Chapter 018

TEACH for PN
18 Breasts and Regional Lymphatic System

TEACHING FOCUS
This chapter helps students learn the structure and function of the breast and regional lymphatic
system, understand the rationale and methods of breast examination, and accurately record the
assessment. Students will also learn to determine, according to current evidence-informed guidelines,
when it is appropriate and desirable to conduct clinical breast examination (CBE), and teach women to
do breast self-examination (BSE).
LEARNING OBJECTIVES
1. Identify significant breast anatomy.
2. Describe the composition of breast glandular tissue.
3. Relate the changes that occur in Cooper’s ligaments with cancer.
4. Describe the ways of documenting clinical findings from a breast examination.
5. Relate the anatomy of the breast lymphatic system.
6. Review breast development in the adolescent female.
7. Review breast changes that occur during pregnancy.
8. Describe the procedure for teaching breast self-examination and incorporating health
promotion concepts when performing an assessment of the breasts.
KEY TERMS
Physical Examination & Health Assessment, 3rd Canadian ed.

Copyright © 2019 Elsevier, Inc. Jarvis
2 Chapter 18 Breasts and Regional Lymphatic System ____________________________________________
 Adipose tissue  Mastitis

 Alveoli  Menarche
 Areola  Montgomery’s glands
 Axillary rash  Nipple
 Breast self-examination (BSE)  Paget’s disease
 Breasts  Peau d’orange
 Central axillary nodes  Pectoral
 Colostrum  Premature thelarche
 Cooper’s ligaments  Rash
 Discharge  Retraction
 Fibroadenoma  Striae
 Galactorrhea  Subscapular
 Glandular tissue  Supernumerary nipple
 Gynecomastia  Surgery
 Inframammary ridge  Swelling
 Intraductal papilloma  Tail of Spence
 Inverted  Tanner’s staging
 Lactiferous  Tenderness
 Lateral  Thelarche
 Lump  Thickening
 Mammography  Trauma
 Mastalgia

____________________________________ Chapter 18  Breasts and Regional Lymphatic System
3
Note: Glossary available on Evolve.
NURSING CURRICULUM STANDARDS

Quality and Safety
 Patient-Centred Care
o Developmental Considerations
o Pregnant Women
o Social Determinants of Health Considerations
o Lactating Women
 Quality Improvement
o Promoting Health: Breast Cancer
o Box 18-1: Summary of Breast Cancer Screening Recommendations for Clinicians and
Policymakers
o Breast Cancer Screening Tools
 Safety
o Table 18-2: Risk Factors for Breast Cancer
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2017).
Concepts for nursing practice. St. Louis, MO: Elsevier. The specific exemplars chosen and listed below for
each concept have been tailored specifically to correspond to Physical Examination and Health
Assessment, Third Canadian Edition.
THEME: Attributes and Resources

 Concept: Development
o Table 18-1: Sexual Maturity Rating in Girls
THEME: Sexuality and Reproduction
 Concept: Reproduction
o Structure and Function
o Pregnant Women
o Subjective Data
o Special Considerations for Advanced Practice
o Objective Data
o Pregnant Women
o Lactating Women
o Table 18-3: Signs of Retraction and Inflammation in the Breast
o Table 18-4: Breast Lump
o Table 18-5: Differentiating Breast Lumps
o Table 18-6: Abnormal Nipple Discharge
o Table 18-7: Disorders Occurring During Lactation
o Table 18-8: Abnormalities in the Male Breast

4 Chapter 18 Breasts and Regional Lymphatic System
____________________________________________
o Abnormal Findings
THEME: Nursing Attributes and Roles
 Concept: Health Promotion
Policymakers
THEME: Care Competencies
 Concept: Communication
o Documentation and Critical Thinking
 Concept: Safety
THEME: Health Care Delivery
 Concept: Health Disparities
STANDARDS OF PRACTICE FOR PRACTICAL NURSES IN CANADA

 Professional Accountability and Responsibility
o Documentation and Critical Thinking
 Knowledge-Based Practice
o Structure and Function
o Surface Anatomy
o Internal Anatomy
o Lymphatic System
o Pregnant Women
o Subjective Data
Policymakers
o Special Considerations for Advanced Practice
o Objective Data
o Pregnant Women
o Lactating Women
o Table 18-3: Signs of Retraction and Inflammation in the Breast
o Table 18-4: Breast Lump
o Table 18-5: Differentiating Breast Lumps
o Table 18-6: Abnormal Nipple Discharge
o Table 18-7: Disorders Occurring During Lactation
o Table 18-8: Abnormalities in the Male Breast

