COURSE:

HEALTH ASSESSMENT NURS 306

LECTURER:

Mr. Abraham Bremnor.

ASSIGNMENT# 1:

Assessment of the Female Breast

DATE OF SUBMISSION: 18th March, 2013

GROUP MEMBERS:

Ayana Downes Sherome Hagley Debra Maraj Petra Sarran Deneisha Sylvester

THE BREAST The breasts are paired mammary glands that lie over the muscles of the anterior chest walls, anterior to pectoralis major and sarratus anterior muscles. Depending on the size and shape the breast extends vertically from second to sixth rib and horizontally from the sternum to midaxillary line. The breast is divided into four quadrants by drawing horizontal and vertical imaginary lines that intersect at the nipple. The upper outer quadrant which extends into axillary area is referred to as the tail of sequence.

THE FEMALE BREAST The female breast is an accessory reproductive organ which has two functions: to produce and store milk, which provides nourishment for newborns and to aid in sexual stimulation. The skin of the beasts is smooth and varies in colour depending on the clients skin tone. The female breasts consist of three types of tissues which include: Glandular Fibrous Fatty or Adipose tissue

Figure 1. Anatomy of the Female Breast (MayoClinic, 2011)

FEMALE BREAST ANATOMY AND PHYSIOLOGY The female breast is a complex structure; it includes, mammary glands, arteries and veins, fat and connective tissue, as well as and lymph nodes, lobes, lobules and ducts. Mammary glands contain the milk-producing cells. These glands are hormone dependent, and enlarge monthly with the menstrual cycle and during pregnancy. The breast has thin, fragile arteries and veins that allow circulation of oxygen and nutrients through the tissues, as well as nerves that provide information about touch and pain. Each breast has a number of sections (lobules) that branch out from the nipple. Each lobule holds tiny, hollow sacs called alveoli. The lobules are linked by a network of thin tubes called ducts. Ducts also, carry milk from the alveoli toward the dark area of skin in the center of the breast (areola) in breast feeding mothers. From the areola, the ducts join together into larger ducts ending at the nipple. There are spaces around the lobules and ducts are filled with fat, suspensory ligaments and connective tissue. This supports the breast and gives it shape. The breast has no muscle tissue. Muscles lie underneath the breasts, however, separating them from your ribs. The breast lies on top of a muscle called the pectoralis major, or the pec. The lymphatic system is a network of lymph nodes and lymph ducts that helps fight infection. Lymph nodes can be found under the armpit or axilla, above the collarbone, behind the breastbone and in other parts of the body. Harmful substances that may be in the lymph nodes drain into the lymph vessels and is safely drained from the body.

SUBJECTIVE DATA Biographical Information Name: Sharmila Sandra Sylvester Mahon Home name: Shums Home Address: Light poll # 55, El Requierdo Land Settlement, Manzanilla Ethnic Group: African D.O.B: 1980/06/12 Religion: Pentecostal Occupation: Clerk

Marital Status: Married

Physical Symptoms: Patient voiced that she gets tired quickly. Present Health Concerns: o Breasts pain: Nil o Breast pain in relation to menstrual period: Yes o Lumps: Nil o Swelling: Nil o Redness: Nil o Changes in size or firmness of your breasts: No o Dimpling in breast: No o History of discharge from the breast: No o Any lump under the arm: No o Multiple Fibroids o Patient menstrual history: Patient stated in her 20s her periods came 9 days Day 1- 2 pads are used, moderate flow and changes pads twice daily Day2- heaviest of all days and stays home from work, changes 2 pads 6 times a day

