NURSING MANAGEMENT Assessment: ~Subjective Data~ Obtain a nursing history about specific breast complaints and general health information from the patient to plan care and appropriate patient teaching.
NURSING MANAGEMENT Assessment: ~Subjective Data~ General Information: age past medical-surgical history, injuries, bleeding tendencies medications, including current or prior use of hormonal contraceptives, OTC products, vitamins, & herbal supplements
NURSING MANAGEMENT Assessment: ~Subjective Data~Gynecologic and Obstetric History: menarche date of last menstrual period Pregnancies, miscarriages, abortions, and deliveries lactation history Prior breast history, including previous hx of irradiation involving breast region family history of breast cancer.
NURSING MANAGEMENT Assessment: ~Subjective Data~Breast Manifestations: palpable lumps- date noted; affected by menstruation changes noted since detection. nipple discharge- date of onset, color, unilateral or bilateral, spontaneous or provoked. pain or tenderness- localized or diffused, cyclic or constant, unilateral or bilateral date of last mammogram and result patient’s practice of BSE
NURSING MANAGEMENT Assessment: ~Breast Examination~Sitting Position: have patient strip to her waist & sit comfortably facing the examiner. Observe breast for abnormalities have patient raise arms overhead Palpate cervical and supraclavicular areas Palpate axillary nodes; hold patient’s forearm in your left palm while you check nodes with your right fingertips. Repeat on other side. have patient place hands on hips and press.
NURSING MANAGEMENT Assessment: ~Breast Examination~Lying Position: instruct the patient to lie down with her right arm under her head. Place a small pillow under her shoulder. with the finger pads of 2 or 3 fingers, gently palpate breast tissue beginning at the UOQ. Proceed in an orderly pattern around the breast and repeat the first quarter examined. Check areolar areas for crustiness, nipple discharge, signs of infection. If nipple discharge is observed, note it from single or multiple ducts.
NURSING MANAGEMENT Assessment: ~Axillary Exam~ Inspect the axillae while the woman is sitting. inspect the skin, noting any rash or infection. Lift the woman’s arm and support it by yourself. Use your right hand to palpate the left axillae. move them firmly down in four directions. Move her arms through ROM. Note any enlarged and tender lymph nodes.
NURSING MANAGEMENT Assessment: Record findings and report abnormalities to the health care provider. instruct the patient in performing self-examination. Encourage her to ask questions; providing her with appropriate literature.
NURSING MANAGEMENT Assessment: ~The Aging Female~ On inspection, the breast looks pendulous, flattened and sagging. Nipples may be retracted but can be pulled outward. On palpation, the breasts feel more granular, and the terminal ducts around the nipple feel more prominent & stingy. Thickening of the inframammary ridge at the lower is normal breast is normal, and it feels more prominent with age.
Patient assessment depends on organs/tissues involved and stageof disease. Different types of breast cancer produce different typesof tumors. The typical breast cancer mass is found in the UPPEROUTER QUADRANT. System Objective Cues Problem Identified General Restless Anxiety/ Fear Appearance Recent weight loss Fatigue Loss of appetite Ineffective sexual Lack of sleep patterns, risk Feelings of Negative feelings helplessness, about body hopelessness, and Inadequate nutrition denial Subjective Cues: Expressed concerns about changes in appearance: disfiguring lesions, surgery Report of fear of rejection by/reaction of others Questions/request for information, verbalization of problem Inaccurate follow-through of instructions/development of preventable complications
System Objective Cues Problem IdentifiedNeurological Neurologic deficits Pressence of systemic metastasis Seizures Tumor in CNS Inc ICP Brain herniation Risk for hemorrhage and hydrocephalus PainHead, Face, Headache Inc ICPand Neck Neck stiffness Pain PapilledemaNoseMouthThroat
Problem System Objective Cues IdentifiedBreast Painless, nontender, hard, irregular/star- Presence of Stage 1 shaped, and immobile breast mass: malignant Stage 1 - 2cm neoplasm Stage 2 - 2 -5cm Ineffective sexual Stage 3/ 4 - 5cm & above; Stage 2-3 patterns, risk Nipple discharge: watery, serous, or bloody Negative feelings Skin dimpling/ skin tether about body Breast asymmetry/ distortion Pain Erythematous Carcinoma Nipple retraction Paget’s disease Nipple crusting Inflammation Stage 4 Burning, itching, rash Vein dilation Local edema & ulceration Peau d’orange (Orange-peel look) Painful breast mass: P – pressure pain caused by growing tumor and venous engorgement Q – crushing pain R – breast S – 0-10 T – exacerbated by movement
