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Nursing Care of the Woman with a Disorder of the Breast. Benign Breast Disorders. Fibrocystic Breast Disease. Related to. Relatively High estrogen and Low progesterone. Normal Breast . Fibrocystic Changes. Development of excess fibrous tissue

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fibrocystic breast disease
Fibrocystic Breast Disease

Related to

Relatively High estrogen

and

Low progesterone

fibrocystic changes
Fibrocystic Changes
  • Development of excess fibrous tissue
  • Hyperplasia of the epithelial lining of the mammary ducts
  • Proliferation of mammary ducts
  • Cyst formation
signs and symptoms
Signs and Symptoms
  • Palpable lumps that are round, well-delineated and freely movable
  • Lumps increase in size premenstrual
  • Tenderness
  • Pain
  • Nipple discharge
diagnosis
Diagnosis
  • Ultrasound
  • Biopsy
    • Aspiration
    • Excisional
nursing care
Nursing Care
  • Patient Teaching
    • Wear good support bra
    • Diet Therapy
      • Low salt
      • No chocolate or caffeine
nursing care1
Nursing Care
  • Medications
    • Vitamin E
    • Antiestrogen - Danazol
    • Diuretics
    • Analgesics
  • Remind Patient to have a Yearly follow-up
  • Continue to perform monthly BSE
review
Review
  • In teaching the patient with painful fibrocystic breast changes about the condition, the nurse explains that
    • All breast lumps must be biopsied to rule out malignant changes
    • The symptoms will probably subside after menopause unless you use HRT
    • Restrictions of coffee and chocolate and supplements of vitamin E may relieve the discomforts
    • The lumps will become progressively larger and more painful, eventually necessitating surgical removal
fibroadenoma

Fibroadenoma

Benign lump in breast

fibroadenoma1
Fibroadenoma
  • Not affected by menstrual cycle
  • Small, painless, well-delineated, very mobile

__________________________

Diagnosed via mammogram or biopsy

Treatment – surgical excision

slide14

Significant health concern for women

    • 1 in 7 chance of being diagnosed
    • with Breast Cancer
    • Intense feelings of shock, fear, denial
    • One of the most common
    • malignancies in American women
risk factors
Risk Factors
  • Female gender; ≥50 years of age
  • Personal History
    • Family history
    • Personal history of cancer (breast, colon, endometrial, ovarian)
  • Hormonal factors
    • Early menarche or late menopause
    • No pregnancies
    • First child after 30 years of age
  • Weight gain and obesity after menopause
  • High fat diet, alcohol intake
  • Exposure to ionizing radiation
risk factors brca gene br east ca ncer susceptibility gene 1 and 2
Risk Factors BRCA genebreast cancer susceptibility gene 1 and 2
  • In normal cells, BRCA1 and BRCA2 help ensure the stability of the cell’s genetic material (DNA) and help prevent uncontrolled cell growth.
  • A woman’s lifetime risk of developing breast and/or ovarian cancer is greatly increased if she inherits a harmful mutation in BRCA1 or BRCA2.

Another risk – a woman who has been on combined estrogen and progesterone therapy

pathophysiology
Pathophysiology
  • Breast Cancer arises from:
    • Epithelial lining of ducts
    • Epithelium of lobules

Most Breast Cancers arise from ducts

and are invasive

prognosis
Prognosis
  • Factors that affect cancer prognosis
    • Size
    • Axillary node involvement
    • Tumor differentiation
    • Human epidermal growth factor receptor 2 (HER-2) status
her 3 receptors
HER-3 Receptors

HER-2 receptors are found on the inside and outside of the

Cancer cell. Receptors join together to send messages telling cancer cells to grow and divide

signs and symptoms1
Signs and Symptoms
  • Detected as a lump
  • Abnormality on mammography
  • If palpable, irregular shaped, poorly delineated, nonmobile (usually attached to chest wall), and nontender
  • May have nipple discharge – bloody
  • Nipple retraction
  • Dimpling
distribution of breast cancer
Distribution of Breast Cancer

