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School of Nursing
Christopher W. Blackwell, Ph.D., ARNP-C
Assistant Professor, School of Nursing
College of Health & Public Affairs
University of Central Florida
NGR 5003: Advanced Health Assessment & Diagnostic Reasoning
Unit Four: Dermatological, Breasts, & Axillae :





Basic assessment of the dermatological system, breasts, and axillae
Advanced assessment of the dermatological system, breasts, and axillae
Assessment findings of abnormal presentations in the dermatological system, breasts,
and axillae
Differential diagnoses of the dermatological system, breasts, and axillae
Advanced Clinical reasoning: A case study approach
ADVANCED ASSESSMENT OF SKIN, HAIR, AND NAILS
LEARNING OBJECTIVES
1. Conduct a history related to skin, hair, and nails.
2. Discuss examination techniques for skin, hair, and nails.
3. Identify normal age and condition variations of skin, hair, and nails.
4. Recognize findings that deviate from expected findings.
5. Relate symptoms or clinical findings to common pathologic conditions.
1
Outline for Chapter 8: Skin, Hair, and Nails
Anatomy and Physiology
 Skin provides an elastic, rugged, self-regenerating, protective covering for the body.
 The skin and its appendages are our primary physical presentation to the world.
 Skin structure and physiologic processes perform the following integral functions:
 Protect against microbial and foreign substance invasion and minor physical
trauma
 Retard body fluid loss by providing a mechanical barrier
 Regulate body temperature through radiation, conduction, convection, and
evaporation
 Provide sensory perception via free nerve endings and specialized receptors
 Produce vitamin D from precursors in the skin
 Contribute to blood pressure regulation through constriction of skin blood vessels
 Repair surface wounds by exaggerating the normal process of cell replacement
 Excrete sweat, urea, and lactic acid
 Express emotions
Epidermis
 The epidermis, the outermost part of the skin, consists of two major layers:
 The stratum corium provides protection. It is composed of dead squamous cells
containing keratin.
 The cellular stratum synthesizes keratin cells.
 The basement membrane, below the cellular stratum, connects the epidermis to the
dermis.
 Stratum lucidum is found only in thicker skin of palms and soles.
 The epidermis is avascular and gets nutrition from the dermis.
Dermis
 The dermis is vascular connective tissue. It separates the epidermis from the
cutaneous adipose tissue.
 Elastin, collagen, and reticulin fibers provide strength and stability.
 The dermis contains sensory and autonomic motor nerve fibers.
Hypodermis
 The hypodermis consists of connective tissue containing fatty cells. Adipose tissue
generates heat and provides insulation and caloric reserve.
2
Appendages
 Appendages are formed from the epidermis invaginating into the dermis.
 Eccrine sweat glands secrete water and regulate body temperature.
 Apocrine glands are deeper glands that respond to emotional stimuli by secreting
odorless white fluid.
 Sebaceous glands secrete sebum as regulated by hormonal levels.
 Hair consists of epidermal cells in the dermal layers. Vellus hair is short, fine, soft,
and nonpigmented. Terminal hair is coarser, longer, thicker, and usually
pigmented.
 Nails are hard plates of keratin. The pink color is from vascular beds under the
plate. The cuticle is stratum corium that covers the nail root. The paronychium is
soft tissue surrounding nail border.
Age- and Condition-Related Variations
 Infants and children. The skin of young people is smoother than that of adults
and lacks terminal hair. After birth, there is variable desquamation. Vernix
caseosa, a mixture of sebum and cornified epidermis, covers the infant’s body at
birth. Lanugo hair is found on shoulders and back. It is shed in about 2 weeks after
birth. Head hair is shed by 2 to 3 months and is replaced by more permanent hair.
Eccrine sweat glands function after the first month of life. Inactive apocrine
glands make the skin less oily.
 Adolescents. During puberty, the apocrine glands enlarge and become active.
Sebaceous glands increase sebum production, which gives an oily appearance and
predisposes the individual to acne. Coarse terminal hair appears in axillae and
pubic area.
 Pregnant women. During pregnancy, increased blood flow results from peripheral
vasodilation and increased capillaries. Sweat and sebaceous gland activity
increases. Skin thickens and fat is deposited in subdermal layers. Increased
pigmentation occurs from hormonal changes.
 Older adults. With age, sebaceous and sweat gland activity decreases. Epidermis
thins and flattens. Vascularity in dermis decreases and becomes less elastic.
Cutaneous tissue decreases. Gray hair occurs from a decrease in the number of
functioning melanocytes. Density and rate of hair growth decline. Nail growth
slows and nails become thicker, brittle, and yellow. They also develop ridges and
are prone to split.
3
Review of Related History
History of Present Illness
 Skin. Patients with skin problems should be asked about changes in skin such as
warts, moles, or lesions, as well as temporal sequence, symptoms, and location of
any skin occurrence. Associated symptoms and factors, such as high temperature,
exposure to drugs, and travel history should be listed. Patient’s response to the
problem and any home treatment should be noted. Patient’s perception of the
cause of the condition should also be explored.
 Hair. Data relevant to a hair condition include the following: changes in hair
patterns, occurrence or recurrence of problem, associated symptoms and factors
(e.g., itching or drug exposures), dietary habits, patient’s reaction to the problem,
and factors affecting condition.
 Nails. Patients with nail conditions should be asked about the following: any
changes in their nails, symptoms (e.g., pain or swelling), temporal sequence of the
problem, recent exposures, and things making condition better or worse.
Past Medical History
 Skin. Data relevant to the past medical history include previous skin problems
(e.g., skin reactions or lesions), exposure to sunlight, changes in sensory stimuli,
and systemic diseases affecting skin.
 Hair. Patients with hair conditions should be questioned about any previous hair
problems (e.g., loss of hair), pattern changes, and systemic problems (e.g., thyroid
disease).
 Nails. Past medical history should include data on previous nail problems (e.g.,
infections) and systemic problems (e.g., cardiac conditions) that could influence
nail condition.
Family History
 Relevant data include current or past dermatologic diseases of family members,
allergic hereditary diseases or skin disorders, and familial hair patterns.
Personal and Social History
 Pertinent data include skin care habits (e.g., cosmetic use and sun exposure), hair
care habits (e.g., cleansing routine, as well as the use of any coloring or permanent
products), nail care habits, use of medications, exposure to environmental or
occupational hazards, and any recent psychologic or physiologic stress.
4
Age- and Condition-Related Variations
 Infants. Relevant data include feeding and diaper history, types of clothing,
products used to wash clothes, bath practices, habits of dressing the infant, and the
home environment.
 Children. Explore eating patterns, disease exposure, allergic disorders and
reactions, previous skin injury, hair manipulation, and nail-biting habits.
 Pregnant women. Pertinent data include weeks of gestation or postpartum,
hygienic practices, presence of prior skin lesions, and effects of pregnancy on
previous skin lesions.
