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THE BREAST

A REVIEW OF
1-EMBRYOLOGY
2-SURGICAL ANATOMY
3-PHYSIOLOGY
4-CLINICAL EXAMINATION

The breast or mammary


gland is found in both sexes.

Well developed in female


after puberty

Rudimentary in male

A modified sweat gland.

BREAST DEVELOPMENT

EMBRYOLOGY
In 5th-6th wk of fetal development
Two
ventral bands of thickened
ectoderm(MAMMARY
RIDGES/MILK
LINES) are evident
Extent of milk line/mammary ridgefrom base of forelimb(future axilla)
to region of hind limb(inguinal area)
ridges disappear after short time
except in pectoral region
each
breast develops when an
ingrowth of ectoderm forms a
primary tissue bud in mesenchyme.

CONGENITAL ABNORMALITIES OF
THE BREAST
AMASTIA:-

bilateral
absence of breast tissue
and nipple,
When breast tissue is
absent unilaterally pectoral
muscles are often absent.

AMASTIA

CONGENITAL
ABNORMALITIES OF THE
BREAST

POLYMASTIA:-

(ACCESSORY

BREAST)
More than one breast on one
or both sides, anywhere
along milk ridge

POLYMASTIA

CONGENITAL
ABNORMALITIES OF THE
BREAST
SYMMASTIA:-

webbing between
the breasts across
midline

SYMMASTIA

CONGENITAL
ABNORMALITIES OF THE
BREAST
POLYTHELIA:-

(ACCESSORY NIPPLES)
Imperfect development of
mammary rudiment,so that
supernumerary nipples are
situated irregularly over
breast/or along milk ridge

POLYTHELIA

CONGENITAL
ABNORMALITIES OF THE
BREAST

ATHELIA

absence
nipple

of

CONGENITAL ABNORMALITIES
OF THE BREAST
INVERTED

NIPPLE
failure of
mammary pit to
elevate above skin
level

INVERTED NIPPLE

OTHER
ASSESSMENT
FINDINGS

PREGNANCY CHANGES

MASTITIS

PAGETS NIPPLE

ANATOMY

Site:- lies in superficial fascia of pectoral


region

A small extension called axillary tail of


Spence pierces deep fascia through
foramen of Langer & lies in axilla

Extent:-

vertical-

2nd

to

6th

ribs

inclusive

Horizontal-

from

lateral

border

sternum to anterior axillary line.

of

SUPERFICIAL ANATOMY

Anatomy

Anatomy

DEEP RELATIONS

Breast rests on
- fascia of pectoralis major muscle
- serratus anterior muscle
- ext. oblique abdominis muscle
- upper extent of rectus sheath

Retromammary

bursa

aspect of breast

identified

on

posterior

between investing fascia of

breast & fascia of pectoralis ms.

LIGAMENTS OF COOPER-The breast is anchored to


the overlying skin & to the underlying pectoral
fascia by bands of connective tissue.

Anatomy

15-20 lobes
lobe:lobules, small
branch, and larger
ducts.
Radial fashion
Peripheral portions
of lobes often
overlap

ARCHITECTURE OF GLAND

Acini -> lobules -> lobes

Lobes arranged in radiating pattern &


converge on nipple

Each lobe is drained by a duct that opens


into the nipple

Ducts surrounded
tissue & fat gives

by

loose connective
roundness.

NIPPLE AREOLA COMPLEX

Nipple
Pigmented
darker
physiological
changes

with

Areola
sebaceous, sweat,&
accessory glands.
produce small
elevations called
MONTGOMERY
TUBERCLES

ARTERIAL BLOOD SUPPLY

perforating branch of
thoracic/mammary artery

lateral
branches
intercostal arteries

branches from axillary artery

superior thoracic

lateral thoracic

of

pectoral
branch
thoracoacromial artery

internal
posterior

of

VENOUS DRAINAGE

perforating branch of internal thoracic vein

perforating branch of posterior intercostal


vein

tributaries of axillary vein

NERVE SUPPLY

Sympathetic

nerves

reach

2nd

via

to

which
6th

intercostal nerves

Overlying
anterior

skin

supplied

& lateral branches

of 4th, 5th, 6th, intercostal


nerves

LYMPHATIC DRAINAGE

axillary(lateral) vein group

external mammary group(anterior or pectoral)


along lower border of pectoralis minor and in
relation with lateral thoracic vessels

scapular group(posterior or subscapular) along


subscapular vessels

central group

apical/subclavicular

interpectoral(Rotters node)

Level of lymphatic drainage


Level

I
lymph node located lateral to
pectoralis minor. (lateral
axillary, external mammary,
subscapular).
Level II
deep to pectoralis minor.
(central and interpectoral).
Level III
medial to or above pectoralis
minor. (subclavicular).

