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Interventions For Clients With Breast Cancer

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    Interventions For Clients With Breast Cancer Interventions For Clients With Breast Cancer Presentation Transcript

    • Interventions for Clients with Breast Disorders
      Jolene Bethune, RN, MSN
    • Anatomy of Breast and Lymph Nodes
    • Objectives
      Provide an overview of breast disorders, including breast cancer, with key terms you will hear in practice.
      Describe 3-pronged approach to early detection of breast disorders.
      Provide a brief outline of pathophysiology and etiology of breast cancer.
      Describe options available to women at high genetic risk for breast cancer.
      Use nursing process to describe the care of clients with breast masses.
    • Key Terms
    • Mammogram – x-ray examination of the breast
      Breast Self Examination – breast examination performed by client (goal is early detection!)
      Mastectomy – surgical breast removal
      Fibroadenoma – solid, slowly enlarging benign mass of connective tissue; usually round, firm, easily movable, nontender, clearly delineated from surrounding tissue
      Chemoprevention – prophylactic use of tamoxifencitrate
    • Fibrocystic breast disease (FBD) – benign breast nodules
      Ductal ectasia– dilation and thickening of the collecting ducts in the subareolar area
      Intraductal papilloma – benign process of an outgrowth of tissue in the epithelia lining of the duct
      Gynecomastia – benign condition of breast enlargement in men
      Noninvasive – cancer cells remain within the ducts
      Invasive – cancer cells penetrate the tissue surrounding the ducts
    • Peau d’orange – orange peel appearance of the skin caused by edema
      Breast biopsy – postoperative examination of the breast tissue
      Lumpectomy – gross resection of a tumor
      Partial mastectomy – removal of the portion of the breast that contains the tumor
      Modified radical mastectomy – affected breast is completely removed
    • EARLY DETECTION: A 3-Pronged Approach
      Mammography
      Breast Self-Examination (BSE)
      Clinical Breast Examination (CBE)
    • Mammography
      Baseline screening mammogram recommended beginning at age 40
      Yearly for women ages 40-50
      Barriers include:
      fear of radiation
      fear of results
      concerns about pain
      knowledge deficit
      accessibility; client cost
    • Breast Self Examination
      Inexpensive, encouraged by health care providers for decades
      Detection before axillary node involvement increases survivability
      Used in conjunction with mammography, CBE , BSE is extremely effective in early detection and reducing mortality rates
      Women taught by a health care provider instead of pamphlets or magazines practice BSE more often, more proficiently and more confidently
      The nurse:
      Stresses that treatment for breast cancer is more successful the earlier the disease is detected
      Discusses client’s fears, beliefs and concerns
      Discusses proper timing of self examinations: 1 week after menstrual period for premenopausal women; postmenopausal women should pick one day each month
    • Clinical Breast Examination
      Typically performed by advanced-practice nurses, physicians, skilled general practice nurses
      Can be done before, during, after teaching sessions
      Breast history is vital
      Visual inspection
      Palpation
    • BENIGN BREAST DISORDERS
      Most breast lumps are benign; related to age.
      Primary concern is ruling out breast cancer.