 Older adults. Ask older patients about changes in touch sensation, chronic itching,
susceptibility to skin infections, changes or slowness in healing, history of falling,
diabetes, vascular diseases, or hair loss.
See Risk Factors: Basal and Squamous Cell Carcinoma (p. 214) and Risk Factors:
Melanoma (p. 215).
Examination and Findings
Summary of Examination—Skin, Hair, and Nails
Skin
 Ensure adequate lighting.
 Assess skin contour, symmetry, color.
 View exposed and unexposed areas.
 Describe lesions according to characteristics, exudates, location, and distribution.
 Use flashlight to see color, elevation, and borders of lesions.
 Use a Wood’s lamp to detect the presence of fungal infection.
 Smell skin odors.
 Feel skin for moisture, temperature, texture, turgor, and mobility.
 Use dorsal surface of hands and fingers to palpate skin temperature.
 View cysts and masses.
Hair
 Assess color, distribution, and quantity of hair.
 Palpate texture.
 Note any hair loss, inflammation, or scarring.
Nails
 Note nail color, length, configuration, angle at the base, and symmetry.
 Observe nail folds for signs of infection, warts, cysts, or tumors.
 Squeeze nail to test adherence.
5
Summary of Skin, Hair, and Nail Findings
Life Cycle
Variations
Adults
Normal
Findings
Typical
Variations
Thinnest skin is on eyelids.
Callused areas are yellow.
Thickest is on soles, palms,
Skin striae, freckles, birth
and
marks, nevi, and melasma
elbows.
uniform,
except
Color
in
is
sun-
exposed areas.
may be present.
Freckling of buccal cavity,
Skin temperature is even
gums,
Texture is smooth, soft, and
present
even.
Findings Associated
with Disorders
and
in
tongue
some
is
dark-
skinned persons.
Skin is resilient. Scalp hair is
Color hues in dark- skinned
shiny, smooth, and resilient.
persons are best seen in
Nail color is a variation of
pink.
Nail edges are smooth and
rounded.
the sclera, mucosa, and
nail beds.
Lips and gums are bluish in
dark-skinned persons.
6
Life Cycle
Variations
Infants
and
children
Normal
Findings
Newborn skin may be red.
Vernix caseosa is a normal
birth covering.
trimmed
scratching.
Findings Associated
with Disorders
At birth, generalized lanugo
Newborn skin distortions suggest
suggests prematurity.
Physiologic
Newborn nails may need to
be
Typical
Variations
to
prevent
masses, nodules, or tumors.
jaundice
is
The
presence
erythema,
common.
Primary
irritant
or
eczematous dermatitis may
of
patches,
scaling,
crusts,
fissures, vesicles, lesions, and
skin irregularities in children
requires investigation.
cause localized lesions.
Skin roughness may result
from clothing, coldness, or
Localized
redness
suggests
inflammation.
Hemorrhage results from injury,
soap.
Nail shape and opacity vary.
steroids, or systemic disorders.
Fluid-filled lesions show red
Pigment deposits may be
present
persons.
in
dark-skinned
Darkened
nails
may result from antimalarial
drug
treatment
or
shoe
trauma.
result from mild trauma.
Peeling nails may occur
with water exposure.
ridging
beading are common.
with
transillumination.
Generalized
lesions
may
indicate a systemic disorder,
allergy,
or
genetic
disorder.
Annular patterns are associated
with
White spots in nail plate may
Longitudinal
glow
pityriasis
rosea,
tinea
corporis and cruris, urticaria.
Connective tissue diseases lead
to changes in skin mobility.
Asymmetric hair loss in males
and
may
indicate
a
pathologic
condition. Female alopecia or
female hirsutism in male hair
patterns may indicate pathology.
Yellow
nails
occur
with
psoriasis, fungal infections, and
respiratory disease. Darkened
nails can result from Candida
infection or hyperbilirubinemia.
Green-black nails are caused by
Pseudomonas
subungual
infection
hematoma.
or
Nail
depression and clubbing occur
from
systemic
disease.
Separation of nail plate from
bed results from psoriasis and
infections.
7
Life Cycle
Variations
Adolescents
Normal
Findings
Typical
Variations
Findings Associated
with Disorders
Adolescents are prone to
Perspiration may result from
Fine or coarse hair and hair loss
acne
from
changes.
hormonal
Terminal
hair
develops at puberty.
women
may
Nail hygiene is a clue about
due
to
thyroid
conditions.
social levels.
During pregnancy, there are
Increased
peripheral vasodilation and
occur
increased capillaries.
changes.
Sweat and sebaceous gland
causes
pigmentations
from
hormonal
Pregnancy
striae,
vascular
spiders, and acne in some.
activity increases.
Palmar erythema., a diffuse
Vascular
spiders
redness that covers the
entire palmar surface or the
present may increase in
thenar
size.
hypothenar
that
and
hemangiomas
and
be
self-care and emotional and
Body odors develop.
Pregnant
anxiety or obesity.
are
eminence, is a common
finding in pregnancy and
usually
disappears
after
delivery.
Older adults
Skin
becomes
transparent,
pale,
wrinkled,
more
Graying hair occurs as a
dry,
result of a decrease in
keratosis are skin conditions
and
functioning melanocytes.
that affect older adults. Cardiac
hyperpigmented with aging.
Hair becomes coarser with
age.
Nails thicken and become
more brittle with age.
Balding patterns in men are
genetically
determined.
Stasis
dermatitis
disease
and
solar
influences
nail
conditions.
Several types of lesions
may be present:
- Cherry angiomas
- Sebaceous hyperplasia
- Cutaneous tags/horns
- Senile lentigines
 See Box 8-1: Patient Instructions for Skin Self-Examination (p. 174).
 See cultural differences discussed in the Physical Variations boxes (pp. 171, 176,
177, 191, 200, and 202) and Box 8-2: Cutaneous Manifestations of Traditional
Health Practices (p. 176).
 See the Mnemonics box for melanoma (p. 215).
 See Table 8-1 (p. 177), Table 8-2 (p. 177) and Table 8-3 (p. 178), which describe
nevi, moles, and cutaneous color changes.
8
 See Figure 8-7 (p. 180), Table 8-4 (pp. 183 to 185), Table 8-5 (pp. 186 to 188),
and Figure 8-15 (p. 193) for skin lesion and nail drawings.
 See Figures 8-10, 8-11, and 8-12 (p. 190) for various patterns of skin lesions.
 See Box 8-5: Expected Color Changes in the Newborn (p. 195); Risk Factors box:
Hyperbilirubinemia in the Newborn (p. 195); Box 8-6: Skin Lesions: External
Clues to Internal Problems (p. 196); and Table 8-7: Estimating Dehydration (p.
199).
 See Box 8-7: Staging of Decubitus Ulcers (p. 202).
 See Table 8-6: Morphologic Characteristics of Skin Lesions (p. 189).
ADVANCED ASSESSMENT OF BREASTS AND AXILLAE
LEARNING OBJECTIVES
1.
2.
3.
4.
5.
