Nursing management of client with breast disorders

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Nursing management of client with breast disorders

• School of Nursing, CGU
• Li-Chueh Weng

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Benign breast disorders

• Mastalgia (breast pain)
• Breast infections
• Mastitis, breast abscess
• Fibrocystic changes
• Fibroadenoma
• Nipple discharge (galactorrhea, intraductal
  papilloma, ductal ectasia), may be benign or
  malignant.
  
• Gynecomastia in man

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Fibrocystic changes

• ?????????, ??????????,?????, ???? (cyst)
• Hormonal influence.
• Aspiration or surgical biopsy may be indicated.
• Follow up examinations, BSE
• ???????????,??????.??????????????????
• Cysts do not turn into cancer.
• ?????????????????,??1-2?, ???????

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Fibroadenoma????

• Benign breast lumps in young women
• Painless, single, unilateral mass
• Treatment surgical excision, which is not urgent
  in women under 25 years of age(25??????????).
  cryoablation
  
• are not reduced by radiation and are not
  affected by hormone therapy.
  
• Follow up examination and BSE.

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Gynecomastia in man

• The most common cause of gynecomastia is a
  disturbance of the normal ratio of active
  androgen to estrogen in plasma or within the
  breast itself(???????).
• It may also accompany organic disease(???,????,
  ???), a side effect of drug therapy (digitalis,
  INH, Aldactone).
  
• Pubertal gynecomastia senescent gynecomastia

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Breast cancer in Taiwan

• 4th cancer death in female (2006).
• Mortality 3. 8 (cancer death 2006)
• Mortality rate 4.35-12.8 (?????,1983-2006)
• Survival rate 5 years 95-15 by stage
• Age 25-44 years, younger than US women

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Breast cancer

• Related factor heredity or genetically, hormonal
  regulation(sex hormones may act as tumor
  promoters). Physical inactivity, dietary fat
  intake, obesity and alcohol intake. Chemical,
  pesticide and radiation.
• GAIL model (relative risk)
• Genetic basis mutation in genes BRCA-1 and BRCA-2

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?????

• Ductal carcinoma epithelial lining of the ducts
• Lobular carcinoma epithelial lining of the
  lobular
  
• Invasive or in situ (??????).
• Most cancers arise from the ducts and are
  invasive.
  
• ????Prognosis factors size, axillary node
  involvement, tumor differentiation(?????), DNA
  content, and estrogen and progesterone receptor
  status.

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Non invasive breast cancer

• ???(cancer in situ)
• Ductal carcinoma in situ (DCIS)
• unilateral, ?????????????
• Lobular carcinoma in situ (LCIS)

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Paget disease

• Lesion of the nipple(??) and areola (??)with or
  without a palpable mass.
  
• Itching, burning, bloody nipple discharge with
  superficial erosion, and ulceration(???????)
  
• Are often diagnosed as an infection or
  dermatitis, which can lead to treatment delay.

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Inflammatory breast cancer

• The most malignant form, aggressive and
  fast-growing cancer.
  
• Skin red, feels warm, thickened appearance,
  hives
  
• Metastases occur early and widely.

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Clinical manifestations-??

• Pain (5)
• Single lump or mammographic abnormality
• Upper, outer quadrant of the breast because it is
  the location of most of the glandular tissue.
  
• Hard, irregularly shaped, poorly delineated,
  non-mobile, and non-tender, nipple discharge
  (clear or bloody), nipple retraction, Peau
  dorange(????)
• In large cancers, infiltration, induration, and
  dimpling of the overlying skin may also be noted.

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Complications-??

• Recurrence??, metastases??
• ??Local or regional meta(skin of soft tissue near
  the mastectomy site, axillary LN or
  supraclavicular LN)
  
• ??Distant meta(skeletal, spinal cord, brain,
  pulmonary, liver, bone marrow)
  
• Lymphatic drain????
• Even in node-negative breast cancer, there is a
  possibility of distant metastases.????????????,
  ??????????

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Diagnosis studies

• Mammography(?????)
• can detect masses of 0.5 cm.
  Calcifications(???) are the most easily
  recognized mammogram abnormality.
  ?(calcium)?????? inflammation, trauma, and
  aging
• In younger women mammography is less sensitive
  because the greater density of breast, resulting
  false-negative results.(???????????)

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• Ultrasound?????
• particular use in women with fibrocystic
  change whose breast are very dense,??????,
  ????????. It can not detect microcalcification.
  