Day3- heavy to moderate, changes 2pads 5 times a day Day4- moderate flow, changes about 5 times a day Day5- pads are changed 3 times a day Day6- pads are changed 3 times a day Day7-1 maxi pad and changes twice a day Day8- 1 pad twice a day and drips Day9- panty shield is used Past Health History: o Have you had any prior breast disease: No o Have you ever had breast surgery: No o Have you ever had a breast biopsy: No o Have you ever had breast implants/breast trauma: No o How old were you when you began to menstruate: At age 12 normal cycle, with age it came heavier o Patient stated that her monthly cycle comes every 25days o Have you given birth to any children: No (Para 0+0) o Thyroid gland enlargement Family History: o Is there a history of breast cancer in your family: No o Grandmother on father side: diabetic, cataract, renal failure o Grandmother on mother side: Nil known o Father: diabetic, Hypertension, renal failure stage (IV), cataract, gall stones, Jaundice and pancreatic head tumour

o Mother- Nil known Lifestyle and Health Practices: o Are you taking any hormones: No o Are you taking contraceptives: No o Are you taking any antipsychotic agents: No o Do you live or work in an area where you have excessive exposure to radiation, benzene, or asbestos ( a fibrous non-combustible silicate of magnesium and calcium): No o What is your typical daily diet: breakfast- sada roti with potatoes (aloo) and pakchoi with lipton tea. Lunch- dumpling and stewed fish and bottle water. Dinner- nothing o Do you consume alcohol- No o How much coffee, tea, cola (or other forms of caffeine) do you consume each day: Nil o Do you engage in any type of regular exercise: No o Patient stated what she consume and how often: staples are consume every day, peas and beans twice a week, fruits and vegetables twice a week, carbohydrates every day, fats and oils weekly but in small amounts and milk 3 times a week on mornings preferably. o How important are your breast to you in relation to a positive feeling and physical appearance: Patient stated that her breast are important to her so that is why she takes the necessary steps to make sure they are cared for properly and that she love that it is perky and disease free. o Do you have any fears regarding breast disease? No! Patient stated that, I am not fearful, but that I am conscious about diseases of the breasts and am being precautious.

o Do you examine your own breasts: No o Have you ever had your breasts examined by a physician: No o Have you ever had a mammogram: No

OBJECTIVE DATA Physical Characteristics o Inspection of size and symmetry- Normal o Inspection of colour and texture- brown to dark brown around the areolas, smooth with no oedema or stretch marks. o Superficial venous pattern was inspected o The areolas was inspected- dark brown in colour, round where small Montgomery tubercles are present o Nipples were also inspected- size and direction of nipples of breasts, no dryness, lesions, bleeding or discharge noted. Equally bilaterally in size and are in the same location of each breast o Inspected for retraction and dimpling- clients breasts rose symmetrically with no sign of dimpling or retraction. Breasts hang freely and symmetrically when client was asked to lean forward o Palpated for texture and elasticity, resulted to be smooth, firm, elastic tissue o Tenderness and temperature was also palpated, body temperature was with in normal range o Palpated for masses and nil was found

o Nipples were palpated o The axillae- inspected and palpated the axillae, no rash or infection noted, no palpable nodes or one to two small (less than 1cm), distinct, non-tender, movable nodes in the central area. o Patient teaching was given Body function o Normal Behaviour o Patient behaviour was talkative and oriented to time, place and person. Measurements o Height- 171cm o Weight- 200lbs o Temperature- 36 8 o Respiration- 22 o Blood Pressure- 124/63 o Pulse- 106 bouncing and regular o Waist- 38 o Hip- 44 Lab Test o Nil

INTERVIEWING THE CLIENT When interviewing female clients about the breast the nurse should keep in mind that this examination may evoke emotions from the client and some women are embarrassed to have their breast examined. The nurse should make the client feel as comfortable as possible and facilitate therapeutic communication. For female patients, the health care provider should perform a more detailed breast assessment.

PERPARATION OF THE FEMALE CLIENT Prepare for the breast examination by having the client sit in an upright position. Explain to the client that it would be necessary to expose both breasts to compare for symmetry during inspection. One breast may be covered to maintain privacy while the other one is palpated.

