Pre‐procedure

ActionRationale

1. 1.Show
   Greet patient and introduce self and role and gain consent for procedure.
   To put patient at ease and inform of process E and gain consent (RCN [133], C).
2. 2.Show
   Offer chaperone.
   Breast examination can be difficult for some women as it is considered intimate (RCN [131], C).
3. 3.Show
   Review history of presenting symptom in patient's own words, noting when first noticed, triggering factors, alterations to symptom since first noting, intervening factors.
   To establish duration of problem, constancy of symptoms. Breast cancer does not fluctuate but hormonal changes do (ABS [6], C).
4. 4.Show
   Assess menstrual history including:

   1. age periods started
   2. number of pregnancies – successful or not
   3. age of first pregnancy
   4. use of in vitro fertilization (IVF)
   5. experience of breastfeeding
   6. use of contraception
   7. regularity of periods
   8. age of menopause
   9. use of hormone replacement therapy (HRT)
   10. oophorectomy and/or hysterectomy.
   Breast tissue is regulated by female hormones both over a lifetime and in each menstrual cycle. Information regarding oestrogen exposure is important to overall risk and may be pertinent to presenting symptom (ABS [6], C).
5. 5.Show
   Assess family history of breast and/or ovarian cancer.
   Family history is a significant risk factor for breast cancer if present and may affect screening recommendations for current assessment and going forward (NICE [109], C).
6. 6.Show
   Assess previous medical history.
   Relevant medical and surgical history as well as prescription drugs can be relevant (ABS [6], C).
7. 7.Show
   Assess lifestyle factors – weight, smoking history, alcohol intake.
   To establish overall risk of breast cancer as well as other possible causes for symptom (ABS [6], C).
8. 8.Show
   Ask patient to remove upper clothes, including bra, behind curtain or screen. Provide a gown for use.
   To enable ease of visible inspection and palpation. E

   Provide gown to maintain personal dignity (RCN [127], C).
9. 9.Show
   Wash hands with soap and warm water and dry, followed by alcohol rub.
   To maintain infection control standards and minimize cross‐infection and contamination (Fraise and Bradley [50], E; RCN [132], C).

Procedure

1. 10.Show
   Ask patient to open gown.
   To allow for visual inspection. E
2. 11.Show
   While patient is in sitting position with arms relaxed at sides, observe both breasts for contour, regularity, size, skin changes, nipple position and direction.
   Malignant changes may attach internally and cause visible skin or shape changes such as tethering, dimpling and in‐pulling (Pandya and Moore [119], E).
3. 12.Show
   Ask patient to raise arms together above head and observe movement of breast over chest wall. Check for symmetry and regular contour.
   This allows inspection of the lower half of the breast (Pandya and Moore [119], E).
4. 13.Show
   Ask patient to bring hands together in prayer‐like stance and push palms together or to put hands on hips and push down and in. Observe for any changes to breast outlines.
   Contraction of muscles beneath breast tissue may exacerbate visible changes (Pandya and Moore [119], E).
5. 14.Show
   Ask patient to lie back on couch in supine position.
   Breast examination is completed in supine position. E
6. 15.Show
   Using the flat of 3 middle fingers, palpate the breast tissue firmly downwards toward the chest wall to assess texture of breast tissue.
   Downward pressure should be constant and firm enough to cover superficial, middle and deep layers. E
7. 16.Show
   Ensure that the entire breast is covered in a systematic fashion including the tail of tissue toward axilla. It is advised that either a vertical stripe (Action figure 16a), radial spoke (Action figure 16b) or concentric circular pattern (Action figure 16c) is followed. A consistent approach should be employed by the clinician.
   A consistent approach increases the likelihood that breast examination is systematic and thorough (Pandya and Moore [119], E).
8. 17.Show
   Examine both breasts equally, starting with the ‘normal’ breast and finishing by specifically examining the area where a lesion is reported (if applicable).
   To ensure an appreciation of what is normal and to allow comparison.

   To prevent concentrating on reported symptom at risk of missing a further change in a different area. E
9. 18.Show
   Inform patient they can get dressed.
   To maintain privacy and dignity. E

Post‐procedure

1. 19.Show
   Annotate findings and assessment on record sheet using the accepted and agreed grading system:

   1. clinically normal = P1
   2. abnormal but no concern = P2
   3. uncertain = P3
   4. suspicious = P4
   5. clinically malignant = P5.

   Note position of any palpated symptom by clock face and distance from nipple.

   Supplement with clinical picture.
   Being required to describe findings and indicate need for investigation focuses the clinician to produce a result. This has been found to optimize clinical breast examination (Goodson et al. [55], E; NMC [114], C).
2. 20.Show
   Explain findings to patient and need for further radiological tests (as necessary).
   To ensure that patient understands what the tests will involve and what to expect. This reduces anxiety and manages expectations realistically. E
3. 21.Show
   Accurately complete request forms for mammography and/or breast ultrasound including patient demographics, history of symptoms and result of examination.
   To ensure that only required tests are requested depending on patient history and symptoms (RCR [134], C).

   To prevent unnecessary radiation exposure (RCR [134], C).
4. 22.Show
   Arrange to see patient with the results of radiological investigations or clearly arrange future follow‐up.
   To ensure that results are acted upon and patient informed of any decision. E