Chapter 48
Assessment and Management of Patients
With Breast Disorders
1
Assessment

Health History
2
Physical Assessment/ Inspection

Retraction Signs
Signs include skin dimpling, creasing, or
changes in the contour of the breast or nipple
 Secondary to fibrosis or scar tissue formation
in the breast
 Retraction signs may
appear only with
position changes or with
breast palpation.

3
Physical Assessment/
Inspection

Breast Cancer Mass (Malignant Tumor)
Usually occurs as a single mass (lump) in
one breast
 Firm, hard, embedded in surrounding tissue
 Referral and biopsy indicated for definitive
diagnosis
 Usually nontender
 Irregular shape

4
Physical Assessment/
Inspection

Breast Cyst (Benign Mass)
Occur as single or multiple lumps in one or both breasts
 Usually tender (omitting caffeine reduces tenderness);
tenderness increases during premenstrual period
 Round shape
 Soft or firm, mobile
 Referral and biopsy indicated
for definitive diagnosis,
especially for first mass.

5
Physical Assessment/
Inspection

Fibroadenoma (Benign Breast Lump)
Usually occurs as a single mass in women aged 15–35
years
 Usually nontender
 May be round or lobular
 Firm, mobile, and not fixed to breast tissue or chest
wall
 No premenstrual changes
 Referral and biopsy indicated
for definitive diagnosis

6
Physical Assessment/
Inspection

Increased Venous Prominence
Associated with breast cancer if unilateral
 Unilateral localized increase in venous pattern
associated with malignant tumors
 Normal with breast
enlargement associated with
pregnancy and lactation if
bilateral and bilateral symmetry

7
Physical Assessment/
Inspection

Peau d'Orange (Edema)
Associated with breast cancer
 Caused by interference with lymphatic
drainage
 Breast skin has orange peel appearance
 Skin pores enlarge
 May be noted on the areola
 Skin becomes thick, hard, immobile
 Skin discoloration may occur

8
Physical Assessment/
Inspection

Nipple Inversion
Considered normal if long-standing
 Associated with fibrosis and malignancy if
recent development

9
Physical Assessment/
Inspection

Acute Mastitis (Inflammation of the
Breasts)
Associated with lactation but may occur at
any age
 Nipple cracks or abrasions noted
 Breast skin reddened and warm to touch
 Tenderness
 Systemic signs include fever and increased
pulse

10
Physical Assessment/
Inspection

Paget Disease (Malignancy of Mammary
Ducts)
Early signs: erythema of nipple and areola
 Late signs: thickening, scaling, and erosion
of the nipple and areola

11
Diagnostic Evaluation

Breast Self-Examination (BSE)
Done on day 5-7 of menstrual cycle (some
changes in breast occur due to hormones
around menstruation)
 Breast examination with the woman in a
supine position. The entire surface of the
breast is palpated from the outer edge of the
breast to the nipple. Alternative palpation
patterns are circular or clockwise, wedge,
and vertical strip.

12
13
Breast-Self Examination
14
Diagnostic Evaluation
Mammography


Detect nonpalpable
lesions and assist in
diagnosing palpable
masses
Recommended to be
done every year
beginning at 40 years
of age (women with
family history, start at
younger age)
15
Diagnostic Evaluation
Magnetic Resonance Imaging
 Procedures for Tissue Analysis

Percutaneous Biopsy
 Fine-Needle Aspiration
 Surgical Biopsy

• Excisional Biopsy
• Incisional Biopsy
16
Comparison of Various Breast Masses
17
Benign Neoplasms:
Fibrocystic Breast Disease(FBD)

Also called chronic mastitis or lumpy breast syndrome, it
is the most common breast lesion in females and usually
occurs between ages 35 and 50. Many cases will subside
after menopause.
18
Benign Neoplasms:
Fibrocystic Breast Disease(FBD)
Incidence of developing breast cancer is
increased 3 to 4 times with FBD.
 Pathology

Cause is unknown; possible hormonal
imbalance
 Condition occurs during reproductive years
and disappears with menopause
 A benign condition affecting 25% of women
over 30 years of age

