Interventions for Clients with Breast Disorders

SCREENING RECOMMENDATIONS SCREENING MAMMOGRAM (Baseline) at age 40, and annually after age 40-50. (Best 1 week after menstrual period) BREAST SELF EXAM monthly, begin @ age 20 CLINICAL BREAST EXAM yearly after age 40    

CLINICAL BREAST EXAM yearly after age 40 BARRIERS: fear of pain, radiation, results accessibility, cost modesty knowledge deficit

CANCER SCREENING: HIGH RISK Screening: BSE monthly, age 20 Mammography annually, ages 25-35 years of age Options: Decrease risk factors? Prophylactic mastectomy Chemoprevention (Tamoxifen & other newer drugs)

BREAST SELF EXAM GOAL: Early detection IN PREPARATION FOR TEACHING: Assess: knowledge base , motivation fears and concerns family history risk factors TEACHING: Use show and tell; use finger pads EXAM: monthly, day 5-7 of menstrual cycle; after menopause same day each month Use in conjunction with mammography & CBE

Breast Self Exam - Step 1 Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips. Here's what you should look for: Breasts that are their usual size, shape, and color. Breasts that are evenly shaped without visible distortion or swelling. If you see any of the following changes, bring them to your doctor's attention: Dimpling, puckering, or bulging of the skin. A nipple that has changed position or become inverted (pushed inward instead of sticking out). Redness, soreness, rash, or swelling.

Breast Self Exam - Step 2 and 3 Raise your arms and look for the same changes. While you're at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge (this could be a milky or yellow fluid or blood).  

Breast Self Exam - Step 4 Feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together. Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage.

Breast Self Exam - Step 5 Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.

CLINICAL BREAST EXAM HISTORY: (Subjective data) Onset of problem? What symptoms? Pain associated with symptoms? Self breast examination practices? Mammograms? Reproductive history? Tobacco & alcohol use? Medical & surgical history? Socio-economic information?

BREAST ASSESSMENT: INSPECTION & PALPATION Symmetry Size Contour Skin color, venous pattern, changes (edema or pitting) Nipple changes   Lesions Discharge- type, color Mass Axillary area Area over clavicle

Equipment Needed None The patient must be properly gowned for this examination. All upper body clothing should be removed.

General Considerations The patient must be properly gowned for this examination. All upper body clothing should be removed. Breast tissue changes with age, pregnancy, and menstrual status. The procedure described here can also be used for self-examination using a mirror for inspection.

Inspection Give a brief overview of examination to patient. [1] Have the patient sit at end of exam table. Ask the patient to remove gown to her waist, assist only if needed. Have the patient relax arms to her side. Examine visually for following: Approximate symmetry Dimpling or retraction of skin Swelling or discoloration Orange peel effect on skin Position of nipple Observe the movement of breast tissue during the following maneuvers: Shrug shoulders with hands on hips Slowly raise arms above head Lean forward with hands on knees (large breasts only) Have the patient replace the gown. Reassure the patient, if the exam is normal so far, say so.

Palpation Have the patient lie supine on the exam table. Ask the patient to remove the gown from one breast and place her hand behind her head on that side. Begin to palpate at junction of clavicle and sternum using the pads of the index, middle, and ring fingers. If open sores or discharge are visible, wear gloves. Press breast tissue against the chest wall in small circular motions. Use very light pressure to assess superficial layer, moderate pressure for middle layer and firm pressure for deep layers. Palpate the breast in overlapping vertical strips. Continue until you have covered the entire breast including the axillary "tail." [2] Palpate around the areola and the depression under the nipple. Press the nipple gently between thumb and index finger and make note of any discharge. Lower the patient's arm and palpate for axillary lymph nodes. Have the patient replace the gown and repeat on the other side. Reassure the patient, discuss the results of the exam.

