Assessment and Management of Patients With Breast Disorders Chapter 48 Assessment and Management of Patients With Breast Disorders

Assessment Health History

Physical Assessment/ Inspection Retraction Signs Signs include skin dimpling, creasing, or changes in the contour of the breast or nipple Secondary to fibrosis or scar tissue formation in the breast Retraction signs may appear only with position changes or with breast palpation.

Physical Assessment/ Inspection Breast Cancer Mass (Malignant Tumor) Usually occurs as a single mass (lump) in one breast Firm, hard, embedded in surrounding tissue Referral and biopsy indicated for definitive diagnosis Usually nontender Irregular shape

Physical Assessment/ Inspection Breast Cyst (Benign Mass) Occur as single or multiple lumps in one or both breasts Usually tender (omitting caffeine reduces tenderness); tenderness increases during premenstrual period Round shape Soft or firm, mobile Referral and biopsy indicated for definitive diagnosis, especially for first mass.

Physical Assessment/ Inspection Fibroadenoma (Benign Breast Lump) Usually occurs as a single mass in women aged 15–35 years Usually nontender May be round or lobular Firm, mobile, and not fixed to breast tissue or chest wall No premenstrual changes Referral and biopsy indicated for definitive diagnosis

Physical Assessment/ Inspection Increased Venous Prominence Associated with breast cancer if unilateral Unilateral localized increase in venous pattern associated with malignant tumors Normal with breast enlargement associated with pregnancy and lactation if bilateral and bilateral symmetry

Physical Assessment/ Inspection Peau d'Orange (Edema) Associated with breast cancer Caused by interference with lymphatic drainage Breast skin has orange peel appearance Skin pores enlarge May be noted on the areola Skin becomes thick, hard, immobile Skin discoloration may occur

Physical Assessment/ Inspection Nipple Inversion Considered normal if long-standing Associated with fibrosis and malignancy if recent development

Physical Assessment/ Inspection Acute Mastitis (Inflammation of the Breasts) Associated with lactation but may occur at any age Nipple cracks or abrasions noted Breast skin reddened and warm to touch Tenderness Systemic signs include fever and increased pulse

Physical Assessment/ Inspection Paget Disease (Malignancy of Mammary Ducts) Early signs: erythema of nipple and areola Late signs: thickening, scaling, and erosion of the nipple and areola

Diagnostic Evaluation Breast Self-Examination (BSE) Done on day 5-7 of menstrual cycle (some changes in breast occur due to hormones around menstruation) Breast examination with the woman in a supine position. The entire surface of the breast is palpated from the outer edge of the breast to the nipple. Alternative palpation patterns are circular or clockwise, wedge, and vertical strip.

Breast-Self Examination

Diagnostic Evaluation Mammography Detect nonpalpable lesions and assist in diagnosing palpable masses Recommended to be done every year beginning at 40 years of age (women with family history, start at younger age) Mammography may detect a breast tumor before it is clinically palpable (ie, smaller than 1 cm);

Diagnostic Evaluation Magnetic Resonance Imaging Procedures for Tissue Analysis Percutaneous Biopsy Fine-Needle Aspiration Surgical Biopsy Excisional Biopsy Incisional Biopsy

Comparison of Various Breast Masses

Benign Neoplasms: Fibrocystic Breast Disease(FBD) Also called chronic mastitis or lumpy breast syndrome, it is the most common breast lesion in females and usually occurs between ages 35 and 50. Many cases will subside after menopause.

Benign Neoplasms: Fibrocystic Breast Disease(FBD) Incidence of developing breast cancer is increased 3 to 4 times with FBD. Pathology Cause is unknown; possible hormonal imbalance Condition occurs during reproductive years and disappears with menopause A benign condition affecting 25% of women over 30 years of age

Benign Neoplasms: Fibrocystic Breast Disease(FBD) Signs and symptoms Subjective: breast tenderness and pain Objective: small, round, smooth nodules Diagnostic tests and methods Mammography, thermomastography, xerography Treatment: conservative Aspiration Biopsy examination to rule out malignancy

Benign Neoplasms: Fibrocystic Breast Disease(FBD) Nursing intervention Explain importance of monthly breast self-examination Encourage patient to seek medical evaluation if nodule forms, because cystic disease may interfere with early diagnosis of breast malignancy

