Chapter 48 Assessment and Management of Patients With Breast Disorders

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

2. 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

3. Anatomy of the Breast

4. 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

5. 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)

6. 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

7. Lymph Nodes

8. 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

9. 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 Breast Self-Examination

10. 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 Breast Self-Examination (cont.)

11. 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 Breast Self-Examination (cont.)

12. 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 Breast Self-Examination (cont.)

13. 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 Breast Self-Examination (cont.)

14. 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

15. 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

16. Mammography

17. Surgical Management—Breast Cancer • Breast conservation treatment • Total mastectomy • Modified radical mastectomy • Sentinel node biopsy and axillary lymph node dissection • Breast reconstruction surgery

18. Breast Reconstruction With Tissue Expander

19. Breast Reconstruction With TRAM

20. Breast Reconstruction—Latissimus Dorsi Flap

21. 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

22. 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?

23. Nursing Process—Preoperative Diagnosis of the Patient Undergoing Breast Cancer Surgery • Deficient knowledge • Anxiety • Fear • Risk for ineffective coping • Decisional conflict

24. 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

25. Collaborative Problems/Potential Complications • Lymphedema • Hematoma/seroma formation • Infection

26. 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

27. 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

28. 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

29. 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

30. Exercises After Breast Surgery Wall climbing Rod lifting Pulley tugging Rope turning

31. 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