Conduct a history related to the breasts and axillae.
Discuss examination techniques for the breasts and axillae.
Identify normal age and condition variations to the breasts and axillae.
Recognize findings that deviate from expected findings.
Relate symptoms or clinical findings to common pathologic conditions.
Outline for Chapter 16: Breasts and Axillae
Anatomy and Physiology
 The breasts are paired mammary glands located on the anterior chest wall,
superficial to the pectoralis major and serratus anterior muscles. In women, the
breast extends from the second or third rib to the sixth or seventh rib, and from the
sternal margin to the midaxillary line. The nipple is located in the center,
surrounded by the areola.
 The female breast is composed of glandular and fibrous tissue (which provides
support for the breast) and fat (subcutaneous and retromammary) in proportions
that vary with age, genetic predisposition, nutritional status, and pregnancy.
 The glandular tissue of the breast is arranged into lobes, each composed of lobules
of milk-producing acini cells that empty into lactiferous ducts during lactation.
 Vascular supply to the breast is primarily through branches of the internal
mammary and the lateral thoracic artery.
 For purposes of examination, the breast is divided into five segments: four
quadrants and the tail of Spence.
9
 Contraction of the circular and longitudinal muscles in the nipple, induced by
tactile, sensory, or autonomic stimuli, causes the milk ducts to empty. Nipple
erection is supported by venous stasis in the erectile vascular tissue. Nipples range
in color from pink to black.
 Each breast contains a lymphatic network (pectoral, subscapular, central, and
brachial) that drains the breast radially and deeply.
Age- and Condition-Related Variations
 Childhood and preadolescence. Childhood and preadolescence represent a latent
phase of breast development when some branching of the primary ducts occurs.
Tanner’s five stages of developing sexual maturity in temporal relationship to
menarche are useful in assessing breast development. Thelarche (breast
development) represents an early sign of puberty in adolescent girls. Breasts
develop at different rates, which can result in asymmetry.
 Pregnant women. During pregnancy, breasts become soft, loose, and enlarged.
They develop darker, wider areolae with Montgomery tubercles. Breasts exhibit a
visible network of veins. Colostrum, containing antibodies and other host resistant
factors, is produced.
 Lactating women. Engorgement is caused by tissue edema and the filling of
alveoli and lactiferous ducts. Two to 4 days after delivery, high-protein milk
replaces colostrum. By the tenth day, protein decreases and lactose increases; this
stabilizes by 1 month. After termination of lactation, breast size decreases, but
seldom to prelactation size.
 Menopausal and older adults. A moderate decrease in glandular tissue and
decomposition of alveolar and lobular tissue occurs before menopause. After
menopause, glandular tissue atrophies and is replaced by fat. In older adults, the
inframammary ridge thickens, suspensory ligaments loosen, and nipples become
smaller, flatter, and less erectile. Skin may become thin and dry, and axillary hair
may decrease.
Review of Related History
History of Present Illness
 Patients with a breast or axilla problem should be asked to describe discomfort,
temporal sequence, relationship to menses, characteristics, nipple retractions,
masses and discharges, relationship to external irritants, and enlargement or
tenderness in the lymph nodes.
 Breast discomfort/pain. Assess temporal sequence, relationship to menses,
character (e.g., pulling, burning, drawing, stabbing, aching, throbbing), any
associated symptoms or contributory factors, and medications taken.
10
 Breast mass or lump. Assess temporal sequence, relationship to menses,
symptoms such as tenderness or pain, changes in lump, any associated symptoms,
and medications taken.
 Nipple discharge. Assess character, any associated symptoms, associated factors,
and medications taken.
Past Medical History
 Pertinent data include previous breast diseases, diagnostic tests, surgeries and
treatment, menstrual history, pregnancy and breast-feeding history, risk factors for
both benign breast disease and breast cancer risks, and the past use of hormonal
and other medications.
Family History
 Family history should include occurrence of breast cancer or other breast disease
in any relative (male or female). Data should be specific as to age at occurrence,
treatment, and results.
Personal and Social History
 Relevant data include age, cyclic and noncyclic changes in breast characteristics,
menstrual or menopausal status, use of breast support, caffeine intake, alcohol
intake, breast self-examination, self-care, use of hormonal medications, and risk
factors for cancer.
Age- and Condition-Related Variations
 Pregnant women. Ask patient about sensations in the breast (fullness, tingling,
tenderness), use of a supportive brassiere, and plans for breast-feeding.
 Lactating women. Data specific to lactating women include self-care habits,
nursing routines, associated problems, cultural beliefs, diet, and medications.
 Older adults. Relevant data include occurrence and treatment of skin irritation and
the use of postmenopausal hormone therapy.
See Risk Factors: Breast Cancer (p. 497).
11
Examination and Findings
Summary of Examination—Breasts and Axillae
Breasts
Inspection
 Examine breasts for size, symmetry, contour, skin color and texture, venous patterns,
and lesions.
 Use several positions for inspection:
 Seated, arms hanging loosely at sides
 Seated, arms extended over head
 Seated, hands pressed against hips
 Seated, hands pressed together
 Leaning forward from the waist
Nipples
Inspection
 Examine nipples for symmetry, direction, contour, color, and texture.
 Mnemonics: Five Ds Related to Nipples
Breasts and Axillae
Palpation
 Palpate breasts and axillae with patient in sitting position with arms hanging freely at
sides.
 Use finger pads and push toward chest in systematic pattern. Use light and then
heavier pressure without lifting fingers.
 Palpate the tail of Spence in each breast, gently compressing the tissue between your
thumb and fingers.
 Continue palpation with the patient in the supine position. Have her raise one arm
behind her head and place a small pillow or folded towel under the shoulder.
 Gently compress the nipple and massage around the areolae.
 Use palmar finger surfaces to palpate into the axillary hollow for lymph nodes.
12
Summary of Breasts and Axillae Findings
Life Cycle
Variations
Adults
Normal
Findings
Breasts
are
Typical
Variations
Findings Associated
with Disorders
nearly
Benign, soft, mobile,
Carcinoma is suspected when
equal in size and
fluid-filled, bilateral
there is peau d’orange color
bilaterally convex.
cysts
from
Breasts have equal
smoothness,
may be present.
and
pigmentation.
venous
mobile
and
(adult
Breast sizes vary.
nipples
and
Breast pairs may also
areolae
are
Striae may be visible.
are
Healthy, large skin
and
pores
tubercles
are
normal.
Breast
dense,
may
pores
seen
with
malignancy. Usual
skin markings and
tissue
is
firm,
and
nevi
may
venous
and
nipple
discharge.
vary in size.
resemble
unilateral
patterns
and
Montgomery
dimpling;
pores; unilateral inversion;
bilateral,
nonsuppurative.
or
smooth, firm, and
may
gynecomastia).
nontender
retractions
be
tissue
are
Breasts
lymph
thickened skin and enlarged
markings
bilaterally equal.
blocked
drainage; nipple inversion,
In some males, breast
contour,
Slight
(fibrocystic)
be
present.