• Biopsy ??(fine needle aspiration, sterotactic
  core biopsy, and open surgical biopsy)
  
• breast ductal lavage

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Diagnostic studies for predicting recurrence

• Axillary LN status, tumor size, estrogen and
  progesterone receptor status, DNA content
  analysis, cell proliferative indices(??????).
  
• Lymphatic mapping and sentinel lymph node
  dissection (??(??)?????SLND).
  

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• Receptor-positive tumor well differentiated????,
  normal DNA, low proliferative indeices, response
  to hormonal therapy.
  
• Genetic marker HER2/neu. Amplification and
  over-expression of this gene have been associated
  with a greater recurrence and poorer prognosis in
  breast cancer.(?????, ?????, ???)

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????

• Radical (Total) mastectomy (TM) ?????(removal of
  breast, pectoral muscles, axillary LN, fat and
  adjacent tissue)
  
• Breast conserving surgery (BCT) /(lumpectomy)
• with or without CT or RT??????
• Modified radical mastectomy (MRM, ?????????,
  ?????)
  
• Consider the prognostic factors and TNM stage
  for treatment decision
  
• Staging TNM (see table 50-7, p.1370), stages
  range from 1 to 4 (zero).

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Surgical therapy

• Axillary lymph node dissection (10-15
  nodes)????????
  
• Tissue expansion and breast implants(fig
  50-8)??????????
  
• Musculocutaneous flap procedures (TRAM flap, fig
  50-9) ??????(????)

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Surgical therapy comparison
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• Breast conservation surgery RT or CT
• Contraindications(???) breast size too small
  to yield an acceptable cosmetic result, masses
  and calcifications are mutifocal, and muticentric
  or diffuse calcification
• MRMreconstruction
• it preserves the pectoralis major muscle.
  Indication(???) the tumor is too large to excise
  with good margins and attain a reasonable
  cosmetic result

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??????

• Lymphedema ????(accumulation of lymph in soft
  tissue) heaviness, pain, impair motor function
  in arm, and numbness(??), and paresthesia(????)
  of the finger. Cellulitis and progressive
  fibrosis.
• ???????????

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• Post-mastectomy pain syndrome chest and arm
  pain, tingling(??) down the arm, numbness,
  shooting or pricking pain, and unbearable
  itching. (neuropathic pain)
• Injury to nerves and tissue, intercosto-brachial
  nerves(?????)
  
• NSAID, antidepressants, topical lidocaine
  patches, psychological counseling,????
  ??????????(frozen shoulder)

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Adjuvant therapy-Radiation therapy

• As the primary treatment to destroy the tumor. It
  is usually performed after local excision of the
  breast mass.
  
• As adjunct to surgery To shrink(??) a large
  tumor to operable size.
  
• High-dose brachytherapy (fig.50-5)
• As the palliative treatment, to stabilize
  symptomatic metastatic lesion

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High-dose brachytherapy
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Adjuvant therapy-Systemic therapy

• Chemotherapy(????????????)
• breast cancer is one of the solid tumors that
  is the most responsive to chemotherapy.
  
• CMF (cytoxan, methotrexate, 5-FU)
• CEF or CAF (cytoxan, epirubicin or
  doxorubicin, 5-FU)
  
• AC (cyclophosphamide, adriamycin)
• Taxol ?????

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Hormonal therapy

• Estrogen can promote the growth of breast cancer
  cells if the cells are estrogen-receptor (ER) or
  progesterone-receptor (PR) positive.
  
• Hormonal therapy removes or blocks the source of
  estrogen, thus promoting tumor regression(??).
  Chances of tumor regression are significantly
  greater in women whose tumors contain estrogen
  and progesterone receptor.
• Pre-menopausal and peri-menopausal women are more
  likely to have tumors that are not hormonal
  dependent.??????????????????????
  

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• ????????
• 1.block or destroy the estrogen receptor
• 2.suppress estrogen synthesis through
  inhibiting aromatase (AI, ???????).
  
• Tamoxifen block estrogen receptor,
  ???postmenopausal, estrogen receptor-positive.
  
• side effects hot flashes, nausea, vaginal
  discharge and dryness, risk for endometrial
  cancer
  
• Letrozole (AI) ??aromatase, ?estrogen?????. side
  effects??Tamoxifen, ?????????????,??????????????
  

