancy in American women.

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Breast Cancer:
Invasive Breast Cancer
Most common breast cancer is invasive
malignancy arising from ducts or lobules.
 Clinical findings:

Breast malignancy usually manifests as solitary,
unilateral, nontender lump, thickening, or mass.
 As mass grows, there may be breast asymmetry,
discoloration (erythema or ecchymosis), unilateral
vein prominence, peau d’orange, ulceration,
dimpling, puckering, or retraction of skin.

41
Breast Cancer:
Invasive Breast Cancer
(contd.)

Clinical findings: Invasive breast cancer:
Lesion sometimes fixed to underlying tissue.
Borders irregular and poorly delineated.
Nipple may be inverted or diverted to one side.
Serosanguineous or clear nipple discharge may be
present.
 May be crusting around nipple or erosion of nipple
or areola.
 Lymph nodes may be palpable in axilla.




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Breast Cancer:
Noninvasive Breast
Cancer



Two types categorized as noninvasive are
ductal carcinoma in situ (DCIS) and
lobular carcinoma in situ (LCIS).
DCIS is true precursor of invasive ductal
carcinoma and considered more
significant.
LCIS is risk factor for subsequent
development of breast cancer.
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Breast Cancer:
Noninvasive Breast
Cancer (contd.)

Clinical findings: Noninvasive breast
cancer:
Most common manifestation of DCIS or LCIS is an
abnormal mammogram.
 Occasionally, DCIS is clinically detected as lump
with well-defined margins or nipple discharge.

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45
Common Problems and
Conditions: Other Breast
Conditions – Mastitis

Mastitis is inflammatory condition of
breast usually caused by a bacterial
infection:
Occurs most frequently in lactating women
secondary to milk stasis or a plugged duct.
 Incidence highest in first few weeks postpartum and
decreases thereafter.
 In nonlactating women, mastitis may also result from
foreign bodies (such as nipple rings and breast
implants) or from trauma.

46
Common Problems and
Conditions: Other Breast
Conditions – Mastitis (contd.)

Clinical findings:
47
Infection generally occurs in one area of breast, which appears as
red, edematous, tender, warm to touch, and hard.
 Axillary lymph nodes are often enlarged and tender.
 Patient usually has associated fever and chills, and experiences
general malaise.

Common Problems and
Conditions: Other Breast
Conditions – Galactorrhea



48
Galactorrhea means inappropriate lactation.
Causes include endocrine-related disorders (such as a
pituitary tumor), systemic diseases (such as renal
failure), and side effect of medications (that interfere
or suppress dopamine: codeine, morphine,
metoclopramide, phenothiazines, reserpine)
Clinical findings: The manifestation is milky-appearing
nipple discharge.
Common Problems and
Conditions: Other Breast
Conditions – Gynecomastia




49
Gynecomastia is noninflammatory enlargement of
one or both male breasts.
Can occur at any age; in neonates, cause is typically
associated with maternal hormones.
At puberty, condition is idiopathic and transient.
Common causes in adult men include side effect of
medications, adrenal or testicular tumors, liver
disease, or renal disease.
Common Problems and Conditions:
Other Breast Conditions –
Gynecomastia (contd.)
50

Clinical findings: Gynecomastia:

May be unilateral or bilateral and manifests as enlargement of
male breast.
Question 1
Nurses teaching patients about breast selfexamination (BSE) need to understand the
important issues related to this important selfcare behavior. Patients should understand that:
Mammography is indicated in all women
older than 30.
B. BSE is used so that women will need to make
fewer health care visits.
C. BSE is used so that women will be able to
identify changes in their breast tissue.
D. Mammography is indicated primarily for
women who do not perform BSE.
A.
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Question 2
During a breast examination, the nurse should
be cognizant of patient comfort and any
questions she may have. Understanding breast
shape means that:
The patient should report recent changes.
The patient should be concerned if one
breast is slightly larger than the other breast.
C. Dimples may be a normal variation.
D. Retractions are considered normal unless
there is exudate.
A.
B.
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The End
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