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Paired mammary glands within the superficial fascia of the chest wall Female breast extends vertically from the 2nd or 3rd rib to 6th or 7th Laterally from sternal margin to midaxillary line. Breast is usually divided into 4 quadrants
Topography of Breast
4 quadrants to describe clinical findings The upper outer quadrent is the site of most breast tumors
SCREENING RECOMMENDATIONS
SCREENING MAMMOGRAM (Baseline) at age 40, and annually after age 40-50. (Best 1 week after menstrual period) BREAST SELF EXAM monthly, begin @ age 20
CLINICAL BREAST EXAM yearly after age 40
BARRIERS: fear of pain, radiation, results accessibility, cost modesty knowledge deficit
Equipment Needed
None The patient must be properly gowned for this examination. All upper body clothing should be removed.
General Considerations
The patient must be properly gowned for this examination. All upper body clothing should be removed. Breast tissue changes with age, pregnancy, and menstrual status. The procedure described here can also be used for self-examination using a mirror for inspection.
Inspection
Give a brief overview of examination to patient. [1] Have the patient sit at end of exam table. Ask the patient to remove gown to her waist, assist only if needed. Have the patient relax arms to her side. Examine visually for following:
Approximate symmetry Dimpling or retraction of skin Swelling or discoloration Orange peel effect on skin Position of nipple
Have the patient replace the gown. Reassure the patient, if the exam is normal so far, say so.
Palpation
Have the patient lie supine on the exam table. Ask the patient to remove the gown from one breast and place her hand behind her head on that side. Begin to palpate at junction of clavicle and sternum using the pads of the index, middle, and ring fingers. If open sores or discharge are visible, wear gloves. Press breast tissue against the chest wall in small circular motions. Use very light pressure to assess superficial layer, moderate pressure for middle layer and firm pressure for deep layers. Palpate the breast in overlapping vertical strips. Continue until you have covered the entire breast including the axillary "tail." [2] Palpate around the areola and the depression under the nipple. Press the nipple gently between thumb and index finger and make note of any discharge. Lower the patient's arm and palpate for axillary lymph nodes. Have the patient replace the gown and repeat on the other side. Reassure the patient, discuss the results of the exam.
DUCTAL ECTASIA
Dilation & thickening of ducts in subareolar area Occurs usually in women nearing menopause Masses due to inflammatory response, may feel tender, hard, irregular (may be difficult to distinguish from malignancy) Redness, edema over mass site Greenish-brown nipple discharge Enlarged axillary nodes
Ductal ecstasia benign, inflamed and dilated, subareolar duct, nipple discharge green/black and sticky, can become abscess
INTRADUCTAL PAPILLOMA
Occurs usually in women nearing menopause Rarely palpable mass Serosanguineous nipple discharge (usually microscopic exam of discharge) Surgical excision if indicated
Large breasts Disproportionate to rest of body Difficult, expensive to find clothes to fit Can cause backaches Can cause fungal infections under breasts Can be treated by REDUCTION MAMMOPLASTY
BREAST CANCER
Most diagnosed invasive cancer in females Second leading cause of breast masses & cancer deaths overall 80% diagnosed in women over age 50 Early detection & treatment key to survival Localized with no regional spread: cure 75%-90% 5 and 10 year survival rates drop with axillary lymph node involvement Incidence lower in African-American & Hispanic women, but death rates higher (highest death rate is Hawaiian)
risk in early menarche (before 12) & late menopause in nulliparity or 1st pregnancy after age 30 in exposure to ionizing radiation (esp. before age 20) with hx of previous breast Ca, & risk for recurrence if diagnosed at earlier age or with hx of ovarian Ca with age
BREAST CANCER
INFILTRATING DUCTAL CARCINOMA
Most common, 80% of all breast Cas Hardness on palpation, may be 5-9 years before mass is palpable May be NONINVASIVE (remain in duct) or INVASIVE (penetrate surrounding tissue causing irregular mass) As grows, fibrosis develops, causes shortening of Coopers ligaments, causes skin dimpling (more advanced disease) Often metastasizes to axillary nodes
HISTORY:
Risk Factors Mass When & by whom discovered When sought care Health maintenance practices: BSE, Mammograms, Diet, Alcohol use, Medications including hormone supplements
MASS
Location usually upper, outer quadrant of breast Size Shape Hard consistency, with irregular borders Fixed, not movable Nipple, Skin Changes (orange peel appearance, ulceration, shortening of Coopers ligaments with dimpling) Lymph nodes Usually nontender, painfree unless in later stages
