Lecture Eighteen: Care of the Client with Breast Dysfunction

1. Lecture Eighteen: Care of the Client with Breast Dysfunction NURS 2208 Fall 2002 T. Dennis RNC, MSN

2. Physiology The breast has regular cyclic changes in response to hormonal stimulation. Mastodynia: premenstrual swelling and tenderness of the breast. Menopuase results in a loss of elasticity and adipose tissue turns into connective tissue.

3. Breast Self Examination (pg. 54) Recommended monthly procedure by which women may detect changes or abnormalities in their breasts (pg. 55). Breast examination should be taught as early as possible and taught correctly. Should be performed one week after the menstrual cycle. Most effective when inspection and palpation are used (after menopause on the same day each month).

4. Mammography (pg. 56) A soft tissue radiograph of the breast without injection of a contrast medium. Detects lesions in the breast before they can be felt. An accepted screening tool for breast cancer. Recommended every 1 to 2 years for women age 40 to 49 and annually for all women 50 and older (age is a primary factor). 30% of women age 40 to 49 are likely to have a false-positive result requiring biopsy. 25% miss in breast cancers in women 40 to 49. Many women avoid mammograms due to the discomfort associated with procedure. Discomfort can be reduced by avoiding caffeine in the diet and scheduling the procedure 2 weeks after menses.

5. Benign Breast Disease (pg. 63) Fibrocystic Breast disease Fibroadenoma Intraductal papilloma Duct ectasia

6. Fibrocystic Breast Disease (pg. 62) Commonly occurs between age 30-50. Associate with breast tenderness Associated with a risk for cancer when the disorder is proliferative and with atypical hyperplasia. Nipple discharge may vary from none to clear, milky, straw colored or green. Location usually the upper outer quadrant. Multiple lumps may occur bilaterally, are influenced by menstrual cycles and be nodular. Needle aspiration, smear of nipple discharge, observation , sonography and biopsy may be used for diagnosis and treatment.

7. Normal Breast

8. Fibrocystic Breast

9. Fibroadenoma (pg. 62) Commonly occurs between ages 15-25 (median age is 20). No pain associated with the disorder. No cancer risk associated with the disorder. No discharge associated with the disorder (a milky discharge may occur with pregnancy). Location may be nipple or upper outer quadrant along the lateral side of the breast. Appears solid, well defined, sharply delineated, rubbery, and mobile. Diagnosis and treatment by mammography, observation and possible surgical excision.

10. Intraductal Papilloma (pg. 62) Found in women 50-60. Pain noted on palpation. Cancer risk occurs with multiple papillomas. Drainage is typically serous, bloody, or brownish green. Occurs in no specific location. May be non-palpable or small, ball-like, poorly delineated. Diagnosis and treatment may consist of smear of nipple discharge, mammography, ductogram, or surgical excision.

11. Duct Ectasia (pg. 63) Commonly occurs between ages 45-55. Pain occurs and may include burning and itching around the nipple. In perimenopausal women, discharge may be thick, sticky, green, greenish brown, or bloodstained. Mass is located behind or around the nipple. Poorly circumscribed, inflammation, nipple retraction, axillary lymph adenopathy. Diagnosis and treatment include: smear of breast discharge, mammography, drug therapy for symptoms, observation and surgical excision.

12. Malignant Breast Disease (pg. 62) Affects one in eight women in the United States. Predisposing factor include: Age-incidence increases steadily with age (especially after 50) History of previous breast cancer Family history of mother or sister with bilateral pre-menopausal breast cancer High fat diet Alcohol consumption No history of pregnancy Longer reproductive phase Geographic location (North America, northern Europe; in the US urban North; Low risk areas: Asia, Africa; in the US, rural south.

13. Malignant Breast Disease (pg. 62) 50% of breast cancers originate in the upper outer quadrant and spread or metastasize to axillary lymph nodes. Common sites of metastasis: lymph nodes, lungs, liver, brain, and bone. Discovery may be by BSE, clinician, mammography, fine needle biopsy, ultrasonography, thermography, and MRI. Diagnosis is determined by biopsy. Treatment plan is based on lymph node involvement and clinical staging of the disease. .

14. Malignant Breast Disease (pg. 62) Surgical treatment may include: mastectomy followed by reconstructive surgery, lumpectomy with adjunct treatment including chemotherapy, radiation, and hormone therapy. Preoperative care: teaching, emotional support, pain management, introduction to support groups. Postoperative care: Minimize edema, BP cuff is never placed on the affected arm. Affected arm elevated, early arm movement encouraged, early ambulation encouraged. Physical therapy is usually prescribed. Convalescent care: may include plans for reconstructive surgery and participation in support groups.

15. Nursing Care (pg. 63) Assessment and Diagnosis: Therapeutic communication Knowledge Deficit related to a lack of information about the diagnostic procedures. Anxiety related to threat to body image or her life. Plan and Implementation: Clarify misconceptions Provide education on self breast care Provide psychological support. Allow client to discuss her fear. Refer to professional support groups.

16. Questions?