Red, scaling, crusty patch on
nipples
suggest
ductal
cancer.
Bilateral firm, rubbery, mobile
masses (fibroadenoma) may
suggest malignancy. Tumors
of
subareolar
ducts
(papillomas) are suggestive
of malignancy. Hard, fixed,
single,
stonelike
mass
suggests malignancy.
elastic.
Infants and
Children
At birth, breasts may
Supernumerary
Female
prepubertal
breast
be enlarged from
nipples may look
enlargement
maternal estrogen.
like
menarche) may be present.
Newborns may also
have a milky nipple
discharge.
moles.
nipples
Both
may
(premature
be
bilaterally inverted.
Montgomery
tubercles may be
present.
Adolescents
Breasts
of
adolescents
female
may
be asymmetric.
Breasts
develop
different
at
rates,
Boys’ breasts may be enlarged
(gynecomastia).
which can result in
increased
temporary
asymmetry.
During
menstrual
13
Life Cycle
Variations
Normal
Findings
Typical
Variations
Findings Associated
with Disorders
cycle, there may
be
increased
nodularity
and
tenderness.
Pregnant
women
Pregnancy
causes
breast
tingling,
tenderness,
and
size increase.
Nipples enlarge and
colostrum appears.
Venous
from
networks
obesity
or
After
termination
during
lactation,
breasts
may
become
size decreases but
swollen,
inflamed,
seldom
infected (mastitis).
lactation,
of
breast
to
Particularly
and
prelactation size.
Spider
veins
may
occur on the upper
chest.
pregnancy may be
present.
Breasts
are
nodular
more
during
pregnancy.
delivery,
may
After
breasts
be
warm,
hard,
reddened,
and
shiny
(engorged).
Breasts are less firm
and
nipples
darker
are
after
lactation.
Older adults
Some premenopausal
decrease
in
glandular
alveolar
Breasts
of
postmenopausal
women
may
experience
be
and lobular tissue
flatter, longer, and
occurs.
more relaxed from
After
menopause,
glandular
atrophies
tissue
and
replaced by fat.
is
chest wall.
Breasts
of
Menopausal
women
may
blocked
subareolar ducts (mammary
duct ectasia).
Firm, discolored, irregular mass
can result from fat necrosis in
older
response to local injury.
women are more
fine and granular.
14
 See Box 16-1: Breast Self-Examination (pp. 498 and 499); Box 16-2: Screening
for Breast Cancer (p. 500); and Box 16-4: Examining the Patient Who Has Had a
Mastectomy (p. 511).
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of
Elsevier Inc
Course Lecture Content:
Dermatological System; Breasts and Axillae:
•
•
•
Advanced assessment of the dermatological system, breasts, and axillae
Assessment findings of abnormal presentations in the
dermatological system, breasts, and axillae
Differential diagnoses of the dermatological system,
breasts, and axillae
Christopher W. Blackwell, Ph.D., ARNP-C
Assistant Professor, School of Nursing
College of Health & Public Affairs
University of Central Florida
NGR 5003: Advanced Health Assessment & Diagnostic Reasoning






Advanced Assessment of Dermatological System
Anatomy and Physiology:
Skin protects against infection and invasion/ minor trauma
Retard body fluid loss through mechanical barrier
Regulate body temp though radiation, conduction, convection, and evaporation
Sensory perception via nerve endings







Produce vitamin D
Help regulate BP through constriction of skin blood vessels
Repair surface skin wounds
Excrete sweat, urea, and lactic acid
Express emotions
Epidermis:
Outermost layer, consists of stratum corneum and cellular stratum
15
 Connects to the dermis via the basement membrane
 Dermis:
 Vascular connective tissue layer supporting and separating epidermis from SQ
adipose
 Sensation of pain, temperature, and touch received in dermis
 Hypodermis:
 SQ layer, rich with connective tissue and adipose cells
 Appendages:
 Eccrine sweat glands, spocrine sweat glands, sebaceous glands
 Vellus and terminal hair
 Nails: eponychium, nail bed, nail plate, paronychium, lunula, cuticle






Advanced Assessment of Dermatological System
Infants and Children:
Skin smoother due to absence of terminal hair and exposure
Vernix caseosa covers the child at birth
SQ layer undeveloped, leading to potential hypothermia
Newborn covered with fine silky hair called lanugo (shed within 10-14 days after
birth); eccrine glands function within a month (no apocrine function)





Adolescents:
Apocrine glands enlarge and become active
Androgen stimulates sebum production, increasing oily skin and acne
Pregnant Women:
Blood flow increases to skin from inc. in # of capillaries and vasodilation (spider
hemangiomas/ telegenctasia); sebaceous gland activity inc.; fragility of tissues
increases due to elastin (separation); pigment increases on face, nipples, areolas,
vulva, perianal skin, and umbilicus
 Older Adults:
 Sebaceous/sweat gland activity decreases (xerosis)
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Dermis becomes less elastic, losing collagen and elastic fibers
Wrinkling increases due to lifelong sun exposure
Functioning melanocytes decrease, graying the hair
Terminal hair begins to soften to vellus, vellus coarsens to terminal
 Advanced Assessment of Dermatological System
 Anatomic Structure of the Skin
 Advanced Assessment of Dermatological System
16
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Review of Related Hx:
Hx of Present Illness:
Skin:
Changes in dryness, pruritus, sores, rashes, lumps, discolorations, changes in
lesions, non-healing areas
 Temporal sequence: date of onset (sudden/gradual), time sequence of
occurrence/development, date of recurrence
 Location: skinfolds, extensor/flexor surfaces, local/general
 Associated Symptoms: presence of systemic disease, fever, sweats, chills,
stress/leisure activity
 Recent exposure to drugs, environmental/occupational toxins, others w/ skin
conditions
 Patient’s perception of cause
 Travel Hx: where, when, length of stay, exposure to environment/people/diseases
 Self-treatment, response, aggravating/alleviating factors
 Affects on ADL, self-concept, etc.
 Rx: topical or systemic; nonRx/Rx
 Hair:
 Changes in loss, growth, distribution, texture, color
 Occurrence: sudden/gradual, symmetric vs. asymmetric patterns, recurrent
 Associated symptoms: pain, itching, lesions, systemic diseases, fever, physiologic/
psychological stress
 Exposure to Rx, environmental/occupational chemicals, commercial hair care
products
 Nutrition: Lipid deficiency; dietary changes/dieting
 Self-treatment, response, aggravating/alleviating factors
 Affects on self-concept, etc.
 Rx: Rx/Non-Rx; hair loss Tx (Propecia, Minoxidil, etc.)
