Breast cancer, classification & nursing considerations.

1. UNIT 2 ONCOLOGY NURSING
2.2 MALIGNANCIES
BREAST CANCER
Prepared by:
Barsha Silwal
Roll no: 4
BNS third year

2. OBJECTIVES
 Introduce breast cancer
 State the epidemiology of breast cancer
 State the risk factor for breast cancer.
 Describe the etiopathogenesis of breast cancer
 List the classification of carcinoma of breast
 Explain the common type of breast cancer
 State the clinical features of breast cancer
 Describe the complications and prognosis of breast
cancer
 Explain the diagnostic evaluation of breast cancer
 Explain the management of breast cancer

3. REVIEW OF BREAST ANATOMY

4. CONT’D
Histologically ducts are composed
of
 Inner layer of cuboidal to low
columnar epithelial cells
surrounded by a discontinuous
layer of myoepithelial cells,
enclosed by a basement
membrane.
 Inner layer of epithelial cells
within the TDLU that gives rise to
the common forms of breast
cancer.

5. BREAST CANCER
 Malignant growth of breast tissue
 Breast cancer are common condition that
primarily affect women.
 Breast cancer rarely seen in a client under the
age of 40
 Cancer of the male breast is rare and
comprises 0.2% of malignant tumours

6. CONT’D
 Ratio between male-female breast cancer is
1:150.
 Clinically, the breast cancer usually presents
as a solitary,painless, palpable lump which is
detected quite often by self-examination.
 Higher the age, more are the chances of
breast lump turning out to be malignant.

7. EPIDEMIOLOGY
 The incidence of breast cancer is highest in the
perimenopausal women.
 Cancer is a leading cause of death worldwide, accounting
for an estimated 9.6 million deaths in 2018.
 Breast cancer is second most common type of cancer
and fifth leading cause of cancer death worldwide.
- WHO fact sheet, 2018

8. CONT’D
The most common cancers are:
1. Lung (2.09 million cases)
2. Breast (2.09 million cases)
3. Colorectal (1.80 million cases)
The most common causes of cancer death are :
1. Lung (1.76 million deaths)
2. Colorectal (862 000 deaths)
3. Stomach (783 000 deaths)
4. Liver (782 000 deaths)
5. Breast (627 000 deaths)

9. IN NEPAL
 Most common cancer in Nepalese women,
second only to carcinoma of cervix.
 Total number of breast cancer : 1, 716
 Total mortality from cancer : 7, 400
 Total mortality from breast cancer : 11.6 % (
858)
-WHO – Cancer Country Profiles, 2014

10. RISK FACTORS
Major increase
 Mutation in BRCA1 , BRCA 2 , Li-Fraumeni syndrome
 Increasing age
 Family history of breast or ovarian cancer in first-degree
relatives
 Benign breast disease with atypical hyperplasia
 Exposure to ionizing radiation
 Prior diagnosis of breast cancer

11. CONT’D
Moderate increase
 Early menarche ( menstruation starts at an early age (11
or younger).
 Late menopause (menopause after age 55)
 Nulliparity or delayed first full-term pregnancy(above age
30)
 High socioeconomic status
 Alcohol intake
 Obesity (postmenopausal women only)

12. CONT’D
 Unfavorable mammographic parenchymal pattern
 Diagnosis of soft-tissue sarcoma in son or daughter
 prior diagnosis of uterine, ovarian, or colon cancer
 Benign breast disease with hyperplasia but
without atypia
 Oral contraceptives (for longer than 10 years)
 Postmenopausal hormone replacement therapy : use
of combined HRT for 5 years or longer have a higher
risk for breast cancer. (CCS)

13. QUESTIONABLE INCREASE
Interrupted first pregnancy
Psychosomatic factors
High-fat diet
Complex fibroadenoma
Exposure to low-frequency electromagnetic
fields

14. DECREASE
Full-term pregnancy before age 20
Multiple pregnancies
Ovariectomy before age 45
Regular exercise, especially during
adolescence and early adulthood
Breast feeding

15. NO EFFECT
Breast size
Fibrocystic disease without
proliferative changes
Smoking

16. ETIOPATHOGENESIS
Two major etiologic factors in
pathogenesis of breast cancer are:
 Hormonal factors
 Genetic factors

17. HORMONAL FACTORS
 Hormone-dependent disease
 Excess endogenous oestrogen or
prolonged use of exogenously oestrogen
 Some evidences in support of relationship
of increased risk with oestrogen excess are
as follows:
 prolonged reproductive life
 Hormone replacement therapy (HRT

18. GENETIC FACTORS
 About 10% breast cancers have been
found to have inherited mutations
 most important of which is mutated
breast cancer (BRCA) susceptibility gene
in inherited breast cancer

19. PATHOGENESIS
Breast epithelium possesses oestrogen and
progesterone receptors
Breast cancer cells secrete many growth
factors which are oestrogen-dependent
Interplay of high circulating levels of
oestrogen, oestrogen receptors and growth
factors bring about progression of breast
cancer.

