med surg #2 breast.docx

**Ch. 52 - Patients with Breast Disorders** - Health Assessment (pg 4551) - General Assessment Onset of disorder - Social History Length of time - Medications Masses? Pain? - Social Habits Swelling, redness and/or skin changes - Recent testing Nipple Discharge...

**Ch. 52 - Patients with Breast Disorders** - Health Assessment (pg 4551) - General Assessment Onset of disorder - Social History Length of time - Medications Masses? Pain? - Social Habits Swelling, redness and/or skin changes - Recent testing Nipple Discharge - Guidelines - **KNOW the best time for self breast exam for women of childbearing age is 5-7 days after menses** - **Report to HCP is there are abnormalities** - Clinical breast exam every three years while in their 20s-30s and monthly for post-menopausal women - Beginning at 40, breast exam every year + mammogram - Inspection and Palpation - Inspection -- 1st - Skin inspected for color, venous pattern, thickening, or edema - Erythema indicates benign local inflammation \[acute mastitis\] or superficial invasion by malignancy - Prominence of veins can indicate increased blood supply secondary to tumor \[angiogenesis\] - Edema & pitting of skin is from blockage of venous drainage - Ulcerations, rashes, or spontaneous nipple discharge requires work up for malignancy - Paget's dz: erythema of nipple & areola; also common in men - **Peau d\'orange: classic sign of advanced inflammatory breast disorder** - Sitting, disrobed to waist; Arms raised overhead to assess for dimpling or retraction & inverted nipple - Hands on hip and push in helps evaluate clavicular and axillary region - Palpation -- 2nd - **KNOW Tail of spence: part of breast that goes up into the axilla; needs to be checked during exams bc it's a common spot for tumor** - Entire surface area of each breast is palpated from outer edge to nipple - Sitting up and lying down; Arm behind head of breast being examined - Sitting up: abducts arm with one hand palpates with other - Chart 52-2, 52-3 p. 4560 - Gynecomastia: firm enlargement of glandular tissues in males (most often caused by spironolactone) - **Mammography** - Gold standard to detect non-palpable lesions with diagnosis of palpable masses; Can detect \< 1 cm - **KNOW Special guideline: begin screening for mammography when they are 10 years younger than the age at which their relative was diagnosed** - Women a should begin getting **mammograms at age 45** - Takes 15-30 min, two views of each breast - Young women and those taking exogenous hormones can be difficult to diagnose due to tissue density - Mammographic density is a strong risk factor for breast cancer as imaging is harder to interpret - **Radiation exposure**, Small amount of pain - Other Diagnostics - **KNOW Ultrasonography: Used in conjunction with mammography to distinguish b/t fluid-filled cysts from other lesions** - **Fluid-filled cysts appear dark on radioimaging** - Cons: Can't rule out malignancy & exam technique and interpretation criteria aren't standardized - Galactography/Contrast Mammography - Used to diagnosis issues when nipple discharge is present or a solitary dilated duct noted on mammogram - Radiopaque material injected into a cannula in a ductal opening on the areola - Mammogram - MRI - **IV contrast dye**, Specific positioning - Most useful with multifocal or multicentric - Response to chemo, chest wall involvement - **Fine Needle Aspiration** (52-1) - **Purpose is to do a histopathologic analysis** - Percutaneous biopsy; Small gauge, inserted into the mass - Suction applied, Cyst filled/tissue - Core Needle Aspiration - Large gauge needle; Tissue core is removed via spring loaded device; More definitive - **KNOW Breast Biopsy (ask if what we need to know about this? OR do we need to know the sentinel biopsy)** - Excisional + Incisional - [Teaching]: discontinue anticoagulant agents, keep the pt NPO, steri-strips will remain on for 7-10 days or until they fall off, avoid high-impact activities for 1 week, tylenol should be sufficient for the pain, follow-up is necessary - Nursing Mgmt \[not in our notes\] - Assess needs, Encourage discussion, Explain, Provide written material, Discuss medication, Pre and Post op information **Benign Condition of the Breast** - **Breast pain/"mastalgia":** can be cyclical or non cyclical; usually seen in pre-menstruation period - Usually related to hormonal fluctuations during menses or to trauma - **Cysts**: fluid filled sacs that develop as breast ducts dilate, tender; common in 30-55 yr olds - **Fibroadenomas**: firm, round, movable, benign tumors, nontender - Fibrocystic disease; precursor to cancer; difficult to diagnose & peaks @ 30 yr - Benign Proliferative breast disorder: atypical hyperplasia and lobular carcinoma, in situ - **Non-malignant BUT this dx increases a woman's risk of breast cancer** **Breast Malignancy** - **Ductal Carcinoma in situ \[DCIS\]**: proliferation of malignant cells inside the milk ducts w/o invasion into the surrounding tissue - Usually seen on mammogram as calcification - Medical Management - Treat with total or simple mastectomy IF caught early - **Breast conservation: tx of breast cancer w/out loss of breast and case-by-case basis** - Invasive (NOT ON EXAM): Infiltrating ductal Carcinoma, Infiltrating Lobular Carcinoma, Medullary Carcinoma, Mucinous Carcinoma, Tubular Ductal Carcinoma, Inflammatory Carcinoma, Paget's Disease - **Risk Factors for Breast Cancer** - **KNOW** **Table 52-3 pg 4572** - **Early menarche, family hx, exposure to ionizing radiation, hx of benign proliferative breast disease, obesity, late menopause**, **increased age,** Female, hormonal