 Advanced Assessment of Dermatological System
 Nails:
 Changes: splitting, breaking, discoloration, ridging, thickening, markings,
separation from nail bed
 Recent Hx: systemic illnesses/fever, trauma, psych/physiologic stress
 Associated pain, edema, exudate
 Temporal: sudden or gradual onset, relationship to injury of nail/finger
17
 Recent exposure to Rx, environmental/occupationa; chemicals, frequent
immersion in water
 Self-treatment, response, aggravating/alleviating factors
 Rx: Rx/NonRx
 Past Medical Hx:
 Skin: Previous conditions/problems, allergic reactions (describe lesion), Tx;
tolerance to sunlight, diminshed/heightened sensitivity to stimuli; cardiac,
respiratory, hepatic, endocrine, or other systemic diseases
 Hair: Previous problems, loss, thinning, usual growth/distribution, brittleness,
breakage, Tx; systemic problems (thyroid/hepatic disorder, severe illness,
malnutrition, skin disorder)
 Nails: Previous problems/injury (bacteria/fungi/virus); systemic problems
(associated skin disorder, congenital anomalies, respiratory, cardiac, endocrine,
hematologic, or other systemic disease
 Advanced Assessment of Dermatological System
 Family Hx: Current/past dermatological diseases, melanoma/CA, pruritus,
allergies, bacterial/fungi/viral infections; hereditary allergic diseases (asthma/hay
fever); familial loss or hair coloration patterns
 Personal and Social Hx:
 Self-care: soaps, oils, lotions, cosmetics, home remedies/preparations, sun
exposure/protection patterns, recent changes in self-care
 Assess monthly performance of SSE (8-1)
 Hair care habits: cleaning routine, shampoos/rinses used, coloring preparations,
perms, recent changes in care
 Nail care habits: difficulty in clipping nails; instruments used; biting
 Exposure to environment/occupation toxins (dyes, chemicals, plants, toxins,
frequent immersion of hands in water, sun exposure)
 Psych/physiologic stress; Use of ETOH; Smoking/recreational drugs
 Infants:
 Feeding Hx (breat/bottle, type of formula, what/when foods introduced
 Diaper Hx: type of diaper used, skin cleaning routines, use of rubber pants,
washable diapers (how cleaned)
 Types of clothing and washing practices (soap, detergents, new blanket/clothing)
 Bath practices (soaps, oils, lotions)
 Dress Habits: amount and type of clothing related to environmental temp
 Temp and humidity of home environment (AC/heat/humidification)
 Rubbing head against mattress, rug, furniture, wall
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Advanced Assessment of Dermatological System
Children:
Eating habits: food allergens; chocolate, candy, soft drinks, bubble gum
Allergies: eczema, urticaria, pruritus, hay fever, asthma, chronic resp. disorders
Pet/animal exposure; outdoor exposures from playing, hiking, camping, picnics
Skin injury Hx: frequency of falls, cuts, abrasions, unexplained injuries
Chronic manipulation of hair/nail biting
Pregnant Women:
Weeks of gestation/postpartum
 Hygiene practices; exposure to irritants; presence of skin problems before
pregnancy (acne tends to worsen)
 Effects of pregnancy on preexisting conditions: psoriasis may remit; condylomata
acuminata become longer and more numerous
 Older Adults:
 Increased/decreased sensation to touch/environment
 Generalized chronic pruritus: exposure to skin irritants, detergents, lotions (w/
high ETOH content), woolen clothing, humidity of environment
 Susceptibility to skin infectionsl healing responsesl frequent falls resulting in
hematomas/ cuts/abrasions
 Hx of DM or PVD; hair loss Hx (gradual vs. sudden; symmetric vs. asymmetric
loss pattern)
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Advanced Assessment of Dermatological System
Examination and Findings:
Skin:
Inspection:
Adequate lighting is essential; daylight best for color detecting
Examine the entire body: assess distribution and extent of lesions, symmetry of
body surfaces, detect different body areas, and compare sun-exposed to non-sunexposed areas
Remove all clothing (provide privacy); pay careful attention to intertriginous
surfaces, especially in bed-riddin and older clients
Assess for presence of lesions, color and uniform thickness, symmetry, hygiene
Skin thinnest on eyelids, thickest soles, elbows, and palms; not callusing on hands
and feet
Darker skin expected around knees and elbows
19
 Nevi present in everyone; differing locations; may be flat, slightly raised, domeshaped, smooth, rough, or hairy (tan, gray, shades of brown-to-black); Most
harmless—may be dysplastic, pre/cancerous
 Cancerous nevi appear on the upper back in men and legs in women
 Cholama (mask) on face common in pregnancy
 Color- hues in dark persons best seen in sclera, conjunctiva, buccal mucosa,
tongue, nail beds, and palms
 Hyperpigmented macules normal on soles of feet; freckling normal in buccal
mucosa, gums, and tongue; slight bluish color to lips/gums normal in darkskinned; muddy sclera
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Abnormal Dermatological Presentations
Pathological Vascular Skin Lesions
Advanced Assessment of Dermatological System
Palpation:
Palpate for moisture, temperature, texture, turgor, and mobility
Dampest areas on the scalp, forehead, and axillae
Assess intertriginous areas carefully for cutaneous candidiasis
Skin should be cool-to-warm to touch; texture smooth, soft and even; widespread
roughness may be kyperkeratosis, also occurs from arsenic/toxin exposure
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Skin should return to baseline < 2 sec for turgor (assess clavicle)
Skin Lesions:
Lesions are primary (spontaneous) or secondary (result from trauma to a lesion)
Describe lesions (size, shape, color, texture, elevation/depression, pedunculation)
according to exudate (color, odor, amt., consistency); configuration (annular,
grouped,
linear,
arciform,
diffuse),
and
location/distribution
(generalized/localized, region of the body, patterns of discreetness or confluent)
 Measure lesions precisely (ht/width/depth—in cm); no household item
comparisons
 5-10 power lamp helpful for detailed lesion inspection
 Transillumination helpful to examine fluid in cysts/masses
 Wood’s lamp useful to distinguish fluorescing lesions (fungus)
 Abnormal Dermatological Presentations
 Primary Skin Lesions
 Macule: Flat, circumscribed
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area at color change; <1cm (Measles)
20
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Papule: Elevated, firm, circumscribed
area; <1cm (Verruca)
Patch: Flat, nonpalpable irregular
macule <1cm (Vitiligo)
Abnormal Dermatological Presentations
Plaque: Elevated, firm, rough
lesion w/ flat top; >1cm (psoriasis)
Nodule: Elevated, firm; deeper in
dermis than papulae; 1-2cm diam
(lipoma)
 Wheal: Eleveated, irregular-shaped
 area of cutaneous edema (urticaria)
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Abnormal Dermatological Presentations
Tumor: Elevated and solid lesion
deeper in dermis; > 2cm diameter
(lipoma)
Vesicle: Elevated, circumscribed,
