Chapter 58

Assessment and Management of

Patients With Breast Disorders
Breast Assessment

 Anatomic and physiologic overview

 Health history
 Physical assessment: female breast and male
o Inspection, palpation, lymph nodes
 Adolescent, obese
 Gynecomastia

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Anatomy of the Breast

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Lymph Nodes

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Diagnostic Assessment #1

 Breast self-examination (BSE; “breast self-awareness”)

o 5 to 7 days after menses
 Mammography
o Annually after the age of 40 years
o Digital and 3D
o Contrast
 Ultrasonography
 MRI

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Diagnostic Assessment #2

 Tissue analysis
o Percutaneous biopsy
o Fine-needle aspiration
o Core needle biopsy
o Stereotactic core biopsy
o Ultrasound-guided core biopsy
o MRI core biopsy

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Mammography

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Surgical Biopsy

 Excisional biopsy
 Incisional biopsy
 Wire needle localization

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Question #1

The nurse is assessing the breast of a female patient.

Upon assessment, the nurse notices that the patient’s
skin of the breast thick and hard and that the skin pores
are enlarged. The patient states that she thinks it looks
like an “orange peel.” How would the nurse document
this assessment finding in her notes?
A. Cellulitis
B. Nipple inversion
C. Peau d’orange
D. Retraction of the skin

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Answer to Question #1

C. Peau d’orange
Rationale: Peau d’orange is associated with
inflammatory breast cancer and is caused by
interference with lymphatic drainage. The breast skin
has an orange peel appearance in that the skin pores
are enlarged and the skin is thick, hard, and immobile.
These assessment findings are not indicative of
cellulitis, nipple inversion, or skin retraction

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Benign Conditions of the Breast

 Breast pain (mastalgia)

 Cysts, fibrocystic breast changes
 Fibroadenomas
 Benign proliferative breast disease
o Atypical hyperplasia
o Lobular carcinoma in situ (LCIS)
 Other: Cystosarcoma phillodes, fat necrosis, intraductal
papilloma, superficial thrombophlebitis

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Malignant Conditions of the Breast

 Ductal carcinoma in situ (DCIS)

o Proliferation of malignant cells inside the milk ducts
without invasion into surrounding tissue
 Invasive cancer
o Infiltrating ductal carcinoma: most common
o Infiltrating lobular carcinoma
o Medullary carcinoma: women <50 yrs old
o Mucinous carcinoma: postmenopausal
o Tubular ductal carcinoma
o Inflammatory carcinoma

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Breast Cancer

 Breast cancer is a major health problem in the United

States. At present, there is no cure
 Over an entire lifetime, a woman’s risk of developing
breast cancer is about 12% or one in eight
 Approximately 231,840 new cases of invasive breast
cancer are diagnosed in women each year
 Risk of developing breast cancer increases with age
 Research suggests that racial disparities in cancer
mortality are driven in large part by differences in social
economic status

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Risk Factors for Breast Cancer
 No single, specific cause
 Combination of genetic, hormonal, and evnvironment
 80% occur sporadic, no family history
 Some evidence with long-term smoking, night shift work
 NO evidence supports the following as risk factors
o Smoking
o Silicon breast implants
o Antiperspirants
o Underwire bra
o Abortion

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Guidelines for Early Detection of Breast
Cancer

 Long term surveillance focuses on early detection

 Women at high risk benefit from MRI and yearly
mammogram
 Clinical breast exams twice a year starting at age 25
 Chemoprevention:
o Women at high risk
o Tamoxifen and raloxifene
 Prophylactic mastectomy

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Clinical Manifestations of Breast Cancer

 Can be found anywhere, usually in upper outer quadrant

 Lesions are non-tender, fixed, and hard with irregular

borders

 Advanced signs—skin dimpling, nipple retraction, skin

ulceration

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Breast Cancer—Diagnosing

 Staging: TMN (tumor, nodes, metastasis)

 Chest x-ray, CT, MRI, PET, bone scan and blood work
 Prognosis
o Tumor size
o Spread to the lymph nodes?
o Certain genes (ERBB2)

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Surgical Management: Breast Cancer

 Modified radical mastectomy

 Total mastectomy
 Breast conservation treatment
 Sentinel node biopsy and axillary lymph node dissection

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Nursing Process: The Care of the Patient
Undergoing Breast Cancer Surgery—
Assessment

 How is the patient responding to her diagnosis?

 What coping mechanisms does she find helpful?
 What psychological or emotional supports doe 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?

