1. Interventions for Clients with Breast Disorders

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

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

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

5. 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

6. 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.

7. 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).

8. 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.

9. 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.

10. 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?

11. 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

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

13. 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.

14. 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.

15. 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.

16. 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

17. 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

18. 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

19. 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

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

21. 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

22. 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

23. 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)

24. 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

25. 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

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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. BREAST ASSESSMENT  
SBE
CBE
Mammography, Galactography
Ultrasound
MRI

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

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

37. 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

38. 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

39. 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

40. 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 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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  

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

52. 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

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

54. 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

55. 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  

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

57. 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

58. 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

59. 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

60. 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