PSYCHOSOCIAL ASSESSMENT
Fear of cancer & prognosis Previous experiences with cancer Knowledge, education level Threats to body image Threats to sexuality and intimate relationships Support systems Need for other resources or counseling
BREAST ASSESSMENT
SBE CBE Mammography, Galactography Ultrasound MRI
RADIOGRAPHIC
Mammography Chest X ray Bone Scan Brain Scan Liver Scan CT- Chest and abdomen
DIAGNOSTIC ASSESSMENT
Ultrasonography- differentiates fluid filled from solid masses Breast biopsy with pathology report Estrogen and progesterone receptors (women with ER + tumors have longer survival rate) Tumor cell differentiation (women with well differentiated tumors have longer survival) Pathology exam of lymph nodes
BREAST BIOPSY
INDICATED: If needle aspirated fluid is bloody No fluid is aspirated from lesion Suspicious mammogram Mass still present after aspiration Cytological study shows malignant cells
STAGE 1 Tumor smaller than 2cm & no lymph node involvement STAGE 2 Tumor 2-5 cm with 0-1 + lymph nodes STAGE 3 (no metastasis evident) Tumor larger than 5cm, no + lymph nodes or Smaller than 2 cm, with + lymph nodes, or 2-5 cm with + nodes STAGE 4 Tumor of any size, + or lymph nodes, with distant metastasis evident
INTERVENTIONS
ANXIETY: GOAL: EFFECTIVE COPING Allow time for ventilation of feelings Active listening Promote clients decision making abilities Active participation in choice of treatment Be flexible Utilize outside resources
NONSURGICAL INTERVENTIONS
Indicated for clients with late-stage breast cancer Indicated for clients who cannot withstand major surgical procedures Based on client preferences, age, menopausal status, pathologic results, hormone receptor status Interventions include chemotherapy, (ER+may have Tamoxifen) & radiation therapy
SURGICAL MANAGEMENT
Breast Conserving (Stages 1 & 2) Lumpectomy Lumpectomy with lymph node dissection Simple Mastectomy-breast tissue & usually nipple removed, lymph nodes remain intact Modified radical Mastectomy-Removal of entire breast tissue and axillary lymph nodes; pectoral muscles & nerves remain intact
SURGICAL MANAGEMENT
SENTINEL LYMPH NODE BIOPSY Identifies clients with axillary involvement without palpable nodes Dye indicates lymph node path, with first reactive nodes removed & examined Absence of positive sentinel nodes prevents unnecessary radical dissections
MASTECTOMY:PREOPERATIVE CARE
Include significant other Recognize & deal with anxiety, lack of knowledge, & body image issues Review type of procedure & presence of drainage devices Describe location of incision Instruct in mobility restrictions Implement basic pre & post op teaching Provide written materials
BREAST RECONSTRUCTION
May begin during the original operative procedure Skin flap- (autogenous reconstruction) Saline filled prosthesis Progressive tissue expander Nipple creation If not done immediately, temporary or permanent prosthesis may be given TRAM flap reconstruction often used
ADJUNCT THERAPY
Decision based on Disease stage Age & menopausal status Client preferences Pathologic examination Hormone receptor status Genetic predisposition
ADJUNCT THERAPY
Radiation therapy Kill Ca cells which might be remaining External beam qd for 6-7 wks or partial breast brachytherapy with radioactive seeds bid for 5 days Skin changes a major side effect Mild soap, rubbing No perfumed soaps/deodorants, nondrying soap if itching occurs Hydrophilic lotions No tight clothes, underwire bras, excessive temperatures, UV lights
Chemotherapy
Often for remaining cells locally + distant sites Dangerous with many side effects: Meds to N& V Prevention & dealing with infection from bone marrow depression Promote communication & deal with anxiety Deal with side effects of taste changes, alopecia, mucositis, dermatitis, fatigue, weight gain or loss
Hormonal Therapy
Estrogen receptor blocking agents (Tamoxifen, Evista) Agents to inhibit estrogen synthesis (Lupron, Zoladex) Aromatase blocking agents to block circulating estrogen (arimidex, Femara)
DISCHARGE TEACHING
Usually does not require modifications in home Incision, Drain care Dressing, Wound care Exercises to regain full range of motion Prevention, Signs of infection and what to do Protection of affected arm- LIFETIME Measures to promote positive body image Management of lymphedema if occurs Reach for Recovery, ENCORE, or other community resources
DISCHARGE TEACHING: CARE OF INCISION Light dressing, keep dry No lotions, ointments, deodorants Observe for continued redness, swelling, heat, tenderness after 1st few weeks Loose fitting clothes ROM exercises when sutures, drains removed Shower after sutures, drains removed
EVALUATION
Evaluate expected outcomes: Client will Be free of infection Demonstrate correct BSE State positive feelings related to self image Regain full ROM in affected arm Be free of lymphedema