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Nursing Care of the Woman with a Disorder of the Breast

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... the implant Infection Hematoma Skin ulceration Hypertropic scar formation To prevent capsular formation following breast reconstruction with implants, ... – PowerPoint PPT presentation

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Title: Nursing Care of the Woman with a Disorder of the Breast


1
Nursing Care of the Woman with a Disorder of the
Breast
2
Benign Breast Disorders
3
Fibrocystic Breast Disease
Related to
Relatively High estrogen and Low progesterone
4
Fibrocystic Changes
  • Development of excess fibrous tissue
  • Hyperplasia of the epithelial lining of the
    mammary ducts
  • Proliferation of mammary ducts
  • Cyst formation


5
Signs and Symptoms
  • Palpable lumps that are round, well-delineated
    and freely movable
  • Lumps increase in size premenstrual
  • Tenderness
  • Pain
  • Nipple discharge

6
Ask Yourself?
Does having a fibrocystic breast condition
increase a womans risk for development of breast
cancer ?
7
Diagnosis
  • Ultrasound
  • Biopsy
  • Fine needle Aspiration
  • Excisional
  • Why is a fine needle aspiration biopsy preferred
    over an excisional biopsy?

8
Nursing Care
  • Patient Teaching
  • Wear good support bra
  • Diet Therapy
  • Low salt
  • No chocolate or caffeine

9
Nursing Care
  • Medications
  • Vitamin E
  • Antiestrogen - Danazol
  • Diuretics
  • Analgesics
  • Remind Patient to have a Yearly follow-up
  • Continue to perform monthly BSE

10
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

11
Breast Cancer
12
  • 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

13
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

14
Risk Factors
BRCA gene breast cancer susceptibility gene 1
and 2
  • BRCA1 and BRCA2 are human genes that belong to a
    class of genes known as tumor suppressors.
  • In normal cells, BRCA1 and BRCA2 help ensure the
    stability of the cells genetic material (DNA)
    and help prevent uncontrolled cell growth.
  • Mutation of these genes has been linked to the
    development of hereditary breast and ovarian
    cancer.
  • A womans lifetime risk of developing breast
    and/or ovarian cancer is greatly increased if she
    inherits a harmful mutation in BRCA1 or BRCA2.

15
How does assessing for HER-2 Receptors help in
determining the prognosis?
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
16
Signs and Symptoms of breast cancer
  • 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

17
Diagnostic Testing
18
Breast Self Examination
  • One of the best ways for a woman 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

19
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

20
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.

21
Diagnosis
  • DNA testing for BRCA 1 and BRCA-2
  • Mammogram / ultrasound
  • Mammogram showing Bilateral Invasive Ductal
    Carcinoma
  • Biopsy

22
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

23
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

24
Treatment
25
Treatment Options
26
Surgical Therapy
27
Surgical Therapy
  • Most common options for resectable Breast Cancer
  • Breast conservation surgery with radiation
    therapy
  • Modified radical mastectomy with or without
    reconstruction

28
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

29
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

30
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

31
Radiation Therapy
32
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

33
Radiation Therapy
  • High-dose brachytherapy
  • Internal radiation delivered via radioactive
    seeds into a balloon catheter
  • Balloon catheter is placed within the lumpectomy
    site
  • Treatment is over 4-5 days

34
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

35
Radiation Therapy
  • Radiation therapy side effects
  • Fatigue
  • Skin changes
  • Breast edema

36
Hormonal Therapy
37
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

38
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

39
Biologic and Targeted Therapies
How are these used in treatment?
40
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 to alone or in combination with
    other chemotherapies
  • Side-effect monitor for signs of ventricular
    dysfunction and congestive heart failure.

41
Chemotherapy
42
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

43
Nursing Care
44
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

45
Nursing Intervention
  • Complications
  • Heaviness
  • Pain
  • Impaired motor function in arm
  • Numbness
  • Paresthesia of the fingers
  • Cellulitis and progressive fibrosis can result

http//www.youtube.com/watch?vDi5E_KXbAnUfeature
related
46
Measures to decrease Lymphedema
  • Positioning
  • Place in a semi-Fowlers position with arm on
    affected side elevated on a pillow, never
    dependent
  • Exercise
  • Flexing and extending fingers should begin in
    recovery room and progressive increase in
    activity
  • Exercises are designed to prevent contractures
    and muscle shortening, maintain muscle tone, and
    improve lymph and blood circulation
  • Postoperative arm and shoulder exercises are
    instituted gradually at surgeons direction

47
Measure to decrease Lymphedema
  • Avoid constriction
  • Do not take Blood pressure readings on that arm
  • Avoid constrictive clothing
  • Compression
  • Wrap arm with bandages going from distal to
    proximal
  • Use intermittent pneumatic compression sleeve or
    a fitted elastic pressure gradient sleeve
  • Massage Therapy

48
Protection of the Arm with Lymphedema
  • Venipunctures, and injections should not be done
    on affected arm
  • Apply insect repellant
  • Wear gloves when gardening
  • Use cooking mitt
  • Use electric razor for shaving axilla
  • Avoid cutting cuticles push back cuticle
  • No heavy lifting
  • Keep clean and dry

49
Postoperative Exercises
50
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

51
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

52
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 to her

53
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

54
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

55
Reconstructive Surgery
56
Breast Reconstruction
Chest prior to Implants
Breast implants placed in pocket under pertoralis
muscle and musculocutaneous skin flap applied
57
Breast Reconstruction
  • Musculocutaneous flap most often taken from
    abdomen or back is used in reconstruction

58
Breast Reconstruction
  • As part of the final stage of reconstruction, the
    nipple and areola are reconstructed

59
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
60
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

61
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.
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