Nipple PeauDischarge d’orang e Dimp Paget’s ling Nipple
System Objective Cues Problem IdentifiedLymphatics Pain Stage 2 Tender Presence of systemic Lump or swelling metastasis Rash Inflammation Stage 3 Ipsilateral arm edema Supraclavicular or axillary lymphadenopathyRespiratory Presence of cough Presence of systemic(Chest) SOB metastasis pleuritic pain Pericardial effusion/ vague chest discomfort tamponade Airway obstruction PainCardiovascular
System Objective Cues Problem IdentifiedAbdomen and Ascites NauseaRectum Localized tenderness Inadequate nutrition Nausea and vomiting Presence of systemic Abdominal pain metastasisGUT Flank pain Urinary obstruction Anuria with polyuria Hydronephrosis PainMusculoskeleta Bone pain Painl Reluctant to attempt ImmobilityElbows, movement Presence of systemicShoulders Limited ROM metastasis Decreased muscle mass/strength Loss of sensibilityHands, Nails, Skin dimpling in the Presence ofSkin & Wrist breast malignant neoplasmSpine Bone/ Back pain Spinal cord compression (+) Lhermitte’s signFeet and HipsHemapoetic anemic Inadequate nutrition Presence of systemic metastasis
ANXIETY may be r/t: • situational crisis • Threat of self-concept: change of body image, loss of body part, sexual attractiveness • Threat of death Taxonomy : Self perception – self concept Pattern Cause Analysis : The psychosocial needs of patients vary with their situation. Many months usually pass between the diagnosis of cancer and the occurrence of these complications, and during this period the patient is severly affected by the possibility of death. The patient imagines the worst in preparation for the end of life.
ANXIETY Cues: • Expressed concerns regarding changes in life events •Restless •Recent weight loss •Loss of appetite •Insomnia •Feelings of helplessness, hopelessness Desired Outcome: • Display appropriate range of feelings & lessened fear. • Appear relaxed and report anxiety is reduced to a manageable level. • Demonstrate use of effective coping mechanisms and active participation in treatment regimen.
Nursing Interventions: Review patient’s/SO’s previous experience with cancer.Encourage questions & provide time for expression of fears. Provide an atmosphere of concern, openness, & availability as well as privacy for patient/SO. Explain purpose and preparation for diagnostic tests. Assist patient/SO in recognizing & clarifying fears to begin developing coping strategies for dealing with these fears. Provide accurate, consistent information regarding diagnosis & prognosis. Permit expressions of anger, fear, despair without confrontation. Give information that feelings are normal and are to be appropriately expressed. Explain the recommended treatment, its purpose, and potential side effects. Help patient prepare for treatments
Nursing Interventions: Explain procedures, providing opportunity for questions and honest answers. Promote calm, quiet environment. Be alert to signs of denial/depression. Determine presence of suicidal ideation and assess potential on a scale of 1–10. Encourage & foster patient interaction with support systems. Include SO as indicated/patient desires when major decisions are to be made.Discuss role of rehabilitation after surgeryCollaborative: Administer antianxiety medications (lorazepam (Ativan)), as indicated.Refer to additional resources for counseling/support as needd.
Impaired skin integrity may be r/t: • altered circulation, presence of edema, drainage • changes in skin elasticity, sensation • tissue destruction -(radiation) Taxonomy : Nutritional Metabolic Pattern Cause Analysis : Breast CA appears as a single mass which is characterized by skin redness & indurations, crusting, scaling, changes in nipple with burning, itching or bleeding. .
Impaired skin integrity Cues: •Painless, nontender, hard, irregular/star-shaped, and immobile breast mass • Nipple discharge: watery, serous, or bloody • Local edema • Erythematous • Vein dilation •Crusting, scaling, rash • Burning, itching Desired Outcome: • Achieve timely wound healing, free of purulent drainage or erythema. • Demonstrate behaviors/techniques to promote healing/prevent complications .
Nursing Interventions: Assess dressings/wound for characteristics of drainage. Monitor amount of edema, redness and pain in the incision. Perform routine assessment of involved arm. Elevate hand/ arm with shoulder positioned at appropriate angles (no more than 65 degrees of flexion, 45–65 degrees of abduction, 45–60 degrees of internal rotation) and forearm resting on wedge or pillow. Monitor temperature. Place in semi-Fowler’s position on back or unaffected side; avoid letting the affected arm dangle. Avoid measuring blood pressure (BP), injecting medications, or inserting IVs in affected arm.
