BREAST AND AXILLA ASSESSMENT

INSPECTION REMARKS

1. SIZE AND SYMMETRY

Have the client disrobe and sit with arms hanging

freely.

Normal Findings
- It varies in size and are somewhat round and
pendulous. (One breast may normally be larger than
the other.).
- The older client often has more pendulous, less firm,
and saggy breast.
Abnormal Findings
- Recent increase in the size of one breast.

2. COLOR AND TEXTURE

Note: Be sure to note client’s overall skin tone when

inspecting the breast skin. Note any lesions.

. Normal Findings
- Skin color lighter than in exposed areas.
- No lesions, redness, or edema.
- Texture in smooth and even. Striae (linear stretch
marks) often seen with breast enlargement during
and after pregnancy or with significant weight gain or
loss.

Abnormal Findings
- Redness, pigskin-like or orange peel (peau d’ orange)
appearance, and edema.

3. SUPERFICIAL VENOUS PATTERN

Note: Observe visibility and pattern of breast veins.

. Normal Findings
- Veins radiate either horizontally and toward the axilla
(transverse) or vertically with a lateral flare
(longitudinal).
- No increase in venous pattern unless patient is
pregnant. Then symmetrical increase is normal.

Abnormal Findings
- Prominent venous pattern and asymmetric venous
pattern.
 4. THE AREOLAS
Note: Both areolas’
Color – dark pink to dark brown, depending on the
client’s skin tone.
(areola and nipple darker than breast tissue and
become
even darker during pregnancy)
Size - (measure with ruler: nipple to left and nipple
to left) may vary in size
Shape - round
Texture - Small Montgomery tubercles are present

Abnormal Findings
- Peaud’ Orange skin and red, scaly crusty areas.
5. THE NIPPLES
Note: Both nipples’
Size - are nearly equal bilaterally in size, in the same
location on each breast
Direction – everted/inverted/flat
Dryness – smooth/rough to dry
Lesion – none/visible
Bleeding – none/visible
Discharges - none/visible
Normal Findings
- Supernumerary nipples may appear along the
embryonic “milk line”.
- No discharges present. Spontaneous discharge
normal during pregnancy and lactation.
- Older clients may have smaller flatter nipples, that
are less erectile on stimulation.
Abnormal Findings
- Recently retracted nipple that was previously everted
and spontaneous discharges.

6. RETRACTION AND DIMPLING

Note: Ask the client to remain seated while
performing several different maneuvers. Ask the client to:
1.) Raise her arms overhead,
2.) Press her hand against her hips,
3.) Press her hands together.
Normal Findings
- Client’s breast rises symmetrically with no sign of
dimpling and retractions.
Abnormal Findings
- Dimpling or Retraction.

4.) Lean forward. Note: Ask your client to lean

forward from the waist. The nurse should support the
client by the hands or forearms.
 Normal Findings
- Breasts hang freely and symmetrically.
Abnormal Findings
- Restricted movement of breasts or retraction of the
skin or nipple.

PALPATION – perform once, then say findings altogether

1. TEXTURE AND ELASTICITY
Note:
1. Ask the client to lie down to place overhead the arm on the
same side as the breast is being palpated.
2. Place a small pillow or rolled towel under the breast being
palpated.
3. Use the flat pads of the three fingers to palpate the client’s
breast.
4. Palpate the breast using of three different patterns. Choose
one that is most comfortable for you, but consistent and
thorough with the method chosen.
5. Be sure to palpate every square inch of the breast, from the
nipple and areola to the periphery of the breast tissue and
up into the tail of sphence. Vary the level pressure as you
palpate
Use the bimanual technique if the client has large breast. Support
the breasts with your non-dominant hand to palpate.
 . Normal Findings
- Palpation reveals smooth, firm, elastic tissue.
 Abnormal Findings
- Thickening of the tissues.

2. FOR TENDERNESS AND TEMPERATURE

 . Normal Findings
- A generalized increase in nodularity and tenderness
may be a normal finding associated with the
menstrual cycle or hormonal medications. Breast
should be anormal body temperature. Premenstrual
fullness, nodularity, and tenderness are common.
 Abnormal Findings
- Painful, tender breasts. Heat in the breast of women
who have not just given birth or who are not
lactating.
3. FOR MASSES
Note:
Location Mobility, Condition of
the skin over the mass.
Size in CM Consistency
Shape Tenderness

If lumps are detected, refer the client for further evaluation.

 . Normal Findings
- No masses palpated. A firm inframammary transverse
ridge may normally be palpated at the lower base od
the breast commonly on larger breast.
 - Fibrocystic tissue that feels ropy, lumpy or, bump in
texture (nodular or glandular breast tissue). Benign
breast disease consists of bilateral multiple, firm,
regular, rubbery, mobile nodules with well-
demarcated borders. Pain and fullness occur just
before menses.
 Abnormal Findings
- Malignant tumors often found on the upper outer
quadrant of the breast. They are usually unilateral,
with irregular, poorly delineated boarders. They are
hard and nontender and fixed to underlying tissues.
- Fibroadenomas: 1-5cm, round or oval, mobile, firm,
solid, elastic, non-tender, single or multiple benign
masses found in one or both breasts.
- Milk Cyst: (sacs filled with milk) and mastitis, may
turn into an abscess.
- Bruises: from an injury that appears as a lump due
to blood collection, which goes away in days or
weeks, or the blood, may have to be drained by a
health care provider.
- Lipomas: collection of fatty tissue that may also
appear as lump.
- Intraductal Papilloma: small growth inside a milk
duct of the breast.

4. MASTECTOMY OR LUMPECTOMY SITE

Note: Palpate the scar and any remaining breast or

axillary tissue for redness, lesions, lumps, swelling, or
tenderness.

 . Normal Findings
- Scar is whitish with no redness or swelling. No lesions,
lumps, or tenderness noted.

 Abnormal Findings
- Redness and inflammation of the scar area. Any
lesions, lumps or tenderness.

INSPECT AND PALPATE THE AXILLA

1. AXILLA

Note:
1. Ask the client to sit up.
2. Inspect the axillary skin for rashes or infection.
3. Hold the client’s elbow with one hand, and use the
three finger pads or your other hand to palpate
firmly the axillary lymph nodes.
4. First, palpate high into the axilla, moving
downward against the ribs to feel for the central
nodes.
5. Continue to move down the posterior axilla to feel
 for the posterior nodes.
6. Use bimanual palpation to feel for the anterior
axillary nodes.
7. Finally palpate down the inner aspect of the
upper arm.
 . Normal Findings
- No rash or infection noted. No palpable nodes or one
to two smalls (less than 1cm), discrete, nontender,
movable nodes in the central area.

 Abnormal Findings
- Redness and inflammation. Dark, velvety
pigmentation of the axillae (Acanthosis Nigricans)
enlarged greater than 1cm lymph nodes. Large node
that are half and fixed to the skin.