SELF BREAST EXAMINATION - a self-inspection of the breasts; screening technique women can do at home to check breast lumps, tumors,

cysts, or other abnormalities in the breasts. CLINICAL BREAST EXAMINATION - is an examination of your breasts by a health professional such as a doctor, nurse practitioner, nurse, or physician assistant. - for this exam, you undress from the waist up. The health professional will first look at your breasts for abnormalities in size or shape, or changes in the skin of the breasts or nipples. Then, using the pads of the fingers, the examiner will gently feel (palpate) your breasts. - is a good tool for women who dont know how to examine their breasts and to learn the right way to do it from their health care professionals.

IMPORTANCE OF SBE AND CBE used to look for unusual lumps, skin changes, or discharge For the early detection of breast cancer Promotes awareness about breast cancer Assessment for any changes that may need interventions Allows a woman to become familiar with how her breasts normal look and feel and can help her more readily detect any changes that may occur Preventive measures to fight against breast cancer by being proactive in realizing the importance of breast self-examinations and performing them regularly

PURPOSE OF SBE AND CBE to identify signs of breast disease and then to initiate early treatment. to evaluate the clients present condition to prevent cancer by detecting any cancerous (malignant) cells to assess normal developmental changes for diagnostic purposes

DISCUSS SELF BREAST EXAMINATION AS TO THEIR: A. INDICATIONS Indications Family history of breast cancer History of previous breast cancer Women 20 years of age and above Lactating and breastfeeding women Women who have had breast surgery Premenopausal and Postmenopausal women Women with breast implants When client wants assistance in breast monitoring (CBE)

B. GUIDELINES 1. Warm hands before proceeding to the examination. 2. Begin the examination in the shower when the breasts are wet and soapy and again after the shower when lying down with a folded towel under the shoulder on the side being examined. Standing up while facing the mirror during the examination can also be done. 3. Inspect for changes in breast shape, size, contour; puckering (dimpling) of the skin; or areas that appear red. 4. Adequate lighting is essential especially during inspection 5. Use the flat pads of three fingers in palpating the breast 6. There are three different patterns in palpating the breasts; choose one that is most comfortable to you 7. Be consistent and thorough in the method or pattern used upon palpation 8. Be sure to palpate every square inch of the breast; cover the entire area 9. Vary the levels of the pressure as you palpate: Light superficial Medium mid-level tissue Firm to the ribs Use the bimanual technique if you have large breasts

10. Specific examination of the nipple, through compression for discharge, and the areola, through palpation should not be forgotten 11. If you are on cyclic estrogen therapy, perform the examination on the last day that the medicine is not being taken 12. Breasts should be examined each month between the fourth through the seventh day of the menstrual cycle and also 2-3 days after menstruation, when the breasts are least congested 13. Remember that any breast changes observed is not always a sign of cancer but it is very important to detect cancer early for effective treatment. 14. It is beneficial to keep a notebook and write down assessment findings every time BSE is done; 15. If you find any changes, consult your doctor right away BREAST HEALTH GUIDELINES Women ages 20-39

Monthly breast-self exam Clinical breast exam by a health professional every 3 years

Women ages 40 and older

Monthly breast-self exam Clinical breast exam by a health professional every 3 years Screening mammogram every year

Client Preparation
Since the tests will require you to undress from waist up, it is recommended for you to wear two piece clothing such as jeans at the bottom and a button blouse on top. The use of deodorants, powder, cream, body lotion, and other products applied on the underarms is not recommended. Avoid stress and fatigue before undergoing an exam as these may actually affect the results of the test Eating properly and avoiding certain pills or medications may also be recommended. Do not wear fitting bra to avoid any compression of the breast