20. CONT’D
a) BRCA 1 gene
 located on chromosome 17
 DNA repair gene
 Implicated in both breast and ovarian
 BRCA1 deletion is seen in about two-third
of women with inherited breast cancer

21. CONT’D
BRCA 2 gene
 Located on chromosome 13
 Another DNA repair gene
 Higher incidence of inherited cancer of the
breast (one-third cases) and ovary in
females, and prostate in men.

22. CONT’D
Mutation in p53
 Tumour suppressor gene on chromosome
17
 Acquired defect accounts for 40% cases of
sporadic breast cancer
 But rarely in women with family history of
breast cancer

23. CLASSIFICATION
BASED ON TISSUE TYPES
A. Non-Invasive (In Situ) Carcinoma
1. Intraductal carcinoma
2. Lobular carcinoma in situ
B. Invasive Carcinoma
1. Infiltrating (invasive) duct carcinoma-NOS :80%
2. Infiltrating (invasive) lobular carcinoma: 10%
3. Tubular (cribriform) carcinoma :6%
4. Medullary carcinoma : 2%
5. Colloid (mutinous) carcinoma : 2%
6. Other types
C. Paget's Disease Of The Nipple

24. BASED ON HORMONE RECEPTOR AND
GENETIC STATUS
 Estrogen and Progesterone Receptor Status
• Estrogen receptor positive
• Estrogen receptor negative
• Progesterone receptor positive
• Progesterone receptor negative
 HER-2 Genetic Status
• HER-2 positive
• HER-2 negative

25. AJC CLINICAL STAGING OF BREAST CANCER

26. NON - INVASIVE BREAST CANCER
 Twenty % of breast cancers are noninvasive
A. Ductal carcinoma in situ (DCIS)
o Unilateral
o May progress to invasive breast cancer if left untreated
o begins with atypical hyperplasia of ductal epithelium
followed by filling of duct with tumor cells.
o Clinically it produces palpable mass in 30-75% cases
and presence of nipple discharge in 30 %, patient.

27. B. LOBULAR CARCINOMA IN SITU (LCIS)
 Women with LCIS are more likely to develop
invasive breast cancer than without LCIS
 Develop invasive cancer of ipsilateral breast in
about 25% in 10 years
 Developing contralateral breast cancer (30%).
 Hormone therapy as a preventive measure to
reduce breast cancer risk

28. INVASIVE (INFILTRATING) DUCTAL CARCINOMA
 Most common type
 Starts in the milk ducts and then breaks
through the walls of the duct, invading the
surrounding tissue
 More frequently in the left breast, often in
upper outer quadrant.
 Retraction of the nipple and attachment to
underlying chest wall may be present.

29. INVASIVE (INFILTRATING) LOBULAR
CARCINOMA
 Carcinoma begins in the lobules (milk-producing
glands)
 Break out of the lobule and potential to metastasize to
other areas of the body
 Usually presents as a subtle thickening
 frequently bilateral and within same breast, it may
have multicentric origin
 Generally not detected by mammography.

30. INFLAMMATORY BREAST CANCER
 Aggressive and fast-growing breast cancer with a high
risk for metastasis
 One to 3% of all breast cancers.
 Term use for breast cancer in which there is redness,
edema, tenderness and rapid enlargement
 Often mistaken for mastitis
 Inflammatory changes do not improve with antibiotics
 A breast mass may not be present and changes may
not show up on mammograms,

31. CONT’D
 Breast looks red, feels
warm, and has a
thickened appearance ,
resembling an orange
peel (peau d'orange).

32. PAGET'S DISEASE
 Paget’s disease of the nipple is an eczematiod lesion
of the nipple, often associated with an invasive or
non invasive ductal carcinoma
 Rare breast malignancy
 Starts in the breast ducts and spreads to the nipple
and areola.
 One % of all breast cancers
 Paget's disease with palpable mass have underlying
invasive (infiltrating) ductal carcinoma
 No palpable breast mass are usually subsequently
found to have intraductal carcinoma

33. PHYLLODES TUMOR
 A rare bulky breast tumor that develops in the
connective tissue ( stroma) of the breast
 Can be classified into benign, borderline and
malignant
 Most patient are between 30-70 years of age
 About 20 % of phyllodes tumors are histologically
malignant and less than half of them may
metastasise.