5
o Abnormal Findings
STUDENT CHAPTER RESOURCES

Chap. READ – Textbook (pp. 418-447)
18
REVIEW – Evolve Resources
 Animations
 Case Studies
 Clinical Reference
 Key Points
 Video-Assessment
o Breasts
ANSWER – Evolve Resources

 Chapter 18, Review Questions
LM ANSWER – Lab Manual

 Chapter 18, Breasts and Regional Lymphatic System
SLS APPLY – Simulation Learning System

 Scenario 12-2, Julie Watson
INSTRUCTOR CHAPTER RESOURCES

TB Test Bank
 To access the ExamView format, go to the Downloads section.
PPT PowerPoint Presentations
IC Image Collection
 To access the Image Collection, click Main Menu, or go to the Evolve Web site
(http://evolve.elsevier.com/Canada/Jarvis/examination/)
SLS APPLY – Simulation Learning System
 Scenario 12-2, Julie Watson

ETC. Video Series Booklets

____________________________________________
LESSON PLANS
COLLABORATIVE/ACTIVE TEACHING
CHAPTER OUTLINE TEACHING STRATEGIES LEARNING RESOURCES
STRUCTURE AND Bring in a model and a diagram  Activity: Provide a Image
FUNCTION of the breast and review the diagram of the breast, Collection:
external and internal and have students label Figure 18-1
Surface Anatomy characteristics. Discuss the three the different tissues, Figure 18-2
different tissues of the breast ligaments, and breast Figure 18-3
and how the glandular tissue characteristics, or have Figure 18-4
produces milk. them draw a sketch of
Internal Anatomy Examine why the upper outer the breast and
quadrant is the site of most surrounding tissues.
breast tumours.
Lymphatic System Explain the function of lymphatic

drainage using a diagram, and
review the four groups of axillary
nodes. Discuss whether the
lymphatic drainage has anything
to do with breast cancer.
DEVELOPMENTAL Review the development of the  Online Activity: Have Image
CONSIDERATIONS breast, starting with embryonic students investigate Collection:
life with the ventral epidermal breast cancer Figure 18-5
ridges. awareness groups in Figure 18-6
their community. What
Review the effect of puberty, and type of services do Table 18-1 in
Adolescents discuss how hormone these groups offer? textbook
development stimulates breast
changes. Use Table 18-1 to
explain sexual maturity rating in
girls. Discuss the common
changes in breasts during
menarche.
Discuss the expansion of the duct

Pregnant Women
system and the physical changes
in the breast during pregnancy.
Explain how a decrease in

Older Women estrogen and progesterone
changes breast characteristics as
a woman ages.
Discuss gynecomastia during

The Male Breast adolescence and testosterone
deficiency in the aging male.
SOCIAL Give some examples of genetic  Discussion Topic: Discuss Table 18-2 in
DETERMINANTS OF and environmental factors that the effects of obesity on textbook

7
LESSON PLANS
HEALTH may affect breast development. breast cancer.
CONSIDERATIONS Discuss how diet, breastfeeding,
and early screening may reduce
the risk for breast cancer.
SUBJECTIVE DATA Emphasize the importance of  Discussion Topic: Review
Breast being sensitive to a patient’s the considerations
Axilla anxiety and attitude about related to transgender
having the breasts examined. patients.
HEALTH HISTORY Review each of the examination  Discussion Topic:
QUESTIONS questions and its rationale. Discuss how patients
Explain how to perform BSE. can lower their risk for
breast cancer.
Discuss risk assessment and  Activity: Designate a
Special
counselling related to hormone day each month to
Considerations for therapy in perimenopausal remind female students
Advanced Practice women. to perform BSE.
SPECIAL Review use of breast cancer  Activity: Provide Box 18-1 in