superficial, not in dermis; filled with
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serous fluid; <1 cm (varicella)
Bulla: Vesicle > 1cm (blister)
Abnormal Dermatological Presentations
Pustule: Elevated, superficial
lesion, similar to vesicle but
purulent (impetigo)
Cyst: Elevated, circumscribed;
encapsulated, in dermis/SQ layer
filled with fluid/semi-sold material
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(acne)
Telangectasia: Fine, irregular, red lines;
vasodilitation (rosacea)
Abnormal Dermatological Presentations
Scale: Heaped-up, keratinized
cells; flaky skin; thick/thin
dry/ oily (seborrheic dermatitis)
Fissure: Linear crack/break from
21
 epidermis to dermis (tinea pedis)
 Erosion: Loss of part of the
 epidermis; follows vesicle rupture
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Abnormal Dermatological Presentations
Ulcer: Loss of epidermis
and dermis; concave
(decubitus)
Crust: Dried serum, blood,
or purulent exudate (eczema)
 Atrophy: Thinning of skin
 surface and loss of skin;
 translucency (striae)
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Advanced Assessment of Dermatological System
Hair:
Palpate for texture; inspect for color, distribution, and quantity
Palpate for dryness/brittleness; could indicate systemic disease
Hair loss to feet/toes could indicate PVD
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Presence of scarring at loss good diagnostic key
Asymmetric hair loss indicates problem
Male pubic: upright triangle; female upside down
Hirsutism in a female could be androgen excess
Nails:
Inspect for color, length, configuration, and cleanliness
Nail bed should be variations of pink
Sudden appearance of white lines in nails, r/o melanoma
Yellowing consistent with onychomycosis
 Single black/blue nail could be hematoma/melanoma
 Look for nail ridging, grooves, deformity, and ptting
 Nail depressions typically result from syphilis, high fevers, PVD, and uncontrolled
DM
 Nail bed should measure 160o; clubbing >180o (Schamroth technique), associated
with resp/CV disease, cirrhosis, cellulitis, thyroid disease (feels boggy)
 Nail plate should feel hard and smooth w/ uniform thickness; nail separation from
bed common in psoriasis, trauma, candidal, or Pseudomonas infection
22
 Advanced Assessment of Dermatological System
 Schamroth Technique
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Abnormal Dermatological Presentations
Pathological Nail Presentations
Advanced Assessment of Dermatological System
Infants and Children:
First few hours of life, newborn is red
Physiologic jaundice mildly present in up to 50%; should subside in 3-4 weeks
 If jaundice extends below nipples, bilirubin excessively high
 Assess newborn carefully over spine, midline of head, nape of neck to bride of
nose, and neck to ear (sinus tracts; clefts; cysts)
 The older the baby, the more simian creases (Down’s Syndrome)
 Transient puffiness in hands, feet, eyelids, legs, pubis, sacrum normal in some
newborns; disappears in 2-3 days
 Cyanosis of the hands and feet present at birth through several days; if persists,
suspect cardiac disease
 Mongolian spots (normal) occur in dark-skinned; bluish-black-to-gray; disappear
in preschool years
 Milia common during 1st 2-3 months (clogged sebaceous glands)
 Sebaceous hyperplasia (tiny yellow macules/papules) common forehead, cheeks,
nose, and chin; disappear at 1-2 months
 Best to assess turgor by pinching skin on ABD; excessive dryness/moisture rarely
significant in children
 Dennie-Morgan fold common flap of skin above eye, results from chronic rubbing
 Advanced Assessment of Dermatological System
 Adolescents: Same exam as an adult; hair and skin oiliness normal; address
concerns about acne
 Pregnant Women: Striae gravidarum normal to occur ABD, thighs, and breasts;
fade but never disappear; telangiectasias on face; most epidermal tags resolve;
linea nigra; cholasma in 70%; pruritus w/o rash over ABD and breasts common;
hair loss w/ shedding 2-4 months after delivery common; acne inc. in 1st
trimester, declines by 3rd
 Older Adults: Normally transparent and paler in light-skinned individuals w/ inc.
freckling; flaking and scaling on EXTs, turgor not reliable for hydration; assess
for breakdown at heels, sacrum, elbows, scapulae, occiput; wrinkling and small
areas of purpura normal; cherry angiomas, seborrheic keraotosis, sebaceous
23
hyperplasia, cutaneous tags/horns, senile lentigines all normal
 Abnormal Dermatological Presentations
 Corn: Results from friction forces thickening of skin; common in
interdigital spaces of toes
 Callus: Superficial area of hyperkeratosis
 Eczematous Dermatitis: Most common inflammatory disorder; acute, subacute,
chronic
 Abnormal Dermatological Presentations
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Furuncle: Small perifollicular pustular nodule (staph)
Folliculitis: Staph infection of hair follicle; small pustules
Abnormal Dermatological Presentations
Cellulitis: Diffuse, acute, strept/staph infection; red, hot, tender, indurated
streaking
Tinea: Fungal infection, typically angular (corporis, cruris, capitis, pedis, unguim)
Abnormal Dermatological Presentations
Pityriasis Rosea: Primary oval or round plaque with superficial scaling on
EXT/trunk; parallel alignment w/ ribs
Psoriasis: Well-circumscribed, dry, silvery, scaling papules and plaques
 Abnormal Dermatological Presentations
 Rosacea: Telangiectasia, erythema, papules, and pustules on central face
 Drug Eruptions: Discrete/confluent erythematous maculopapules on trunk, face,
EXT, palms, and soles
 Abnormal Dermatological Presentations
 Herpes Zoster: Varicella infection; single dermatome consisting of red, swollen
plaques, vesicles become filled w/ purulent fluid
 Herpes Simplex: Grouped, painful erosions/ulcer; forms crust (type 1 oral; type 2
genital)
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Abnormal Dermatological Presentations
Basal Cell Carcinoma: Most common; race, ears, neck, scalp, shoulders, and back
Abnormal Dermatological Presentations
Squamous Cell Carcinoma: Malignant tumor arising from epidermis; scalp, back
of hands, lip* and ear*; base could be inflammed
 *- Most vulnerable areas
24
 Abnormal Dermatological Presentations
 Malignant Melanoma: Develops from melanocytes
 ABCDE Rule: Asymmetry; Borders; Color; Diameter; Elevation
 Abnormal Dermatological Presentations
 Kaposi Sarcoma: Malignant tumor of the endothelium: soft, bluish-purple,
painless; immunocompromise (HIV)
 Abnormal Dermatological Presentations
 Alopecia Areata: Sudden, rapid onset of hair loss (shaft poorly developed and
breaks)
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Traction/Scarring Alopecia
Abnormal Dermatological Presentations
Paronychia: Redness, swelling, and tenderness at lateral nail folds
Tinea Unguium: Yellow, hardening of nail due to fungus
Ingrown Nails: Nail pierces nail fold and grows into dermis
Subungal Hematoma: Blood collects under the nail plate until nail grows out.
