interventions for clients with breast disorders
DESCRIPTION
Interventions for Clients with Breast Disorders. 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. - PowerPoint PPT PresentationTRANSCRIPT
Interventions for Clients with Breast Disorders
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• 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:
– Approximate symmetry – Dimpling or retraction of skin – Swelling or discoloration – Orange peel effect on skin – Position of nipple
• Observe the movement of breast tissue during the following maneuvers: – 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.
BENIGN BREAST DISORDERSFIBROADENOMA
• 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
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
• 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 ASSESSMENTLABORATORY:
• 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 sitesDangerous 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