CONSIDERATIONS screening tools. Discuss the students with textbook
FOR ADVANCED recommendations in Box 18-1. recommended
PRACTICE Review the limitations of screening tools, and
screening tools. have them apply the
tool on themselves or
Breast Cancer one another.
Screening Tools
OBJECTIVE DATA Describe or show a video  Activity: Assign Image
INSPECT THE demonstrating how to prepare a students to perform a Collection:
BREASTS patient for a breast examination. breast examination on Figure 18-7
Explain the equipment needed a patient in a clinical Figure 18-8
for the examination. With the setting. Figure 18-9
help of a volunteer, demonstrate  Activity: Have students Figure 18-10
the positions used for the interview patients for Figure 18-11
different parts of the barriers to BSE. Figure 18-12
examination.  Small Group Activity: Figure 18-13
Supply a breast Figure 18-14
Inspect the Breasts Discuss symmetry of size and mannequin for each Figure 18-15
shape of the breasts and normal one or two students. Figure 18-16
ranges. Emphasize that a sudden While students perform Figure 18-17
increase in size should be an examination on the Figure 18-18
investigated. Define mannequins, observe Figure 18-19
supernumerary nipple. Review for technique. Figure 18-20
how to observe the axillary and  Discussion Topic: Figure 18-21
supraclavicular regions. Discuss the importance
Demonstrate retraction of examining the male
manoeuvres. breast and ways of
creating an
Inspect and Palpate Review positioning of the patient environment that will
the Axillae and palpations of axillae in four provide psychological
directions. comfort for both

____________________________________________
LESSON PLANS
patient and
Palpate the Breasts Detail the characteristics of a practitioner.
lump using Figure 18-14, and use
Tables 18-4 and 18-5 to explain
how to differentiate breast
lumps.
Teach Breast Self- Discuss how to teach BSE and the

Examination best time to perform the
examination. Remember: Keep it
simple!
The Breast Ask a male volunteer to act as

Examination in Men the patient, and demonstrate the
examination in this section.
Review areas of palpation.
Review care for adolescent
males. Discuss both normal and
possible abnormal findings.
Developmental Use a doll or an infant

Considerations mannequin to demonstrate the
correct way to examine an infant.
Review breast development age
in adolescents. Describe how to
distinguish breast development
from extra adipose tissue present
in obese children. Explain that a
chart can be helpful in showing
the adolescent the normal stages
of breast maturity.
Review nursing and changes in
the breasts.
Discuss the changes in the breast
that are caused by aging.
DOCUMENTATION Review the sample  Discussion Topic:
AND CRITICAL documentation. Discuss the case studies
THINKING as a class.
Sample Charting:
Female
Sample Charting:
Male
Focused Assessment:
Clinical Case Study 1
Focused Assessment:
Clinical Case Study 2

9
LESSON PLANS
ABNORMAL Review Tables 18-3 through 18-8.  Online Activity: Have Tables 18-3
FINDINGS students review the to 18-8 in
resources available at textbook
the Canadian Task
Force on Preventive
Health Care—Breast
Cancer Web site
(https://canadiantaskfo
rce.ca/guidelines/publi
shed-guidelines/breast-
cancer/)
IN-CLASS/ONLINE CASE STUDY

D.F. is a 27-year-old female who presents to the gynecologist’s office for her yearly examination
complaining of bilateral breast pain and tenderness.
Subjective Data
Last menstrual cycle: 18 days ago
Pain is dull pain
Breasts feel heavy and tender
Performs monthly breast self-examinations
Objective Data
Breasts moderate size, evenly pigmented, bilaterally symmetrical, and hang equally with smooth
contour. Venous patterns similar bilaterally. Breasts firm, smooth, elastic without tenderness, lumps, or
nodules. Areolae round, nipples protruding, symmetrical, soft, pliable, smooth, and intact without
discharge. Axillary lymph nodes are not palpated.
Questions
1. What other questions should the nurse ask about the breast pain?
2. What are some of the causes of breast pain?
3. Develop a problems list from the objective and subjective data.
4. What should be included in the plan of care?
5. On the basis of the readings and the subjective and objective data, what is the most likely cause of
breast pain for this patient?
Answers
1. Questions or assessments associated with breast pain include the following:
 Where does it hurt?
 Is it in one breast or both?
 Is there a specific location, or is the pain generalized?
 When did the pain in your breasts first begin?
 Describe the pain. Rate the severity of the pain on a scale of 0 to 10.
 Does the pain or tenderness prevent you from carrying out routine activities?
 Have you noticed any specific activities that bring on the pain? For example, do you experience

