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INTERVENTIONS FOR CLIENTS WITH BREAST DISORDERS
Jolene Bethune, RN, MSN
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 tamoxifen citrate
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)
MammographyBaseline screening
mammogram recommended beginning at age 40
Yearly for women ages 40-50Barriers include: fear of radiation fear of results concerns about pain knowledge deficit accessibility; client cost
Breast Self ExaminationInexpensive, encouraged by health care providers for decadesDetection before axillary node involvement increases survivabilityUsed in conjunction with mammography, CBE , BSE is extremely
effective in early detection and reducing mortality ratesWomen 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 DISORDERSMost 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 DiseaseMost 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
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 cancerEtiologic 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
OVERVIEWMost commonly diagnosed cancer in womenLeading cause of cancer deaths in US women age
35-45Leading cause of cancer mortality in women,
second to lung cancerMost women have strong reaction to the threat of
breast cancer; influencing their health habitsUltimate 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 invasive or 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
Noninvasive Lobular Carcinoma Invasive 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 CANCERFamily history suggests a predisposition to the
disease Multiple relatives with breast cancer Early age at diagnosis Ovarian cancer Inherited genetic mutationsOptions 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 : AnxietyThe 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: AnxietyIntervention: 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: AnxietyIntervention: 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 MetastasisNonsurgical 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 ReconstructionThe 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 ReconstructionThe 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 CareHome Care ManagementHealth 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 incisionHealth 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