PHYSIOLOGY

Puberty menstrual cycle


Early follicular phase: Day 3-7. dense
stroma, only one epithelial type.
Minimum volume in 5-7 days.
Follicular
phase:
Day
8-14,
progression of epithelial in to three
cell type: luminal , myoepiethelial
and intermediate cell.
Ovulation: Increase alveoli volume
and number.
Secretory
phase:
Day
21-27,
maximum size of the lobules
Menstrual phase: Day 28-32

Pregnancy
diminution of fibrous stroma
lobular hyperplasia
hormones active are estrogen,
progesterone & prolactin
Lactation
prolactin & oxytocin
Menopause
irregularity & functional
nodularity

NURSING HISTORY

Major complaints
Pain

in breast.
Discharge from nipple.
Ulcer over breast.
Lump (mode of onset,
duration, rate of growth)
Discharge from nipple
Retraction of nipple
Loss of weight

COLDSP
A

History of Present Health Concern


Presence of lumps (rate of increase
in size, relation to menstrual cycle,
location, presence of rash, redness,
warmth or dimpling)
Change in size or firmness of the
breasts
Pain and tenderness
Discharge from nipples (color,
consistency, odor)
Clear discharge (OCPs,
phenothiazines, steroids, digitalis,
diuretics)

Past Health History


Prior breast disease
Breast surgery
Breast biopsy
Breast trauma
Breast implant
Age of menarche and menopause
Parity; age of first pregnancy
First and last day of menstrual cycle

Family History
History of breast cancer in the
Family
Lifestyle and Health
family

Practices

Intake of hormones, OCPs, antipsychotic agents


Exposure to radiation, benzene or asbestos
Typical daily diet
Intake of alcohol or caffeine containing beverage
Type of exercise; use of supportive bra
Importance of breasts to self-worth
Practice of BSE
Clinical examination
Mammogram

PHYSICAL
EXAMINATION

Position
sitting

position
semi-recumbent position
recumbent position
bending forward position

Inspection
With arms by side of body
With arms raised above her
head
Hands on her hips
Patient bending forwards from
the waist

Breasts
Position
Size

& shape
Any puckering or
dimpling
Any ulcer

Skin over the breast


Colour

& texture
Engorged veins
Peau d orange
Nodules

PEAU D ORANGE

Nipple
Presence
Position
Number
Size

& shape
Surface
Discharge

Arm & Thorax


Cancer

en cuirasse - a carcinoma
that involves a considerable portion
of the skin of one or both sides of the
thorax.
Brawny edema of arm
axilla & supraclavicular fossa
submammary fold must be
inspected

Palpation
Position
Normal breast 1st
With palmar surface of fingers
with the hand flat
Four quadrants
Axillary tail
Behind nipple

Examination of lump
Local temp & tenderness
Site as per quadrant
Number
Size & shape
Surface
Margin
Consistency

Fluctuation
Transillumination test
Fixity to skin
tethered to skin
fixed to skin
Fixity to breast tissue
Fixity to underlying fascia &
muscles
Fixity to chest wall & palpation of
nipple

Examination of lymph nodes


Axillary

group of lymph

nodes
pectoral group
brachial group
subscapular group
central group
apical group
Cervical lymph nodes
supraclavicular nodes

Sample Documentation:
Subjective data
Forty year-old woman,. No history of
breast disease, biopsies or surgery in
self or family. Takes hormone
replacement therapy for early onset
of menopause. Performs monthly BSE.
Reports no breast lesions, lumps,
swelling, pain, rashes or discharge.
Has yearly mammogram and breast
examination by gynecologist. Eats a
low-fat diet. Does not drink alcohol.
Exercises four times a week wearing
supportive, firm bra. Menstruation
started at age 14. has one adopted
child. Comfortable with discussing

Sample Documentation:
Objective data

Inspection
Bilateral breasts moderate in size,
pendulant and symmetric. Breast skin
pale pink with light brown areola.
Montgomery tubercles present. Nipples
everted bilaterally. Free movement of
breasts with position changes of arms
and hands. No dimpling, retraction,
lesions, or inflammation noted. Axillae
free of rashes and inflammation

Palpation
No masses or tenderness palpated.
Bilateral mammary ridge present. No
discharge from nipples. Axillary and

Nursing Diagnoses

Wellness Diagnoses:
Readiness for enhanced health management of
breasts
Health-Seeking Behavior: Requests information on
BSE

Risk Diagnoses
Risk for Ineffective Management of Therapeutic
Regimen related to busy lifestyle and lack of
knowledge of monthly BSE

Actual Diagnoses
Fear of breast cancer related to increased risk factors
Ineffective Individual Coping related to diagnosis of
breast cancer
Disturbed Body Image related to mastectomy
Anticipatory Grieving related to anticipation of poor
outcome of breast biopsy
Ineffective Management or Therapeutic Regimen
related to lack of knowledge of BSE