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Skill: Assessing The Breasts and Axillae: Assessment

This document provides instructions for assessing a client's breasts and axillae. It outlines 14 steps, including inspecting the breasts and surrounding skin for any abnormalities, palpating lymph nodes in the axilla, and palpating the breasts and nipples to check for any masses or discharge. The assistant is to gather the client's medical history related to breast issues, explain the assessment procedure, and teach breast self-examination techniques.

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Dr. Abiola Komolafe
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517 views2 pages

Skill: Assessing The Breasts and Axillae: Assessment

This document provides instructions for assessing a client's breasts and axillae. It outlines 14 steps, including inspecting the breasts and surrounding skin for any abnormalities, palpating lymph nodes in the axilla, and palpating the breasts and nipples to check for any masses or discharge. The assistant is to gather the client's medical history related to breast issues, explain the assessment procedure, and teach breast self-examination techniques.

Uploaded by

Dr. Abiola Komolafe
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Skill: Assessing the Breasts and Axillae

Performed
Preparation Yes No Mastered Comments
1. Assemble equipment:
• Centimeter ruler
Procedure
1. Introduce yourself and verify the
client’s identity. Explain to the
client what you are going to do,
why it is necessary, and how she
can cooperate.
2. Perform hand hygiene and observe
other appropriate infection control
procedures.
3. Provide for client privacy.
4. Inquire if the client has any history
of the following:
• Breast masses, and what was
done about them
• Any pain or tenderness in the
breasts and relation to the
woman’s menstrual cycle
• Any discharge from the nipple
• Medication history
• Estrogen replacement therapy
• Mother, sister, aunt with breast
cancer
• Alcohol consumption
• High-fat diet
• Obesity
• Use of oral contraceptive
• Menarche before age 12
• Menopause after age 55
• Pregnancy after age 30
• Breast self-examination;
technique used and when
performed in relation to the
menstrual cycle
Assessment
5. Inspect the breasts for size,
symmetry, and contour or shape
while the client is in a sitting
position.
6. Inspect the skin of the breast for
localized discolorations or
hyperpigmentation, retraction or
dimpling, localized hypervascular
areas, swelling, or edema.
7. Emphasize any retraction by
having the client:
• Raise arms above head;
• Push the hands together, with
elbows flexed; and
• Press hands down on hips.
8. Inspect the areola area for size,
shape, symmetry, color, surface
characteristics, and any masses or
lesions.
9. Inspect the nipples for size, shape,
position, color, discharge, and
lesions.
10. Palpate the axillary, subclavicular,
and supraclavicular lymph nodes.
The client is seated with her arms
abducted and supported on the
nurse’s forearm.
Use the flat surfaces of all fingertips
to palpate the four areas of the axilla:
• The edge of the greater pectoral
muscle along the anterior axillary
line
• The thoracic wall in the
midaxillary area
• The upper part of the humerus
• The anterior edge of the
latissimus dorsi muscle along the
posterior axillary line
11. Palpate the breast for masses,
tenderness, and any discharge from
the nipples.
12. Palpate the areola and the nipples
for masses.
Compress each nipple to determine
the presence of any discharge. If
discharge is present, milk the breast
along its radius to identify the
discharge-producing lobe.
Assess any discharge for amount,
color, consistency, and odor.
Note any tenderness on palpation.
13. Teach the client the technique for
breast self-examination.
14. Document findings in the client
record.

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