      Benign disorders in age-related order:
      Fibroadenoma
      Fibrocystic Breast Disease
      Ductal Ectasia
      Intraductal Papilloma
      Issues of Large Breasted Women
      Gynecomastia
    • Fibroadenoma
      Occurs in adolescents; may be in some women in their thirties
      Solid, slowly enlarging benign mass of connective tissue; usually round, firm, easily movable, nontender
      Clearly delineated from surrounding tissue
      Only 0.9% of the masses are malignant
      Usually located in upper outer quadrant of the breast
      Multiple masses are possible
      Health care provider may order a breast ultrasound or needle aspiration to establish whether lesion is cystic or solid
      If lesion is solid, outpatient excision using local anesthesia is the treatment of choice
    • Fibrocystic Breast Disease
      Most common breast problem of women between 20-30 years
      3 Clinical stages:
      First stage: premenstrual bilateral fullness and tenderness
      Second stage: bilateral multicentric nodules
      Third stage: microscopic, macroscopic cysts
    • Fibroadenoma & Cysts
    • Ductal Ectasia
      Usually seen in women approaching menopause
      Masses often difficult to distinguish from breast cancer
      Microscopic examination of nipple discharge; affected area is excised
      Nursing care is directed at alleviating the anxiety associated with the threat of breast cancer; supporting the woman through the diagnostic and treatment procedures
    • Intraductal Papilloma
      Primarily in women 40-55
      Intraductal papilloma – benign process of an outgrowth of tissue in the epithelia lining of the duct; ducts become distended, filling with cellular debris, activating an inflammatory response
      Diagnosis aimed at ruling out breast cancer
      Microscopic examination of the nipple discharge and surgical excision of the mass and ductal area are usually indicated
    • Issues of Large-Breasted Women
      Fashion difficulties
      Discomfort
      Fungal infections under the breasts
      Reduction mammoplasty
      Nursing considerations consistent with those for women undergoing reconstructive surgery
    • Gynecomastia
      Can be result of a primary cancer like lung cancer
      Etiologic factors include :
      Drugs
      Aging
      Obesity
      Underlying diseases causing estrogen excess (malnutrition)
      Liver disease
      Hyperthyroidism
      Androgen deficiency states (age, chronic renal failure)
      Men are carefully evaluated for breast cancer
    • OVERVIEW
      Most commonly diagnosed cancer in women
      Leading cause of cancer deaths in US women age 35-45
      Leading cause of cancer mortality in women, second to lung cancer
      Most women have strong reaction to the threat of breast cancer; influencing their health habits
      Ultimate goal of early diagnosis:
      Reduce mortality by identifying women at risk
      Predicting response to different therapies
      Early detection the key to survivability
      Staging the most reliable predictor of prognosis
    • Types of Breast Cancer
    • Infiltrating Ductal Carcinoma
      Accounts for 80% of most breast cancer cases
      Epithelial cells of the mammary ducts
      Can be invasiveor noninvasive
      Rates of growth depend on hormonal influence
      Estimates 5-9 years for lesion to be palpable
      Most breast cancers arise from immediate ducts and are invasive
      Once invasive, growth occurs in tissue surrounding the ducts and becomes an irregular, poorly defined mass once palpable
      Tumor continues to grow, becomes fibrotic; causes shortening of the Cooper’s ligaments, resulting in the skin dimpling seen in more advanced disease
    • Ductal Carcinoma
      Invasive Ductal Carcinoma
      Noninvasive Ductal Carcinoma
    • Lobular Carcinoma
      Invasive Lobular Carcinoma
      Noninvasive Lobular Carcinoma
    • Complications of Breast Cancer
      Tumor invades lymphatic channels, causing skin edema, peau d’orange (orange peel appearance of the skin)
      Invasion of lymphatic channels carries tumor cells to nodes, including those in axillary nodes (nodal examination imperative)
      The tumor replaces the skin itself, ulcerating overlying skin
      Metastases result from seeding of cancer cell into the blood and lymph system
      Most common ‘met’ sites are bones, lungs, brain, liver
    • Vascular/Lymphatic Invasion
    • Breast Cancer in Men
      1% of breast cancer cases
      Average age of onset is 60 years
      Staged the same as women; treatment parallels that of women
      Prognosis is worse for men
      Often disseminated disease, accounting for the lower survival rates
    • WOMEN AT HIGH GENETIC RISK FOR BREAST CANCER
      Family history suggests a predisposition to the disease
      Multiple relatives with breast cancer
      Early age at diagnosis
      Ovarian cancer
      Inherited genetic mutations
      Options include:
      Cancer Surveillance
      Prophylactic Mastectomy
      Chemoprevention
    • Cancer Surveillance
      Referred to as “secondary prevention”
      Monthly BSE beginning at age 18-21
      CBE every 6-12 month beginning at age 25-35
      Annual mammography beginning at age 25-35
    • Prophylactic Mastectomy
      Usually elective
      An option for decades
      Small risk that breast cancer will develop in residual breast glandular tissue (no mastectomy reliably removes all mammary tissue)
    • Chemoprevention
      Tamoxifen (Nolvadax, Tamofen, Tamone)
      Complaints of side effects
      Treatment is expensive
    • Etiology: Risk Factors
      Female gender
      History of previous breast cancer
      Age >40 years
      Menstrual history: early menarche, late menopause or both
      Reproductive history: nulliparity; 1st child after 30yr
      Family history: mother, sister or both
    • Etiology: Risk Factors
      Diet : high fat (?)
