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Normal Findings
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Deviation from Normal
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1.
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Inspect the breasts for size, symmetry, and contour or shape while the client is in a sitting position.
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Females: rounded shape; slightly unequal in size; generally symmetric
Males: breast even with the chest wall; if obese, may be similar in shape to female breast
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Recent change in breast size; swellings; marked assymetry
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2.
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Inspect the skin of the breast for localized discolorations or hyperpigmentation, retraction or dimpling, localized hypervascular areas, swelling, or edema.
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Skin uniform in color;
Smooth and intact;
Diffuse symmetric horizontal or vertical vascular pattern in light-skinned people;
Striae;
Moles and nevi
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Localized discoloration or hyperpigmentation;
Retraction or dimpling;
Unilateral, localized hypervascular;
Swelling or edema appearing as pig skin or orange peel due to exaggeration of pores.
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3.
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Emphasize any retraction by having the client:
• Raise arms above head;
• Push the hands together, with elbows flexed; and
• Press hands down on hips.
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No retraction
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Presence of retraction
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4.
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Inspect the areola area for size, shape, symmetry, color, surface characteristics, and any masses or lesions.
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Round or oval and bilaterally the same;
Color varies widely, from light pink to dark brown;
Irregular placement of sebaceous glands on the surface of the areola
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Any assymetry, mass or lesion
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5.
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Inspect the nipples for size, shape, position, color, discharge, and lesions.
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Round, everted, and equal in size; similar in color; soft and smooth; both nipples point in the same direction;
No discharge, except from pregnant or breast-feeding females;
Inversion of one or both nipples that is present from puberty;
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Assymetrical size and color;
Presence of discharge, crusts or cracks;
Recent inversion of one or both nipples
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6.
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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
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No tenderness, muscles or nodules
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Tenderness, masses or nodules
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7.
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Palpate the breast for masses, tenderness, and any discharge from the nipples.
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No tenderness, masses, nodules, or nipple discharge
No tenderness, masses, nodules, or nipple discharge
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Tenderness, masses, nodules, or nipple discharge
Tenderness, masses, nodules, or nipple discharge
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9.
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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.
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No tenderness, masses, nodules, or nipple discharge
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Tenderness, masses, nodules, or nipple discharge
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