Download 10 - Assessment of breast and axillae

Interventions for Clients with
Breast Disorders
Anatomy and Physiology
Paired mammary glands within the
superficial fascia of the chest wall
Female breast extends vertically from the
2nd or 3rd rib to 6th or 7th
Laterally from sternal margin to midaxillary
line.
Breast is usually divided into 4 quadrants
Breasts and Regional
Lymphatics
Topography of Breast
• 4 quadrants to
describe clinical
findings
• The upper outer
quadrent is the site of
most breast tumors
Anatomy and Physiology:
Female Breast
• Three types of tissue: glandular,
subcutaneous and retromammary fat,
and fibrous
– Glandular: 20 lobes per breast which
radiates around the nipple in spoke like
pattern. Most glandular tissue lies in the
upper outer quadrant. From here the
breast extends into the axilla forming the
Tail of Spence.
Breast Lymphatic Drainage
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
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BARRIERS:
fear of pain, radiation, results
accessibility, cost
modesty
knowledge deficit
CANCER SCREENING: HIGH RISK
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Screening:BSE monthly, age 20
CBE q6-12 mo., ages 25-35
Mammography annually, ages 25-35 years of
age
Options:
Decrease risk factors?
Prophylactic mastectomy
Chemoprevention
(Tamoxifen & other newer drugs)
BREAST SELF EXAM
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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
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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).
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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
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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
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Symmetry
Size
Contour
Skin color, venous
pattern, changes
(edema or pitting)
Nipple changes
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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
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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:
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Observe the movement of breast tissue during the following maneuvers:
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Approximate symmetry
Dimpling or retraction of skin
Swelling or discoloration
Orange peel effect on skin
Position of nipple
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
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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.
• Fibroadenoma – benign, glandular and
fibrous, small, rubbery, nontender
BENIGN BREAST DISORDERS
FIBROADENOMA
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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
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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
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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
• Ductal ecstasia – benign, inflamed and dilated,
subareolar duct, nipple discharge green/black
and sticky, can become abscess
INTRADUCTAL PAPILLOMA
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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
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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)
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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
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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
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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
Invasive Ca – ducts or lobules,
irregular, poorly delineated
Non invasive Ca – ductal in situ or
lobular in situ, abnormal mammogram
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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
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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
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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
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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
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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:
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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
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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
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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
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SBE
CBE
Mammography, Galactography
Ultrasound
MRI
DIAGNOSTIC ASSESSMENT
LABORATORY:
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Pathology reports
Study of cancer markers
Liver enzymes
 Serum calcium
 Alkaline phosphatase
RADIOGRAPHIC
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Mammography
Chest X ray
Bone Scan
Brain Scan
Liver Scan
CT- Chest and abdomen
DIAGNOSTIC ASSESSMENT
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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
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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
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Prior to biopsy, avoid agents interfering with blood
clotting
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NPO
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Care of biopsy site
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Avoid strenuous exercises for 1 week
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Pain management
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Supportive bra for 3-7 days
Post test: Monitor:
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Effects of anesthesia
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Toleration of fluids, food, ambulation
BREAST CANCER STAGING
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• 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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Hematoma at incision site
Infection
Seroma (accumulation of serosanguineous
fluid after drain removed)
Nerve trauma
Impaired arm mobility
Lymphedema
Psychological effects
BREAST RECONSTRUCTION
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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
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Decision based on
Disease stage
Age & menopausal status
Client preferences
Pathologic examination
Hormone receptor status
Genetic predisposition
ADJUNCT THERAPY
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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 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
Hormonal Therapy
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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
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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
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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
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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
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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