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Other therapy

• Bilateral oophrectomy, adrenalectomy and
  hypohysectomy
  
• Biology therapy to stimulate the bodys natural
  defense to recognize and attack cancer cells.
  Herceptin is an antibody to HER-2/neu.
  
• Bone marrow and stem cell transplantation
  remains under investigation.

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Health problems?????????????????????

• Decisional conflict
• Fear
• Disturbed body image

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Goal and planning

• Actively participate in the decision- making
  process related to treatment options.
  
• Fully comply with the therapeutic plan.
• Manage the side effects of adjuvant therapy.
• Be satisfied with the support provided by
  significant others and health care provides.

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Nursing implementation

• Acute intervention(the time between diagnosis to
  selection of treatment)
  
• Exploring the womens usual decision making
  patterns, helping the women accurately evaluate
  the advantage and disadvantage of the options,
  providing information relevant to the decision,
  and supporting the patient once the decision is
  made.
• Sufficient information to ensure informed
  consent.
  
• sensitive to an individuals need for
  information is essential.
  

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Treatment phase (surgery)

• Restoring arm function???? on the affected side
  is one of most important goal.
  
• semi-fowler position with the arm on the affected
  side elevated on a pillow. Flexing and extending
  the fingers should begin in the recovery room.
  Postoperative arm and shoulder exercise are
  instituted gradually at the surgeons direction
  (Fig 50-6)
• Purpose ???????????, ??????, ?????????

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(No Transcript)
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• The goal of all exercise is a gradual return to
  full range of motion within 4 to 6 weeks.
  
• Administering analgesics about 30 minutes before
  initiating exercise.
  
• Warm water showering

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Measure to prevent lymphedema

• ??????????????????????
• ???????????????????
• ?????????????????????????????????????????
• The patient must know and understand that she is
  at risk of developing lymphedema for the rest of
  her life.
  

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????????????

• The affected arm should never be dependent.
• ????????????????,?????????
• ??????????
• ???????????,?????
• ??????????????
• ??????????????
• ?????????,elastic bandage should not be used in
  early postoperative period.????????????(??)
  
• ???????5-10?(2.5-4.5kg)

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??????????????

• Apply insect repellent to avoid bug bites.
• Wear gloves for gardening.
• Avoiding cutting cuticles. Venipunctures and
  injections should not be done on the affected
  arm.
  
• Using electric razor.
• Protect the arm from even small trauma. If trauma
  to the arm occur, washed thoroughly, topical
  antibiotic ointment and sterile dressing,
  observed closely, surgeon must be advised.

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• ?????????
• ?????????
• ?????(????)
• ????????????????
• ???????(thimble )
• ???????
• ?????????????????
• ??????????

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??????(???)???

• ??????????????,?????????????????
• Use sunscreen for extended exposure to sun (SPF
  15 ).
  
• ??????????
• ????????,??????????,????????(?????)

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• when lymphedema is acute
• Intermittent pneumatic compression sleeve
  (mechanical massage)
  
• Manual massage
• Elevation of the arm, diuretics, and isometric
  exercise may be recommended
  
• Wear a elastic pressure-gradient sleeve during
  waking time

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Psychological care

• Nurse must keep in mind the extensive
  psychological impact of the breast cancer.
  
• Assisting her to develop a positive but realistic
  attitude. Positive goal oriented realistic
  risk
  
• Helping her identify sources of support and
  strength.
  
• Encouraging her to verbalized her anger and fears
  about her diagnosis.
  
• Promoting open communication of thoughts and
  feelings between patient and her family.
  

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• Providing accurate and complete answers.
• Offering information about community resources.
• Arranging a visit from a woman who had similar
  treatment.
  
• The nurses accepting, concern attitude can do a
  great deal
  
• Encourage to ask question about any concerns.

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Home care

• Follow up routine
• Continue BSE and annual mammography
• Referral to a mental health provider
• Report symptoms infection, swelling, back pain,
  weakness, SOB, confusion etc.
  
• Wearing a well-fitting prosthesis.
• Sexual identity and relationships
• Psychological support group

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• ???????????,??????,?????????
• ???????????,????(?????,??????,??????? ,light soft
  cotton breast form ,??????????cotton
  padding????)
  
• ????????????????????????,???????
• ?????????????????????
• ???????,???????
• ?????????

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Culturally competent care

• Ethnicity and culture.
• Fatalism, evitable fate or Gods will.
• Shy, bashful.
• Delay treatment seeking