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Nursing Process: The Care of the Patient
Undergoing Breast Cancer Surgery—
Preoperative Diagnoses

 Deficient knowledge about the planned surgical

treatments
 Anxiety related to the diagnosis of cancer
 Fear related to specific treatments and body image
changes
 Risk for defensive or ineffective coping related to the
diagnosis of breast cancer and related treatment options
 Decisional conflict related to treatment options

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Nursing Process: The Care of the Patient
Undergoing Breast Cancer Surgery—
Postoperative Diagnoses

 Acute pain and discomfort

 Peripheral neurovascular dysfunction
 Disturbed body image
 Risk for impaired coping
 Self-care deficit
 Risk for sexual dysfunction
 Deficient knowledge: drain management after breast
surgery, arm exercises to regain mobility of affected
extremity, hand and arm care after ALND

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Collaborative Problems and Potential
Complications

 Lymphedema
 Hematoma or seroma formation
 Infection

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Nursing Process: The Care of the Patient
Undergoing Breast Cancer Surgery— Planning

 Major goals may include

o Increased knowledge about disease and treatment
o Reduction of pre- and postoperative fear, anxiety,
and emotional stress
o Improvement of decision-making ability
o Pain management
o Improvement in coping abilities
o Increased self-care abilities
o Absence of complications

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Preoperative Nursing 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

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Postoperative Nursing Interventions

 Relieve pain and discomfort

 Inform patient regarding common postoperative
sensations
 Maintain privacy
 Bra with breast form
 Provide information about home plan of care
 Support coping and adjustment; counseling and referral
 Monitor for potential complications
o Lymphedema, hematoma or seroma, infection

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Educating Patients—Self-Care

 Surgical site management and care of drain (drains are

usually removed when the output is less than 30 mL in a
24-hour period, approximately 7 to 10 days)
 Shower on second postoperative day and wash the
incision or drain site with soap and water. If immediate
reconstruction has been performed, showering may be
contraindicated until the drain is removed
 Patients are taught arm exercises on the affected side to
perform three times a day for 20 minutes at a time until
full range of motion is restored (generally 4 to 6 weeks)
 Heavy lifting (more than 5 to 10 pounds) is avoided for
about 4 to 6 weeks

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Question #2

What should be included in the education plan for a

patient after axillary lymph node dissection (ALND)?
(Select all that apply.)
A. Avoid blood pressures, injections, and blood draws in
affected extremity
B. Wear gloves for gardening
C. Maintain cuticles by cutting them
D. Use disposable razors for shaving armpits
E. Avoid lifting objects greater than 5 to 10 pounds

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Answer to Question #2

A. Avoid blood pressures, injections, and blood draws in

affected extremity
B. Wear gloves for gardening
E. Avoid lifting objects greater than 5 to 10 pounds
Rationale: The patient should be instructed to avoid blood
pressures, injections, and blood draws in the affected
extremity; wear gloves for gardening; and avoid lifting
objects greater than 5 to 10 pounds. They should also be
instructed NOT to cut their cuticles but to have them
pushed back during manicures and to use electric razors
when shaving their armpits

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Nursing Process: The Care of the Patient
Undergoing Breast Cancer Surgery— Evaluation

 Exhibits knowledge about diagnosis and surgical

treatment
 Verbalizes willingness to deal with anxiety and fears
 Demonstrates ability to cope and makes decisions
regarding treatment
 Reports that pain has decreased and identifies
postoperative sensations
 Exhibits clean, dry, and intact surgical incisions
 Verbalizes feelings regarding change in body image
 Participates actively in self-care measures

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Question #3

Within what time frame is collateral circulation usually

developed in a woman after a mastectomy?
A. 1 week
B. 2 weeks
C. 3 weeks
D. 4 weeks

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Answer to Question #3

D. 4 weeks
Rationale: After a mastectomy, arm exercises facilitate
the development of collateral circulation, which
decreases lymphedema. Collateral circulation is usually
developed within 4 weeks

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Nonsurgical Management of Breast
Cancer

 Radiation therapy—external beam, brachytherapy

 Chemotherapy
 Hormonal therapy
o Estrogen and progesterone receptor assay
o Selective estrogen receptor modulators (SERMs)—
tamoxifen
o Aromatase inhibitors—anastrazole, letrozole,
exemestane
 Targeted therapy

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Reconstructive Procedures After
Mastectomy

 Tissue expander followed by permanent implant

 Tissue transfer procedures
o Transverse rectus abdominal myocutaneous (TRAM)
flap
 Nipple–areola reconstruction
 Prosthetics
 Reconstructive breast surgery: mammoplasty
o Reduction, augmentation
o Mastopexy

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Breast Reconstruction With Tissue
Expander

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Breast Reconstruction: Transverse
Rectus Abdominal Myocutaneous (TRAM)
Flap

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Special Considerations

 Implications of genetic testing: Rapid advancement

 Pregnancy and breast cancer
 Breast cancer: quality of life and survivorship
 Gerontologic considerations
 Breast health of women with disabilities
 Diseases of the male breast
o Gynecomastia
o Male breast cancer

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