Nursing Interventions:• Inspect donor/graft site (if done) for color, blister formation; note drainage from donor site.• Assess wound drains, periodically noting amount & characteristics of drainage.• Encourage wearing of loose-fitting/nonconstrictive clothing. Tell patient not to wear wristwatch or other jewelry on affected arm.Collaborative:• Administer antibiotics as indicated
Risk for infection may be r/t: •Inadequate secondary defenses and immunosuppression, •Malnutrition, chronic disease process • Invasive procedures Taxonomy : Cognitive-Perceptual Pattern Cause Analysis : Infections are the common cause of death & an even more common cause of morbidity in patients with a wide variety of neoplasms. A common clinical problem following radical mastectomy is the development of cellulitis, usually caused by streptococci and staphylococci, because of lymphedema and inadequate lymph drainage.
Risk for infection Cues: • Axillary lymphadenopathy • Ipsilateral arm edema • Abnormal breast conditions • Systemic metastasis • Loss of weight • Loss of appetiteDesired Outcome : The patient remain free of infection as evidenced by temperature remaining within normal limits and demonstrated knowledge related to prevention of infection.
Nursing Interventions: Promote good handwashing procedures by staff and visitors. Screen/limit visitors who may have infections. Place in reverse isolation as indicated.Emphasize personal hygiene.Monitor temperature.Assess all systems (e.g., skin, respiratory, genitourinary) for signs/symptoms of infection on a continual basis.Reposition frequently; keep linens dry and wrinkle-free.Promote adequate rest/exercise periods.Stress importance of good oral hygiene.Avoid/limit invasive procedures. Adhere to aseptic techniques.Collaborative:Monitor CBC with differential WBC and granulocyte count, and platelets as indicated.Obtain cultures as indicated.Administer antibiotics as indicated.
PAIN, Acute/CHRONIC may be r/t: • disease process (compression/destruction of nerve tissue, obstruction of a nerve pathway and inflammation) • side effects of various cancer therapy agents Taxonomy : Cognitive-Perceptual Pattern Cause Analysis : Pain occurs with variable frequency in the cancer patient. In about 70% of cases, pain is caused by the tumor itself – by invasion of bone, nerves, blood vessels, or mucous membranes or obstruction of a hollow viscous or duct causing compression of surrounding tissues and their blood supply.
Pain, acute/chronic Cues: • Reports of pain: P – pressure pain caused by growing tumor and venous engorgement Q – crushing pain R – breast S – 0-10 T – exacerbated by movement • Guarding behavior • Vein dilation on breast Desired Outcome: • Report maximal pain relief/control with minimal interference with ADLs • Follow prescribed pharmacological regimen. • Demonstrate use of relaxation skills and diversional activities as indicated for individual
Nursing Interventions: Determine pain history, e.g., location of pain, frequency, duration, & intensity using numeric rating scale (0–10 scale) or verbal rating scale (“no pain” to “excruciating pain”) and relief measures used. Believe patient’s report. Evaluate/be aware of painful effects of particular therapies. Provide nonpharmacological comfort measures and diversional activities (e.g., music, television).Encourage use of stress management skills/complimentary therapies.Provide cutaneous stimulation, e.g., heat/cold, massage.Be aware of barriers to cancer pain management related to patient, as well as the healthcare system.
Nursing Interventions: Evaluate pain relief/control at regular intervals. Inform patient/SO of the expected therapeutic effects and discuss management of side effects.Discuss use of additional alternative/complementary therapiesCollaborative:Develop individualized pain management plan with the patient and physician.Administer analgesics as indicated.Provide/instruct in use of PCA, as appropriate.Instruct in use of electrical stimulation (e.g., TENS) unit.Prepare for/assist with procedures.Refer to structured support group, psychiatric clinical spiritual advisor for counseling as indicated.
Impaired gas exchanger/t airway obstruction associated with cancerTaxonomy : Nutritional-Metabolic Pattern Cause Analysis : Generally, airway obstruction refers to a blockage at the level of the mainstem bronchi or above. It may result either from intraluminal tumor growth or from extrinsic compression of the airway. Extrathoracic primary tumors such as renal cell, colon, ovarian, or breast cancer can cause airway obstruction through endobronchial and/or mediastinal lymph node metastases.
