Nursing Care of the Woman with a Disorder of the Breast

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Nursing Care of the Woman with a Disorder of the
Breast
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Benign Breast Disorders
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Fibrocystic Breast Disease
Related to
Relatively High estrogen and Low progesterone
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Normal Breast
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Fibrocystic Changes

• Development of excess fibrous tissue
• Hyperplasia of the epithelial lining of the
  mammary ducts
• Proliferation of mammary ducts
• Cyst formation

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Signs and Symptoms

• Palpable lumps that are round, well-delineated
  and freely movable
• Lumps increase in size premenstrual
• Tenderness
• Pain
• Nipple discharge

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Diagnosis

• Ultrasound
• Biopsy
• Aspiration
• Excisional

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Nursing Care

• Patient Teaching
• Wear good support bra
• Diet Therapy
• Low salt
• No chocolate or caffeine

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Nursing Care

• Medications
• Vitamin E
• Antiestrogen - Danazol
• Diuretics
• Analgesics
• Remind Patient to have a Yearly follow-up
• Continue to perform monthly BSE

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Review

• In teaching the patient with painful fibrocystic
  breast changes about the condition, the nurse
  explains that
• All breast lumps must be biopsied to rule out
  malignant changes
• The symptoms will probably subside after
  menopause unless you use HRT
• Restrictions of coffee and chocolate and
  supplements of vitamin E may relieve the
  discomforts
• The lumps will become progressively larger and
  more painful, eventually necessitating surgical
  removal

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Fibroadenoma

• Benign lump in breast

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Fibroadenoma

• Not affected by menstrual cycle
• Small, painless, well-delineated, very mobile
• __________________________
• Diagnosed via mammogram or biopsy
• Treatment surgical excision

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Breast Cancer
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• Significant health concern for women
• 1 in 7 chance of being diagnosed
• with Breast Cancer
• Intense feelings of shock, fear, denial
• One of the most common
• malignancies in American women

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Risk Factors

• Female gender 50 years of age
• Personal History
• Family history
• Personal history of cancer (breast, colon,
  endometrial, ovarian)
• Hormonal factors
• Early menarche or late menopause
• No pregnancies
• First child after 30 years of age
• Weight gain and obesity after menopause
• High fat diet, alcohol intake
• Exposure to ionizing radiation

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Risk Factors
BRCA gene breast cancer susceptibility gene 1
and 2

• In normal cells, BRCA1 and BRCA2 help ensure the
  stability of the cells genetic material (DNA)
  and help prevent uncontrolled cell growth.
• A womans lifetime risk of developing breast
  and/or ovarian cancer is greatly increased if she
  inherits a harmful mutation in BRCA1 or BRCA2.
• Another risk a woman who has been on combined
  estrogen and progesterone therapy

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Pathophysiology

• Breast Cancer arises from
• Epithelial lining of ducts
• Epithelium of lobules
• Most Breast Cancers arise from ducts
• and are invasive

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Prognosis

• Factors that affect cancer prognosis
• Size
• Axillary node involvement
• Tumor differentiation
• Human epidermal growth factor receptor 2 (HER-2)
  status

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HER-3 Receptors
HER-2 receptors are found on the inside and
outside of the Cancer cell. Receptors join
together to send messages telling cancer cells to
grow and divide
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Signs and Symptoms

• Detected as a lump
• Abnormality on mammography
• If palpable, irregular shaped, poorly delineated,
  nonmobile (usually attached to chest wall), and
  nontender
• May have nipple discharge bloody
• Nipple retraction
• Dimpling

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Distribution of Breast Cancer
Most commonly found in the upper outer quadrant
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Diagnostic Testing
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Breast Self Examination

• Helps women to become self-aware of how their
  breasts normally look and feel and to detect when
  something changes.
• Should be done monthly when the breasts are non
  tender, right after the end of menses
• If no longer have menses use the first day of
  each month

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Breast Self Examination

• 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

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Breast Self Examination

• Use a firm, smooth touch with the first few
  finger pads of your hand,
• keeping the fingers flat and together. Use a
  circular motion, about
• the size of a quarter. Go around breast, up
  and down over breast
• and in outward from nipple.
• Look at breasts with arms at side and arms raised
  and on hips
• Next, lie down and do same procedure in palpating
  breasts.