Malignant Neoplasms: Breast Cancer Second major cause of cancer death among women. Statistics indicate that 1 in 10 will develop cancer sometime during her life. The key to cure is early detection by physical examination, mammography, and breast self-examination. Image 1: Inflammatory Breast CA Image 2: Advanced Breast CA

Risk factors for Breast Cancer Female gender Increasing age Personal history of breast cancer Family history of breast cancer Genetic mutations (BRCA-1 and BRCA-2 mutations are responsible for majority of inherited breast cancer cases) Late menopause Nulliparity

Risk factors for breast Cancer Hormonal factors Early menarche First child after 30 years of age Hormone therapy (HT) Exposure to ionizing radiation during adolescence and early adulthood History of benign proliferative breast disease Obesity High-fat diet (controversial) Alcohol intake

Protective Factors Regular exercise (after age of 35, strenuous excursive ˅ chance for BC by 14%. Breastfeeding Having completed a full-term pregnancy before 30 years of age

Types of Breast Cancer Ductal Carcinoma in Situ Characterized by the proliferation of malignant cells inside the milk ducts without invasion into the surrounding tissue. It is a noninvasive form of cancer (also called intraductal carcinoma). If not treated, ? become invasive cancer

Types of Breast Cancer Infiltrating Ductal Carcinoma Is the most common histologic type of breast cancer. Accounts for 75% of all cases. The tumors arise from the duct system and invade the surrounding tissues. They often form a solid irregular mass in the breast.

Other types of breast cancer Infiltrating Lobular Carcinoma (5-10%) Medullary Carcinoma (5%) Mucinous Carcinoma (3%) Tubular Ductal Carcinoma (2%) Inflammatory Carcinoma (2%) Paget Disease (1%) Infiltrating Lobular Carcinoma Infiltrating lobular carcinoma accounts for 5% to 10% of breast cancers. The tumors arise from the lobular epithelium and typically occur as an area of ill-defined thickening in the breast. They are often multicentric and can be bilateral. Medullary Carcinoma Medullary carcinoma accounts for about 5% of breast cancers, and it tends to be diagnosed more often in women younger than 50 years. The tumors grow in a capsule inside a duct. They can become large and may be mistaken for a fibroadenoma. The prognosis is often favorable. Mucinous Carcinoma Mucinous carcinoma accounts for about 3% of breast cancers and often presents in postmenopausal women 75 years and older. A mucin producer, the tumor is also slow-growing and thus the prognosis is more favorable than in many other types. Tubular Ductal Carcinoma Tubular ductal carcinoma accounts for about 2% of breast cancers. Because axillary metastases are uncommon with this histology, prognosis is usually excellent. Inflammatory Carcinoma Inflammatory carcinoma is a rare (1% to 2%) and aggressive type of breast cancer that has unique symptoms. The cancer is characterized by diffuse edema and brawny erythema of the skin, often referred to as peau d'orange (resembling an orange peel). This is due to malignant cells blocking the lymph channels in the skin. An associated mass may or may not be present; if there is, it is often a large area of indiscrete thickening. Inflammatory carcinoma can be confused with an infection because of its presentation. The disease can spread to other parts of the body rapidly. Chemotherapy often plays an initial role in controlling disease progression, but radiation and surgery may also be useful. Paget Disease Paget disease of the breast accounts for 1% of diagnosed breast cancer cases. Symptoms typically include a scaly, erythematous, pruritic lesion of the nipple. Paget disease often represents ductal carcinoma in situ of the nipple but may have an invasive component. Mammography should be performed followed by a biopsy of the involved skin area.

