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 DISORDERSFIBROADENOMA

•   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 ASSESSMENTLABORATORY:

• 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

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: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 sitesDangerous 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