Chapter 48 Assessment and Management of Patients With Breast Disorders 1.

Chapter 48

Assessment and Management of Patients With Breast Disorders

1

Assessment

Health History

2

Physical Assessment/ Inspection

Retraction Signs Signs include skin dimpling, creasing, or

changes in the contour of the breast or nipple Secondary to fibrosis or scar tissue formation in

the breast Retraction signs may

appear only with

position changes or with

breast palpation.

3


Breast Cancer Mass (Malignant Tumor) Usually occurs as a single mass (lump) in

one breast Firm, hard, embedded in surrounding tissue Referral and biopsy indicated for definitive

diagnosis Usually nontender Irregular shape

4


Breast Cyst (Benign Mass) Occur as single or multiple lumps in one or both breasts Usually tender (omitting caffeine reduces tenderness);

tenderness increases during premenstrual period Round shape Soft or firm, mobile Referral and biopsy indicated

for definitive diagnosis,

especially for first mass.

5


Fibroadenoma (Benign Breast Lump) Usually occurs as a single mass in women aged 15–35

years Usually nontender May be round or lobular Firm, mobile, and not fixed to breast tissue or chest wall No premenstrual changes Referral and biopsy indicated

for definitive diagnosis

6


Increased Venous Prominence Associated with breast cancer if unilateral Unilateral localized increase in venous pattern

associated with malignant tumors Normal with breast

enlargement associated with

pregnancy and lactation if

bilateral and bilateral symmetry

7


Peau d'Orange (Edema) Associated with breast cancer Caused by interference with lymphatic drainage Breast skin has orange peel appearance Skin pores enlarge May be noted on the areola Skin becomes thick, hard, immobile Skin discoloration may occur

8


Nipple Inversion Considered normal if long-standing Associated with fibrosis and malignancy if

recent development

9


Acute Mastitis (Inflammation of the Breasts) Associated with lactation but may occur at any

age Nipple cracks or abrasions noted Breast skin reddened and warm to touch Tenderness Systemic signs include fever and increased

pulse

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Paget Disease (Malignancy of Mammary Ducts) Early signs: erythema of nipple and areola Late signs: thickening, scaling, and erosion

of the nipple and areola

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Diagnostic Evaluation

Breast Self-Examination (BSE) Done on day 5-7 of menstrual cycle (some

changes in breast occur due to hormones around menstruation)

Breast examination with the woman in a supine position. The entire surface of the breast is palpated from the outer edge of the breast to the nipple. Alternative palpation patterns are circular or clockwise, wedge, and vertical strip.

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Breast-Self Examination

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Diagnostic Evaluation Mammography Detect nonpalpable

lesions and assist in diagnosing palpable masses

Recommended to be done every year beginning at 40 years of age (women with family history, start at younger age)

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Diagnostic Evaluation

Magnetic Resonance Imaging Procedures for Tissue Analysis

Percutaneous Biopsy Fine-Needle Aspiration Surgical Biopsy

• Excisional Biopsy• Incisional Biopsy

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Comparison of Various Breast Masses

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Also called chronic mastitis or lumpy breast syndrome, it is the most common breast lesion in females and usually occurs between ages 35 and 50. Many cases will subside after menopause.

Benign Neoplasms:

Fibrocystic Breast Disease(FBD)

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Benign Neoplasms:


Incidence of developing breast cancer is increased 3 to 4 times with FBD.

Pathology Cause is unknown; possible hormonal

imbalance Condition occurs during reproductive years

and disappears with menopause A benign condition affecting 25% of women

over 30 years of age

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Benign Neoplasms:


Signs and symptoms Subjective: breast tenderness and pain Objective: small, round, smooth nodules

Diagnostic tests and methods Mammography, thermomastography,

xerography Treatment: conservative

Aspiration Biopsy examination to rule out malignancy

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Benign Neoplasms:


Nursing intervention Explain importance of monthly breast self-

examination Encourage patient to seek medical evaluation

if nodule forms, because cystic disease may interfere with early diagnosis of breast malignancy

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Malignant Neoplasms:

Breast Cancer Second major cause of

cancer death among women. Statistics indicate that 1 in 10 will develop cancer sometime during her life.

The key to cure is early detection by physical examination, mammography, and breast self-examination.

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Risk factors for Breast Cancer Female gender Increasing age Personal history of breast cancer Family history of breast cancer Genetic mutations (BRCA-1 and BRCA-2

mutations are responsible for majority of inherited breast cancer cases) Late menopause Nulliparity

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Risk factors for breast Cancer Hormonal factors

Early menarche First child after 30 years of age Hormone therapy (HT)

Exposure to ionizing radiation during adolescence and early adulthood

History of benign proliferative breast disease Obesity High-fat diet (controversial) Alcohol intake

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Protective Factors

Regular exercise (after age of 35, strenuous excursive ˅ chance for BC by 14%.

Breastfeeding Having completed a full-term pregnancy

before 30 years of age

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Types of Breast CancerDuctal Carcinoma in Situ

Characterized by the proliferation of malignant cells inside the milk ducts without invasion into the surrounding tissue.

It is a noninvasive form of cancer (also called intraductal carcinoma).

If not treated, ? become invasive cancer

26

Types of Breast CancerInfiltrating Ductal Carcinoma

Is the most common histologic type of breast cancer.

Accounts for 75% of all cases. The tumors arise from the duct system

and invade the surrounding tissues. They often form a solid irregular mass in

the breast.

