Chapter 73: Care of Patients with Breast Disorders Flashcards
Fibroadenoma
Most common benign lesion. Is a solid mass of connective tissue that is unattached to the surrounding tissue. It is the most common during the teenage years into the 30s. The tumor is usually oval, freely mobile, and rubbery. Ultrasound or needle aspiration to determine if solid. If solid maybe excised.
Fibrocystic breast condition
Usually during the late teens and 20; premenopausal women between 20-50. The first stage is characterized by premenstrual bilateral fullness and tenderness. The second stage is the presence of bilateral, multicentric nodules. The third stage is the presence of microscopic and macroscopic cysts. Depressed , tender mom, areas of thinking me. The lungs are rubbery, you’ll define common and found in the upper outer quadrant. They contain fibrosis which are firm and hard or cysts which are filled with fluid.
Cysts may be drained to relieve pressure and pain. A biopsy is indicated if no fluid is aspirated, there is a suspicious mammogram, a palpable mass after aspiration, or the fluid reveals cancer cells.
Treatment includes hormones such as oral contraceptives to suppress oversecretion of estrogen and progesterone. Vitamin C, E, and B complex may help. Diuretics may relieve premenstrual breast engorgement. Reduction of dietary fat and caffeine can help. The patient should limit salt before menses, wear a supportive bra, and perform breast self exams.
Ductal Ectasia
Usually occurs in women approaching menopause. It has hard, irregular mass or masses with nipple discharge, enlarge axillary nodes, redness, and edema. It is difficult to distinguish from cancer.
The mass feels hard with irregular borders and may be tender. There may be a greenish brown nipple discharge. A microscopic examination of the nipple discharge rules out cancer. Nursing care is to reduce anxiety and support. It may improve without treatment but warm compresses and antibiotics may be helpful. The duct can be removed if symptoms do not improve.
Intraductal papilloma
From 40 to 55 years old. It is a benign process that forms a outgrowth of tissue. As it grows, trauma and erosion with in the duct result in a bloody or serious nipple discharge. A mass is rarely palpable. Rule out breast-cancer by evaluating the nipple discharge. Surgical excision of the mass and ductal area is usually indicated
Large breasted women
Difficulty finding clothes and bras, dents in the shoulders from bra straps, fungal infections under the breasts, backaches. Breast reduction surgery may help. Reduction mammoplasty may be indicated and is a major surgery. Nursing care is the same as women having reconstructive surgery.
Small breasted women
Breast augmentation with saline (which can be absorbed if leaks), silicone (which will not be absorbed), or own tissue.
Preop the patient needs to stop smoking, avoid aspirin and NSAIDs, avoid herbs that can cause bleeding such as garlic, ginkgo biloba, and ginseng. Incisions will be hidden as much as possible. One or more drains will be inserted. Complications include infection, prosthesis leakage, pain, fever. After surgery the patient needs care for 24 hours. Breast will feel tight and sensitive, the skin may itch. She will have difficulty raising arms over her head, should not lift, push, or pull. Need to avoid strenuous activity or twisting above the waist. Walk every few hours to avoid DVT. Swelling will last for 3 to 4 weeks. Still need to continue to have breast self exams. Mammography may not work as well.
Gynecomastia
Breast enlargement in the man that can be the result of cancer such as lung or testicular. Enlargement is usually bilateral. Other causes include drugs such as anti-androgen agent and corticosteroids, aging, obesity, diseases causing estrogen excess such as malnutrition, liver disease, or hyperthyroidism, and androgen deficiency such as chronic kidney disease or alcoholism. You must rule out breast cancer.
Pathophysiology of breast cancer
Most commonly diagnosed cancer in women and second only to lung cancer as the cause of female cancer deaths. Early detection is the key. It begins as a single cell that transforms and grows into the linings, ducts, and lobules.
Noninvasive 20%: confined to the duct
Ductal carcinoma in situ DCIS. It may spread if left untreated. Lobular carcinoma in situ LCIS. Does not show up on mammogram and is usually found during biopsy.
Invasive 80%: penetrates around the duct. The most common type is infiltrating ductal carcinoma. The lesion is felt as an irregular, poorly defined mass. Fibrosis occurs as it continues to grow. This may result in skin dimpling from shortening of the coopers ligament.
Once it invades the lymph, it can cause skin edema, redness, warmth, and orange peel appearance. This is called inflammatory breast cancer and is the most malignant.
Breast-cancer metastasizes to the bone, lungs, brain, and liver.
Breast cancer in men
Less than 1% of all breast-cancer is in Maine. Average age is 60 years. Most have a mutation in the BRCA1 or BRCA2 gene. They usually have a hard, painless, subareolar mass with possible gynecomastia. They may have nipple discharge, retraction, erosion, or ulceration.
Breast cancer in young women
Younger women under 40 often present with more aggressive earlier forms of the disease. Screening tools are less effective because breasts are more dence. Unique aspects include infertility after treatment and managing work and parenting.
Etiology and risk of breast cancer
There’s no single no calls. Period age is the primary risk factor. Family history. Having a first-degree relative doubles the risk. Having two first-degree relatives five times the risk. Exposure to radiation to the thorax before 20 years old. Early menarche before 12 years. Late menopause after 50 years. History of breast cancer. Nulliparity/no pregnancies. First birth after 30 years old. Having dense breasts. Oral contraceptives or hormone therapy. Obesity. Alcohol, high socioeconomic status, Jewish heritage. Having the BRCA1 or BRCA2 increase your risk.
Higher in Africans. American indian have poorest survival rate, but also a low rate of breast cancer. Hispanics have lower rate of cancer but higher death rate. Slightly higher for japanese and hawaiian.
Breast self exam
Should do it monthly beginning in your 20s. For premenopausal women examine the breast one week after the menstrual period. After menopause pick a day each month to do the self exam. Teach a woman how to perform the exam and walk her through what feels normally lumpy. Show her the inframammary bridge where the skin folds under the breast. Teach her how to determine a rib from a mass. Stand in front of a mirror to inspect the breast for abnormalities. Raise arms above head, press hands on hip to see change in shape. Perform exam lying down and in shower. Demonstrate proper pressure and to use the pads of the fingers. With arm above head, use wedge, vertical strip, or circular motions.
Clinical breast exam
Should be done at least every three years for women in their 20s and 30s and every year for women after 40. They are examined for symmetry, size, contour, skin changes such as color, texture, venous patterns, nipple changes, and lesion. Note a mass by a clock position. Note where breast was compressed if it caused discharge. If there is an abnormality, refer to specialist, possibly order mammogram and ultrasound. Biopsy a mass on a high risk person even if the mammogram is negative.
History for breast cancer
Interview focuses on risk factors, breast mass, and health maintenance practices. Include the age of menarche, age of menopause, symptoms of menopause, age of first childbirth, the number of children and pregnancies. Find out how and when the mass was discovered. Ask about other changes, possible bone pain. Nutritional history, alcohol intake, OTC drugs, meds and herbs, birth control use.
Pyschosocial assessment: fear of cancer; threats to body image, sexuality, and intimacy; decisional conflict related to treatment options; uncertainty
neoadjuvant therapy
Chemotherapy that shrinks the size of the tumor before it is surgically removed. this may allow a lumpectomy instead of a mastectomy.