34. TRIPLE-NEGATIVE BREAST CANCER:
 Breast cancer tests negative for all three receptors
(estrogen, progesterone, and HER-2)
 Incidence is higher in African Americans, Hispanics,
premenopausal women, and those with a BRCA1 mutation
 More aggressive tumors with a poorer prognosis
 Do not usually respond to Hormone therapy or therapy for
the human epidermal growth factor receptor 2 (HER-2)
 Chemotherapy is most successful method of treatment

35. CLINICAL FEATURES
 Occurs more often in
left breast than the
right and is bilateral in
about 4% cases.

36. CONT’D
 Palpable mass is usually painless,
nontender, hard irregular in shape
and non-mobile in 64 to 70% of
cases
 But breast cancers can be tender,
soft, or rounded. They can even be
painful.
 Nipple discharge and retraction,
edema with "peau d' orange" skin,
and dimpling, usually unilateral
and may be clear or bloody

37. COMPLICATIONS
 Main complication of breast cancer is
recurrence
 Recurrence may be local or regional or
distant

38. DIAGNOSTIC EVALUATION
 HEALTH HISTORY
 PHYSICAL ASSESSMENT
 RADIOLOGY AND IMAGING
 LABORATORY TESTS
 BIOPSY
 TESTS TO DETECT METASTASIS

39. MAMMOGRAPHY
 Imaging technique that reduce the breast cancer
mortality.
 Detect non palpable mass and assist in diagnosis of
palpable mass.
 Detect tumor before it is clinically palpable i.e less than
1cm.
 Sensitivity is 75%.
 Both screen film and digital mammography use x-rays
to obtain images. With digital mammography, a film
image is replaced with an electronic image similar to
digital photography.

40. TYPES
 Screening mammogram
 Diagnostic mammogram

41. CONT’D
The indications for a screening mammogram
ACS recommend mammogram every year
beginning at the age of forty (40 years).
Patients aged < 40 years who are asymptomatic
but are high-risk group.
Begin screening 10 years earlier than the age at
which the youngest family member developed
breast cancer but not before 25 years of age.

42. CONT’D
The indications for a diagnostic
mammogram
Patients with breast complaints and/or
symptoms.
When a lump is found on physical
examination.
 Abnormal screening mammogram

43. CONT’D
a. Category 1 is a negative result (normal mammogram)
with nothing on which to comment.
b. Category 2 is a normal mammogram but there is a
benign finding on which to comment.
c. Category 3 is probably benign, but short interval
follow-up may be recommended to determine stability
of the finding.
d. Category 4 describes a suspicious abnormality and
biopsy should be considered.
e. Category 5 is highly suggestive of malignancy
requiring appropriate action.
f. Category 6 describes a known, biopsy-proven
malignancy requiring appropriate action.

44. NURSING CARE CONSIDERATIONS
 Compression of the breast is used to reduce the amount
of the radiation absorbed by the breast tissue and
separate overlapping tissue.
 Two views are taken routinely: craniocaudal and
mediolateral; other views are done as necessary.
 Remind patients not to apply deodorant, cream, or
powder to breast, nipple, or underarm areas on
examination day.

45. CONT’D
 Benefits overweight the exposure to low dose of
radiation. The radiation is equal to about 1 hour
exposure to sunlight.
 Mammography is not routinely done if a woman
is pregnant.
 The breasts of young women tend to be
extremely dense and are poorly suited to
mammography

46. LABORATORY TESTS
Tumor-Specific Tests:
 Tests to evaluate the characteristics of a tumor and/or its
potential to regrow
1. Estrogen and progesterone receptors:
 Positive tumor benefit from hormonal therapy.
 Approximately 75% are estrogen receptor positive.
 A negative result is associated with a less favorable
prognosis.
2. HER2—Human epidermal growth factor receptor
 Demonstrated in 15% to 30% of breast cancers.
 Associated with poorer survival, regardless of clinical
stage. May affect treatment decisions.

47. NIPPLE DISCHARGE CYTOLOGY
 Secretions are smeared on a slide, fixed, and
submitted for cytologic examination.
 High rate of false-negative test results with this
method
 Wash nipple area with water and pat dry before
obtaining specimen if crusting of drainage is present.

