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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 • • • • • BARRIERS: fear of pain, radiation, results accessibility, cost modesty knowledge deficit CANCER SCREENING: HIGH RISK • • • • • • • 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 • • • • • • • • • 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: – – – – – • Observe the movement of breast tissue during the following maneuvers: – – – • • 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 • • • • • • • • • 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 • • • • • 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 • Ductal ecstasia – benign, inflamed and dilated, subareolar duct, nipple discharge green/black and sticky, can become abscess 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 Invasive Ca – ducts or lobules, irregular, poorly delineated Non invasive Ca – ductal in situ or lobular in situ, abnormal mammogram • • • • • 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 ASSESSMENT LABORATORY: • • • • • 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 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 • • • • 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