Most commonly found in the upper outer quadrant

breast self examination
Breast Self Examination
  • Helps women to become self-aware of how their breasts normally look and feel and to detect when something changes.
  • Should be done monthly when the breasts are non tender, right after the end of menses
  • If no longer have menses – use the first day of each month
breast self examination1
Breast Self Examination
  • Step 1:
  • Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.
  • Here's what you should look for:
    • Breasts that are their usual
    • size, shape, and color
    • Breasts that are evenly
    • shaped without visible
    • distortion or swelling
breast self examination2
Breast Self Examination
  • Use a firm, smooth touch with the first few finger pads of your hand,
  • keeping the fingers flat and together. Use a circular motion, about
  • the size of a quarter. Go around breast, up and down over breast
  • and in outward from nipple.
  • Look at breasts with arms at side and arms raised and on hips
  • Next, lie down and do same procedure in palpating breasts.
diagnosis1
Diagnosis
  • DNA testing for BRCA – 1 and BRCA-2
  • Mammogram / ultrasound

Mammogram showing Bilateral Invasive Ductal Carcinoma

  • Biopsy
diagnostic studies
Diagnostic Studies
  • Lymphatic mapping and sentinel lymph node dissection (SLND)
    • Helps surgeon identify lymph nodes that drain first from tumor site
    • Radioisotope and/or blue dye is injected into tumor site
    • Lymph nodes dissected and sent to lab for analysis
review1
Review
  • While discussing risk factors for breast cancer, the nurse stresses that the greatest known risk factor for breast cancer is
    • Being a woman over 60 years of age
    • Experiencing menstruation for 40 years or more
    • Using estrogen replacement therapy during menopause
    • Having a paternal grandmother with postmenopausal breast cancer
surgical therapy
Surgical Therapy
  • Most common options for resectable Breast Cancer
    • Breast conservation surgery with radiation therapy
    • Modified radical mastectomy with or without reconstruction
surgical therapy axillary node dissection
Surgical TherapyAxillary Node Dissection
  • Sentinel lymph node dissection (SLND) has replaced ALND for patients who do not have malignant cells
  • ALND performed when one or more sentinel lymph nodes contain malignant cells
  • Examination of lymph nodes provides prognosis and treatment information
surgical therapy breast conservation therapy
Surgical TherapyBreast Conservation Therapy
  • Involves removal of entire tumor with a margin of normal tissue
  • Radiation therapy is delivered to entire breast, ending with a boost to tumor bed
  • Evidence of systemic disease may warrant chemotherapy before radiation
surgical therapy1
Surgical Therapy
  • Modified radical mastectomy
    • Removal of breast and axillary lymph nodes with preservation of the pectoralis major muscle
    • Patient has the option of breast reconstruction
radiation therapy
Radiation Therapy
  • Primary radiation therapy
    • Usually performed after local excision of breast mass
    • Breast is radiated daily over ~5 to 6 weeks
    • “Boost” treatment may be given to full breast

following primary dose

  • Intraoperative Radiation Therapy
    • Single intense dose delivered to surgery site in the operating room
radiation therapy1
Radiation Therapy
  • High-dose brachytherapy
    • Internal radiation delivered via radioactice seeds into a balloon catheter
    • Balloon catheter is placed within the lumpectomy site
    • Treatment is over 4-5 days
radiation therapy2
Radiation Therapy
  • Palliative radiation therapy
    • Used to stabilize symptomatic metastatic lesions in such sites as
        • Bone
        • Soft tissue organs
        • Brain
        • Chest
    • Relieves pain
    • Successful in controlling recurrent or metastatic disease for long periods
radiation therapy3
Radiation Therapy
  • Radiation therapy side effects
    • Fatigue
    • Skin changes
    • Breast edema
hormonal therapy
Hormonal Therapy
  • Removes or blocks source of estrogen, promoting tumor regression
      • Estrogen can increase growth of BC cells if cells are estrogen receptor positive
  • Most common drug used in estrogen-receptor positive women is:
      • Tamoxifen (Nolvadex) – antiestrogen
        • Side effects – decreased visual acuity, and vascular changes
      • Fulvestrant (Faslodex) - antiestrogen
hormonal therapy1
Hormonal Therapy
  • Hormonal therapy (cont'd)
    • 2 advances have increased use in BC
      • Hormone receptor assays developed to identify those likely to respond to treatment
      • Drugs have been developed that can inactivate hormone-secreting glands as effectively as surgery or radiation
biologic and targeted therapies
Biologic and Targeted Therapies
  • Trastuzumab (Herceptin) is a monoclonal antibody to HER-2
  • Once the antibody attaches to antigen, it is taken to cells and eventually kills them
  • It can be used alone or in combination with other chemotherapies
  • Side-effect – monitor for signs of ventricular dysfunction and congestive heart failure.
chemotherapy
Chemotherapy
  • Use of cytotoxic drugs to destroy cancer cells
  • BC is one of the solid tumors that is most responsive to chemotherapy
  • Given preoperatively in some patients to decrease size of primary tumor
chemotherapy1
Chemotherapy
  • Variety of side effects since healthy cells are also affected
  • Influenced by specific drug combinations, drug schedule, and dose of drug(s)
  • Most common side effects involve
    • Gastrointestinal tract
    • Bone marrow
    • Hair follicles
goals
Goals