48. BIOPSY
1. Percutaneous biopsy
a. Fine-Needle Aspiration (FNA)
b. Core Needle Biopsy:
c. Stereotactic Core Needle
2. Surgical biopsy
a. Incisional biopsy
b. Excisional biopsy
c. Wire Needle Localization.

49. 1. PERCUTANEOUS BIOPSY
 Performed on an outpatient
basis to simple palpable and
nonpalpable lesions.
 Less invasive than a surgical
biopsy
 Percutaneous biopsy is a
needle or core biopsy that
obtains tissue by making a
small puncture in the skin.

50. A. FINE-NEEDLE ASPIRATION (FNA)
 Noninvasive biopsy technique that is generally well tolerated
 A small gauge needle (25- or 22-gauge) attached to a syringe
is inserted into the mass or area of nodularity.
 Suction is applied to the syringe, and multiple passes are
made through the mass.
 For nonpalpable masses, the same procedure can be
performed by a radiologist using ultrasound guidance
 If no fluid is obtained, any cellular material obtained in the
hub of the needle is spread on a glass slide or placed in a
preservative and sent to the laboratory for analysis.
 false-negative or false-positive results are possible

51. B. CORE NEEDLE BIOPSY
 Similar to FNA, except that a larger gauge needle is
used (usually 14-gauge).
 A local anesthetic is applied, and tissue cores are
removed via a spring-loaded device.
 This procedure allows for a more definitive diagnosis
than FNA, because actual tissue, not just cells, is
removed.
 It is often performed for relatively large tumors that are
close to the skin surface.

52. C. STEREOTACTIC CORE NEEDLE
 An x-ray-guided method for
localizing and sampling
nonpalpable lesions detected on
mammography with 90% to 95%
sensitivity in detecting breast
cancer.
 Outpatient procedure with the
patient lying prone on a special
table using an automated biopsy
gun with a vacuum system to draw
tissue into a sampling chamber and
rotate cutter to excise tissue.

53. 2. SURGICAL BIOPSY
 Usually performed using
local anesthesia and IV
sedation.
 After an incision is made,
the lesion excised and sent
to a laboratory for
pathologic examination.

54. A. EXCISIONAL BIOPSY
 Standard procedure for complete pathological
assessment of a palpable breast mass.
 The entire mass, plus a margin of surrounding tissue,
is removed.
 Also called lumpectomy

55. B. INCISIONAL BIOPSY:
 Surgically removes a portion of a mass.
 To confirm a diagnosis and to conduct special studies
 Complete excision of the area may not be possible or
immediately beneficial to the patient, depending on the clinical
situation.
 Performed on women with locally advanced breast cancer or
on women with suspected cancer recurrence
 Pathological information may be easily obtained from core
needle biopsy, and incisional biopsy is becoming less
common.

56. C. WIRE NEEDLE LOCALIZATION
 Used to locate nonpalpable
masses or suspicious calcium
deposits detected on a
mammogram, ultrasound, or
MRI
 Radiologist inserts a long,
thin wire through a needle,
which is then inserted into the
area of abnormality using x-
ray or ultra-sound

57. CONT’D
 Wire remains in place after the needle is withdrawn to
ensure the precise location
 Taken to the operating room, where the surgeon follows
the wire to the tip and excises the area
 Excisional biopsy is then done removing the area
around the tip of the wire.

58. TESTS TO DETECT METASTASIS
 Increased values on liver function tests may indicate
possible liver metastasis.
 Increased calcium and alkaline phosphatase levels may
indicate possible bony metastasis.
 Additional metastatic workup may include chest x-ray,
bone scan, computed tomography (CT) scan, and
positron emission tomography (PET) scan.
 Biological markers (ie, CA15.3 and CA27.29) may be
used for monitoring patients with metastatic disease

59. PROGNOSIS
Two most important factors are
 Tumor size
 Spread to the lymph nodes under the arm (axilla)
 Generally, the smaller the tumor, the better the
prognosis.
 The 5-year survival rate can be as high as 98.1 % for
a stage I breast cancer and as low as 27.1% for a
stage IV breast cancer (National Cancer Institute,
2008).