factors, high fat diet, childbirth after the age of 35 years old, excessive alcohol intake - Genetic mutations: BRCA1 and BRCA2 - Multiple 1st degree relatives, breast and ovarian cancer in the same family - **Protective Factors** - **KNOW Chemoprevention -- tamoxifen/Nolvadex (pre-menopause) and raloxifene/Evista (post-menopause)** - **Raloxiefene reduces cancer invasion** - Postmenopausally, anastrozole and exemestane are also now used for chemoprevention - Physical activity esp. Postmenopause - Breastfeeding, Full term pregnancy before the age of 30 - Long term surveillance: mammogram/ MRI; Prophylactic mastectomy - Clinical Manifestations - **Nontender, fixed, hard with irregular borders** - **Advanced signs will be skin dimpling (peau de orange), nipple retraction and skin ulceration** - **Diffuse breast pain and tenderness → evaluate menstrual cycle** - **Common site for metastasis are the bones and axillary lymph nodes** - Normally found in upper outer quadrant - Staging \[TNM\] - Tumor size: T0-T4; Nodes (has it spread to lymph nodes): N0-N3; Metastasis: M0-M1 - Prognosis - Tumor size and whether it has spread to the lymph nodes - The smaller, the better - 5yr survival : 98% stage 1 to 27.1% stage 49 - (Fig 52-5) Most common site of metastasis is **axillary lymph nodes** - Surgical Management - Modified Radical Mastectomy: axillary lymph node dissection (ALND) and breast - Avoid BP, injections in affected arm, and avoid lifting heavy objects - Total Mastectomy: removes entire breast, axillary lymph nodes, surrounding tissue, chest wall tissue - **Post-mastectomy, pt are prone to lymphedema in affected extremity, decrease ROM on operative side, seroma formation at excision, and hematoma, infection** - Breast Conservation Treatment, Sentinel Lymph Node Biopsy (SLNB) - Nursing Management: - Depending on procedure could be outpatient or overnight stay - Dye could discolor urine and stool - Possible complications: bleeding, discharge - Listen, education and support - **Post-op education Drains & drain care \[chart 52-7\]:** - Care for the drain site and incision as per surgeon's recommendation. - Demonstrate how to empty and measure fluid from the drainage device. - Demonstrate how to milk clots through the tubing of the drainage device. - Identify when the drain is ready for removal (usually when draining \ - Complications - **Lymphedema (chart 52-5, pg 4586): can be chronic if it develops** - **Active and passive exercises assist in moving lymphatic fluid into the bloodstream.** - **External compression devices to milk the fluid** - **Custom-fitted graduated compression stockings or sleeves are worn** - **Hematoma/Seroma Formation \[usually w/ in 12 hour post-op\]** - Hematoma: blood leaking into surrounding tissues - Assess for swelling, tight, pain and bruising - **Use hot compress or warm showers (if permitted by the surgeon) to help increase the absorption** - Seroma: collection of serous fluid - Assess for fullness, heavy, discomfort, "sloshing" of fluid - Need to drain bc it can lead to infection - Infection: IV abx - Nursing Education - Assess ability to perform self-care - Teach s/sx of possible problems - Drain care: may have to milk clots through the tubbing - Shower 2nd post op day - No lotion or cream till healed - Arm exercises Chart 52-8 p. 4590 - Wall hand climb, rope turning (rotating arm back and forth) - Lifting restrictions: 5 to 10 lbs until cleared by surgeon - **Client teaching after mastectomy with axillary lymph node dissection should include?** - Avoid BP, injections in affected arm and avoid lifting heavy objects - Driving abilities: drains must be removed and can't be on pain meds - Radiation - External beam radiation most common; usually done for 6 weeks and before or after chemo - Begins after chemotherapy - 1st meeting to map out/mark areas - A/E: erythema, breast edema, fatigue, possible skin breakdown - Nursing Management: education patient on self care - Mild soap with minimal rubbing - No perfumed soap or deodorant - Lubriderm, Eucerin, Aveeno for dryness - No tight clothes, underwire and ultraviolet light - Chemotherapy - Adjuvant: anticancer agents in addition to other treatments - Table 52-6, need for adjuvant chemo - Treatment based on factors regarding cancer - Most common in CMF: cyclophosphamide (Cytoxan), methotrexate (Trexall) and fluorouracil (Fluoroplex) - For lowest risk of recurrence, highest risk of CV disease - Taxanes: larger node negative cancers in the axillary lymph nodes - **KNOW A/E for chemotherapy: N/V, bone marrow suppression, hair loss/alopecia, fatigue, weight gain, xerostomia/mouth ulcers**, mucositis, neuropathies, taste changes (pg 4597) - **Xerostomia nursing interventions: zero-sugar hard candy & water sips** - **Nursing Management** - Medications: - Treat nausea/vomiting: ondansetron, metoclopramide, lorazepam, dexamethasone - **KNOW Boost WBC: filgrastim (neupogen) pegfilgrastim (Neulasta)** - **KNOW Boost RBC: epoetin alfa (Epogen)** - **Rinse mouth with normal saline b/c of ulcers; Avoid hot/spicy food** - **Soft toothbrush for mucositis, inflammation of the gums** - Wig or cap; Emotional support - Recurrent Cancer - Determine overall prognosis and optimal treatment - Control the spread- hormonal therapy, chemo, targeted therapy, Palliative treatment - Nursing Mgmt: Educate, Listen, Refer - Reconstruction - Help with body image and emotional distress, Consult plastic surgeon, Discuss pros and cons - Can be done immediately following mastectomy, Tissue expander followed by permanent implant (Fig 52-6) - Tissue transfer procedure (Figure 52-7), Nipple-Areola Reconstruction, Prosthetics