1. BREAST CANCER:
NURSING CARE PLAN

2. NURSING ASSESSMENT: Risk Factors
Personal/family histories of breast cancer
menopause (early menses or late menopause increase risk)
Symptoms of menopause
first child’s birth
Number of children (nulliparity/birth of first child after age 30 increase risk)

3. History of Breast Mass
Reveals course of disease, health care-seeking practices. BSE or accidental discovery? Time interval between discovery and seeking health care provider
Review of systems focusing on the most common areas of metastases
Client’s Health Maintenance Practices
Knowledge, practice and regularity of BSE
Mammographic history
Diet history (High alcohol, fat intake increase risk)
Medications – hormone supplements, birth control pills

4. PHYSICAL ASSESSMENT: Focused Assessment of breast mass Shape Size
Consistency
Fixation to surrounding tissues
Any skin change (peau d’orange)
Palpate axillary, superclavicular areas for enlarged lymph nodes
Pain, soreness?
Diagram

5. A firm lump or thickness in breast, usually painless; 50% are located in the upper outer quadrant of the breast.
Spontaneous nipple discharge; may be bloody, clear or serous.
Asymmetry of the breast may be noted as the patient changes positions; compare one breast with the other.
Nipple retraction or scalliness, especially in Paget’s disease.
Enlargement of auxiliary or supraclavicular lymph nodes may indicate metastasis.

6. PSYCHOSOCIAL ASSESSMENT:
Fear Threats to body image, intimate relationships and survival
Decisions regarding treatment options
Explore client’s feelings, support system, client’s & family’s knowledge
Client’s level of education
Sexuality – psychologic, physiologic, relational
Evaluate need for additional resources

7. NURSING DIAGNOSIS:
Anxiety related to diagnosis of breast cancer Collaborative Problem: Potential for Metastasis
Anticipatory Grieving r/t loss and possible or impending death
Acute Pain r/t tumour compression on nerve endings
Disturbed Sleep Pattern r/t pain and anxiety
Disturbed Body Image r/t loss of a body part
Sexual Dysfunction r/t body image or self-esteem disturbance

8. NURSING OBJECTIVE: Expected Outcomes
The client will demonstrate the correct method of breast self- examination (BSE) and practice BSE on a monthly basis
The client will comply with the guidelines for mammography and professional examination
The client will be able to cope with the diagnosis, as shown by her use of social support, use of information to deal with uncertainty, absence of physical signs of anxiety and verbal confirmation of feeling calm
The client will state that she feels positive about her self- image
The client will regain full range of motion of the affected arm
The client will remain free from lymphedema or infection

9. NURSING PLANNING: Anxiety Seek information to reduce anxiety
Control anxiety responses
Use effective coping strategies throughout the treatment period
Participate in decision making
Discuss concerns
Learn self-care measures
Potential for Metastasis
The client with breast cancer is expected to remain free of metastases or recurrence of cancer

10. NURSING IMPLEMENTATION:
Anxiety
Anxiety Reduction:
Allow the client to vent her feelings; listen attentively
Use calm, reassuring approach
Provide factual information concerning diagnosis, treatment and prognosis
Encourage verbalization of feelings, perceptions and fears
Identify when level of anxiety changes
Support the use of appropriate defense mechanisms
Determine client’s decision-making ability
Flexibility is the key
Suggest support groups

11. Potential for Metastasis
Nonsurgical Management:
Late-stage breast cancer; may be only treatment possible.
Tumour removal with local anaesthetic or resection
F/U with hormonal therapy, chemotherapy, radiation

12. Surgical Management:
Halsted radical mastectomy – breast tissue, nipple, underlying muscles, lymph nodes (rarely performed)
Modified radical mastectomy – breast tissue, nipple, lymph nodes
Simple mastectomy – breast tissue, nipple (lymph nodes left intact)
Lumpectomy – only tumour , small amount of surrounding tissue removed

13. The nurse provides:
Preoperative care – psychologic preparation, preoperative teaching; assess need for drainage tube, mobility restrictions, length of hospital stay, possibility of additional therapy; address body image issues
Intra-operative care – circulator, scrub
Postoperative care – avoid using affected side for B/P, injections, blood draws; care of drainage tubes, comfort measures, client teaching, ambulation, adls, exercise,

14. Breast Reconstruction
The nurse:
Assesses incision, flap sites
Teaches client to avoid pressure flap, suture lines
Cares for drainage devices
Teaches client to avoid sleeping in prone position
Teaches client to avoid contact sports
Teaches client to minimize pressure to breast during sexual relations
Teaches client to refrain from driving
Reassures client that optimal appearance may not occur for 3-6 months post – surgery
Reviews BSE procedure
Reminds client that mammograms should be scheduled at least yearly for the rest of her life
Refers to ACS
Assesses the client’s attitude toward appearance restoration

15. Adjuvant Therapy:
F/U with radiation, chemotherapy, hormone therapy; stem cell therapy; bone marrow therapy
The nurse knows the specific agents to be used and their properties; provides care for client before, during, after procedures

16. Community-Based Care:
Home Care Management
Health Teaching – teaching plan should include:
Measures to optimize body image
Information to enhance interpersonal relationships
Exercises to regain full ROM
Measures to prevent infection of incision
Health Care Resources:
The nurse makes referrals to community resources

17. NURSING INTERVENTION:
Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough, nausea, anorexia.
Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea and vomiting, alopecia, weight gain or loss, fatigue, stomatitis, anxiety, and depression.
Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. Provide psychological support to the patient throughout the diagnostic and treatment process.
Involve the patient in planning and treatment.
Describe surgical procedures to alleviate fear.

18. Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia, fatigue.
Administer antiemetics prophylactically, as directed, for patients receiving chemotherapy.
Administer I.V. fluids and hyperalimentation as indicated.
Help patient identify and use support persons or family or community.
Suggest to the patient the psychological interventions may be necessary for anxiety, depression, or sexual problems.
Teach the recommended cancer-screening procedures.

19. NURSING EVALUATION:
The nurse evaluates the care of the client with breast cancer on the basis of the identified nursing diagnoses and collaborative problems.

20. BY: SRY INDAH WULAN SARI
THANK YOU
BY: SRY INDAH WULAN SARI