60. CONT’D
Pathologic Factors Associated With Favorable Prognosis for
Breast Cancer
 Noninvasive tumors or invasive tumors less than 1 cm
 Negative axillary lymph nodes
 Estrogen receptor (ER) and progesterone receptor (PR)
proteins
 Well-differentiated tumors
 Low expression of HER-2/neu oncogene (also known as
ERBB2)
 No vascular or lymphatic invasion
 Diploid tumors with low S-phase fraction

61. MANAGEMENT
 Chemotherapy
 Surgery
 Radiation Therapy
 Hormone Therapy
 Immunotherapy And Targeted Therapy
 Palliative care

62. SURGERY
 Primary treatment for breast cancer
 The most common surgical options for operable
breast cancer are
(1) Breast conservation surgery (lumpectomy
[segmental mastectomy]) and
(2) Mastectomy with or without reconstruction
Breast cancer management.docx

64. PHANTOM BREAST PAIN
 Feeling pain in the breast after a mastectomy.
 The brain continues to send signals to nerves in
the breast area that were cut during surgery,
even though the breast is no longer physically
there.

65. CHEMOTHERAPY
 Used in the neoadjuvant and adjuvant setting
 Usually given for 3 to 6 months.
 However, when a patient has metastasis,
chemotherapy may be given for the rest of
the patient's life.

66. CONT’D
 Most widely used adjuvant therapy
 CMF : Cyclophosphamide , Methotrexate and
Fluorouracil
 Also indicated in patient with high risk for
cardiac toxicity ( a potential side effect of
antracycline based regimens)
 For higher risk patient
 CAF : Cyclophosphamide, doxorubicin and
Fluorouracil

67. CONT’D
 For larger, node –negative cancer and for
those with positive axillary lymph nodes
 ACT :Doxorubicin, Cyclophosphamide and
Taxane

68. RADIATION THERAPY
o Adjuvant (additional) therapy that can be used after
surgery.
o Radiation therapy may be used for breast cancer to
(1) Prevent local breast cancer recurrences after breast-
conserving surgery;
(2) Prevent local and lymph node recurrences after
mastectomy; or
(3) Relieve pain caused by local, regional, or distant
spread of cancer.

69. CONT’D
External-beam radiation
 The most common type
 Typically begins about 6 weeks after breast conservation
 If systemic chemotherapy is indicated, radiation therapy
usually begins after its completion
 Each treatment lasts only a few minutes and is generally
given 5 days a week for 5 to 6 weeks
 After completion of radiation to the entire breast, many
patients receive a "boost," a dose of radiation to the
lumpectomy site where the cancer cells were located

70. CONT’D
 One approach is brachytherapy (Internal radiation)
 Delivers partial breast radiation by placing a radioactive
source within the lumpectomy site
 Lead to an improved quality of life
 Administered over 4 to 5 days
 Internal radiation therapy is primarily delivered using a
multicatheter method or balloon-catheter system.

71. CONT’D
 In the multicatheter method (e.g., SAVI brachytherapy)
many very small catheters are placed in the breast at the
site of the tumor.
 Small radioactive seeds are placed in the catheters. The
seeds are left in place just long enough to deliver the
radiation dose (e.g., 5 to 10 minutes).
 Inserted only during treatment and then removed.
 The radiation does not remain in the body between
treatments or after the final treatment is over.

72. BALLOON-CATHETER SYSTEM FOR
BRACHYTHERAPY

73. PALLIATIVE RADIATION THERAPY
Reducing the primary tumor mass with
a resultant decrease in pain
 Also used to treat symptomatic
metastatic lesions.
Radiation therapy often relieves pain
and is successful in controlling
recurrent or metastatic disease

74. HORMONE THERAPY
 If the cells are estrogen receptor positive
 Block the effect and source of estrogen thus promoting
tumor regression.
 Chances of tumor regression are significantly greater in
women whose tumors have positive estrogen and
progesterone receptors.
 Hormone therapy can
(1) Block estrogen receptors or
(2) Suppress estrogen synthesis by inhibiting aromatase,
an enzyme needed for estrogen synthesis.

75. Breast cancer management.docx

76. IMMUNOTHERAPY AND TARGETED
THERAPY
 Trastuzumab (Herceptin) is a monoclonal antibody
that binds specifically to the HER-2/neu protein,
 Inactivates the HER-2/neu protein, thus slowing tumor
growth
Breast cancer management.docx

77. NURSING MANAGEMENT
 Assessment
 Nursing Diagnosis
 Nursing Interventions
Evaluation: Expected Outcomes

78. ASSESSMENT : SUBJECTIVE DATA
 Breast Manifestations
1. Palpable lumps—date noted; affected by
menstruation; changes noted since detection.
2. Nipple discharge—date of onset, color, unilateral or
bilateral, spontaneous or provoked.
3. Pain or tenderness—localized or diffuse, cyclic or
constant, unilateral or bilateral.
4. Date of last mammogram and result.
5. Patient's practice of breast self-examination (BSE).

