Breast Disorders: Nursing Management for HNII

Shelby Garner PhD, RN, CNE

Objectives

Discuss the human needs framework, and the interrelationships that exist among the human needs (within the contexts of family, ethics and teaching needs). Relate the pathogenesis, clinical manifestations, diagnosis, and treatment for the identified conditions to nursing care. Plan care to facilitate fulfillment of human needs (alterations in reproduction function, alterations in oxygenation, circulation, regulation, sensation, perception and renal elimination) based on goal oriented outcome criteria. Utilize evidence based practice as a basis for nursing interventions.

Nursing Assessment of the Breast

Chapter 51 Review steps to teaching self breast exam in Fig 52-1 in Lewis

Assessment of Breast Disorders

Yearly mammogram starting at age 40 and continuing for as long as a woman is in good health. Clinical breast exam (CBE) preferably at least every 3 years for women between ages of 20 & 30 and every year for women beginning at the age of 40 Women should report any breast changes to their HCP. Breast self exam (BSE) is an option for women starting at age 20

Benign Breast Disorders

Breast

Infections Fibrocystic Changes Fibroadenoma Gynecomastia

Mastalgia
Assessment

Pain, burning, aching, soreness Is it cyclic or noncyclic?

Nursing

Interventions Teach: Caffeine and dietary fat, Vitamins E, A, B, Primrose oil, support bra, cold compresses, analgesics, antiinflammatories, oral contraceptives

Breast Infection - Mastitis

Assess for clinical manifestations

Warm to touch, indurated, painful, often unilateral, cracked nipple

Nursing Interventions

Fibrocystic Changes

Assessment

Cyst formation in the upper and outer quadrant Watery-milky, yellow or green nipple discharge
Treat pain as described for mastalgia Teach importance of follow-up care Pre and Post op teaching and prep if aspiration or surgical excision is indicated

Nursing Interventions

Fibroadenoma
Assessment:

Typically 2-3 cm, painless, round, well delineated, fold, firm or rubbery, and mobile without retraction or nipple discharge

Nursing

Intervention:

Teach importance of regular monitoring Pre and Post op care if surgical excision or cryoablation is needed

Gynecomastia in Men
Assessment:

Inspect for transient noninflammatory enlargement of one or both breasts

Nursing

Intervention:

Reassurance that it is typically temporary Psychological implications Pre and Post op care if cosmetic surgery is elected

Breast Cancer & Culturally Competent Care

Did you know?

White women have a higher incidence of breast cancer than nonwhites African American women have lower survival rates from breast cancer than white women, even when diagnosed at an early state Hispanic and Asian/Pacific Islander women have lower mortality rates than whites and African Americans. Hispanic women have the lowest screening rates Hispanic and African American women are more likely to be diagnosed at a later stage than white women

Breast Cancer and Culturally competent care

do you believe these disparities exist?

What

nursing actions might decrease these disparities?

Breast Cancer Nursing Assessment

Subjective data
Past

health history

Atypical changes in benign breast disease Previous breast cancer Early menarche Nulliparity or 1st pregnancy after age 30 Hx endometrial, ovarian, or colon cancer Hx hyperestrogenism and testicular atrophy in men

Breast Cancer Nursing Assessment

Data

Medications:
Use of hormones, especially HRT after menopause and use of oral contraceptives History of infertility treatments

Surgery or other treatments:

to therapeutic radiation such as for Hodgkins lymphoma or thyroid radiation

Breast Cancer Nursing Assessment

Data

Family history, alcohol use, changes felt on BSE, sedentary lifestyle Possible indicators of metastasis including reports of unexplained weight loss, changes in cognition, bone pain, headache Psychological stress, anxiety

Breast Cancer Nursing Assessment

Objective data

Axillary and supraclavicular lymphadenopathy Hard, irregular discrete nodular, non-painful, immobile lump Nipple fixation or retraction, erosion, edema, peud orange, erythema, induration, infiltration or dimpling Possible indicators of metastasis: nodule at mastectomy site, hepatomegally, jaundice,ascites