Impaired gas exchanger/t airway obstruction associated with cancer Cues: • Reports of pain: • Presence of cough •SOB •Pleuritic pain •Vague chest discomfort Desired Outcome: • Verbalized understanding of causative factors and appropriate interventions in alleviating difficulty in breathing.
Nursing Interventions: Monitor respiratory rate, depth, and effort. Auscultate breath sounds. Note declining level of awareness/ consciousness. Monitor heart rate/rhythm. Note skin color, temperature, moisture. Encourage/assist with deep-breathing exercises, turning, and coughing. Suction as necessary. Provide airway adjunct as indicated. Place in semi-Fowler’s position. Restrict use of hypnotic sedatives or tranquilizers. Discuss cause of chronic condition (when known) and appropriate interventions/self-care activities.
Nursing Interventions:CollaborativeAssist with identification/treatment of underlying cause.Monitor/graph serial ABGs, pulse oximetry readings; Hb, serum electrolyte levels.Administer oxygen as indicated. Increase respiratory rate or tidal volume of ventilator, if used.Assist with ventilatory aids. Monitor peak flow pressure.Maintain hydration (IV/PO)/provide humidification.Provide appropriate chest physiotherapy, including postural drainage and breathing exercises.Administer IV solutions such as lactated Ringer’s solution or 0.6 M solution of sodium lactate.Administer medications as indicated, e.g.: Naloxone hydrochloride (Narcan); and Bronchodilators; Provide low-carbohydrate, high-fat diet, if indicated.
INTRACRANIAL ADAPTIVE CAPACITYr/t SUSTAINED INCREASED IN ICP associated with CANCERTaxonomy : Activity- Exercise Pattern Cause Analysis : About 25% of cancer patients die with intracranial metastasis. The tumor mass and surrounding edema may cause obstruction of the circulation of the CSF. Increased ICP may be caused by increased intracranial blood volume and increased CSF volume or increased brain tissue bulk.
INTRACRANIAL ADAPTIVE CAPACITYr/t SUSTAINED INCREASED IN ICP associated with CANCER Cues: • Neurologic deficits • Seizure • Headache • Neck Stiffness • Papilledema • ICP > 10-15 mmHg Desired Outcome: •Demonstrate stable ICP as evidenced by normalization of pressure waveforms/ response ot stimuli. • Display improved neurologic signs
Nursing Interventions: Elevate head of bed 15-45°. Have patient intubated and hyperventilated, induced by a ventilator or by “bagging” a person. Pay meticulous attention to maintaing respiratory function. Frequently draw arterial blood gases. Maintain patent airway by suctioning. Adequately oxygenate intubated people before each passage of a suction catheter. Keep the passage of a suction catheter as briefly as possible, never exceed 15 sec. Maintain head/neck in neutral position, support with small towel rolls or pillow. Avoid placing head on large head on large pillow or causing hip flexion of 90° or more. Maintain a regular bowel program.
Nursing Interventions:Collaborative: Administer osmotic diuretics, commonly Mannitol, as indicated. Administer antihypertensives, analgesics/sedatives, antipyretics, vasopressors, antiseizure drugs, neruomuscular blocking agents, and corticosteroids, as appropriate.
ACUTE/CHRONIC URINARY RETENTION R/T URINARY OBSTRUCTION ASSOCIATED WITH CANCERTaxonomy : Elimination Pattern Cause Analysis : Urinary retention may occur in patients with gynecologic malignancies, which interferes with bladder emptying caused by obstruction in the urine outflow channel that result from or cause dysfunction in neural innervation or bladder muscle tone.
ACUTE/CHRONIC URINARY RETENTION R/T URINARY OBSTRUCTION ASSOCIATED WITH CANCER Cues: •Urinary obstruction •Anuria with polyuria •Hematuria •Proteinuria •↑serum creatinine •Flank painDesired Outcome • Voided in sufficient amounts with no palpable bladder distension. • Demonstrated postvoid residuals of less than 50 mL, with absence of dribbling/ overflow.
Nursing Interventions:Independent: Encourage patient to void every 2–4 hr and when urge is noted. Ask patient about stress incontinence when moving, sneezing, coughing, laughing, lifting objects. Observe urinary stream, noting size and force. Have patient document time and amount of each voiding. Note diminished urinary output. Measure specific gravity as indicated. Percuss/palpate suprapubic area. Encourage oral fluids up to 3000 mL daily, within cardiac tolerance, if indicated. Monitor vital signs closely. Observe for hypertension, peripheral/dependent edema, changes in mentation. Weigh daily. Maintain accurate I&O. Provide/encourage meticulous catheter and perineal care. Recommend sitz bath as indicated.
