Skill: Assessing the Breasts and Axillae

Performed
Mastered Comments Preparation Yes No
1. Assemble eqipment:
Centimeter ruler
Pro!edre
1. "ntrod!e #orself and $erif# the
!lient%s identit#. &xplain to the
!lient 'hat #o are going to do(
'h# it is ne!essar#( and ho' she
!an !ooperate.
). Perform hand h#giene and obser$e
other appropriate infe!tion !ontrol
pro!edres.
*. Pro$ide for !lient pri$a!#.
+. "nqire if the !lient has an# histor#
of the follo'ing:
Breast masses, and what was
done about them
Any pain or tenderness in the
breasts and relation to the
womans menstrual cycle
Any discharge from the nipple
Medication history
Estrogen replacement therapy
Mother, sister, aunt with breast
cancer
Alcohol consumption
High-fat diet
Obesity
se of oral contracepti!e
Menarche before age "#
Menopause after age $$
%regnancy after age &'
Breast self-e(amination)
techni*ue used and when
performed in relation to the
menstrual cycle
Assessment
,. "nspe!t the breasts for si-e(
s#mmetr#( and !ontor or shape
'hile the !lient is in a sitting
position.
.. "nspe!t the skin of the breast for
lo!ali-ed dis!olorations or
h#perpigmentation( retra!tion or
dimpling( lo!ali-ed h#per$as!lar
areas( s'elling( or edema.
/. &mphasi-e an# retra!tion b#
ha$ing the !lient:
+aise arms abo!e head)
%ush the hands together, with
elbows fle(ed) and
%ress hands down on hips,
0. "nspe!t the areola area for si-e(
shape( s#mmetr#( !olor( srfa!e
!hara!teristi!s( and an# masses or
lesions.
1. "nspe!t the nipples for si-e( shape(
position( !olor( dis!harge( and
lesions.
12. Palpate the axillar#( sb!la$i!lar(
and spra!la$i!lar l#mph nodes.
-he client is seated with her arms
abducted and supported on the
nurses forearm,
se the flat surfaces of all fingertips
to palpate the four areas of the a(illa.
-he edge of the greater pectoral
muscle along the anterior a(illary
line
-he thoracic wall in the
mida(illary area
-he upper part of the humerus
-he anterior edge of the
latissimus dorsi muscle along the
posterior a(illary line
11. Palpate the breast for masses(
tenderness( and an# dis!harge from
the nipples.
1). Palpate the areola and the nipples
for masses.
Compress each nipple to determine
the presence of any discharge, /f
discharge is present, mil0 the breast
along its radius to identify the
discharge-producing lobe,
Assess any discharge for amount,
color, consistency, and odor,
1ote any tenderness on palpation,
1*. 3ea!h the !lient the te!hniqe for
breast self4examination,
1+. 5o!ment findings in the !lient
re!ord.