BENIGN BREAST DISORDERS FIBROADENOMA   Most common cause of breast masses, especially in teens & young women (to early 30’s) Often upper, outer quadrant Solid, slowly enlarging, benign mass, unattached to surrounding breast tissue Usually round, firm, easily movable, nontender, clearly distinct from surrounding tissue Enlarges slowly

FIBROCYSTIC BREAST DISEASE Most common in adult women, ages 20-30 Ducts dilate & cysts form, more diffuse May occur in stages: Stage 1: premenstrual sx, bilateral, 20’s Stage 2: sx +, bilateral, nodular, 30’s Stage 3: cystic, smooth, painful or tender, 35-55

FIBROCYSTIC BREAST DISEASE Treatment (usually symptomatic) may include: Hormones (oral contraceptives, estrogen, progestin, Danazol) Vitamins C, E, B complex Diuretic agents  NaCl, avoid caffeine Anti-inflammatory meds (Ibuprofen) as needed Wear supportive bra Heating pad, ice

DUCTAL ECTASIA Dilation & thickening of ducts in subareolar area Occurs usually in women nearing menopause Masses due to inflammatory response, may feel tender, hard, irregular (may be difficult to distinguish from malignancy) Redness, edema over mass site Greenish-brown nipple discharge Enlarged axillary nodes

INTRADUCTAL PAPILLOMA Occurs usually in women nearing menopause Rarely palpable mass Serosanguineous nipple discharge (usually microscopic exam of discharge) Surgical excision if indicated

OTHER BENIGN BREAST DISORDERS Large breasts Disproportionate to rest of body Difficult, expensive to find clothes to fit Can cause backaches Can cause fungal infections under breasts Can be treated by REDUCTION MAMMOPLASTY

GYNECOMASTIA ( breast size in male) Can be secondary to other diseases such as lung Ca 90% bilateral May be due to: Aging Estrogen excess (malnutrition, liver disease, hyperthyroidism) Androgen deficiency Obesity Drugs Chronic renal failure

BREAST CANCER Most diagnosed invasive cancer in females Second leading cause of breast masses & cancer deaths overall 80% diagnosed in women over age 50 Early detection & treatment key to survival Localized with no regional spread: cure 75%-90% 5 and 10 year survival rates drop with axillary lymph node involvement Incidence lower in African-American & Hispanic women, but death rates higher (highest death rate is Hawaiian)

BREAST CANCER: ETIOLOGY/ RISK FACTORS 70% women diagnosed with breast cancer have no identifiable risk factors other than age & gender Age: > 45, as age , risk  History: client’s & family’s 3X in females with affected 1st degree relative (but 90% have no affected relatives)  in women with multiple affected 1st degree relatives, or if relative has Ca bilaterally or diagnosed at early age

risk in early menarche (before 12) & late menopause  in nulliparity or 1st pregnancy after age 30  in exposure to ionizing radiation (esp. before age 20)  with hx of previous breast Ca, &  risk for recurrence if diagnosed at earlier age or with hx of ovarian Ca  with age

QUESTIONABLE RISK FACTORS Diet: high in animal fats, low in fiber Obesity Oral contraceptives Alcohol/ Tobacco Hormone replacement rx > 5 years

BREAST CANCER: PREVENTION IN HIGH RISK WOMEN TAMOXIFEN: results of Breast Cancer Prevention Trial in women high risk for breast Ca-> those receiving had  Ca by 45% EVISTA: lower incidence of Breast Ca ARIMIDEX: new Ca prevention drug being studied PROPHYLACTIC MASTECTOMY: often with immediate reconstruction

BREAST CANCER INFILTRATING DUCTAL CARCINOMA Most common, 80% of all breast Ca’s Hardness on palpation, may be 5-9 years before mass is palpable May be NONINVASIVE (remain in duct) or INVASIVE (penetrate surrounding tissue causing irregular mass) As grows, fibrosis develops, causes shortening of Cooper’s ligaments, causes skin dimpling (more advanced disease) Often metastasizes to axillary nodes

COMPLICATIONS OF BREAST CANCER Tumor invades lymphatic channels Blocks skin drainage causing skin edema & “orange peel” appearance, may -> skin breakdown Metastasis occurs from seeding of CA cells into blood and lymph systems Most common metastatic sites are *bone, lungs, brain, and liver