Breast Cancer
Initial

Nursing Diagnosis

Decisional conflict related to knowledge about treatment options and their effects Fear and or anxiety related to diagnosis of breast cancer Disturbed body image related to anticipated physical and emotional effects of treatment modalities

Breast Cancer
Initial

Planning

The patient diagnosed with breast cancer will:

participate in the decision-making process related to treatment options Comply with the therapeutic plan Manage the side effects of adjuvant therapy Be supported to access and benefit from the support provided by significant others and health care providers

19

Breast Cancer - Nursing Implementation

Psychologic Care Assist in developing positive but realistic attitude Help identify sources of support Encourage verbalization of anger and fears Promote open communication of thoughts and feelings between patient and family Provide accurate and complete answers to treatment and disease related questions Offer information on community resources and support groups
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Evidence-Based Nursing

In a study by Stephens et al. (2008) major concerns of women newly diagnosed with breast cancer (after mastectomy) included:

Fear of recurrence (PRIMARY CONCERN) Anxiety regarding postoperative treatments Anxiety regarding the future Impact of diagnosis and performance Impact of cancer on finances and loved ones Depression

Breast Cancer Nursing Implementation

21

for Mastectomy/ Lumpectomy or Mammoplasty

Preoperative teaching
Turn,

cough, deep breathing Post-operative exercises Pain management

Semi-Fowlers with arm on affected side elevated on a pillow Flexing & extending fingers &/or arm Teach measures to prevent lymphedema Care of drains if present
No

procedures on affected side!!!

Breast Cancer Nursing Implementation

Teach measures to prevent lymphedema:

Frequent & sustained elevation of arm Perform exercised daily No venipunctures or blood pressures to affected arm Avoid tight clothing or jewelry on affected arm Carry purse, luggage with other arm Use electric razor when shaving underarm Careful manicures, avoid cutting cuticles Avoid burns or sunburns to affected arm/hand May use elastic sleeve, or sequential compression device

23

25

Breast Cancer: Nursing Implementation

Monitor for Radiation Side Effects Skin changes similar to sunburn Teach:
Use

mild, unscented soap or nondrying antipruitic soap if dryness & itchiness persist Pat the area dry, avoid rubbing Avoid applying deodorant to affected area Avoid tight tops or underwire bra Avoid extremes in temperature Protect area from ultraviolet light for at least 1 year post therapy Report worsening pain/discomfort to HCP

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Nursing Care
Ambulatory

& Home Care

Self-care techniques BSE & annual mammography Referral to mental health provider/support group Symptoms to report to HCP Prosthesis fitting Loose-fitting clothing for drains

Application to the LHSON Human Needs Framework

Body/ Physiological

activity and rest nutrition elimination fluid and electrolytes oxygenation and circulation regulation, sensation and perception safety and comfort cellular adaptation reproduction

Application to the LHSON Human Needs Framework

Psychological

understanding, order and predictability adequacy, competency, and security self-esteem, worth and identity (sexuality) Personal Growth and Fulfillment

Mind/

Sociological

Love, belonging, and approval

Application to the LHSON Human Needs Framework

Spiritual

values meaning hope

Class Activity
Access

Lewis Nursing Care Plan 52-1 (Dont forget to review this care plan for the test!) groups of 2 or 3, write a multiple choice test question using information from the care plan:

In

Class Activity
These

stems might help you get started:

The nurse cares for a patient ___(hours or days) after a mastectomy of the ___ (right or left) breast. Which nursing intervention is appropriate (or most important)? A patient reports_______ after a mastectomy. Which action should the nurse take?

REFERENCES

Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher,

Evidence-Based Research Article

Stephens, P. A., Osowski, M., Fidale, M. S. & Spagnoli,

C. (2008). Identifying the educational needs and concerns of newly diagnosed patients with breast cancer after surgery. Clinical Journal of Oncology Nursing, 12, 253258. doi:10.1188/08.CJON.253-258