10/22/24, 1:33 NR509 Final Exam Study Guide
PM 113021
NR 509 Final Exam Study Guide
Chapter 18 Breasts and Axillae
• Techniques of examination
o Inspect the breasts in four views: arms at sides, arms over head, arms pressed
against hips, and leaning forward (skin appearance, size, symmetry, contour, nipple
characteristics).
o Palpate the breasts (consistency, tenderness, nodules, nipple for color, consistency,
and quantity of any discharge).
o Inspect the axillae (rash, irritation, infection, unusual pigmentation).
o Palpate the axillary nodes (size, shape, delimitation, mobility, consistency, and
any tenderness).
o In men:
o Inspect the nipple and areola (nodules, swelling, ulceration).
o Palpate the areola and breast tissue (nodules).
• Anatomy- The female breast lies against the anterior thoracic wall, extending from the clavicle
and second rib down to the sixth rib, and from the sternum across to the midaxillary line. The
breast overlies the pectoralis major and, at its inferior and lateral margins, the serratus
anterior. The glandular tissue of the breast is divided into 15 to 20 segments, or lobes, which
converge in a radial fashion as lactiferous ducts and sinuses before opening on the surface of
the nipple and areola. Each lactiferous duct drains a lobe that is made up of 20 to 40 smaller
lobules, which consist of milk-secreting tubuloalveolar glands. Adipose tissue surrounds the
breast, predominantly in the superficial and peripheral areas. The superficial fascia lies deep
to the dermis, and the deep fascia lies anterior to the pectoralis major muscle. The breast is
attached to the skin by suspensory Cooper ligaments, fibrous bands that travel through the
breast and insert perpendicular to the dermis
• The axilla is a pyramidal structure defined by the axillary vein superiorly, the latissimus dorsi
muscle laterally, and the serratus anterior muscle medially.4 Three important nerves course
through the axilla; these include the thoracodorsal nerve, the long thoracic nerve, and the
intercostobrachial nerve. The thoracodorsal nerve supplies the latissimus dorsi muscle, while
the long thoracic nerve innervates the serratus anterior muscle. The intercostobrachial nerve is
a sensory nerve that innervates the skin of the axilla and upper medial arm. The lymphatic
drainage of the breast is of great importance in the spread of carcinoma, and about three-
quarters of it is to the axillary nodes.
• Female breast/axillae assessment: Redness suggests local infection or inflammatory carcinoma.
Thickening and prominent pores (peau d’orange) suggest breast cancer. Flattening of the
normally convex breast suggests cancer. Asymmetry due to change in nipple direction suggests
an underlying cancer. Eczematous changes with rash, scaling, or ulceration on the nipple
extending to the areola occurs in Paget disease of the breast, associated with underlying ductal
or lobular carcinoma. A nipple pulled inward, tethered by underlying ducts signals nipple
retraction from a possible underlying cancer. The retracted nipple may be depressed, flat,
broad, or thickened.
o Assess with arms over head, Hands on hip and leaning forward- Breast dimpling or
retraction in these positions suggests an underlying cancer. Cancers with fibrous strands
attached to the skin and fascia over the pectoral muscles may cause inward dimpling of
the skin during muscle contraction. Occasionally, these signs accompany benign
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,10/22/24, 1:33 NR509 Final Exam Study Guide
PM 113021
conditions such as posttraumatic fat necrosis or mammary duct ectasia but should
always be further evaluated. Leaning forward- This position may reveal asymmetry or
retraction of the breast, areola, or nipple that is not otherwise visible, suggesting an
underlying cancer.
o Axillae- Sweat gland infection from follicular occlusion (hidradenitis suppurativa) may be
present. Deeply pigmented velvety axillary skin suggests acanthosis nigricans—
associated with diabetes; obesity; polycystic ovary syndrome; and, rarely, malignant
paraneoplastic disorders.
• Lymph nodes-
o Anterior (pectoral) group: Lying along the lower border of the pectoralis minor behind
the pectoralis major, these nodes receive lymph vessels from the lateral quadrants of
the breast and superficial vessels from the anterolateral abdominal wall above the level
of the umbilicus.
o Posterior (subscapular) group: Lying in front of the subscapularis muscle, these
nodes receive superficial lymph vessels from the back, down as far as the level of the
iliac crests.
o Lateral (humeral or deep) group: Lying along the medial side of the axillary vein, these
nodes receive most of the lymph vessels of the upper limb (except those superficial
vessels draining the lateral side).
o Central group: Lying in the center of the axilla in the axillary fat, these nodes receive
lymph from the above three groups. Nodes are also located between the pectoralis
minor and pectoralis major muscles in an area called the Rotter space (Rotter’s
nodes).
o Apical (terminal) group: Lying at the apex of the axilla at the lateral border of the first
rib, these nodes receive the efferent lymph vessels from all the other axillary nodes.