NURSING RESPONSIBILITIES

Before: 1. 2. 3. 4. Tell patient to perform breast self examination 2-3 days after menstruation Do medical hand washing Inform patient of the different alternative positions for breast self examination Explain to the patient that it will be necessary to expose both breasts to compare for symmetry during inspection 5. Warm hands before coming in contact with the patient During: 1. Drape one breast while palpating the other to provide as much privacy as possible. 2. Note for lumps or any abnormalities 3. Instruct to squeeze nipple to note if any discharges is secreted. Note color of discharge 4. All parts of the breast should be checked After: 1. Record the findings of the procedure after it is performed. 2. Assist the patient in clothing themselves if necessary. 3. If breast examination is performed by the nurse for the first time, teach the patient how to perform breast self examination and ask them to demonstrate what they have learned.

NORMAL AND ABNORMAL FINDINGS WHEN PERFORMING SELF-BREAST EXAMINATION ASSESSMENT NORMAL Breasts can be a variety of sizes and are somewhat round and pendulous. One breast may be larger than the other. Clients breasts should rise symmetrically with no sign of dimpling or retraction. ABNORMAL A recent increase in size of one breast SIGNIFICANCE Inflammation or abnormal growth Results from edema which is seen in metastatic breast cancer Usually caused by malignant tumor that has fibrous strands attatched to the breast tissue and fascia of the muscles

Peau d orange appearance

Size and Symmetry

Dimpling or retraction usually caused by malignant tumor that has fibrous strands attached to the breast tissue and fascia of the muscles.

Color and Texture

Color varies depending on the clients skin tone. Texture is smooth with no edema. Linear stretch marks may be seen during or after pregnancy or when there is significant weight loss. Veins radiate either horizontally and towards the axilla (transverse) or vertically with a lateral flare (longitudinal). Veins are more prominent during pregnancy.

Redness

Associated with breast inflammation.

Superficial Venous Pattern

A prominent venous pattern May occur as a result of increased circulation due to a malignancy. An asymmetric venous May be due to pattern malignancy.

ASSESSMENT

Areolas

Nipples

NORMAL Areolas vary from dark pink to dark brown, depending on the clients skin tone. They are round and may vary in size. Small Montgomery tubercles are present. Nipples are equally bilateral in size and are in the same location of each breast. Nipples are usually everted but they may be inverted or flat. Supernumerary Nipples may appear along the embryonic milk line. Smooth, firm, elastic tissue Older clients breasts may feel more granular A generalized increase in nodularity and tenderness may be a normal finding associated with the menstrual cycle or hormonal medication. Breasts should be a normal body temperature.

ABNORMAL Peau d orange skin may be first seen in the areola.

SIGNIFICANCE Results from edema which is usually seen in metastatic breast malignancy.

Red, scaly, crusty areas

Indicative of Pagets disease

A recently retracted nipple that was previously everted

May suggest malignancy Any type of spontaneous discharge should be referred for cytologic study and further evaluation.

Texture and Elasticity

Thickening of tissues

May suggest underlying malignant tumor Indicative of benign breast disease but can also be malignant.

Painful breasts

Tenderness and Temperature

Heat in the breast of women who have not just given birth or who are not lactating

Inflammation

ASSESSMENT

Presence of Masses

NORMAL No masses should be palpated. However, a firm ridge may normally be palpated at the lower base of the breasts.

ABNORMAL Malignant tumors are most often found in the upper outer quadrant of the breast. They are usually unilateral, irregular, poorly delineated borders. They are hard and nontender and fixed to underlying tissues.

SIGNIFANCE Should be referred to cytologic study and further evaluation for management.

No rash or infection noted.

Axillae Enlarged (greater than 1cm) lymph nodes may indicate infection of the hand or arm.

May indicate infection of the hand or arm.

Inspection and Palpation

No palpable nodes or one or two small (less than 1cm) discrete, nontender moveable nodes in the central area.

Large nodes that are hard or May indicate an fixed to the skin may underlying indicate an underlying malignancy. malignancy.

