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Breast cancer
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Risk factors:
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Women > age 50.
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Family history of breast cancer.
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Never bore children, or bore first child after age 30.
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Had breast cancer in other breast.
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Menarche before age 11.
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Menopause after age 50.
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Exposure to endogenous estrogens.
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Exposure to ionizing radiation.
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High alcohol and fat intake may increase risk.
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Annual incidence: 181,600 new cases; 44,190 estimated
deaths.
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Assessment:
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Subjective data:
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Burning, itching of nipple.
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Reported painless lump.
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Objective data:
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Firm, nontender lump or
mass.
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Asymmetry of breast.
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Nipple - retraction,
discharge.
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Alteration in breast
skin - redness, dimpling, ulceration.
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Palpation reveals lump.
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Diagnostic tests: mammography, needle biopsy, core
biopsy, excisional biopsy - level of estrogen-receptor protein predicts response to hormonal manipulation
of metastatic disease and may represent a prognostic indicator for primary cancer; carcinoembryonic
antigen (CEA) useful with metastatic disease of the breast.
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Analysis/nursing diagnosis:
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Risk for injury related to surgical
intervention.
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Body image disturbance related to effects
of surgery, radiation, or chemotherapy.
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Altered sexuality patterns related to
loss of breast.
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Nursing care
plan/implementation:
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Goal: assist through treatment protocol.
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Radiation - primary treatment
modality; adjunctive, external, or implantation to primary lesion site or nodes.
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Chemotherapy usually given in combinations.
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Cytotoxic agents to destroy
tumor and control metastasis.
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Alkylating agents:
cyclophosphamide (Cytoxan).
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Antitumor antibiotics:
doxorubicin (Adriamycin).
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Antimetabolites:
fluorouracil (5-FU); methotrexate (Amethopterine, MTX).
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Plant alkaloids:
vincristine sulfate (Oncovin).
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Hormones to control
metastasis, provide palliation: androgens, fluoxymesterone (Halotestin), testosterone (Teslac),
diethylstilbesterol (estrogen).
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Antiestrogens: tamoxifen
(Nolvadex) may be used after initial treatment.
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Cortisols: cortisone,
prednisolone (Delta-Cortef), prednisolone acetate (Meticortelone), prednisone (Deltasone,
Deltra).
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Surgery.
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Preoperative:
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Goal: prepare for surgery-types:
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Lumpectomy (with or without
radiation) - used when lesion is small; section of breast is removed (often accompanied by
radiation therapy and then radium interstitial implant).
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Simple mastectomy - breast
removed, no alteration in nodes.
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Modified radical mastectomy - breast, some axillary nodes, subcutaneous tissue removed; pectoralis minor muscle
removed.
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Radical mastectomy - breast,
axillary nodes, and pectoralis major and minor muscles removed.
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Reconstructive surgery - done at time of
initial mastectomy or (most often) later, when other adjuvant therapy has been completed.
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Goal: promote comfort.
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Allow patient and family
to express fears, feelings.
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Provide correct
information about diagnostic tests, operative procedure, postoperative expectations.
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Patient may be
hospitalized for 24 hours or less. Have telephone number available for questions. Make
appropriate community referrals.
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Postoperative:
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Goal: facilitate healing.
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Observe pressure
dressings for bleeding; will appear under axilla and toward the back.
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Report if dressing
becomes saturated; reinforce dressing as need; monitor drainage from Hemovac or suction
pump.
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Position: semi-Fowler’s to facilitate venous and
lymphatic drainage; use pillows to elevate
affected arm above right
atrium, to prevent edema if nodes removed.
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Goal: prevent
complications.
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Monitor vital signs for shock.
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Use gloves when emptying drainage.
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Maintain joint mobility - flexion and
extension of fingers, elbow, shoulder.
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ROM as ordered to prevent ankylosis.
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If skin graft done, check
donor site and limit exercises.
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Goal: facilitate
rehabilitation.
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Encourage patient,
significant others, and family to look at incision.
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Involve patient in
incisional care, as tolerated.
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Refer to Reach to Recovery program of the American Cancer Society
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Exercise program, hydrotherapy for
postmastectomy patients, to reduce lymphedema.
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Evaluation/outcome criteria:
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Identifies feelings regarding
loss.
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Demonstrates postmastectomy
exercises.
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Gives rationale for avoiding
fatigue and avoiding constricting garments on affected arm; necessity for avoiding injury (cuts,
bruises, burns) while carrying out activities of daily living.
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Describes signs and symptoms of
infection.
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Demonstrates
correct BSE technique.