Leukonychia Punctata: White spotting under the nail (from injury)
Habit-tic Deformity: Horizontal sharp grooving in band extending to tip of nail
Onycholysis: Loosening of the nail plate with separation from bed
 Koilonychia (spooning): Fe-deficiency, anemia, syphillis, fungal infection causes
concavity of nail
 Beau Lines: Coronary occlusion, hypercalcemia, or dkin disease causes sharp
lateral lines in nail
 Terry Nails: Cirrhosis and hypoalbuminemia causes transerve white band over
nails
 Psoriasis: Pitting, onycholysis, and subungual thickening
 Warts: Epidermal neoplasms cause by virus
 Digital Mucous Cysts: Groove in nail plate w/ jelly-like filled cysts at tip
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Abnormal Dermatological Presentations
Pregnant Women:
PUPP
Herpes
Infants and Children:
Café-Au Lait Patches: > 5 patches w/ diameter > 1cm in children <5 indicates
neurofibromatosis; treat as suspicious
 Seborrheic Dermatitis: erupts in scalp (craddle cap), back, intertriginous areas, and
25
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diaper
Miliaria: Irregular, red, macular rash w/ occlusion of sweat glands
Impetigo: Highly contagious staph infection; honey-colored crusts; exudative
Acne Vulgaris: Inflammed lesions of acne w/ sebum and comedone formation
Reddened Patchiness: Red lesions on capillary bed on upper eyelids, forehead, and
upper lip; disappear at 1
Varicella: Chickenpox; fever, mild malaise, and pruritic maculopapular skin
eruption which becomes vesicular; scalp and trunk start spread to EXT
Measles: Rubeola; highly-communicable viral w/ prodromal fever, conjunctivitis,
coryza, and bronchitis, followed by red blotchy rash, lasting 4-7 days;
complications of respiratory tract and CNS
German Measles (Rubella): Light pink to red maculopapular rash; rash on face an
trunk quickly papules and fades within 3 days; reddish spots on palate
Physical Abuse: Bruises (cord, belts, prior to mobile is concern); Lacs (oral—
forced feeding, bites); Burns (scald/stocking glove distribution; hair loss
Older Adults: Stasis Dermatitis (associated w/ PVD; cellulitis, erosion, and
scaling); Solar Keratosis (raised, erythematous lesion <1cm; premalignant)
 Advanced Assessment: Breasts & Axillae
 Anatomy and Physiology:
 Superficial to pectoralis major & serratus anterior
 Composed of glandular/fibrous/SQ/retromammary fat
 15-20 lobes/breast; each lobe 20-40 lobules w/ milk-producing acini cells
emptying into lactiferous ducts
 Coopers ligaments extend through breast and anchor to muscle fascia
 Vascular supply via internal mammary gland and lateral thoracic artery (deep
tissue); IC arteries feed superficial arteries
 For exam, breast divided into upper/lower-inner, upper/lower-outer qdts Tail of
Spence
 Contraction of smooth muscles in nipple erects nipple and empties lactiferous
ducts
 Lymphatics drain breast radially and deeply; superficial drain skin and deep drain
mammary lobules
 Axillary nodes easily palpable when enlarged; pectoral nodes located in lateral
axillary fold, central nodules high in axilla, subscapular nodes at border of scapula
deep in posterior axillary fold, brachial nodes upper humerus
 Menarche typically 2 years s/p breast buds
 Breasts can enlarge 2-3 times normal from luteal and placental hormones; alevoli
26
engorge, tissue becomes softer/looser, colustrum accumulates; veins highly visible
 Colostrum secreted in 1st few days after delivery—more protein/minerals/ATB
than milk; involution occurs 3 months after breastfeeding cessation; breast size
usually larger
 Older women have more loose breasts due to relaxation of Coopers ligaments and
decrease in glandular tissue w/ decomposition of lobular tissue; nipples smaller,
flatter, and lose erectile function
____________________________________________________________________
 Advanced Assessment: Breasts & Axillae
 Review of Related Hx:
 Hx of Present Illness:
 Breast pain: onset gradual/sudden; length of symptoms, come and go or persist;
relation to menses timing/severity; character (stinging, burning, stabbing, aching,
throbbing, uni/bilateral; localization, radiation); associated s/s (lump, mass, DC,
inframammary skin irritation due to repeated skin-skin/brassiere contact;
strenuous activity/injury); Rx Hx
 Mass or lump: Temporal (length of time when 1st noted, come/go or persist—
relation to menses); symptoms (tenderness/pain, dimpling, changing in contour);
Rx Hx
 Nipple DC: character (spontaneous/provoked, uni/bilateral, gradual/sudden onset,
duration, amt, color, consistency, odor; associated symptoms (nipple retraction,
breast lump, discomfort); associated factors (relationship to menses or other
activity; recent injury) Rx hx (contraceptives, phenothiazines, digoxin, diuretics,
steroids)
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Advanced Assessment: Breasts & Axillae
Anatomy/Lymphatic Flow of Breast
Advanced Assessment: Breasts & Axillae
Past Medical Hx:
Previous breast disease (CA, fibrocystic)
Known BRCA1/2 mutation; other hereditary symptoms (hereditary nonpolyposis
colorectal CA; Li-Fraumeni/Cowden syndrome)
Previous CA (ovarian, colorectal, endometrial)
Surgeries (breast biopsy, aspirations, implants, reductions, plasties,
oophorectomy)
Changes in breast characteristics (pain, tenderness, lumps, DC, skin changes,
shape changes)
Changes with menses (tenderness, swelling, pain, enlarged nodes)
Mammography Hx (how frequent, last exam, results)
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 Menstrual Hx (1 day of LMP, age of menarche/pause, cycle length, amt of flow,
regularity, associated breast symptoms (nipple DC, pain, discomfort)
 Pregnancy: age at each pregnancy, length of each preg, date of
delivery/termination
 Lactation: # of children breast-fed, duration of feeding time, date of cessation of
feeding, Rx to suppress lactation
 Menopause: age of onset, course, associated problems, residual problems
 Use of hormonal Rx (name, dosage, route, reason for use—contraception,
menstrual control, menopausal symptom relief, length of prescription, date of
termination); other Rx (Tamoxifen/Raloxifene)
 Advanced Assessment: Breasts & Axillae
 Family Hx:
 Breast CA (primary/secondary relatives, type of cancer, age of time of occurrence;
Tx/results; BRCA1/BRCA 2 mutation
 Other CA (ovarian, colorectal, known hereditary cancern syndromes—discussed)
 Other breast diseases (female/male relatives—types of disease, age at time of
occurrence, Tx/results)
 Personal/Social Hx: Age, breast support w/ strenuous activity, sports, exercise;
amt of caffeine intake, BSE (frequency—timing in menstrual cycle); use of ETOH
 Pregnant Women: Sensation/fullness, tingling, tenderness; presence of colustrum
and knowledge of self breast care; use of supportive brassiere; knowledge of
breastfeeding; plans to breastfeed, expectations (all women should be encouraged
to breastfeed)
 Lactating Women: Cleaning procedures (soap products can dry out breasts);
frequency of use nipple preparation; use of nursing brassiere; nipple tenderness,
cracking, pain, retraction; problems w/ feeding; associated problems
(engorgement, leakage, localized tenderness, lumping—indicates plugged duct),
