BREAST CANCER:NURSING CARE PLAN

NURSING ASSESSMENT:

Risk Factors Personal/family histories of breast cancer Age @ menarche/Age @ menopause (early menses or

late menopause increase risk) Symptoms of menopause Age @ first child’s birth Number of children (nulliparity/birth of first child after

age 30 increase risk)

History of Breast Mass Reveals course of disease, health care-seeking practices.

BSE or accidental discovery? Time interval between discovery and seeking health care provider

Review of systems focusing on the most common areas of metastases

Client’s Health Maintenance Practices Knowledge, practice and regularity of BSE Mammographic history Diet history (High alcohol, fat intake increase risk) Medications – hormone supplements, birth control pills

PHYSICAL ASSESSMENT:

Focused Assessment of breast mass Shape Size Consistency Fixation to surrounding tissues Any skin change (peau d’orange) Palpate axillary, superclavicular areas for enlarged

lymph nodes Pain, soreness? Diagram

A firm lump or thickness in breast, usually painless; 50% are located in the upper outer quadrant of the breast.

Spontaneous nipple discharge; may be bloody, clear or serous.

Asymmetry of the breast may be noted as the patient changes positions; compare one breast with the other.

Nipple retraction or scalliness, especially in Paget’s disease.

Enlargement of auxiliary or supraclavicular lymph nodes may indicate metastasis.

PSYCHOSOCIAL ASSESSMENT:

Fear Threats to body image, intimate relationships and survival

Decisions regarding treatment options Explore client’s feelings, support system, client’s &

family’s knowledge Client’s level of education Sexuality – psychologic, physiologic, relational Evaluate need for additional resources

NURSING DIAGNOSIS:

Anxiety related to diagnosis of breast cancer Collaborative Problem: Potential for Metastasis

Anticipatory Grieving r/t loss and possible or impending death

Acute Pain r/t tumour compression on nerve endings Disturbed Sleep Pattern r/t pain and anxiety Disturbed Body Image r/t loss of a body part Sexual Dysfunction r/t body image or self-esteem

disturbance

NURSING OBJECTIVE:

Expected Outcomes The client will demonstrate the correct method of breast self-

examination (BSE) and practice BSE on a monthly basis The client will comply with the guidelines for mammography

and professional examination The client will be able to cope with the diagnosis, as shown

by her use of social support, use of information to deal with uncertainty, absence of physical signs of anxiety and verbal confirmation of feeling calm

The client will state that she feels positive about her self-image

The client will regain full range of motion of the affected arm The client will remain free from lymphedema or infection

NURSING PLANNING:

1. Anxiety Seek information to reduce anxiety Control anxiety responses Use effective coping strategies throughout the treatment

period Participate in decision making Discuss concerns Learn self-care measures

2. Potential for Metastasis The client with breast cancer is expected to remain free

of metastases or recurrence of cancer

NURSING IMPLEMENTATION:

1. Anxiety

Anxiety Reduction: Allow the client to vent her feelings; listen attentively Use calm, reassuring approach Provide factual information concerning diagnosis, treatment

and prognosis Encourage verbalization of feelings, perceptions and fears Identify when level of anxiety changes Support the use of appropriate defense mechanisms Determine client’s decision-making ability Flexibility is the key Suggest support groups

2. Potential for Metastasis

Nonsurgical Management: Late-stage breast cancer; may be only treatment

possible. Tumour removal with local anaesthetic or resection F/U with hormonal therapy, chemotherapy, radiation

Surgical Management: Halsted radical mastectomy – breast tissue, nipple,

underlying muscles, lymph nodes (rarely performed) Modified radical mastectomy – breast tissue, nipple,

lymph nodes Simple mastectomy – breast tissue, nipple (lymph

nodes left intact) Lumpectomy – only tumour , small amount of

surrounding tissue removed

The nurse provides: Preoperative care – psychologic preparation,

preoperative teaching; assess need for drainage tube, mobility restrictions, length of hospital stay, possibility of additional therapy; address body image issues

Intra-operative care – circulator, scrub Postoperative care – avoid using affected side for B/P,

injections, blood draws; care of drainage tubes, comfort measures, client teaching, ambulation, adls, exercise,

Breast Reconstruction

The nurse: Assesses incision, flap sites Teaches client to avoid pressure flap, suture lines Cares for drainage devices Teaches client to avoid sleeping in prone position Teaches client to avoid contact sports Teaches client to minimize pressure to breast during sexual relations Teaches client to refrain from driving Reassures client that optimal appearance may not occur for 3-6 months post –

surgery Reviews BSE procedure Reminds client that mammograms should be scheduled at least yearly for the

rest of her life Refers to ACS Assesses the client’s attitude toward appearance restoration

Adjuvant Therapy: F/U with radiation, chemotherapy, hormone therapy;

stem cell therapy; bone marrow therapy The nurse knows the specific agents to be used and their

properties; provides care for client before, during, after procedures

Community-Based Care: Home Care Management

Health Teaching – teaching plan should include: Measures to optimize body image Information to enhance interpersonal relationships Exercises to regain full ROM Measures to prevent infection of incision

Health Care Resources: The nurse makes referrals to community resources

NURSING INTERVENTION:

Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough, nausea, anorexia.

Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea and vomiting, alopecia, weight gain or loss, fatigue, stomatitis, anxiety, and depression.

Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. Provide psychological support to the patient throughout the diagnostic and treatment process.

Involve the patient in planning and treatment. Describe surgical procedures to alleviate fear.

Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia, fatigue.

Administer antiemetics prophylactically, as directed, for patients receiving chemotherapy.

Administer I.V. fluids and hyperalimentation as indicated.

Help patient identify and use support persons or family or community.

Suggest to the patient the psychological interventions may be necessary for anxiety, depression, or sexual problems.

Teach the recommended cancer-screening procedures.

NURSING EVALUATION:

The nurse evaluates the care of the client with breast cancer on the basis of the identified nursing diagnoses and collaborative problems.

THANK YOUBY: SRY INDAH WULAN SARI