The apical nodes are the final common pathway for all of the axillary lymph nodes.
o Infraclavicular (deltopectoral) group: These nodes are not strictly axillary nodes
because they are located outside the axilla. They lie in the groove between the deltoid
and pectoralis major muscles and receive superficial lymph vessels from the lateral
side of the hand, forearm, and arm.
o Nodes that are large (≥1 to 2 cm) and firm or hard, matted together, or fixed to the skin
or underlying tissues suggest malignancy.
• The male breast-The male breast consists chiefly of a small nipple and areola overlying a thin
disc of undeveloped breast tissue consisting primarily of ducts. In the absence of estrogen and
progesterone stimulation, ductal branching and development of lobules are lacking, and it is
difficult to distinguish male breast tissue from the pectoralis muscle of the chest wall. Some
men develop benign breast enlargement from gynecomastia, a proliferation of palpable
glandular tissue generally defined as more than 2 cm, or pseudogynecomastia, an accumulation
of subareolar fat. Causes of gynecomastia include increased estrogen, decreased testosterone,
and medication side effects. Tender subareolar cords suggest mammary duct ectasia, a benign
but sometimes painful condition of dilated ducts with surrounding inflammation and, at times,
with associated masses. Check for cysts and inflamed areas; some cancers may be tender. Hard
irregular poorly circumscribed nodules, fixed to the skin or underlying tissues, strongly suggest
cancer. strongly suggest cancer.
•
• A mobile mass that becomes fixed when the arm relaxes is attached to the ribs and intercostal
muscles; if fixed when the hand is pressed against the hip, it is attached to the pectoral fascia.
• Breast cancer (including screening and risk factors)- The strongest risk factors for breast cancer
in women are increasing age, first-degree family members diagnosed with breast cancer
about:bl 2/
, 10/22/24, 1:33 NR509 Final Exam Study Guide
PM 113021
about:bl 3/
PM 113021
NR 509 Final Exam Study Guide
Chapter 18 Breasts and Axillae
• Techniques of examination
o Inspect the breasts in four views: arms at sides, arms over head, arms pressed
against hips, and leaning forward (skin appearance, size, symmetry, contour, nipple
characteristics).
o Palpate the breasts (consistency, tenderness, nodules, nipple for color, consistency,
and quantity of any discharge).
o Inspect the axillae (rash, irritation, infection, unusual pigmentation).
o Palpate the axillary nodes (size, shape, delimitation, mobility, consistency, and
any tenderness).
o In men:
o Inspect the nipple and areola (nodules, swelling, ulceration).
o Palpate the areola and breast tissue (nodules).
• Anatomy- The female breast lies against the anterior thoracic wall, extending from the clavicle
and second rib down to the sixth rib, and from the sternum across to the midaxillary line. The
breast overlies the pectoralis major and, at its inferior and lateral margins, the serratus
anterior. The glandular tissue of the breast is divided into 15 to 20 segments, or lobes, which
converge in a radial fashion as lactiferous ducts and sinuses before opening on the surface of
the nipple and areola. Each lactiferous duct drains a lobe that is made up of 20 to 40 smaller
lobules, which consist of milk-secreting tubuloalveolar glands. Adipose tissue surrounds the
breast, predominantly in the superficial and peripheral areas. The superficial fascia lies deep
to the dermis, and the deep fascia lies anterior to the pectoralis major muscle. The breast is
attached to the skin by suspensory Cooper ligaments, fibrous bands that travel through the
breast and insert perpendicular to the dermis
• The axilla is a pyramidal structure defined by the axillary vein superiorly, the latissimus dorsi
muscle laterally, and the serratus anterior muscle medially.4 Three important nerves course
through the axilla; these include the thoracodorsal nerve, the long thoracic nerve, and the
intercostobrachial nerve. The thoracodorsal nerve supplies the latissimus dorsi muscle, while
the long thoracic nerve innervates the serratus anterior muscle. The intercostobrachial nerve is
a sensory nerve that innervates the skin of the axilla and upper medial arm. The lymphatic
drainage of the breast is of great importance in the spread of carcinoma, and about three-
quarters of it is to the axillary nodes.