____________________________________________
pain during sexual activity? When you exercise? When wearing a certain bra or when not
wearing a bra? Does it worsen with drinking coffee or other caffeinated beverages?
 Have you noted any recent changes in your breasts, such as change in size, shape, or tenderness
and presence of lumps or discharge?
 Is the breast tenderness associated with a swollen feeling in the breasts? If yes, when do you
notice the swelling? Is the swelling related to your menstrual cycle?
2. Benign breast disease is a term that represents a number of breast-related symptoms and
problems, including breast pain or tenderness, swelling, lumps, discharge, and inflammation.
Fibrocystic changes to the breast are a variety of conditions associated with multiple benign
masses in the breast caused by ductal enlargement and the formation of fluid-filled cysts,
commonly seen in middle-aged women. Fibroadenoma is a common, benign breast tumour in
young women and consists of glandular and fibrous tissue. Ductal ectasia is a benign breast
disease characterized by inflammation and dilation involving one or multiple subareolar ducts. An
intraductal papilloma is a small, benign tumour growth in the major ducts, usually within 1 to 2
cm of the areolar edge. Breast cancer is a major health problem for women. It is the most
common non–skin-related malignancy among North American women.
3. The problems list includes the following:
 Breast pain
 Heaviness and tenderness
4. The plan of care should include having the patient continue monthly BSE and monitor for changes.
Teaching should also include checking the nipples for discharge. Management for the breast pain
would include anti-inflammatories, such as ibuprofen.
5. The most likely cause of this patient’s breast pain is cyclical bilateral breast edema or fullness. This
is a normal occurrence caused by hormonal fluctuations associated with the menstrual cycle.
Significant edema should be further evaluated, especially if it is unilateral, has other associated
findings, or influences the woman’s ability to participate in normal activities.
CHAPTER 18: ANSWERS TO STUDY GUIDE QUESTIONS IN LAB MANUAL
1. History questions to ask regarding the breast examination can be found in the “Subjective Data”
section, beginning on p. 424.
2. The breast is composed of glandular tissue; fibrous tissue, including the suspensory ligaments; and
adipose tissue. See the text discussion on pp. 419.
3. See Table 18-1, Sexual Maturity Rating in Girls, p. 422.
4. Components of the breast examination:

• History
• Inspection, including manoeuvres to screen for retraction
• Inspection and palpation of the axillae

11
• Palpation of each breast and nipple
5. When advising women about BSE, include the following points:

• Women 40 to 74 years of age and are at average or low risk for breast cancer are advised not to
routinely do BSE because research supports that the harms outweigh the benefits.
• Most women never get breast cancer.
• Most breast lumps are benign.
• Women should be aware of their individual risk factors for breast cancer.
• Women with a higher-than-average risk for breast cancer or women with low or average risk
who express a preference for doing BSE after discussing this with their health care provider
should be taught to do BSE by a health care provider.
• The key point of teaching BSE is for a woman to become familiar with the way her own breasts
look and feel so that she can recognize any changes.
• Early detection of breast cancer is important; if the cancer is not invasive, the survival rate is
close to 100%, so women who do BSE should report any changes to their health care provider
promptly.
6. A supernumerary nipple is an extra nipple along the embryonic “milk line” on the thorax or
abdomen. It is a congenital finding, and is not significant. It is usually located 5 to 6 cm below the
breast near the midline and has no associated glandular tissue. It is similar in appearance to a mole
but is not the same as a mole.
7. For details on female breast examination and findings, see text description, pp. 429-437. The
examination of the male breast is much more abbreviated but should not be omitted. See the
description of male breast examination and findings on pp. 437-438.
For breast examination of transgender individuals, acknowledge their preferred name and pronoun.
See p. 424.
8. For benign breast disease, cancer, and fibroadenoma, see Table 18-4, Abnormal Findings: Breast
Lump, pp. 442-443. For Paget’s disease, see Table 18-6, Abnormal Findings: Abnormal Nipple
Discharge, p. 444. For acute mastitis and abscess, see Table 18-7, Abnormal Findings: Disorders
Occurring during Lactation, p. 445.
9. Refer to Table 18-5, Abnormal Findings: Differentiating Breast Lumps, p. 443, for descriptions of the
following characteristics:
• Location—Using the breast as a clock face, describe the distance in centimetres from the nipple,
or diagram the breast in the medical record and mark the location of the lump.
• Size—Judge in centimetres in three dimensions: width, length,/ and thickness.
• Shape—State if the lump is oval, round, lobulated, or indistinct.
• Consistency—State if the lump is soft, firm, or hard.
• Movable—Is the lump freely movable, or is it fixed when you try to slide it over the chest wall?
• Distinctness—Is the lump solitary or multiple?
• Nipple—Is it displaced or retracted?
• Note the skin over the lump—Is it erythematous, dimpled, or retracted?
• Tenderness—Is the lump tender to palpation?
• Lymphadenopathy—Are any regional lymph nodes palpable?