fever, infection, Tx/results, infant w/ oral candidiasis; nursing routine (length of
feeding, frequency, rotation of breasts, positions used); breast milk pumping
devices used, frequency; cultural beliefs about nursing; food and environmental
agents that can affect breast milk (chocolate, photo chemicals), Rx that cross milkblood barrier (cimetidine, clemastine, thiouracil—all Rx should be evaluated for
potential newborn effects
 Older Adults: Skin irritations from tissue-to-tissue contact or rubbing of brassiere;
Tx; hormone Tx during or since menopause (name and dosage, diuration of Tx)
 Advanced Assessment: Breasts & Axillae
28
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Examination and Findings:
Disrobe both breasts to the waist; be matter-of-fact
Inspection:
Have pt sit w/ arms hanging loosely at sides, inspect each breast and compare w/
other for size, symmetry, contour, skin color, texture, venous patterns, and lesions
Lift breasts with fingertips–determine if any changes
Conical, convex, pendulous, large pendulous
Skin should appear smooth and contour uninterrupted
Retractions and dimpling could indicate CA
Peau d’ orange results from edema caused by blocked lymph draining or advanced
CA
Venous patters should be bilatterally similar; unilateral visible veins could indicate
feeding to a CA tumor; bilateral typically OK
Recent change in any lesion ALWAYS warrants further study
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Advanced Assessment: Breasts & Axillae
Breast Morphology
Advanced Assessment: Breasts & Axillae
Areola should be round or oval, bilat equal
Color ranges from pink to black
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 Areola typically darkens during preg and remains so
 Retraction is seen as flattening, withdrawal, or inversion of the nipple (indicates
inflammation/CA)
 Change in axis of the nipple could result from cancerous tumor tissue pulling
 Nipple color should match areola; surface may be smooth or wrinkled, but free of
cracking, crusting, or DC
 Supernumerary nipples follow the mammary ridge and are typically mistaken for
nevi
 Reinspect in various positions
 Advanced Assessment: Breasts & Axillae
 Inspection Positions
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Advanced Assessment: Breasts & Axillae
Palpation:
Palpate breasts, axillae, supra/infra clavicular regions
Seated Palpation:
Chest Wall Sweep: Palm of hand “sweeps” from clavicle to nipple
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 Bimanual Digital: Compress tissue between flat-handed fingers, with one hand
securing the floor of breast
 Lymph Node Palpation: Flex arm at elbow, support L arm w/ your L hand and
palpate w/ your R finger pads; push firm; roll tissue downward, exploring all areas
of axillae; also palpate supra/infra clavicular nodes, rotating entire supraclavicular
fossa—have pt. turn head towards palpated side and lift that shoulder; palpate
Virchow’s nodes down SCM muscle while pt. tilts chin to chest lightly (THESE
NODES FIRST TO REFLECT CA OF ABD/THORAX—SENTINEL NODES
 Describe nodes’ location, size, shape, consistency, tenderness, fixation,
delineation of borders
 Advanced Assessment: Breasts & Axillae
 Seated Position Palpation Techniques

Sweep
Bimanual Digital
Axilla
 Advanced Assessment: Breasts & Axillae
 Supine Palpation:
 Pt. raises hand above head, place a folded towel under that shoulder to spread
breast tissue
 Palpate each breast separately
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Palpate all areas of breast tissue (including tail of Spence) for lumps or nodules
Palpate using finger pads; push in gently firm, rotate counter/ clockwise
Use either vertical strips, concentric circles, or tire-spoke:
End at nipple and compress if DC present; note dimensions, consistency, and
mobility of any palpable lesions
 Advanced Assessment: Breasts & Axillae
 Special Populations:
 Breast tissue in women should feel dense, firm, and elastic; lobular tissue is like
widely-dispersed tiny granular bumps
 A firm transverse ride of breast tissue is felt at inframammary ridge—not a mass
 Normal for the newborn to have enlarged breasts from passed estrogen for a
relatively short time after birth; disappears by 3 months; Witch’s Milk
 R/L breasts may not develop at same time in adolescents
 Adolescent males sometimes have a normal subareolar mass
 Most breast changes in pregnancy are noticeable during the 1st trimester; nipples
may
flatten/invert;
crusted
colostrum
may
appear
on
nipple;
striae/hyperpigmentation/spider veins normal
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 Engorged breasts feel warm, firm, dense, and are shiny and painful
 Clogged ducts create a tender spot that is hot and lumpy; apply heat, continue to
nurse, and expectorate milk; assess cracking/trauma
 Breasts in postmenopausal women flattened, elongated, and suspended more
loosely from chest wall; granular feel to palpation; no longer necessary to time
BSE w/ menses—pick one day out of the month; HRT can result in painful, fluidfilled cysts
 Abnormal Presentations: Breasts/ Axillae
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Fibrocystic Changes:
Benign cyst formation caused by ductal enlargement
Associated w/ long follicular/luteal phases of cycle
Differential Dx: Breast Masses
Fibroadenoma:
Benign tumors of stromal/epithelial elements—hyperplastic or proliferative
process in a single duct; asymptomatic w/o change w/ menses; rare in older
women (SUSPECT CA); slight risk of becoming CA
Malignancy:
Peak between 40-75 years; majority > 50; 80% present w/ a painless lump; mass
or thickening of the breast, marked asymmetry of breasts, prominent unilater
veins; discolorations, peau d’ orange, ulcerations, dimpling, puckering
(retraction), fixed inversion of nipples
Fat Necrosis: Firm, irregular mass due to localized trauma
Intraductal Papillomas: Benign 2-3 cm tumors of subareolar ducts—tend to have
serous/sanginous DC; biopsy for CA
Paget Disease: Surface manifestation of underlying CA; red, scaling crust on
nipple, areola, surrounding skin (unilaterally—rules out eczema)
Adult Gynecomastia: Breast tissue development in males (testicular/pituitaryhormones/liver failure/antiHTNive Rx w/ estrogens/steroids
 Retention Cysts: Inflammation of sebaceous glands of areola; tender and
suppurative
 Galactorrhea: Lactation not associated w/ childbearing (prolactin-secreting
tumors, hypothyroid, Cushing, hypoglycemia)
 Premature Thelarche: Premature development of breasts (typically bilateral)
 Mastitis: Swelling, tenderness, erythema, and heat from infection (chills, swets,
fever, tachycardia)
 Mammary Duct Ectasia: Bilateral pain, tenderness, inflammation, spontaneous,
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sticky, multicolored nipple DC
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Abnormal Presentations: Breasts/ Axillae
Fibrocystic Breasts
Fibroadenoma
Abnormal Presentations: Breasts/ Axillae
Malignancy
Fat Necrosis
Abnormal Presentations: Breasts/ Axillae
Intraductal Papillomas
Paget Disease
Abnormal Presentations: Breasts/ Axillae
 Mastitis
Mammary Duct Ectasia
 Differential Dx: Breast Masses
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