chapter 48 assessment and management of patients with breast disorders

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Copyright © 2008 Lippincott Williams & Wilkins. Chapter 48 Assessment and Management of Patients With Breast Disorders

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Chapter 48 Assessment and Management of Patients With Breast Disorders. Breast Disorders. Overview of anatomy of the breast Cultural and psychosocial considerations Breast cancer is a major health problem - PowerPoint PPT Presentation

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Page 1: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Chapter 48

Assessment and Management of Patients With Breast Disorders

Chapter 48

Assessment and Management of Patients With Breast Disorders

Page 2: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Breast DisordersBreast Disorders

• Overview of anatomy of the breast

• Cultural and psychosocial considerations

• Breast cancer is a major health problem

• In the U.S., more than 215,000 women and 1,450 men develop breast cancer annually, and more than 40,000 die

Page 3: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Anatomy of the BreastAnatomy of the Breast

Page 4: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Risk Factors for Breast CancerRisk Factors for Breast Cancer

• Female gender

• Age

• Personal and family history including genetic mutations

• Hormonal factors

• Exposure to radiation

• History of benign breast disease

• Obesity

• High-fat diet (controversial)

• Alcohol intake

Page 5: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Guidelines for Early Detection of Breast Cancer

Guidelines for Early Detection of Breast Cancer

• Women in their 20s and 30s: clinical breast exam at least every 3 years, then preferably annually after age 40

• Mammography annually beginning at age 40

• Women at increased risk may have earlier initial screening, shorter screening intervals, or additional screening procedures such as ultrasound and MRI

• Teach women in their 20s the benefits and limitations of breast self-examination (BSE)

Page 6: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Breast Self-ExaminationBreast Self-Examination

• Provide instruction to women regarding BSE

• Instructions should be provided to men if there is a family history of breast cancer

• Encourage BSE but do not overemphasize it

• Instructional materials can be obtained from the American Cancer Society and The National Cancer Institute

Page 7: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Lymph NodesLymph Nodes

Page 8: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Teaching Breast Self-ExaminationTeaching Breast Self-Examination

• Best performed days 5 to 7 days after first day of menses or once monthly for postmenopausal women

• Review the feel of normal breast tissue and ways or identify changes

• Routine BSE helps patients become familiar with their own “normal abnormalities”

• Demonstrate the examination technique

• Encourage the student to perform a BSE demonstration on herself or on a breast model

Page 9: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Breast Self-ExaminationBreast Self-Examination

• Stand in front of a mirror

• Check both breasts for anything unusual

• Look for discharge from the nipple and puckering, dimpling, or scaling of the skin

Page 10: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Breast Self-Examination (cont.)Breast Self-Examination (cont.)

• Watch closely in the mirror as you clasp your hands, bend your head, and press your hands forward

• Note any change in the contour or your breasts

Page 11: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Breast Self-Examination (cont.)Breast Self-Examination (cont.)

• Next, press your hands firmly on your hips and bow slightly toward the mirror as you pull your shoulders and elbows forward

• Note any change in the contour of your breasts

Page 12: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Breast Self-Examination (cont.)Breast Self-Examination (cont.)

• Raise your left arm; using 2 or 3 fingers, feel your left breast carefully and thoroughly

• Beginning at the outer edge, press the flat part of your fingers in small circles, moving the circles slowly around the breast

• Gradually work toward the nipple

• Cover the whole breast

Page 13: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Breast Self-Examination (cont.)Breast Self-Examination (cont.)

• Feel for any lumps or masses.

• Repeat on the right breast; step 4 should be repeated lying down

• Lie flat on your back with your left arm over you head and a pillow or folded towel under the left shoulder

• Use the same circular motion

• Repeat on the right breast

Page 14: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Teaching Breast Self-ExaminationTeaching Breast Self-Examination

• Part of the examination may be done in the shower with soapy hands to glide over the breast and focus on underlying tissue

• Note the importance of including the area between the breast and underarm, and the underarm itself

• Discuss reporting of any changes

• Describe the goals, methods of instruction, and methods of evaluation for a teaching plan for BSE

• List resources for information and materials

Page 15: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Diagnostic TestsDiagnostic Tests

• Mammography

• Galactography

• Ultrasonography

• Magnetic resonance imaging (MRI)

• Biopsies

– Percutaneous: fine-needle aspiration and core biopsies

– Surgical biopsies: excision, incision, and wire needle localization

Page 16: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

MammographyMammography

Page 17: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Surgical Management—Breast CancerSurgical Management—Breast Cancer