      Alcohol (?)
      Obesity (?)
      Ionizing radiation
      Benign breast disease
      Oral contraceptives
      Exogenous hormones
    • COLLABORATIVE MANAGEMENT
      Assessment
      Analysis
      Planning & Implementation
      Community-Based Care
      Evaluation
    • Assessment: History
      Risk factors
      History of the breast mass
      Client’s health maintenance practices
    • 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)
    • Assessment: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
    • Assessment: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
    • Psychosocial Assessment
      Major issues
      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
    • Laboratory Assessment
      Radioimmunoassay (RIA)
      Tumor markers
      Pathologic examination of lymph nodes
      Liver enzymes (indicate possible liver metastases)
      Serum calcium levels/alkaline phosphatase levels (indicate possible bone mets)
    • Radiographic Assessment
      Mammography – can reveal preclinical lesions
      Chest x-ray
      Bone, liver, brain scans
      CT scans of chest & abdomen
      The nurse prepares client for the procedure
    • Other Assessments
      Ultrasound (differentiates solid mass from cyst)
      Breast biopsy
      Pathologic examination of the tumor
      The nurse provides pre- and post-procedure care; client teaching
    • Analysis
      Common Nursing Diagnosis:
      Anxiety related to diagnosis of breast cancer
      Collaborative Problem:
      Potential for Metastasis
    • Analysis: Additional Nursing Diagnoses
      Anticipatory Grieving r/t loss and possible or impending death
      Acute Pain r/t tumor 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
    • Planning : Anxiety
      The client is expected to:
      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
    • Implementation: Anxiety
      Intervention: 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
    • Implementation: Anxiety
      Intervention: Anxiety Reduction
      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
    • Planning: Potential for Metastasis
      The client with breast cancer is expected to remain free of metastases or recurrence of cancer
    • Implementation: Potential for Metastasis
      Nonsurgical Management:
      Late-stage breast cancer; may be only treatment possible
      Tumor removal with local anesthetic or resection
      F/U with hormonal therapy, chemotherapy, radiation
    • Implementation: Potential for Metastasis
      Surgical Management:
      Halsted radical mastectomy – breast tissue, nipple, underlying muscles, lymph nodes (rarely performed)
      Modified radical mastectomy – breast tissue, nipple, lymph nodes
    • Implementation: Potential for Metastasis
      Surgical Management:
      Simple mastectomy – breast tissue, nipple (lymph nodes left intact)
    • Implementation: Potential for Metastasis
      Surgical Management:
      Lumpectomy – only tumor , small amount of surrounding tissue removed
    • Implementation: Potential for Metastasis
      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,
    • Implementation: Potential for Metastasis
      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
    • Implementation: Potential for Metastasis
      Breast Reconstruction
      The nurse:
      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
    • Implementation: Potential for Metastasis
      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
    • Evaluation
      The nurse evaluates the care of the client with breast cancer on the basis of the identified nursing diagnoses and collaborative problems.
    • 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
    • References
      Breastcancer.org
      Fotosearch.com
      Googleimages.com
      Ignatavicius, D. D., & Workman, M. L. (2002). Medical-Surgical Nursing: Critical Thinking for Collaborative Care (4 ed.). Philadelphia, PA: W. B. Saunders Company