1. Definitions, Structure and Function Chapters 14,20,21,&22
Breasts & Regional Nodes Male and Female Reproductive System Anus, Rectum, Prostrate N1037
Definitions, Structure and Function
Chapters 14,20,21,&22

2. Key Definitions
Gynecomastia: abnormal enlargement of one or two breasts in men.
Supernumerary breast: extra breast tissue, sometimes with a nipple.
Dysmenorrhea: painful menstration
Dyspareunia: painful intercourse
Gravida: # of pregnancies regardless of outcome.
Parity: # of deliveries, regardless of outcome.
Menarche: age at which menstruation begins.

3. Key Definitions Menopause: age at which menstruation ends.
Puberty: secondary sexual characteristics appear, reproductive ability develops.
Androgens: male sex hormones.
Circumcision: surgical removal of the prepuce (foreskin)
Phimosis: abnormal tightness of the prepuce.
Hypospadias: opening of the urethral meatus on ventral surface of the penis.

4. Breast and Regional Lymphatics
Structure and Function

5. Surface Anatomy
Lie anterior to the pectoralis major & serratus ant. mus.
Between the second and sixth ribs
From lateral side of sternum to the midaxillary line.
Tail of Spence: projects up and laterally into the axilla.
Nipple is located below the center of the breast (milk duct openings)
Areola: surrounds the nipple, contains small elevated sebaceous glands called “Montgomery’s glands/tubercles ” (secrete protective lipid material during lactation).
cm in diameter

6. One breast may be slightly larger than the other, this is normal.

7. Quadrants of Left Breast
Breast may be divided into 4 quadrants
UIQ
LIQ
LOQ
UOQ extends into axilla
note Tail of Spence

8. Internal Anatomy The breast is composed of: Glandular tissue
Fibrous tissue including suspensory ligaments (Cooper’s Ligament) provide support for breast tissue. In Cancer these become contracted and cause dimpling.
Adipose tissue (fat)
Breasts are supported by a bed of muscles:
Pectoralis major & minor
Latissimus dorsi
Serratus anterior
Rectus abdominus
External oblique

9. 15-20 lobes
Each with 20-40
Lobules (contain alveoli)
Each empties into
Lactiferous dusts to
Lactiferous sinuses.
(reservoir behind nipple)

10. Milk Line Ectodermal Galactic Band
Develops during 5th week of fetal devmt
Most of the band atrophies except in the thoracic area
Incomplete atrophy results in the development of extra nipples known as supernumerary nipples

11. Lymphatic Drainage The breast has extensive lymphatic drainage.
More than 75% drain into the ipsilateral axillary nodes.
Central axillary nodes, pectoral, subscapular and lateral nodes.
Internal mammary nodes

12. ** * *
Sm group flow up into infraclavicular, chest, abdomen or across to breast

13. Developmental Considerations
Diagram of breast development-note changes p 416
at puberty - breast development begins between ages 8 & 10 – stimulated by estrogen release during puberty- with the appearance of breast buds - onset of menses usually follows in 2-3 years – asymmetry in breast development is not abnormal.
during pregnancy and lactation - enlarge several times normal size, colostrum after the fourth month
maturity - after menopause - as estrogen secretion declines the tissue atrophies and is replaced with fatty deposits - reduction in breast size results - breasts become flabbier and hang more loosely from the chest wall as the ligaments relax

14. Male Breast
During adolescence, temporary enlargement is common (gynecomastia)
Unilateral
Provide reassurance
Gynecomastia reappears in the aging male and may be due to testosterone deficiency.

15. Health History Patient profile Common chief complaints Age Gender Race
Breast mass, tenderness, discharge
Assess characteristics
Location
Quality
Quantity
Associated manifestations
Aggravating factors
Alleviating factors
Timing

16. Health History Past health history Family history Medical
Breast specific vs. nonbreast specific
Surgical
Medications
Allergies
Injuries and accidents
Family history
Breast cancer
Benign breast disease

17. Health History Social history Health maintenance activities
Alcohol use
Tobacco use
Work environment
Home environment
Economic status
Ethnic background
Health maintenance activities
Diet
Exercise
Use of safety devices
Health check-ups
Monthly breast self-exam
Mammogram

18. Assessment Equipment General approach Inspection Patient positions
Towel, drape, centimeter ruler, teaching aid for breast self-exam
General approach
Inspection
Patient positions

19. Subjective Data Breast Pain Lump Discharge Rash Swelling Trauma
Hx of breast disease
Surgery
Breast self-exam, mammogram
Axilla
Tenderness
Lump or swelling
rash

20. Assessment Inspect specific areas Breasts Axillae Areolar areas
Nipples
Contour (see pg 422 for illustrations)
Lesions or masses
Exudates