EQIUPMENTS Centimeter ruler Small pillow Gloves Client handouts for BSE Slide for specimen

INSPECTION Firstly, he/she should inspect the breasts by Inspecting the size and symmetry client should sit with arms hanging freely at sides during assessment of breast size and symmetry. In most women, one breast is slightly larger than the other. The breasts could be round and pendulous. A recent increase in size could indicate inflammation or abnormal growth. It should be smooth with no redness, lesions, dimpling, extreme vascularity or retractions. Lymph nodes in the breast area should not be visible or bulging. Next, assess the nipples, which should be symmetrical, show no scaling, discharge, lesions or bleeding. Then watch the patient as she raises her arms, presses her hands on her hips and leans forward. In each position, you should see no puckering, dimpling or retraction. Inspecting colour and texture- note the clients overall skin tone when inspecting the breast skin, be aware of any lesions. Linear stretch marks may be seen during and after pregnancy or with significant weight gain or loss. The clients colour varies depending on the clients skin tone and texture is smooth with no edema. Redness is associated with breast inflammation. Inspecting superficial venous pattern- observe visibility and pattern of the breast veins. Veins should be radiate either horizontally and toward the axilla (transverse) or vertically with lateral flare (longitudinal). Female breast veins are more prominent during pregnancy. A prominent venous pattern may occur as a result of increase circulation due to a malignancy. An asymmetric venous pattern may be due to malignancy. Inspecting the areolas- the nurse must note the color, size, shape and texture of the areolas of both breasts. Areolas vary from dark pink to dark brown depending on the clients skin tones. They are round and may vary in size. Small Montgomery tubercles are present. Peau dorande

skin associated with carcinoma may be first seen in areola whereas red, scaly, crusty areas are indicative of Pagets disease. Inspecting the nipples- must note the size and direction of the nipples of both breasts. Also note any dryness, lesions, bleeding or discharge. Nipples are nearly equally bilaterally in size and are in the same location on each breasts. Nipples are usually everted, but they may be inverted or flat. Supernumerary nipples may appear along the embryonic milk line or discharge sho uld be present. A recently retracted nipple that was previously everted suggests malignancy. Any type of spontaneous discharge should be referred for cytologic study and further evaluation. Inspecting nipples for retraction and dimpling- to inspect the breast accurately for retraction and dimpling ask the client to remain seated while performing several different mancurves, asks the client to raise her arms overhead then press her hands against her hip. Next ask her to press her hands together. These actions contract the pectoral muscles. Finally ask the client to lean forward from the waist. The nurse should support the client by the hands or forearms. This breast should arise symmetrically with no signs of dimpling or retraction. Breast should hang freely and symmetrically. PALPATION Palpate texture and elasticity. As the patient leans forward her breasts should swing freely. The nurse or health care provider should use the pads of her middle fingers to palpate the axillary to assess the lymph nodes. Lymph node chains in the Breast, Axillaries and Upper arm include: Internal Mammary nodes

 Pectoral nodes Sub- scapular nodes Mid axillary nodes Infraclavicular nodes Supraclavicular nodes and Brachial nodes Be sure to reach behind the pectoral muscle and move your fingers towards the clavicle and down against the ribs. Small, freely, movable lymph nodes are normal. Then instruct the patient to lie down and place a pillow under her shoulder on the side that you are examining. After, ask her to raise her arm on that side. With the pads of your middle fingers, use a circular motion to palpate each section of the breast. You should start at the nipple and then move out in concentric circles. As you do this, teach the patient the proper palpation techniques and encourage her to do a breast exam monthly. If the healthcare provider prefers she could use an in and out pattern when palpating or sweep the finger pads across the breasts. No matter which pattern is used be consistent. Palpate for masses and tenderness.

Next, palpate the nipple, compressing it gently. The nurse should not detect any indurations or masses. If there is a nipple discharge, obtain a culture. If you suspect a mass try to illicit dimpling by moving or compressing the tissue and check the opposite side for symmetry. If you find a mass document its size, shape, consist, mobility and degree of tenderness. When documenting your findings, mentally divide the breast into four quadrants or imagine the breast

as a clock face. Now check the epi-throchlea lymph nodes by palpating the groove between the biceps and triceps muscles. The nodes should not feel enlarged or tender. A generalized increase in nodularity and tenderness may be a normal finding associated with the menstrual cycle or hormonal medications. The breasts should be a normal body temperature. Painful breasts may be indicative of benign breast disease but can also occur with a malignant tumor. The client should be referred for further evaluation. Heat in the breasts of women who have not given birth or who are not lactating indicates inflammation.