BREAST CANCER IN MEN 1% of all cases of breast cancer Average onset 60 years of age Risk factors: hx of mumps orchitis, Klinefelter’s syndrome Symptoms can include: Hard, nonpainful, subareolar lesion Nipple erosion, retraction, or discharge (75% have Ca) Treatment: modified radical mastectomy with radiation v   5 year survival rates are only 58% in Stage 1

ASSESSMENT: BREAST CANCER HISTORY: Risk Factors Mass When & by whom discovered When sought care Health maintenance practices: BSE, Mammograms, Diet, Alcohol use, Medications including hormone supplements

BREAST CANCER: PHYSICAL ASSESSMENT MASS Location – usually upper, outer quadrant of breast Size Shape Hard consistency, with irregular borders Fixed, not movable Nipple, Skin Changes (orange peel appearance, ulceration, shortening of Cooper’s ligaments with dimpling) Lymph nodes Usually nontender, painfree unless in later stages

PSYCHOSOCIAL ASSESSMENT Fear of cancer & prognosis Previous experiences with cancer Knowledge, education level Threats to body image Threats to sexuality and intimate relationships Support systems Need for other resources or counseling

BREAST ASSESSMENT   SBE CBE Mammography, Galactography Ultrasound MRI

DIAGNOSTIC ASSESSMENT LABORATORY: Pathology reports Study of cancer markers Liver enzymes  Serum calcium  Alkaline phosphatase 

RADIOGRAPHIC Mammography Chest X ray Bone Scan Brain Scan Liver Scan CT- Chest and abdomen

DIAGNOSTIC ASSESSMENT Ultrasonography- differentiates fluid filled from solid masses Breast biopsy with pathology report Estrogen and progesterone receptors (women with ER + tumors have longer survival rate) Tumor cell differentiation (women with well differentiated tumors have longer survival) Pathology exam of lymph nodes

BREAST BIOPSY INDICATED: If needle aspirated fluid is bloody No fluid is aspirated from lesion Suspicious mammogram Mass still present after aspiration Cytological study shows malignant cells

BREAST BIOPSY:NURSING CARE Assess anxiety & fear (80% are negative) Education Prior to biopsy, avoid agents interfering with blood clotting NPO Care of biopsy site Avoid strenuous exercises for 1 week Pain management Supportive bra for 3-7 days   Post test: Monitor: Effects of anesthesia Toleration of fluids, food, ambulation

STAGE 3 (no metastasis evident) BREAST CANCER STAGING STAGE 1   Tumor smaller than 2cm & no lymph node involvement STAGE 2 Tumor 2-5 cm with 0-1 + lymph nodes STAGE 3 (no metastasis evident) Tumor larger than 5cm, no + lymph nodes or Smaller than 2 cm, with + lymph nodes, or 2-5 cm with + nodes STAGE 4 Tumor of any size, + or – lymph nodes, with distant metastasis evident

POSSIBLE NURSING DIAGNOSES Anxiety related to possible diagnosis of cancer Grieving, Anticipatory, related to loss Pain, Acute related to breast disease Sleep Pattern, Disturbed related to pain and anxiety Body Image, Disturbed related to possible loss of body part Sexual dysfunction related to body image and/or self esteem

INTERVENTIONS ANXIETY: GOAL: EFFECTIVE COPING   Allow time for ventilation of feelings Active listening Promote client’s decision making abilities Active participation in choice of treatment Be flexible Utilize outside resources

NONSURGICAL INTERVENTIONS Indicated for clients with late-stage breast cancer Indicated for clients who cannot withstand major surgical procedures Based on client preferences, age, menopausal status, pathologic results, hormone receptor status Interventions include chemotherapy, (ER+may have Tamoxifen) & radiation therapy

SURGICAL MANAGEMENT Breast Conserving (Stages 1 & 2) Lumpectomy Lumpectomy with lymph node dissection Simple Mastectomy-breast tissue & usually nipple removed, lymph nodes remain intact Modified radical Mastectomy-Removal of entire breast tissue and axillary lymph nodes; pectoral muscles & nerves remain intact

SURGICAL MANAGEMENT SENTINEL LYMPH NODE BIOPSY Identifies clients with axillary involvement without palpable nodes Dye indicates lymph node path, with first reactive nodes removed & examined Absence of positive sentinel nodes prevents unnecessary radical dissections