21. Assessment Normal Findings for Inspection:
Breast and axillae are flesh colored
Areolar areas and nipples are darker in pigmentation
Moles and nevi are normal variants
No thickening or edema
Minor size variation in the breasts and areolar areas
Breast on dominant side usually is larger
Nipples should point upward and laterally, may point outward & downward
Breasts, areolar areas, nipples should be symmetrical
Breasts are convex, without flattening, retractions, or dimpling
Free from masses, tumors, primary or secondary lesions
No discharge from nipples in nonpregnant, nonlactating female

22. Palpation Sequential manner Supraclavicular and infraclavicular nodes
Breasts with arms at side, arms raised over head
Axillary lymph node region
Breasts with pt in supine position

23. Palpation while sitting
Palpate Supraclavicular & Infraclavcicular lymph nodes
Bimanual palpation while sitting
Palpation of Axillary Nodes while sitting

24. Palpation while supine
Palpation Methods
Wedge
Concentric lines
Parallel lines
Palpation of Glandular tissue
Palpation of Areola
Palpation of Nipple

25. Normal Findings for Palpation
Palpable lymph nodes less than 1 cm in diameter usually are clinically insignificant
Palpation should not elicit pain
Consistency of breast tissue is highly variable depending on age, time in menstrual cycle, and proportion of adipose tissue
Breasts are usually nodular or granular before menses
Variation with breast augmentation—breasts feel firm throughout

26. Evaluation of Breast Mass Characteristics
Location
Size
Shape
Number
Consistency
Definition
Mobility
Tenderness
Erythema
Dimpling or retraction
Lymphadenopathy
P. 429

27. Risk Factors for Breast Cancer
Age > 50
Personal history of breast cancer
Mother, grandmother, or sister with breast cancer
Menarche at an early age
Menopause at advanced age
Obesity
Alcohol intake > 3 servings per day
American or European descent
Urban dweller
(continues)

28. Risk Factors for Breast Cancer
Estrogen replacement therapy (ERT), Hormone (HRT)
Nulliparous
First birth after age 30
Higher education and socioeconomic status
Atypical hyperplasia
Significant mammographic breast density (indicates a grter amt of glandular tissue)
BRCA 1 or BRCA 2 gene mutation

29. Jarvis p.416
Mutation of BRCA1 and BRCA2 genes
Previous positive breast biopsy or irrradiation
Menopause after 50s
White race
Long term use of HRT
No breast feeding
Physical inactivity

30. Breast Cancer Second major cause of death from cancer in women
identify risk factors
70% of breast cancers occur with only age and gender as identifiable risk.
5 year survival rate for localized breast cancer is 98%.
If cancer has spread regionally, the rate is 76 to 88%.

31. Breast Self-Exam Video in lab See handout last pages
Teach during palpation stage of assessment
Check for dimpling, retraction, breast flattening, discharge
Also report redness, inflammation, masses, puckering, sunken areas, asymmetrical nipples direction, bleeding, lesions

32. Rule out cancer with biopsy
Benign Breast Disease
Cyclic Swelling
Pain, cyclic: non-cyclic
Nodularity, cyclic: non-cyclic bilaterally
mobile, feel rubbery like water balloons
Dominant lumps
Nipple discharge
Infections/inflammations
50% have some form of benign breast
Disease.
Rule out cancer with biopsy
Sometimes difficult to detect cancer
lumps

33. Cancer Diagnosed by biopsy Solitary, unilateral non-tender mass
Single focus (one area)
Solid, hard, dense and fixed to
tissues or skin as cancer becomes
invasive
Borders irregular and poorly delineated
Grows constantly
May have pain or be painless
Most common in upper outer quadrant
30-80 yrs
Advanced cancer=firm or hard irregular
axillary nodes
skin dimpling, nipple retraction, elevation
and discharge
Diagnosed by biopsy

34. Fibroadenoma Diagnosed by biopsy Solitary non-tender mass
Category of benign breast disease
Solid, firm, rubbery, and elastic
Round, oval, or lobulated
1 to 5 cm
Freely movable, slippery
Most common between 15 to 30
Up to age 55
Grows quickly and constantly
Diagnosed by biopsy

35. Diagnostic Techniques
Mammography
X ray
Ultrasonography
Magnetic resonance imaging

36. Gerontological Variations
Breast tissue atrophies
Decreased glandular tissue, resulting in granular feel
Breasts become smaller, pendulous, and wrinkled
Ductal tissue becomes more palpable; feels stringy

37. Breast Self-Examination (BSE)
Performed once a month
Performed on a fixed date each month, or 8 days after menses
Avoid completing during menstruation or ovulation
Use calendar for monthly reminder
Include significant other in examination process

38. Breast Self-Examination (BSE)
Bed (B): Supine position
Use palmar surface of fingers
Place right arm over head and palpate right breast
Move in concentric circles from the periphery inward
Squeeze the nipple to examine for discharge
Use same procedure to check left breast

39. Breast Self-Examination (BSE)
Standing (S)
Repeat previous process in standing position
Stand before mirror, arms at side
Assess for symmetry, retractions, dimpling, inverted nipples, or nipple deviation
Repeat with arms above head
Repeat with hands pressed into hips

40. Lying Down & Standing BSE