• Breast conservation treatment

• Total mastectomy

• Modified radical mastectomy

• Sentinel node biopsy and axillary lymph node dissection

• Breast reconstruction surgery

Page 18: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Breast Reconstruction With Tissue Expander

Breast Reconstruction With Tissue Expander

Page 19: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Breast Reconstruction With TRAMBreast Reconstruction With TRAM

Page 20: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Breast Reconstruction—Latissimus Dorsi Flap

Breast Reconstruction—Latissimus Dorsi Flap

Page 21: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Nonsurgical Management of Breast Cancer

Nonsurgical Management of Breast Cancer

• Radiation therapy: external beam, brachytherapy

• Chemotherapy

• Hormonal therapy

– Estrogen and progesterone receptor assay

– Selective estrogen receptor modulators (SERMs): tamoxifen

– Aromatase inhibitors: anastrozole, letrozole, and exemestane

• Targeted therapy

Page 22: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Nursing Process—Assessment of the Patient Undergoing Breast Cancer

Surgery

Nursing Process—Assessment of the Patient Undergoing Breast Cancer

Surgery

• How is the patient responding to her diagnosis?

• What coping mechanisms does she find helpful?

• What psychological or emotional supports does she have and use?

• Is there a partner, family member, or friend available to assist in making treatment choices?

• What are her educational needs?

• Is she experiencing any discomfort?

Page 23: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Nursing Process—Preoperative Diagnosis of the Patient Undergoing

Breast Cancer Surgery

Nursing Process—Preoperative Diagnosis of the Patient Undergoing

Breast Cancer Surgery

• Deficient knowledge

• Anxiety

• Fear

• Risk for ineffective coping

• Decisional conflict

Page 24: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Nursing Process—Postoperative Diagnosis of the Patient Undergoing

Breast Cancer Surgery

Nursing Process—Postoperative Diagnosis of the Patient Undergoing

Breast Cancer Surgery• Pain

• Disturbed sensory perception

• Disturbed body image

• Self-care deficit

• Risk for sexual dysfunction

• Deficient knowledge

– Drain management

– Arm exercises

– Hand and arm care

Page 25: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Collaborative Problems/Potential Complications

Collaborative Problems/Potential Complications

• Lymphedema

• Hematoma/seroma formation

• Infection

Page 26: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Nursing Process—Planning the Care of the Patient Undergoing Breast Cancer

Surgery

Nursing Process—Planning the Care of the Patient Undergoing Breast Cancer

Surgery

• Major goals may include:

– Increased knowledge about the disease and its treatment

– Reduction of preoperative and postoperative fear, anxiety, and emotional stress

– Improvement of decision-making ability and improvement of coping skills

– Improvement in sexual function

– Absence of complications

Page 27: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Preoperative InterventionsPreoperative Interventions• Review and reinforce information on treatment options

• Prepare patient regarding what to expect before, during, and after surgery

• Inform patient regarding surgical drain, arm and shoulder mobility, and range-of-motion exercises

• Maintain open communications

• Provide patient with realistic expectations

• Support coping

• Involve or provide information for supportive services and resources

• Support patient decisions

Page 28: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Postoperative InterventionsPostoperative Interventions

• Inform patient regarding common postoperative sensations

• Maintain privacy

• Provide bra with breast form

• Provide information

• Support coping and adjustment

• Provide counseling and referral

• See Table 48-5 and Chart 48-6

• Monitor for potential complications

Page 29: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Hand and Arm CareHand and Arm Care• Potential for lymphedema formation after auxiliary lymph

node dissection (ALND)• Patient education• Prevention is vital; follow guidelines for the rest of life• No blood pressure, injections, or blood draws in the

affected arm• Perform exercises 3X a day for 20 minutes to increase

circulation and muscle strength, prevent stiffness and contractures, and restore ROM

• A mild analgesic or a warm shower may be helpful prior to exercise

• Initial limitation of lifting (over 5 to 10 lbs) and activity• See Chart 48-7

Page 30: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Exercises After Breast SurgeryExercises After Breast Surgery

Wall climbing

Rope turning

Rod liftingPulley tugging

Page 31: Chapter 48 Assessment and Management of Patients With Breast Disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Drain ManagementDrain Management

• May need home care referral to assist with drain management

• Drains are usually removed when drainage is less than 30 mL in a 24-hour period; usually occurs in 7 to 10 days

• Drain site and incision care

• See Chart 48-8