POSSIBLE NURSING DIAGNOSES: MASTECTOMY Pain related to tissue trauma from surgery Skin integrity, Impaired due to surgical incision Mobility, Impaired Physical related to pain & tissue trauma Infection, Risk for related to disruption in skin integrity Body Image, Disturbed related to loss of breast Social interaction, Impaired related to changes in body image Knowledge, Deficient related to exercises to regain arm mobility

MASTECTOMY:PREOPERATIVE CARE Include significant other Recognize & deal with anxiety, lack of knowledge, & body image issues Review type of procedure & presence of drainage devices Describe location of incision Instruct in mobility restrictions Implement basic pre & post op teaching Provide written materials

MASTECTOMY: POSTOPERATIVE CARE Anesthesia recovery Pain management Assess vital signs q30 min –q4hours Assess dressing for bleeding Wound care , observe incision for swelling , infection Maintain skin integrity Prevention of infection Institute measures to promote respiratory function Drainage tube care, usually JP’s with gentle suction

MASTECTOMY: SPECIFIC POSTOPERATIVE CARE Semi-fowler’s position- HOB 30 Elevate affected arm, DO NOT USE FOR PROCEDURES- (No BP, labs, or injections) BE SURE TO PLACE A SIGN OVER BED! Early ambulation & assistance with prescribed exercises (flex, extend fingers, lower arm, & wrist) consult physician before full arm exercises on the affected side Teach drainage tube care MASTECTOMY: SPECIFIC POSTOPERATIVE CARE  

MASTECTOMY: POSSIBLE COMPLICATIONS Hematoma at incision site Infection Seroma (accumulation of serosanguineous fluid after drain removed) Nerve trauma Impaired arm mobility Lymphedema Psychological effects

BREAST RECONSTRUCTION May begin during the original operative procedure Skin flap- (autogenous reconstruction) Saline filled prosthesis Progressive tissue expander Nipple creation If not done immediately, temporary or permanent prosthesis may be given TRAM flap reconstruction often used

ADJUNCT THERAPY Decision based on Disease stage Age & menopausal status Client preferences Pathologic examination Hormone receptor status Genetic predisposition

ADJUNCT THERAPY Radiation therapy Kill Ca cells which might be remaining External beam qd for 6-7 wks or partial breast brachytherapy with radioactive seeds bid for 5 days Skin changes a major side effect Mild soap,  rubbing No perfumed soaps/deodorants, nondrying soap if itching occurs Hydrophilic lotions No tight clothes, underwire bras, excessive temperatures, UV lights  

Chemotherapy Often for remaining cells locally + distant sites Dangerous with many side effects: Meds to  N& V Prevention & dealing with infection from bone marrow depression Promote communication & deal with anxiety Deal with side effects of taste changes, alopecia, mucositis, dermatitis, fatigue, weight gain or loss  

Hormonal Therapy Estrogen receptor blocking agents (Tamoxifen, Evista) Agents to inhibit estrogen synthesis (Lupron, Zoladex) Aromatase blocking agents to block circulating estrogen (arimidex, Femara)

Stem Cell transplantation   Autologous: Bone marrow transplantation taken from client’s bone marrow Peripheral blood stem cell transplantation taken from client’s circulating blood Allogenic: Bone marrow or peripheral blood taken from a health donor Targeted Therapy Herceptin if indicated

DISCHARGE TEACHING Usually does not require modifications in home Incision, Drain care Dressing, Wound care Exercises to regain full range of motion Prevention, Signs of infection and what to do Protection of affected arm- LIFETIME Measures to promote positive body image Management of lymphedema if occurs   Reach for Recovery, ENCORE, or other community resources  

DISCHARGE TEACHING: CARE OF INCISION Light dressing, keep dry No lotions, ointments, deodorants Observe for continued redness, swelling, heat, tenderness after 1st few weeks Loose fitting clothes ROM exercises when sutures, drains removed Shower after sutures, drains removed

EVALUATION Evaluate expected outcomes: Client will Be free of infection Demonstrate correct BSE State positive feelings related to self image Regain full ROM in affected arm Be free of lymphedema