Nursing Interventions:Collaborative:Administer medications as indicated: Rectal suppositories (B & O); Antibiotics and antibacterials. Catheterize for residual urine and leave indwelling catheter as indicated. Irrigate catheter as indicated.Monitor laboratory studies, e.g.: • BUN, Cr, electrolytes; • Urinalysis and culture.
Impaired physical mobility may be r/t: •Neuromuscular impairment • pain/discomfort • edema formation Taxonomy : Activity- Exercise Pattern Cause Analysis : Cancer patients experience a limitation of ability for independent physical movement. Movement exacerbates discomfort.
Impaired physical mobility Cues: • Reluctant to attempt movement • Limited ROM • Decreased muscle mass/strength Desired Outcome: • Demonstrate techniques/behaviors that enable resumption of activities. • Maintain or increase strength and function of body.
Nursing Interventions:Independent Elevate affected arms as inidcated. Begin passive ROM as soon as possible. Have patient move fingers, noting the sensations and color of hand on affected side. Encourage patient to use affected arm for personal hygeine. Help with self-care activities as necessary. Assist with ambulation and encourage corrert posture. Evaluate presence/degree of exercise-related pain and changes in joint mobility.Collaborative: Administer analgesics and diuretics, as indicated. Maintain integrity of elastic bandages or custom-fitted pressure-gradient elastic sleeve. Refer to physical/occupational therapist.
Imbalanced nutrition Less than body requirements may be r/t: • hypermetabolic state associated with cancer • consequences of chemotherapy, radiation & surgery • fatigue and poorly-controlled pain Taxonomy : Nutritional-Metabolic Pattern Cause Analysis : Cancer may lead to a decrease in nutrient intake of sufficient magnitude to cause weight loss and alteration of intermediary metabloism. A variety of both tumor-derived factor (ACTH) and host-derived factors (tumor necrosis factor, interleukin 1 & 6, growth hormone) contribute to the altered metabolism, & a vivius cycle is established in which protein catabolism, glucose intolerance, and lipolysis cannot be
Imbalanced nutrition Less than body requirements Cues: • Recent weight loss: decreased subcutaneous fat muscle • Loss of appetite • Lack of sleep • Nausea & vomiting • Anemic • Desired Outcome: • Demonstrate stable weight/progressive weight gain toward goal with normalization of laboratory values and be free of signs of malnutrition. • Verbalize understanding of individual interferences to adequate intake. • Participate in specific interventions to stimulate appetite/increase dietary intake.
Nursing Interventions:Nutrition Therapy Monitor daily food intake; have patient keep food diary as indicated.Measure height, weight, and tricep skinfold thickness. Weigh daily or as indicated. Assess skin/mucous membranes for pallor, delayed wound healing, enlarged parotid glands. Encourage patient to eat high-calorie, nutrient-rich diet, with adequate fluid intake. Encourage use of supplements and frequent/smaller meals spaced throughout the day.Create pleasant dining atmosphere; encourage patient to share meals with family/friends.Encourage open communication regarding anorexia
Nursing Interventions:Chemotherapy Management:Adjust diet before and immediately after treatment. Give liquids 1 hr before or 1 hr after meals.Control environmental factors. Avoid overly sweet, fatty, or spicy foods.Encourage use of relaxation techniques, visualization, guided imagery, moderate exercise before meals.Identify the patient who experiences anticipatory nausea/ vomiting and take appropriate measures.Administer antiemetic on a regular schedule before/during & after administration of antineoplastic agent as appropriate.Evaluate effectiveness of antiemetic.Hematest stools, gastric secretions.
Nursing Interventions:Collaborative: Review laboratory studies as indicated.Administer medications as indicated: •5-HT3 receptor antagonists •Corticosteroids •Vitamins, especially A, D, E, and B6. •Antacids.Nutrition Therapy: Refer to dietitian/nutritional support team. Insert/maintain NG or feeding tube for enteric feedings, or central line for total parenteral nutrition (TPN) if indicated.
Other nursing care plans Body Image Disturbed r/t loss or alteration of the breast secondary to surgical procedure. Risk for Altered Family Process r/t • Situational/transitional crises: long-term illness, change in roles/economic status • Developmental: anticipated loss of a family member Knowledge Deficit regarding prognosis, treatment, self-care, and discharge needs. Situational Low Self-Esteem r/t • Biophysical: disfiguring surgical procedure • Psychosocial: concern about sexual attractiveness