Breast cancer Signs and symptoms Diagnostic tests and methods Subjective: nontender nodule Objective: Enlarged axillary nodes Nipple retraction or elevation Skin dimpling Nipple discharge usually appeal in the upper outer quadrant Diagnostic tests and methods Mammography, breast biopsy examination

Breast cancer Treatment Lumpectomy: removal of the lump and partial breast tissue; indicated for early detection Mastectomy Simple mastectomy: removal of breast Modified radical mastectomy: removal of breast, pectoralis minor muscle, and some of an adjacent lymph nodes Radical mastectomy: removal of the breast, pectoral muscles, pectoral fascia, and axillary lymph node disection

Breast cancer Treatment Oophorectomy, adrenalectomy, hypophysectomy to remove source of estrogen and the hormones that stimulate the breast tissue Radiation therapy to destroy malignant residual malegnant cells Chemotherapeutic agents to shrink, retard, and destroy cancer growth Corticosteroids, antigens, and anti-estrogens to alter cancer that is dependent on hormonal environment

Collaborative Problems/Potential Complications Based on the assessment data, potential complications may include the following: Lymphedema Hematoma/seroma formation Infection

Breast Cancer/ Preop Nsg Dx 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

Preoperative Nursing Interventions Providing Education and Preparation About Surgical Treatments Reducing Fear and Anxiety and Improving Coping Ability Promoting Decision-Making Ability

Breast Cancer/ Postop Nsg Dx Pain and discomfort related to surgical procedure Disturbed sensory perception related to nerve irritation in affected arm, breast, or chest wall Disturbed body image related to loss or alteration of breast Risk for impaired adjustment related to the diagnosis of cancer and surgical treatment Self-care deficit related to partial immobility of arm

Breast Cancer/ Postop Nsg Dx 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 an axillary lymph node dissection (ALND)

Postoperative Nursing Interventions Relieving Pain and Discomfort Managing Postoperative Sensations Promoting Positive Body Image Promoting Positive Adjustment and Coping Monitoring and Managing Potential Complications

Lymphedema Occurs in about 10% to 30% of patients who undergo ALND and in about 0% to 7% of patients who have SLNB lymphatic channels become inadequate to ensure a return flow of lymph fluid to the general circulation. Risk factors: age, obesity, extensive axillary disease, radiation treatment, and injury or infection to the extremity

Lymphedema Edema resolved after development of collateral circulation. Postoperative transient edema develops until collateral circulation has completely taken over this function, which generally occurs within a month. Performing prescribed exercises, elevating the arm above the heart several times a day, and gentle muscle pumping (making a fist and releasing) can help reduce the transient edema. The patient needs reassurance that this transient swelling is not lymphedema

Hand and Arm Care After Axillary Lymph Node Dissection Avoid BP, injections, and blood draws in affected arm. Use sunscreen for extended exposure to sun. Apply insect repellent to avoid insect bites. Wear gloves for gardening. Use cooking mitt for removing objects from oven. Avoid cutting cuticles; push them back during manicures. Use electric razor for shaving armpit. Avoid lifting objects greater than 2-4 kg. If a trauma or break in the skin occurs, wash the area with soap and water, and apply an antibacterial ointment. Observe the area and extremity for 24 hours; if redness, swelling, or a fever occurs, call the surgeon or nurse.

Post-op arm exercise Wall handclimbing Rope turning

Post-op arm exercise Rod or broomstick lifting Pulley tugging

Breast cancer Nursing intervention Provide atmosphere of acceptance, frequent patient contact, and encouragement in illness adjustment Encourage grooming activities Arrange attractive environment If the patient is receiving radiation or chemotherapy, explain and assist with potential site effects

Breast cancer If the patient has undergone surgical intervention, follow post operative nursing actions Elevate affected arm above level of right atrium to prevent edema Drawing blood or administering parenteral fluids or taking blood pressure on affected arm is contraindicated Monitor dressing for hemorrhage, observed back for pooling of blood Empty Hemovac and measure drainage every 8 hours Assess circulatory status of affected limb Measure upper arm and forearm, twice daily, to monitor edema Encourage exercises of the affected arm when approved by a physician; avoid abduction

Breast cancer Patient teaching on discharge Exercise to tolerance Sleep with arm elevated Elevated arm several times daily Avoid injections, vaccinations, IV, and taking blood pressure, in affected arm

Malignant Neoplasms: Breast Cancer Five year survival rate is 97% for localized cancer, 76% for cancer that has spread regionally, and 21% for cancers having distant metastases. Metastatic breast cancer to the back

Male Breast Cancer Accounts for less than 1% of all cases of breast cancer Average age at diagnosis is 67 years Risk factors: A history of mumps orchitis, Radiation exposure, Decreased testosterone levels Liver disease (compromises estrogen metabolism).