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Interventions For Clients With Breast Cancer


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  • 1. Interventions for Clients with Breast Disorders
    Jolene Bethune, RN, MSN
  • 2. Anatomy of Breast and Lymph Nodes
  • 3. 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.
  • 4. Key Terms
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. EARLY DETECTION: A 3-Pronged Approach
    Breast Self-Examination (BSE)
    Clinical Breast Examination (CBE)
  • 9. 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
  • 10. 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
  • 11. 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
    Most breast lumps are benign; related to age.
    Primary concern is ruling out breast cancer.
    Benign disorders in age-related order:
    Fibrocystic Breast Disease
    Ductal Ectasia
    Intraductal Papilloma
    Issues of Large Breasted Women
  • 13. 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
  • 14. 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
  • 15. Fibroadenoma & Cysts
  • 16. 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
  • 17. 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
  • 18. Issues of Large-Breasted Women
    Fashion difficulties
    Fungal infections under the breasts
    Reduction mammoplasty
    Nursing considerations consistent with those for women undergoing reconstructive surgery
  • 19. Gynecomastia
    Can be result of a primary cancer like lung cancer
    Etiologic factors include :
    Underlying diseases causing estrogen excess (malnutrition)
    Liver disease
    Androgen deficiency states (age, chronic renal failure)
    Men are carefully evaluated for breast cancer
  • 20.
  • 21. 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
  • 22. Types of Breast Cancer
  • 23. 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
  • 24. Ductal Carcinoma
    Invasive Ductal Carcinoma
    Noninvasive Ductal Carcinoma
  • 25. Lobular Carcinoma
    Invasive Lobular Carcinoma
    Noninvasive Lobular Carcinoma
  • 26. 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
  • 27. Vascular/Lymphatic Invasion
  • 28. 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
    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
  • 30. 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
  • 31. 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)
  • 32. Chemoprevention
    Tamoxifen (Nolvadax, Tamofen, Tamone)
    Complaints of side effects
    Treatment is expensive
  • 33. 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
  • 34. Etiology: Risk Factors
    Diet : high fat (?)
    Alcohol (?)
    Obesity (?)
    Ionizing radiation
    Benign breast disease
    Oral contraceptives
    Exogenous hormones
    Planning & Implementation
    Community-Based Care
  • 36. Assessment: History
    Risk factors
    History of the breast mass
    Client’s health maintenance practices
  • 37. 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)
  • 38. 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
  • 39. 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
  • 40. Physical Assessment
    Focused Assessment of breast mass
    Fixation to surrounding tissues
    Any skin change (peau d’orange)
    Palpate axillary, superclavicular areas for enlarged lymph nodes
    Pain, soreness?
  • 41. Psychosocial Assessment
    Major issues
    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
  • 42. 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)
  • 43. 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
  • 44. 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
  • 45. Analysis
    Common Nursing Diagnosis:
    Anxiety related to diagnosis of breast cancer
    Collaborative Problem:
    Potential for Metastasis
  • 46. 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
  • 47. 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
  • 48. 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
  • 49. 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
  • 50. Planning: Potential for Metastasis
    The client with breast cancer is expected to remain free of metastases or recurrence of cancer
  • 51. 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
  • 52. 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
  • 53. Implementation: Potential for Metastasis
    Surgical Management:
    Simple mastectomy – breast tissue, nipple (lymph nodes left intact)
  • 54. Implementation: Potential for Metastasis
    Surgical Management:
    Lumpectomy – only tumor , small amount of surrounding tissue removed
  • 55. 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,
  • 56. 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
  • 57. 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
  • 58. 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
  • 59. 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
  • 60. Evaluation
    The nurse evaluates the care of the client with breast cancer on the basis of the identified nursing diagnoses and collaborative problems.
  • 61. 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
  • 62. References
    Ignatavicius, D. D., & Workman, M. L. (2002). Medical-Surgical Nursing: Critical Thinking for Collaborative Care (4 ed.). Philadelphia, PA: W. B. Saunders Company