The patient will:

  • Actively participate in decision-making process related to treatment options
  • Fully comply with therapeutic plan
  • Manage side effects of therapy
  • Be satisfied with support provided by significant others and health care providers
nursing intervention
Nursing Intervention
  • Prevention of Lymphedema:
    • Heaviness
    • Pain
    • Impaired motor function in arm
    • Numbness
    • Paresthesia of the fingers
    • Cellulitis and progressive fibrosis can result
nursing implementation
Nursing Implementation
  • Restoring arm function on affected side after mastectomy and axillary lymph node dissection is one of the most important goals
    • Place in a semi-Fowler’s position with arm on affected side elevated on a pillow, never dependent
    • Flexing and extending fingers should begin in recovery room and progressive increase in activity
    • Blood pressure readings, venipunctures, and injections should not be done on affected arm
    • Use intermittent pneumatic compression sleeve or a fitted elastic pressure gradient sleeve
nursing implementation1
Nursing Implementation
  • Postoperative arm and shoulder exercises are instituted gradually at surgeon’s direction
  • Exercises are designed to prevent contractures and muscle shortening, maintain muscle tone, and improve lymph and blood circulation
  • Instruct patient to protect arm from even minor trauma (e.g., sunburn, pinprick)
nursing interventions
Nursing Interventions
  • Relieve postmastectomy pain syndrome:
    • Chest and upper arm pain, tingling down arm
    • Numbness, shooting or prickling pain
    • Unbearable itching persisting beyond 3-month healing time
  • Treatment includes
    • Nonsteroidal antiinflammatory drugs
    • Antidepressants
    • Topical lidocaine patches or EMLA
nursing implementation2
Nursing Implementation
  • Postoperative discomfort can be minimized by administering analgesics ~30 minutes prior to exercises
  • When showering is appropriate, warm water has a soothing effect and decreases joint stiffness
nursing implementation3
Nursing Implementation
  • Psychologic care
    • All aspects of care must include sensitivity to woman’s effort to cope
    • Nurse can help by:
      • Assisting her to develop a positive but realistic attitude
      • Helping her identify sources of support and strength
follow up care
Follow up Care
  • Must be follow-up for rest of life at regular intervals
  • Professional examinations every 6 months for 2 years, then annually
  • Practice monthly breast self examinations (BSE) on both breasts or remaining breast
review2
Review
  • A patient had a radical mastectomy with lymph node dissection. Post op nursing care focused on restoring arm functioning would include
    • Use of heating pads or blankets to increase circulation
    • Daily application of ice packs to minimize the risk of lymphedema
    • Compression bandaging with sleeves or stocking for acute swelling
    • Frequent and sustained exercises with the arm in a dependent position
breast reconstruction
Breast Reconstruction

Chest prior to Implants

Breast implants placed in pocket under pertoralis muscle and musculocutaneous skin flap applied

breast reconstruction1
Breast Reconstruction
  • Musculocutaneous flap most often taken from abdomen or back is used in reconstruction
breast reconstruction2
Breast Reconstruction
  • As part of the final stage of reconstruction, the nipple and areola are reconstructed
tissue expander
Tissue Expander

The tissue expander starts out with

minimal inflation.

Gradually filled with water weekly to

stretch the skin and muscle

Tissue expander in place

after mastectomy

breast reconstruction complications
Breast Reconstruction Complications
  • Capsular formation
    • Part of bodies natural defense mechanism to form a fibrous capsule around the implant
  • Infection
  • Hematoma
  • Skin ulceration
  • Hypertropic scar formation
review3
Review
  • To prevent capsular formation following breast reconstruction with implants, the nurse teaches the patient to
    • Gently massage the area around the implant
    • Bind the breasts tightly with elastic bandage
    • Exercise the arm on the affected side to promote drainage
    • Avoid strenuous exercise until implant healing has occurred.