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Chapter 48
Assessment and Management of
Patients With Breast Disorders
Copyright © 2008 Lippincott Williams & Wilkins.
Breast 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
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Anatomy of the Breast
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Risk 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
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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)
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Breast 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 Nodes
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Teaching 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
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Breast 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.)
• 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.)
• 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
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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
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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
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Teaching 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 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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Mammography
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Surgical 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
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Breast Reconstruction With TRAM
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Breast Reconstruction—Latissimus Dorsi
Flap
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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
• 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?
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Nursing Process—Preoperative
Diagnosis of the Patient Undergoing
Breast Cancer Surgery
• Deficient knowledge
• Anxiety
• Fear
• Risk for ineffective coping
• Decisional conflict
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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
• Lymphedema
• Hematoma/seroma formation
• Infection
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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
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Preoperative 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 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 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
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Exercises After Breast Surgery
Wall climbing
Rod lifting
Rope turning
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Pulley tugging
Drain 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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