PATTERNS FOR PALPATION

Wedge

Circular (Starting from the Tail of Spence)

Linear Method

Methods and Positions in Performing BSE: 1. Inspection before a Mirror Look for any change in size or shape; lumps or thickenings; any rashes or other skin irritations; dimpled or puckered skin; any discharge or change in the nipples (e.g. position or asymmetry). Inspect the breasts in all of the following positions: 1.1 Stand and face the mirror with your hands resting on the hips; then turn to the right and the left for a side view. This will allow you to observe for any flattening or dimpling on the peripheral areas of the breasts; repeatedly alternating the left and the right side aids in checking for lateral symmetry.

1.2 Bend forward from the waist and raise your arms over your head. With the breasts not resting or flattened on your chest wall, it will accentuate any changes in shape or size. 1.3 Still facing the mirror, raise both arms over your head to inspect for skin or nipple retraction. Such movements can cause the contraction of anterior chest muscles and stretch the breast ligament 1.3 Press your hands firmly down on your hips and again, look at your breasts for any changes of size, shape, contour, or dimpling. The pressing down on the hips position contracts the chest wall muscles and enhances any breast changes. 1.4 Check your nipples for discharge (fluid). Place your thumb and forefinger on the tissue surrounding the nipple and pull outward toward the end of the nipple. Look for any discharge. If discharge is present, milk the breast along its radii. Assess discharge for amount, color, consistency, and odor. Repeat on your other breast. The pressing motion pushes any fluid, if any, from the opening. Pulling on the nipple enables you to assess its elasticity and consistency. Milking the breast along its radii enables you to identify the lobe producing discharge.

2. Palpation: Lying Position 2.1 Place a pillow under your right shoulder and place the right hand behind your head. This position allows the breast tissue to spread evenly over the chest wall as thinly as possible, making it much easier to feel all the breast tissue. The shoulders can be elevated by a small pillow placed under them to allow the breasts to rest more symmetrically on the chest wall for more detailed and convenient examination. 2.2 Mark imaginary lines around the breast. Take the nipple as the central point, a horizontal line and a vertical line through the central point departs the breast into four quadrants. This makes it convenient to locate the lesion or masses if any. 2.3 Use the finger pads of the 3 middle fingers (held together) on your left hand to feel for lumps. The pads of the fingers are used because their concentration of nerve endings makes them highly sensitive to tactile discrimination. 2.4 Press the breast tissue against the chest wall firmly enough to know how your breast feels. A ridge of firm tissue in the lower curve of each breast is normal. 2.5 Use small, circular motions systematically all the way around the breast as many times as necessary until the entire breast is covered. Start and end at a fixed point to ensure that all breast surfaces are assessed. 2.6 The left breast should be palpated from the upper lateral quadrant, with a procedure of clockwise direction for thorough examination, The same procedure is adopted for palpation of the right breast with anti-clockwise direction. Pay particular attention to the upper outer quadrant area and the tail of Spence. About 50% of breast cancers develop in the upper outer quadrant area and in the tail of Spence.

2.7 Each quadrant is palpated superficially and then deeply, and the nipple is palpated finally.

Note: Vary the levels of the pressure as you palpate: Light superficial Medium mid-level tissue Light palpation should always precede deeper palpation because heavy pressure on the fingertips can dull the sense of touch. 2.8 Repeat the steps on your left breast.

3. Palpation: Standing or Sitting 3.1 the steps are similar with that of palpating supine. Perform the examination while upright (sitting or standing) with one arm raised behind your head. This position makes it easier to check the area where a large percentage of breast cancers are found, the upper outer part of the breast and toward the armpit. 3.2 Palpate the axillary, subclavicular and supraclavicular lymph nodes. Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. The axilla, supraclavicular region and neck should be palpated carefully, to detect any enlargement of lymph nodes or other abnormalities; these areas are usually involved in inflammatory lesion. Raising your arm straight up tightens the tissue in this area and makes it very difficult to examine.