Palpate mastectomy or lumpectomy site

If the client has a mastectomy or lumpectomy, it is still important to perform a thorough examination palpate the scar and any remaining breast or axillary tissue for redness, lesions, lumps, swelling or tenderness. Redness and inflammation of the scar area may indicate infection. Any lesions lumps or tenderness should be referred for further evaluation.

RATIONALE Present health history In asking the patient about feeling changes in the breast in terms of lumps and swelling will help to determine the findings of the assessment. If a woman is post maternal she may have breast swelling and/or milky discharge from nipples for up to 2 weeks.

 Pregnant women breasts enlarge as glandular tissue responds to pregnancy hormones to prepare for breastfeeding. In elderly women the glandular tissue is replaced by fatty tissue, and elasticity of connective tissue is lost after menopause, both contribute to breasts becoming pendulous or flaccid. You assess for redness, warmth and breast dimpling because it occurs over a mass or induration the patient usually discovers other signs before becoming aware of this one. Any spontaneous discharge from the nipple the nurse should find out about to make necessary findings. The fluid may be clear, milky, bloody, or even green. If the patient is pregnant, breast-feeding, or have recently had a baby, a milky fluid that comes out of both breasts is most likely related to the pregnancy. If the patient has any pain in the breast, an assessment would have to be made on how long the patient has the pain or and how the patient would rate the pain from mild to moderate or to severe. Change in shape, in size in breast could relate to when last the patient had there menses, or is menopausal or even if the patient is pregnant. Past Health History Any past breast disease would determine if any problems are arising again whereas similar comparisons could be made on assessing the patient of past problem. If the patient had a biopsy done or a breast surgery, finding out the results on it would be helpful in aid of making proper findings. If the portion of the lump removed was benign or malignant.

 Many women have changes in their breasts that are related to their monthly menstrual cycle. Swelling, tenderness, and pain in the breasts may occur before and sometimes during the menstrual period. At the same time, one or more lumps or a feeling of increased "lumpiness" may appear in the breasts. These symptoms are caused by extra fluid collecting in the breast tissue, which is normal. If patient has irregular menstrual cycle finding out if that is normal or not normal for them or not is important too. Finding out about breast cancer in the family is a hereditary factor, chances of getting breast cancer is highly possible of happening because of the past shown statistics. Lifestyle and Family Practices Finding out about the client humans response is important. Which include nutritional habits, activity and exercise patterns, sleep and rest patterns, use of medications and substances, selfconcept and self-care activities, social and community activities, relationships, values and beliefs system, education and work, stress level and coping style. Here clients describe how they are managing their lives, their awareness of healthy versus toxic living patterns, and the strengths and supports they have or use. With this part of the assessment, knowing if you have to make a referral for the patient would be a finding. If the patient never performed a Breast Self-Examination this would now give the nurse the opportunity to organize educational resources or even demonstrating on the patient on how to carry about the examination and how often to have it done.

If the patient never had a breast exam done by a health care professional the nurse would have to take the opportunity to educate the patient on the steps on how things would be done so it would be as comfortable as possible for the patient. If the patient never had a mammogram done it is advisable depending on the patient age to have it done every one to two years. If the test was never done by the patient, explaining what the test is to the patient would be an ideal step on further educating the patient.

BIBLIOGRAPHY

Breast Cancer. (n.d.). HealthBase. Retrieved March 9, 2013, from https://www.healthbase.com/hb/images/cm/procedures/cancer/female_breast_anatomy.jp g

Slide show: Female breast anatomy - MayoClinic.com. (n.d.). Mayo Clinic. Retrieved March 9, 2013, from http://www.mayoclinic.com/health/breast-cancer-earlystage/BC00001

Weber, J., Kelly, J. (2010). Health assessment in nursing (4th ed.). Philadelphia: Lippincott Williams & Wilkins.