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

2. Assessment
Health History

3. 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.

4. 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

5. 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.

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. 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.

14. Breast-Self Examination

15. 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);

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

17. Comparison of Various Breast Masses

18. 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.

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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.

28. 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.

29. 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

30. 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

31. 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

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

33. 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

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

35. 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

36. 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)

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

38. 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

39. 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

40. 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.

41. Post-op arm exercise
Wall handclimbing
Rope turning

42. Post-op arm exercise
Rod or broomstick lifting
Pulley tugging

43. 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

44. 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

45. 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

46. 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

47. 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).