19
Benign Neoplasms:
Fibrocystic Breast Disease(FBD)

Signs and symptoms
Subjective: breast tenderness and pain
 Objective: small, round, smooth nodules


Diagnostic tests and methods


Mammography, thermomastography,
xerography
Treatment: conservative
Aspiration
 Biopsy examination to rule out malignancy

20
Benign Neoplasms:
Fibrocystic Breast Disease(FBD)

Nursing intervention
Explain importance of monthly breast selfexamination
 Encourage patient to seek medical evaluation
if nodule forms, because cystic disease may
interfere with early diagnosis of breast
malignancy

21
Malignant Neoplasms:
Breast Cancer


Second major cause
of cancer death
among women.
Statistics indicate that
1 in 10 will develop
cancer sometime
during her life.
The key to cure is
early detection by
physical examination,
mammography, and
breast selfexamination.
22
Risk factors for Breast Cancer





Female gender
Increasing age
Personal history of breast cancer
Family history of breast cancer
Genetic mutations (BRCA-1 and BRCA-2
mutations are responsible for majority of
inherited breast cancer cases)
 Late menopause
 Nulliparity
23
Risk factors for breast Cancer

Hormonal factors








Early menarche
First child after 30 years of age
Hormone therapy (HT)
Exposure to ionizing radiation during
adolescence and early adulthood
History of benign proliferative breast disease
Obesity
High-fat diet (controversial)
Alcohol intake
24
Protective Factors
Regular exercise (after age of 35, strenuous
excursive ˅ chance for BC by 14%.
 Breastfeeding
 Having completed a full-term pregnancy
before 30 years of age

25
Types of Breast Cancer
Ductal Carcinoma in Situ
Characterized by the proliferation of
malignant cells inside the milk ducts
without invasion into the surrounding
tissue.
 It is a noninvasive form of cancer (also
called intraductal carcinoma).
 If not treated, ? become invasive cancer

26
Types of Breast Cancer
Infiltrating Ductal Carcinoma
Is the most common histologic type of
breast cancer.
 Accounts for 75% of all cases.
 The tumors arise from the duct system
and invade the surrounding tissues.
 They often form a solid irregular mass in
the breast.

27
Other types of breast cancer
Infiltrating Lobular Carcinoma (5-10%)
 Medullary Carcinoma (5%)
 Mucinous Carcinoma (3%)
 Tubular Ductal Carcinoma (2%)
 Inflammatory Carcinoma (2%)
 Paget Disease (1%)

28
Breast cancer

Signs and symptoms
Subjective: nontender nodule
 Objective:

•
•
•
•
•

Enlarged axillary nodes
Nipple retraction or elevation
Skin dimpling
Nipple discharge
usually appeal in the upper outer quadrant
Diagnostic tests and methods

Mammography, breast biopsy examination
29
Breast cancer

Treatment
 Lumpectomy: removal of the lump and partial
breast tissue; indicated for early detection
 Mastectomy
• Simple mastectomy: removal of breast
• Modified radical mastectomy: removal of
breast, pectoralis minor muscle, and some
of an adjacent lymph nodes
• Radical mastectomy: removal of the breast,
pectoral muscles, pectoral fascia, and
axillary lymph node disection
30
Breast cancer

Treatment
• Oophorectomy, adrenalectomy,
hypophysectomy to remove source of
estrogen and the hormones that stimulate
the breast tissue
• Radiation therapy to destroy malignant
residual malegnant cells
• Chemotherapeutic agents to shrink, retard,
and destroy cancer growth
• Corticosteroids, antigens, and antiestrogens to alter cancer that is dependent
on hormonal environment
31
Collaborative Problems/Potential
Complications
Based on the assessment data, potential
complications may include the following:
 Lymphedema
 Hematoma/seroma formation
 Infection

32
Breast Cancer/ Preop Nsg Dx





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 ineffective coping (individual or family)
related to the diagnosis of breast cancer and
related treatment options
Decisional conflict related to treatment options
33
Preoperative Nursing Interventions
Providing Education and Preparation
About Surgical Treatments
 Reducing Fear and Anxiety and Improving
Coping Ability
 Promoting Decision-Making Ability