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Diagnosis

• DNA testing for BRCA 1 and BRCA-2
• Mammogram / ultrasound
• Mammogram showing Bilateral Invasive Ductal
  Carcinoma
• Biopsy

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Diagnostic Studies

• Lymphatic mapping and sentinel lymph node
  dissection (SLND)
• Helps surgeon identify lymph nodes that drain
  first from tumor site
• Radioisotope and/or blue dye is injected into
  tumor site
• Lymph nodes dissected and sent to lab for analysis

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Review

• While discussing risk factors for breast cancer,
  the nurse stresses that the greatest known risk
  factor for breast cancer is
• Being a woman over 60 years of age
• Experiencing menstruation for 40 years or more
• Using estrogen replacement therapy during
  menopause
• Having a paternal grandmother with postmenopausal
  breast cancer

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Treatment
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Treatment Options
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Surgical Therapy
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Surgical Therapy

• Most common options for resectable Breast Cancer
• Breast conservation surgery with radiation
  therapy
• Modified radical mastectomy with or without
  reconstruction

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Surgical TherapyAxillary Node Dissection

• Sentinel lymph node dissection (SLND) has
  replaced ALND for patients who do not have
  malignant cells
• ALND performed when one or more sentinel lymph
  nodes contain malignant cells
• Examination of lymph nodes provides prognosis and
  treatment information

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Surgical TherapyBreast Conservation Therapy

• Involves removal of entire tumor with a margin of
  normal tissue
• Radiation therapy is delivered to entire breast,
  ending with a boost to tumor bed
• Evidence of systemic disease may warrant
  chemotherapy before radiation

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Surgical Therapy

• Modified radical mastectomy
• Removal of breast and axillary lymph nodes with
  preservation of the pectoralis major muscle
• Patient has the option of breast reconstruction

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Radiation Therapy
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Radiation Therapy

• Primary radiation therapy
• Usually performed after local excision of breast
  mass
• Breast is radiated daily over 5 to 6 weeks
• Boost treatment may be given to full breast
  
• following primary dose
• Intraoperative Radiation Therapy
• Single intense dose delivered to surgery site in
  the operating room

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Radiation Therapy

• High-dose brachytherapy
• Internal radiation delivered via radioactice
  seeds into a balloon catheter
• Balloon catheter is placed within the lumpectomy
  site
• Treatment is over 4-5 days

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Radiation Therapy

• Palliative radiation therapy
• Used to stabilize symptomatic metastatic
  lesions in such sites as
• Bone
• Soft tissue organs
• Brain
• Chest
• Relieves pain
• Successful in controlling recurrent or metastatic
  disease for long periods

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Radiation Therapy

• Radiation therapy side effects
• Fatigue
• Skin changes
• Breast edema

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Hormonal Therapy
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Hormonal Therapy

• Removes or blocks source of estrogen, promoting
  tumor regression
• Estrogen can increase growth of BC cells if cells
  are estrogen receptor positive
• Most common drug used in estrogen-receptor
  positive women is
• Tamoxifen (Nolvadex) antiestrogen
• Side effects decreased visual acuity, and
  vascular changes
• Fulvestrant (Faslodex) - antiestrogen

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Hormonal Therapy

• Hormonal therapy (cont'd)
• 2 advances have increased use in BC
• Hormone receptor assays developed to identify
  those likely to respond to treatment
• Drugs have been developed that can inactivate
  hormone-secreting glands as effectively as
  surgery or radiation

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Biologic and Targeted Therapies
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Biologic and Targeted Therapies

• Trastuzumab (Herceptin) is a monoclonal antibody
  to HER-2
• Once the antibody attaches to antigen, it is
  taken to cells and eventually kills them
• It can be used alone or in combination with other
  chemotherapies
• Side-effect monitor for signs of ventricular
  dysfunction and congestive heart failure.

