Interventions for Clients with Breast Disorders

Anatomy and Physiology

Paired mammary glands within the superficial fascia of the chest wall Female breast extends vertically from the 2nd or 3rd rib to 6th or 7th Laterally from sternal margin to midaxillary line. Breast is usually divided into 4 quadrants

Breasts and Regional Lymphatics

Topography of Breast
4 quadrants to describe clinical findings The upper outer quadrent is the site of most breast tumors

Anatomy and Physiology: Female Breast

Three types of tissue: glandular, subcutaneous and retromammary fat, and fibrous
Glandular: 20 lobes per breast which radiates around the nipple in spoke like pattern. Most glandular tissue lies in the upper outer quadrant. From here the breast extends into the axilla forming the Tail of Spence.

Breast Lymphatic Drainage

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 CBE q6-12 mo., ages 25-35 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.

 Fibroadenoma benign, glandular and fibrous, small, rubbery, nontender

BENIGN BREAST DISORDERS FIBROADENOMA

Most common cause of breast masses, especially in teens & young women (to early 30s) 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, 20s Stage 2: sx +, bilateral, nodular, 30s 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

 Ductal ecstasia benign, inflamed and dilated, subareolar duct, nipple discharge green/black and sticky, can become abscess

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: clients & familys 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

Invasive Ca ducts or lobules, irregular, poorly delineated

Non invasive Ca ductal in situ or lobular in situ, abnormal mammogram

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 Cas 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 Coopers 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, Klinefelters 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 Coopers 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 ASSESSMENT LABORATORY:

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 clients 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 JPs with gentle suction

MASTECTOMY: SPECIFIC POSTOPERATIVE CARE

Semi-fowlers 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 sites Dangerous 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 clients bone marrow Peripheral blood stem cell transplantation taken from clients 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