27

Other types of breast cancer

Infiltrating Lobular Carcinoma (5-10%) Medullary Carcinoma (5%) Mucinous Carcinoma (3%) Tubular Ductal Carcinoma (2%) Inflammatory Carcinoma (2%) Paget Disease (1%)

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Breast cancer Signs and symptoms

Subjective: nontender nodule Objective:

• Enlarged axillary nodes• Nipple retraction or elevation• Skin dimpling• Nipple discharge• usually appeal in the upper outer quadrant

Diagnostic tests and methods Mammography, breast biopsy examination

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Breast cancer Treatment

Lumpectomy: removal of the lump and partial breast tissue; indicated for early detection

Mastectomy• Simple mastectomy: removal of breast• Modified radical mastectomy: removal of

breast, pectoralis minor muscle, and some of an adjacent lymph nodes

• Radical mastectomy: removal of the breast, pectoral muscles, pectoral fascia, and axillary lymph node disection

30

Breast cancer Treatment

• Oophorectomy, adrenalectomy, hypophysectomy to remove source of estrogen and the hormones that stimulate the breast tissue

• Radiation therapy to destroy malignant residual malegnant cells

• Chemotherapeutic agents to shrink, retard, and destroy cancer growth

• Corticosteroids, antigens, and anti-estrogens to alter cancer that is dependent on hormonal environment

31

Collaborative Problems/Potential Complications

Based on the assessment data, potential complications may include the following:

Lymphedema Hematoma/seroma formation Infection

32

Breast Cancer/ Preop Nsg Dx Deficient knowledge about the planned surgical

treatments Anxiety related to the diagnosis of cancer Fear related to specific treatments and body

image changes Risk for ineffective coping (individual or family)

related to the diagnosis of breast cancer and related treatment options

Decisional conflict related to treatment options

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Preoperative Nursing Interventions

Providing Education and Preparation About Surgical Treatments

Reducing Fear and Anxiety and Improving Coping Ability

Promoting Decision-Making Ability

34

Breast Cancer/ Postop Nsg Dx Pain and discomfort related to surgical procedure Disturbed sensory perception related to nerve

irritation in affected arm, breast, or chest wall Disturbed body image related to loss or alteration of

breast Risk for impaired adjustment related to the

diagnosis of cancer and surgical treatment Self-care deficit related to partial immobility of arm

35

Breast Cancer/ Postop Nsg Dx Risk for sexual dysfunction related to loss of

body part, change in self-image, and fear of partner's responses

Deficient knowledge: drain management after breast surgery

Deficient knowledge: arm exercises to regain mobility of affected extremity

Deficient knowledge: hand and arm care after an axillary lymph node dissection (ALND)

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Postoperative Nursing Interventions

Relieving Pain and Discomfort Managing Postoperative Sensations Promoting Positive Body Image Promoting Positive Adjustment and

Coping Monitoring and Managing Potential

Complications

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Lymphedema Occurs in about 10% to 30% of patients

who undergo ALND and in about 0% to 7% of patients who have SLNB

lymphatic channels become inadequate to ensure a return flow of lymph fluid to the general circulation.

Risk factors: age, obesity, extensive axillary disease, radiation treatment, and injury or infection to the extremity

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Lymphedema Edema resolved after development of collateral

circulation. Postoperative transient edema develops until

collateral circulation has completely taken over this function, which generally occurs within a month. Performing prescribed exercises, elevating the arm above the heart several times a day, and gentle muscle pumping (making a fist and releasing) can help reduce the transient edema. The patient needs reassurance that this transient swelling is not lymphedema

39

Hand and Arm Care After Axillary Lymph Node Dissection

Avoid BP, injections, and blood draws in affected arm. Use sunscreen for extended exposure to sun. Apply insect repellent to avoid insect bites. Wear gloves for gardening. Use cooking mitt for removing objects from oven. Avoid cutting cuticles; push them back during manicures. Use electric razor for shaving armpit. Avoid lifting objects greater than 2-4 kg. If a trauma or break in the skin occurs, wash the area with soap and

water, and apply an antibacterial ointment. Observe the area and extremity for 24 hours; if redness, swelling, or a

fever occurs, call the surgeon or nurse.

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Post-op arm exercise

Wall handclimbing Rope turning

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Post-op arm exercise

Rod or broomstick lifting Pulley tugging

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Breast cancer Nursing intervention

Provide atmosphere of acceptance, frequent patient contact, and encouragement in illness adjustment

Encourage grooming activities Arrange attractive environment If the patient is receiving radiation or

chemotherapy, explain and assist with potential site effects

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Breast cancer If the patient has undergone surgical intervention,

follow post operative nursing actions• Elevate affected arm above level of right atrium to prevent

edema• Drawing blood or administering parenteral fluids or taking

blood pressure on affected arm is contraindicated• Monitor dressing for hemorrhage, observed back for pooling

of blood• Empty Hemovac and measure drainage every 8 hours• Assess circulatory status of affected limb• Measure upper arm and forearm, twice daily, to monitor

edema• Encourage exercises of the affected arm when approved by

a physician; avoid abduction

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Breast cancer Patient teaching on discharge

• Exercise to tolerance• Sleep with arm elevated• Elevated arm several times daily• Avoid injections, vaccinations, IV, and taking blood

pressure, in affected arm

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Malignant Neoplasms:

Breast Cancer Five year survival rate

is 97% for localized cancer, 76% for cancer that has spread regionally, and 21% for cancers having distant metastases.

Metastatic breast cancer to the back

46

Male Breast Cancer Accounts for less than 1% of all cases of

breast cancer Average age at diagnosis is 67 years Risk factors:

A history of mumps orchitis, Radiation exposure, Decreased testosterone levels Liver disease (compromises estrogen

metabolism).47

Chapter 48 Assessment and Management of Patients With Breast Disorders 1.

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Transcript of Chapter 48 Assessment and Management of Patients With Breast Disorders 1.