____________________________________________
10. Gynecomastia: an enlargement of the male breast tissue, which is normally a flat disc of
undeveloped breast tissue beneath the nipple. It feels like a smooth, firm, movable disc and is
normal during puberty. It normally only affects one breast and is temporary.
11. A mammogram is an x-ray image of the breast. It can reveal cancers too small to be detected by
direct palpation. The Canadian Task Force on Preventive Health Care (2011) breast screening
guidelines suggest that women ages 50 to 74 years with low or average breast cancer risk undergo
screening mammography every 2 to 3 years. Women ages 40 to 49 years with low or average breast
cancer risk are advised not to have routine screening mammography or CBE, but they should discuss
their risk for breast cancer, and the risks and benefits of routine mammography screening with their
health care professional. Women age 75 years and older should discuss routine breast cancer
screening with their health care professional. See Box 18-1, Summary of Breast Cancer Screening
Recommendations for Clinicians and Policymakers, p. 428.
12. See Table 18-2, Risk Factors for Breast Cancer, p. 423.
13. Labelling Exercises:

• Breast Tissues: see Figure 18-2, p. 419.
• Lymph Nodes: see Figure 18-4, p. 420.


Chapter 018

Uploaded by

Copyright:

Available Formats

Chapter 018

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Chapter 018

Uploaded by

Copyright:

Available Formats

TEACH for PN

18 Breasts and Regional Lymphatic System

Physical Examination & Health Assessment, 3rd Canadian ed.

 Adipose tissue  Mastitis

Physical Examination & Health Assessment, 3rd Canadian ed.

Note: Glossary available on Evolve.

NURSING CURRICULUM STANDARDS

THEME: Attributes and Resources

Physical Examination & Health Assessment, 3rd Canadian ed.

STANDARDS OF PRACTICE FOR PRACTICAL NURSES IN CANADA

Physical Examination & Health Assessment, 3rd Canadian ed.

STUDENT CHAPTER RESOURCES

ANSWER – Evolve Resources

LM ANSWER – Lab Manual

SLS APPLY – Simulation Learning System

INSTRUCTOR CHAPTER RESOURCES

 Scenario 12-2, Julie Watson

Physical Examination & Health Assessment, 3rd Canadian ed.

Lymphatic System Explain the function of lymphatic

Discuss the expansion of the duct

Explain how a decrease in

Discuss gynecomastia during

Physical Examination & Health Assessment, 3rd Canadian ed.

SPECIAL Review use of breast cancer  Activity: Provide Box 18-1 in

Physical Examination & Health Assessment, 3rd Canadian ed.

Teach Breast Self- Discuss how to teach BSE and the

The Breast Ask a male volunteer to act as

Developmental Use a doll or an infant

Physical Examination & Health Assessment, 3rd Canadian ed.

IN-CLASS/ONLINE CASE STUDY

Physical Examination & Health Assessment, 3rd Canadian ed.

3. The problems list includes the following:

CHAPTER 18: ANSWERS TO STUDY GUIDE QUESTIONS IN LAB MANUAL

3. See Table 18-1, Sexual Maturity Rating in Girls, p. 422.

4. Components of the breast examination:

Physical Examination & Health Assessment, 3rd Canadian ed.

• Palpation of each breast and nipple

5. When advising women about BSE, include the following points:

Physical Examination & Health Assessment, 3rd Canadian ed.

13. Labelling Exercises:

Physical Examination & Health Assessment, 3rd Canadian ed.

You might also like