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Chapter 48 Assessment and Management of Patients With Breast Disorders. Breast Disorders. Overview of anatomy of the breast Cultural and psychosocial considerations Breast cancer is a major health problem - PowerPoint PPT Presentation
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Copyright © 2008 Lippincott Williams & Wilkins.
Chapter 48
Assessment and Management of Patients With Breast Disorders
Chapter 48
Assessment and Management of Patients With Breast Disorders
Copyright © 2008 Lippincott Williams & Wilkins.
Breast DisordersBreast Disorders
• Overview of anatomy of the breast
• Cultural and psychosocial considerations
• Breast cancer is a major health problem
• In the U.S., more than 215,000 women and 1,450 men develop breast cancer annually, and more than 40,000 die
Copyright © 2008 Lippincott Williams & Wilkins.
Anatomy of the BreastAnatomy of the Breast
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Risk Factors for Breast CancerRisk Factors for Breast Cancer
• Female gender
• Age
• Personal and family history including genetic mutations
• Hormonal factors
• Exposure to radiation
• History of benign breast disease
• Obesity
• High-fat diet (controversial)
• Alcohol intake
Copyright © 2008 Lippincott Williams & Wilkins.
Guidelines for Early Detection of Breast Cancer
Guidelines for Early Detection of Breast Cancer
• Women in their 20s and 30s: clinical breast exam at least every 3 years, then preferably annually after age 40
• Mammography annually beginning at age 40
• Women at increased risk may have earlier initial screening, shorter screening intervals, or additional screening procedures such as ultrasound and MRI
• Teach women in their 20s the benefits and limitations of breast self-examination (BSE)
Copyright © 2008 Lippincott Williams & Wilkins.
Breast Self-ExaminationBreast Self-Examination
• Provide instruction to women regarding BSE
• Instructions should be provided to men if there is a family history of breast cancer
• Encourage BSE but do not overemphasize it
• Instructional materials can be obtained from the American Cancer Society and The National Cancer Institute
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Lymph NodesLymph Nodes
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Teaching Breast Self-ExaminationTeaching Breast Self-Examination
• Best performed days 5 to 7 days after first day of menses or once monthly for postmenopausal women
• Review the feel of normal breast tissue and ways or identify changes
• Routine BSE helps patients become familiar with their own “normal abnormalities”
• Demonstrate the examination technique
• Encourage the student to perform a BSE demonstration on herself or on a breast model
Copyright © 2008 Lippincott Williams & Wilkins.
Breast Self-ExaminationBreast Self-Examination
• Stand in front of a mirror
• Check both breasts for anything unusual
• Look for discharge from the nipple and puckering, dimpling, or scaling of the skin
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Breast Self-Examination (cont.)Breast Self-Examination (cont.)
• Watch closely in the mirror as you clasp your hands, bend your head, and press your hands forward
• Note any change in the contour or your breasts
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Breast Self-Examination (cont.)Breast Self-Examination (cont.)
• Next, press your hands firmly on your hips and bow slightly toward the mirror as you pull your shoulders and elbows forward
• Note any change in the contour of your breasts
Copyright © 2008 Lippincott Williams & Wilkins.
Breast Self-Examination (cont.)Breast Self-Examination (cont.)
• Raise your left arm; using 2 or 3 fingers, feel your left breast carefully and thoroughly
• Beginning at the outer edge, press the flat part of your fingers in small circles, moving the circles slowly around the breast
• Gradually work toward the nipple
• Cover the whole breast
Copyright © 2008 Lippincott Williams & Wilkins.
Breast Self-Examination (cont.)Breast Self-Examination (cont.)
• Feel for any lumps or masses.
• Repeat on the right breast; step 4 should be repeated lying down
• Lie flat on your back with your left arm over you head and a pillow or folded towel under the left shoulder
• Use the same circular motion
• Repeat on the right breast
Copyright © 2008 Lippincott Williams & Wilkins.