• Female breast/axillae assessment: Redness suggests local infection or inflammatory carcinoma.
Thickening and prominent pores (peau d’orange) suggest breast cancer. Flattening of the
normally convex breast suggests cancer. Asymmetry due to change in nipple direction suggests
an underlying cancer. Eczematous changes with rash, scaling, or ulceration on the nipple
extending to the areola occurs in Paget disease of the breast, associated with underlying ductal
or lobular carcinoma. A nipple pulled inward, tethered by underlying ducts signals nipple
retraction from a possible underlying cancer. The retracted nipple may be depressed, flat,
broad, or thickened.
o Assess with arms over head, Hands on hip and leaning forward- Breast dimpling or
retraction in these positions suggests an underlying cancer. Cancers with fibrous strands
attached to the skin and fascia over the pectoral muscles may cause inward dimpling of
the skin during muscle contraction. Occasionally, these signs accompany benign
about:bl 1/
,10/22/24, 1:33 NR509 Final Exam Study Guide
PM 113021
conditions such as posttraumatic fat necrosis or mammary duct ectasia but should
always be further evaluated. Leaning forward- This position may reveal asymmetry or
retraction of the breast, areola, or nipple that is not otherwise visible, suggesting an
underlying cancer.
o Axillae- Sweat gland infection from follicular occlusion (hidradenitis suppurativa) may be
present. Deeply pigmented velvety axillary skin suggests acanthosis nigricans—
associated with diabetes; obesity; polycystic ovary syndrome; and, rarely, malignant
paraneoplastic disorders.
• Lymph nodes-
o Anterior (pectoral) group: Lying along the lower border of the pectoralis minor behind
the pectoralis major, these nodes receive lymph vessels from the lateral quadrants of
the breast and superficial vessels from the anterolateral abdominal wall above the level
of the umbilicus.
o Posterior (subscapular) group: Lying in front of the subscapularis muscle, these
nodes receive superficial lymph vessels from the back, down as far as the level of the
iliac crests.
o Lateral (humeral or deep) group: Lying along the medial side of the axillary vein, these
nodes receive most of the lymph vessels of the upper limb (except those superficial
vessels draining the lateral side).
o Central group: Lying in the center of the axilla in the axillary fat, these nodes receive
lymph from the above three groups. Nodes are also located between the pectoralis
minor and pectoralis major muscles in an area called the Rotter space (Rotter’s
nodes).
o Apical (terminal) group: Lying at the apex of the axilla at the lateral border of the first
rib, these nodes receive the efferent lymph vessels from all the other axillary nodes.
The apical nodes are the final common pathway for all of the axillary lymph nodes.
o Infraclavicular (deltopectoral) group: These nodes are not strictly axillary nodes
because they are located outside the axilla. They lie in the groove between the deltoid
and pectoralis major muscles and receive superficial lymph vessels from the lateral
side of the hand, forearm, and arm.
o Nodes that are large (≥1 to 2 cm) and firm or hard, matted together, or fixed to the skin
or underlying tissues suggest malignancy.
• The male breast-The male breast consists chiefly of a small nipple and areola overlying a thin
disc of undeveloped breast tissue consisting primarily of ducts. In the absence of estrogen and
progesterone stimulation, ductal branching and development of lobules are lacking, and it is
difficult to distinguish male breast tissue from the pectoralis muscle of the chest wall. Some
men develop benign breast enlargement from gynecomastia, a proliferation of palpable
glandular tissue generally defined as more than 2 cm, or pseudogynecomastia, an accumulation
of subareolar fat. Causes of gynecomastia include increased estrogen, decreased testosterone,
and medication side effects. Tender subareolar cords suggest mammary duct ectasia, a benign
but sometimes painful condition of dilated ducts with surrounding inflammation and, at times,
with associated masses. Check for cysts and inflamed areas; some cancers may be tender. Hard
irregular poorly circumscribed nodules, fixed to the skin or underlying tissues, strongly suggest
cancer. strongly suggest cancer.
•
• A mobile mass that becomes fixed when the arm relaxes is attached to the ribs and intercostal
muscles; if fixed when the hand is pressed against the hip, it is attached to the pectoral fascia.
• Breast cancer (including screening and risk factors)- The strongest risk factors for breast cancer
in women are increasing age, first-degree family members diagnosed with breast cancer
about:bl 2/
, 10/22/24, 1:33 NR509 Final Exam Study Guide
PM 113021
about:bl 3/
