Breast and Lymphatics

Anatomy Breasts ● Located over the anterior pectoralis muscle on the chest wall for males and females ● Nipple: Round protrusion slightly inferior to the breast center ○ Surrounded 1-2 cm in diameter by the round areola ● Montgomery glands: Small bumps on the surface of the areola ● Nipple and areola are usually pigmented and darker than surrounding skin Quadrants ● Upper outer, lower outer, upper inner, and lower inner ● Lines cross the nipple vertically and horizontally ● Tail of Spence: An additional triangular area of breast tissue in females ○ Extends up and into the axillae lateral to the upper outer quadrant Breast Tissue ● Confined to a small area under the nipple and areola in men ● In the female breasts, glandular tissue is arranged in 15-20 oval-shaped lobes extending from the nipple area, each consisting of smaller lobules ● Contained in the breast lobules are alveoli lined with cells that produce milk ● A lactiferous duct connects to each lobe and converge near the nipple to form lactiferous sinuses, which act as storage for breast milk ● Cooper ligaments: Fibrous CT bands that provide support and suspension for the breast tissue by running from the skin surface across to the chest wall muscles Lymphatic System ● Network of nodes, vessels, and organs that transport thin, clear lymph fluid from interstitial spaces to the blood circulation Vessels & Ducts ● Lymphatic vessels join and form two large primary trunks, which empty the lymph into the vascular system via the subclavian veins ● The right lymphatic duct drains the body’s upper right side, including the upper right area of the liver, into the right subclavian vein ● The remainder of the body is draineod by the thoracic duct into the left subclavian vein Nodes ● Small, oval glands arranged in chain-like groups along lymphatic vessels ● Some are superficial and can be palpated; others are deeply situated ● Four main areas where superficial nodes can be palpated: Cervical, axillary, epitrochlear, and inguinal regions Associated Organs ● ● ● ● Tonsils at the entrance to the GI and respiratory tract Thymus between the aorta and sternum Spleen in the LU abd quadrant Bone marrow Physiology Breast ● Primarily for lactation ● Nipple stimulation from infant suckling initiates a neurohormonal response, in which alveoli contract and expel milk into the ductal system and out of the nipple ● Montgomery glands secrete a lipid substance to protect the nipple and areola integrity ● The male breast has an underdeveloped ductal structure with no function Lymphatic System Three Main Functions ● Detecting and eliminating microorganisms, like bacteria and viruses ● Absorbing lipids from the SI during digestion ● Reabsorbing fluid from interstitial tissues Female Breast ● Contains a large lymphatic system that mainly drains into the axilla on each body side ● Removal or damage to the lymphatic system, such as with breast CA treatment, can lead to lymphatic fluid leaking into surrounding tissues ○ Causes a fluid shift, drawing water from the circulatory system into the tissues and causing upper limb edema Associated Organs ● The tonsils are lymphatic tissue that respond to inflammation ● The thymus shrinks significantly after puberty and produces T lymphocytes ● The spleen produces Abs and filters pathogens from the blood and bone marrow ○ Produces B lymphocytes Health History Interview Present Health Conditions Question Subjects ● ● ● ● ● ● Pain or tenderness in breasts/axillae Any changes in appearance of breasts, nipples, or axillae Swelling, lumps, or rashes Nipple discharge Menstruation and related breast changes Painful or swollen lymph nodes Past Health History Question Subjects ● Breast disease, like CA or fibrocystic changes ● Breast trauma, surgeries, or biopsies ○ Includes augmentation or reduction, including total mastectomy ● Routine examination by healthcare professional and self Family History Question Subjects ● Family members with breast CA ○ Who and age at diagnosis Breasts Skin Color and Condition Inspection ● Client’s arms relaxed at sides ● If breasts are larger or pendulous, ask them to lift to inspect underside Expected Findings ● Skin over breasts should be smooth and similar color to surrounding skin Expected Variations ● Visible veins beneath skin surface if obese or pregnany (should be bilaterally visible) ● Striae, appearing as pale, linear marks ● Inflammation or excoriation on the underside of large breasts due to skin friction Unexpected Findings ● Thickened, rough skin; unilateral dilated veins, dimpling of the skin, edema, inflammation, or unilateral rash are all associated with breast CA ● Peau d’orange: Breast tissue resembles the skin of an orange ○ Caused by edema, which dilates the hair follicles ○ Associated with breast CA ● Inflamed, warm, edematous breast can indicate infection of the tissue Shape and Size Inspection ● With client’s arms at rest and with movement ● Shapes and sizes may vary Expected Findings ● Breasts approximately equal in size ● Smooth and unchanged contour with movement Expected Variations ● Scars from breast surgeries ● Surgical removal of breast tissue due to CA or gender-affirming treatment ○ May leave a scar extending into the axilla ● Gynecomastia: Enlargement of male breast tissue ○ Seen in adolescents, with weight gain, and from certain diseases/conditions ● Increased male breast development can occur due to hormone medication ● Menopause-related hormonal changes and breast tissue atrophy lead to female breasts becoming pendulous and flattened Unexpected Findings ● Significant differences in breast sizes, a difference in contour of one breast, or a dimpling/retraction of the skin are all associated with breast CA ● A change in contour when the client moves can indicate a mass within the breast ● A bulging area from the male or female breast can signify breat CA Areolas and Nipples Inspection ● Observe the color, shape, and skin characteristics ● Color can vary from pink to black and is based on hormones and ethnicity Skin Condition Expected Findings ● Round or oval areola; small bumps of the Montgomery glands may be visible ● Nipple typically protrudes but may be flat or inverted; expected if present since puberty ● Smooth and intact areola/nipple skin; no open areas, crusting, rash, or drainage Unexpected Findings ● A dry scaling rash on the nipple and areola is associated with a form of breast CA ● Nipple discharge in a non-lactating client can indicate infection or types of breast CA Symmetry, Alignment, and Orientation Expected Findings ● Bilateral symmetry between nipples and positioning along the same plane of the breasts ● Nipples should be oriented in the same direction Expected Variations ● Presence of a supernumerary (extra) nipple is an occasional finding ○ Typically pink or brown and appear along the embryonic milk like that runs from the breast to the groin area ○ Often mistaken for moles Unexpected Findings ● Change in nipple presentation from protruding to inverted or a change in the direction it points can indicate a benign or cancerous mass in the breast Axillae Skin Color and Condition Expected Findings ● Smooth and intact with no discoloration, edema, or rash Expected Variations ● A mastectomy can cause lymphedema due to disruption of normal pathways of lymph drainage from the breast area Unexpected Findings ● Edema in the axillae or arm can be related to an infection in the breast, arm, or hand ● A rash can indicate a sweat gland infection or irritation from shaving or antiperspirant use ● Very smooth, deeply pigmented skin suggests presence of other disease (diabetes, PCOS) Lymph Nodes Expected Findings ● Lymph nodes should not be visible and there should be no axillary discomfort Unexpected Findings ● Visible lymph nodes indicate enlargement, suggesting an infection or cancer Interventions Needed for Unexpected Findings Findings of Concern ● ● ● ● ● ● ● ● A change in breast size, shape, or contour Unilateral superficial vein dilation, inflammation, or edema of the breast/axillae Nipple drainage Enlarged lymph nodes A change in the presentation or orientation of the nipple A rash on the nipple/areola A dimpled/retracted area in the breast tissue A visible/palpable lump in the breast tissue Subjective Data Subjects Nipple Discharge ● ● ● ● ● ● ● When it was first noticed Pregnant, breastfeeding, or recently stopped breastfeeding From both nipples or one Where on the nipple drainage comes from Present on clothing or visible only on the breast Color, consistency, and odor Breast pain or lumps Axillae/Arm Edema ● ● ● ● ● ● When it was first noticed Pregnant, breastfeeding, or recently stopped breastfeeding History of breast CA Surgery to the breast Recent trauma to the breast or nipple Symptoms of illness like fever, chills, or pain Health Promotion Breast Self-Exam ● Typically best to assess 4-7 days after the start of their cycle; tissue is less full and tender ○ Same if augmentation has been done Method 1. Look at the breasts in front of the mirror with their hands on their hips a. Contracts the muscles of the chest wall and makes any changes easier to see 2. Inspect for any changes in color, shape, contour, or dimpling 3. Inspect the nipple for the presence of a rash or drainage 4. To palpate, lie down and place the arm closest to the examined breast behind the head 5. Palpate using the pads of three middle fingers 6. Make overlapping dime sized circular motions with the finger pads to assess for lumps 7. Apply light, medium, then firm pressure to each area 8. Begin at the outer edge by the axilla; move across from top to bottom toward the sternum 9. Palpate the area in the axilla 10. Repeat for the other breast and axilla;can be done while showering Expected Findings ● Approximately equal sized and shaped breasts with smooth contour ● No dimpling, rashes, edema, palpablelumps, or localized tenderness ● The firm inframammary ridge may be palpated along the lower portion in larger breasts ○ Expected; due to compressed breast tissue ● No rash or drainage in the nipple or areola Unexpected Findings ● Significant breast size differences, asymmetry of contour/shape, inflammation, warmth, localized tenderness, changes in skin appearance or texture, lumps, or drainage Tests ● Mammogram recommendations vary depending on age, prior breast health history, and family history of breast CA ● Advised every two years > 50 until 74; may start at 40 if increased risk ● Increased risk for those undergoing gender-affirming hormone therapy or with a FH of hormone-sensitive breast CA