Teaching Breast Self-ExaminationTeaching Breast Self-Examination
• Part of the examination may be done in the shower with soapy hands to glide over the breast and focus on underlying tissue
• Note the importance of including the area between the breast and underarm, and the underarm itself
• Discuss reporting of any changes
• Describe the goals, methods of instruction, and methods of evaluation for a teaching plan for BSE
• List resources for information and materials
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Diagnostic TestsDiagnostic Tests
• Mammography
• Galactography
• Ultrasonography
• Magnetic resonance imaging (MRI)
• Biopsies
– Percutaneous: fine-needle aspiration and core biopsies
– Surgical biopsies: excision, incision, and wire needle localization
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MammographyMammography
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Surgical Management—Breast CancerSurgical Management—Breast Cancer
• Breast conservation treatment
• Total mastectomy
• Modified radical mastectomy
• Sentinel node biopsy and axillary lymph node dissection
• Breast reconstruction surgery
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Breast Reconstruction With Tissue Expander
Breast Reconstruction With Tissue Expander
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Breast Reconstruction With TRAMBreast Reconstruction With TRAM
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Breast Reconstruction—Latissimus Dorsi Flap
Breast Reconstruction—Latissimus Dorsi Flap
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Nonsurgical Management of Breast Cancer
Nonsurgical Management of Breast Cancer
• Radiation therapy: external beam, brachytherapy
• Chemotherapy
• Hormonal therapy
– Estrogen and progesterone receptor assay
– Selective estrogen receptor modulators (SERMs): tamoxifen
– Aromatase inhibitors: anastrozole, letrozole, and exemestane
• Targeted therapy
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Nursing Process—Assessment of the Patient Undergoing Breast Cancer
Surgery
Nursing Process—Assessment of the Patient Undergoing Breast Cancer
Surgery
• How is the patient responding to her diagnosis?
• What coping mechanisms does she find helpful?
• What psychological or emotional supports does she have and use?
• Is there a partner, family member, or friend available to assist in making treatment choices?
• What are her educational needs?
• Is she experiencing any discomfort?
Copyright © 2008 Lippincott Williams & Wilkins.
Nursing Process—Preoperative Diagnosis of the Patient Undergoing
Breast Cancer Surgery
Nursing Process—Preoperative Diagnosis of the Patient Undergoing
Breast Cancer Surgery
• Deficient knowledge
• Anxiety
• Fear
• Risk for ineffective coping
• Decisional conflict
Copyright © 2008 Lippincott Williams & Wilkins.
Nursing Process—Postoperative Diagnosis of the Patient Undergoing
Breast Cancer Surgery
Nursing Process—Postoperative Diagnosis of the Patient Undergoing
Breast Cancer Surgery• Pain
• Disturbed sensory perception
• Disturbed body image
• Self-care deficit
• Risk for sexual dysfunction
• Deficient knowledge
– Drain management
– Arm exercises
– Hand and arm care
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Collaborative Problems/Potential Complications
Collaborative Problems/Potential Complications
• Lymphedema
• Hematoma/seroma formation
• Infection
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Nursing Process—Planning the Care of the Patient Undergoing Breast Cancer
Surgery
Nursing Process—Planning the Care of the Patient Undergoing Breast Cancer
Surgery
• Major goals may include:
– Increased knowledge about the disease and its treatment
– Reduction of preoperative and postoperative fear, anxiety, and emotional stress
– Improvement of decision-making ability and improvement of coping skills
– Improvement in sexual function
– Absence of complications
Copyright © 2008 Lippincott Williams & Wilkins.
Preoperative InterventionsPreoperative Interventions• Review and reinforce information on treatment options
• Prepare patient regarding what to expect before, during, and after surgery
• Inform patient regarding surgical drain, arm and shoulder mobility, and range-of-motion exercises
• Maintain open communications
• Provide patient with realistic expectations
• Support coping
• Involve or provide information for supportive services and resources
• Support patient decisions
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Postoperative InterventionsPostoperative Interventions
• Inform patient regarding common postoperative sensations
• Maintain privacy
• Provide bra with breast form
• Provide information
• Support coping and adjustment
• Provide counseling and referral
• See Table 48-5 and Chart 48-6
• Monitor for potential complications
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Hand and Arm CareHand and Arm Care• Potential for lymphedema formation after auxiliary lymph
node dissection (ALND)• Patient education• Prevention is vital; follow guidelines for the rest of life• No blood pressure, injections, or blood draws in the
affected arm• Perform exercises 3X a day for 20 minutes to increase
circulation and muscle strength, prevent stiffness and contractures, and restore ROM
• A mild analgesic or a warm shower may be helpful prior to exercise
• Initial limitation of lifting (over 5 to 10 lbs) and activity• See Chart 48-7
Copyright © 2008 Lippincott Williams & Wilkins.
Exercises After Breast SurgeryExercises After Breast Surgery
Wall climbing
Rope turning
Rod liftingPulley tugging
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Drain ManagementDrain Management
• May need home care referral to assist with drain management
• Drains are usually removed when drainage is less than 30 mL in a 24-hour period; usually occurs in 7 to 10 days
• Drain site and incision care
• See Chart 48-8
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