34
Breast Cancer/ Postop Nsg Dx





Pain and discomfort related to surgical procedure
Disturbed sensory perception related to nerve
irritation in affected arm, breast, or chest wall
Disturbed body image related to loss or alteration of
breast
Risk for impaired adjustment related to the
diagnosis of cancer and surgical treatment
Self-care deficit related to partial immobility of arm
35
Breast Cancer/ Postop Nsg Dx
Risk for sexual dysfunction related to loss of
body part, change in self-image, and fear of
partner's responses
 Deficient knowledge: drain management after
breast surgery
 Deficient knowledge: arm exercises to regain
mobility of affected extremity
 Deficient knowledge: hand and arm care after
an axillary lymph node dissection (ALND)

36
Postoperative Nursing Interventions
Relieving Pain and Discomfort
 Managing Postoperative Sensations
 Promoting Positive Body Image
 Promoting Positive Adjustment and
Coping
 Monitoring and Managing Potential
Complications

37
Lymphedema
Occurs in about 10% to 30% of patients
who undergo ALND and in about 0% to
7% of patients who have SLNB
 lymphatic channels become inadequate to
ensure a return flow of lymph fluid to the
general circulation.
 Risk factors: age, obesity, extensive
axillary disease, radiation treatment, and
injury or infection to the extremity

38
Lymphedema


Edema resolved after development of collateral
circulation.
Postoperative transient edema develops until
collateral circulation has completely taken over
this function, which generally occurs within a
month. Performing prescribed exercises,
elevating the arm above the heart several times
a day, and gentle muscle pumping (making a
fist and releasing) can help reduce the transient
edema. The patient needs reassurance that this
transient swelling is not lymphedema
39
Hand and Arm Care After Axillary
Lymph Node Dissection










Avoid BP, injections, and blood draws in affected arm.
Use sunscreen for extended exposure to sun.
Apply insect repellent to avoid insect bites.
Wear gloves for gardening.
Use cooking mitt for removing objects from oven.
Avoid cutting cuticles; push them back during manicures.
Use electric razor for shaving armpit.
Avoid lifting objects greater than 2-4 kg.
If a trauma or break in the skin occurs, wash the area with soap
and water, and apply an antibacterial ointment.
Observe the area and extremity for 24 hours; if redness, swelling,
or a fever occurs, call the surgeon or nurse.
40
Post-op arm exercise
Wall handclimbing
Rope turning
41
Post-op arm exercise
Rod or broomstick lifting
Pulley tugging
42
Breast cancer

Nursing intervention
Provide atmosphere of acceptance, frequent
patient contact, and encouragement in illness
adjustment
 Encourage grooming activities
 Arrange attractive environment
 If the patient is receiving radiation or
chemotherapy, explain and assist with
potential site effects

43
Breast cancer

If the patient has undergone surgical intervention,
follow post operative nursing actions
• Elevate affected arm above level of right atrium to prevent
edema
• Drawing blood or administering parenteral fluids or taking
blood pressure on affected arm is contraindicated
• Monitor dressing for hemorrhage, observed back for pooling
of blood
• Empty Hemovac and measure drainage every 8 hours
• Assess circulatory status of affected limb
• Measure upper arm and forearm, twice daily, to monitor
edema
• Encourage exercises of the affected arm when approved by
a physician; avoid abduction
44
Breast cancer

Patient teaching on discharge
•
•
•
•
Exercise to tolerance
Sleep with arm elevated
Elevated arm several times daily
Avoid injections, vaccinations, IV, and taking blood
pressure, in affected arm
45
Malignant Neoplasms:
Breast Cancer

Five year survival rate
is 97% for localized
cancer, 76% for
cancer that has
spread regionally, and
21% for cancers
having distant
metastases.
Metastatic breast cancer to the
back
46
Male Breast Cancer
Accounts for less than 1% of all cases of
breast cancer
 Average age at diagnosis is 67 years
 Risk factors:

A history of mumps orchitis,
 Radiation exposure,
 Decreased testosterone levels
 Liver disease (compromises estrogen
metabolism).

47