79.  History General Information
1. Age.
2. Past medical-surgical history; injuries; bleeding tendencies.
3. Medications, including current or prior use of hormonal con-
traceptives and hormones, over-the-counter (OTC) products,
vitamins, and herbal supplements.
 Gynecologic and Obstetric History
1. Menarche.
2. Date of last menses.

80. NURSING DIAGNOSIS
Preoperative Nursing Diagnoses
 Deficient knowledge about the planned surgical
treatments
 Anxiety related to the diagnosis of cancer
 Fear related to specific treatments and body image
changes
 Risk for ineffective coping (individual or family) related
to the diagnosis of breast cancer and related treatment
options
 Decisional conflict related to treatment options

81. POSTOPERATIVE NURSING DIAGNOSES
 Pain and discomfort related to surgical procedure
 Disturbed, sensory perception related to nerve irritaion in affected
arm, breast, or chest wall
 Disturbed body image related to loss or alteration of the breast after
surgery.
 Self-care deficit related to partial immobility of upper extremity on
operative side
 Risk for sexual dysfunction related to loss of body part, change in
self-image, and fear of partner's responses
 Deficient knowledge: drain management after breast surgery
 Deficient knowledge: arm exercises to regain mobility of affected
extremity
 Deficient knowledge: hand and arm care after ALND

82. NURSING INTERVENTIONS
PRE OPERATIVE CARE
1. The nature of the procedure is explained, along with expected post
operative care that includes drain care, location of incision, and
mobility of the arm.
2. Information is clarified about diagnosis and possibility of further
therapy.
3. Recognize the extreme anxiety and fear , that the patient, family, and
significant others experience.
a. Discuss patients concerns and usual coping mechanisms.
b. Explore support systems with patient.
c. Discuss concerns regarding body-image changes.
4. Determine how well the patient will tolerate surgery

83. NURSE SHOULD EXPLAIN ABOUT POTENTIAL
COMPLICATIONS
 Infection.
 Hematoma, seroma.
 Lymphedema.
 Paresthesia, pain of axilla and arm.
 Impaired mobility of arm.

84. POSTOPERATIVE NURSING CARE
In addition to general operative care:
1. Dressing is removed and the wound is assessed for
erythema, hematoma (, edema, tenderness, odor, and
drainage.
a. Initial dressing may consist of gauze held in place by
elastic, tape, or clear occlusive dressing wrap.
b. Usually removed within 24 hours.
c. Incision may remain open to air or elastic wrap may be
replaced if patient prefers.

85. CONT’D
2. Suction drain from wound is maintained.
a. May have 100 to 200 mL serous to serosanguineous
drainage in the first 24 hours.
b. Report if grossly bloody or excessive in amount.
3. Arm on affected side is observed for edema, erythema,
and pain.
4. Patient teaching absout drain care, exercises,
surgical outcome, and BSE occurs.
5. Female relatives, especially sisters, daughters, and
mother who may need closer breast cancer
surveillance are discussed

86. IN ADDITION TO ROUTINE POSTOPERATIVE
INTERVENTIONS, PROVIDE THE FOLLOWING CARE.
 Psychosocial Support
 Mobilizing Affected Arm
 Increasing Knowledge
 Enhancing Body Image
 Reducing Anxiety
 Promoting Lymphatic Drainage
 Maintaining Sexual Activity
 Facilitating Family Coping
 Patient Education and Health Maintenance

88. EVALUATION: EXPECTED OUTCOMES
 Moves affected arm within prescribed limits.
 States care of incision, drains, follow-up guidelines.
 No infection or complications in affected arm.
 Expresses positive body image.
 Exhibits minimal anxiety.
 Reports satisfactory sexual activity and sexuality.
 Maintains a functional support system.

89. REFERENCES
 Brunner & S. (2011). Textbook of Medical- Surgical Nursing
(12thedi.). New Delhi, India,Vol II, Wolters Kluwer.
 Sharma, S. K.(Ed.).(2017). Lippincott Manual of Medical
Surgical Nursing (10thedi.). New Delhi, India, Wolters
Kluwer.
 Lewis, et al.,(2018). Medical Surgical Nursing: Assessment
and Management of Clinical Problems (3rdedi.). New Delhi,
Voll II, India, Elsevier.
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