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Chemotherapy
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Chemotherapy

• Use of cytotoxic drugs to destroy cancer cells
• BC is one of the solid tumors that is most
  responsive to chemotherapy
• Given preoperatively in some patients to decrease
  size of primary tumor

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Chemotherapy

• Variety of side effects since healthy cells are
  also affected
• Influenced by specific drug combinations, drug
  schedule, and dose of drug(s)
• Most common side effects involve
• Gastrointestinal tract
• Bone marrow
• Hair follicles

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Nursing Care
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Goals

• The patient will
• Actively participate in decision-making process
  related to treatment options
• Fully comply with therapeutic plan
• Manage side effects of therapy
• Be satisfied with support provided by significant
  others and health care providers

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Nursing Intervention

• Prevention of Lymphedema
• Heaviness
• Pain
• Impaired motor function in arm
• Numbness
• Paresthesia of the fingers
• Cellulitis and progressive fibrosis can result

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Nursing Implementation

• Restoring arm function on affected side after
  mastectomy and axillary lymph node dissection is
  one of the most important goals
• Place in a semi-Fowlers position with arm on
  affected side elevated on a pillow, never
  dependent
• Flexing and extending fingers should begin in
  recovery room and progressive increase in
  activity
• Blood pressure readings, venipunctures, and
  injections should not be done on affected arm
• Use intermittent pneumatic compression sleeve or
  a fitted elastic pressure gradient sleeve

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Nursing Implementation

• Postoperative arm and shoulder exercises are
  instituted gradually at surgeons direction
• Exercises are designed to prevent contractures
  and muscle shortening, maintain muscle tone, and
  improve lymph and blood circulation
• Instruct patient to protect arm from even minor
  trauma (e.g., sunburn, pinprick)

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Postoperative Exercises
Fig. 52-8
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Nursing Interventions

• Relieve postmastectomy pain syndrome
• Chest and upper arm pain, tingling down arm
• Numbness, shooting or prickling pain
• Unbearable itching persisting beyond 3-month
  healing time
• Treatment includes
• Nonsteroidal antiinflammatory drugs
• Antidepressants
• Topical lidocaine patches or EMLA

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Nursing Implementation

• Postoperative discomfort can be minimized by
  administering analgesics 30 minutes prior to
  exercises
• When showering is appropriate, warm water has a
  soothing effect and decreases joint stiffness

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Nursing Implementation

• Psychologic care
• All aspects of care must include sensitivity to
  womans effort to cope
• Nurse can help by
• Assisting her to develop a positive but realistic
  attitude
• Helping her identify sources of support and
  strength

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Follow up Care

• Must be follow-up for rest of life at regular
  intervals
• Professional examinations every 6 months for 2
  years, then annually
• Practice monthly breast self examinations (BSE)
  on both breasts or remaining breast

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Review

• A patient had a radical mastectomy with lymph
  node dissection. Post op nursing care focused on
  restoring arm functioning would include
• Use of heating pads or blankets to increase
  circulation
• Daily application of ice packs to minimize the
  risk of lymphedema
• Compression bandaging with sleeves or stocking
  for acute swelling
• Frequent and sustained exercises with the arm in
  a dependent position

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Reconstructive Surgery
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Breast Reconstruction
Chest prior to Implants
Breast implants placed in pocket under pertoralis
muscle and musculocutaneous skin flap applied
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Breast Reconstruction

• Musculocutaneous flap most often taken from
  abdomen or back is used in reconstruction

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Breast Reconstruction

• As part of the final stage of reconstruction, the
  nipple and areola are reconstructed

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Tissue Expander
The tissue expander starts out with
minimal inflation. Gradually filled with
water weekly to stretch the skin and
muscle
Tissue expander in place after mastectomy
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Breast Reconstruction Complications

• Capsular formation
• Part of bodies natural defense mechanism to form
  a fibrous capsule around the implant
• Infection
• Hematoma
• Skin ulceration
• Hypertropic scar formation

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Review

• To prevent capsular formation following breast
  reconstruction with implants, the nurse teaches
  the patient to
• Gently massage the area around the implant
• Bind the breasts tightly with elastic bandage
• Exercise the arm on the affected side to promote
  drainage
• Avoid strenuous exercise until implant healing
  has occurred.