Breast Cancer Nursing Care Plan Notes

 

Description

1. Is the leading type of cancer in women.Most breast cancer begins in the lining of the milk ducts, sometimes the lobule.
2. The cancer grows through the wall of the duct and into the fatty tissue.
3. Breast cancer metastasizes most commonly to auxiliary nodes, lung, bone, liver, and the brain.
4. The most significant risk factors for breast cancer are gender (being a woman) and age (growing older).
5. Other probable factors include nulliparity, first child after age 30, late menopause, early menarche, long term estrogen replacement therapy, and benign breast disease.
6. Controversial risk factors include oral contraceptive use, alcohol use, obesity, and increased dietary fat intake.
7. About 90% of breast cancers are due not to heredity, but to genetic abnormalities that happen as a result of the aging process and life in general.
8. A woman’s risk of breast cancer approximately doubles if she has a first-degree relative (mother, sister, daughter) who has been diagnosed with breast cancer. About 20-30% of women diagnosed with breast cancer have a family history of breast cancer.

Stages of Breast Cancer

STAGE	DEFINITION
Stage 0	Cancer cells remain inside the breast duct, without invasion into normal adjacent breast tissue.
Stage I	Cancer is 2 centimeters or less and is confined to the breast (lymph nodes are clear).
Stage IIA	No tumor can be found in the breast, but cancer cells are found in the axillary lymph nodes (the lymph nodes under the arm)ORthe tumor measures 2 centimeters or smaller and has spread to the axillary lymph nodesOR the tumor is larger than 2 but no larger than 5 centimeters and has not spread to the axillary lymph nodes.
Stage IIB	The tumor is larger than 2 but no larger than 5 centimeters and has spread to the axillary lymph nodesORthe tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes.
Stage IIIA	No tumor is found in the breast. Cancer is found in axillary lymph nodes  that are sticking together or to other structures, or cancer may be found in lymph nodes near the breastboneORthe tumor is any size. Cancer has spread to the axillary lymph nodes, which are sticking together or to other structures, or cancer may be found in lymph nodes near the breastbone.
Stage IIIB	The tumor may be any size and has spread to the chest wall and/or skin of the breastANDmay have spread to axillary lymph nodes that are clumped together or  sticking to other structures, or cancer may have spread to lymph     nodes near the breastbone.Inflammatory breast cancer is considered at least stage IIIB.
Stage IIIC	There may either be no sign of cancer in the breast or a tumor may be  any size and may have spread to the chest wall and/or the skin of the breastANDthe cancer has spread to lymph nodes either above or below the collarboneAND the cancer may have spread to axillary lymph nodes or to lymph nodes  near the breastbone.
Stage IV	The cancer has spread — or metastasized — to other parts of the body.

Assessment

1. A firm lump or thickness in breast, usually painless; 50% are located in the upper outer quadrant of the breast.
2. Spontaneous nipple discharge; may be bloody, clear or serous.
3. Asymmetry of the breast may be noted as the woman changes positions; compare one breast with the other.
4. Nipple retraction or scalliness, especially in Paget’s disease.
5. Enlargement of auxiliary or supraclavicular lymph nodes may indicate metastasis.

Diagnostic Evaluation

1. Mammography (most accurate method of detecting non-palpable lesions) shows lesions and cancerous changes, such as microcalcification. Ultrasonography may be used to distinguish cysts from solid masses.
2. Biopsy or aspiration confirms diagnosis and determines the type of breast cancer.
3. Estrogen or progesterone receptor assays, proliferation or S phase study (tumor aggressive), and other test of tumor cells determine appropriate treatment and prognosis.
4. Blood testing detects metastasis; this includes liver function tests to detect liver metastasis and calcium and alkaline phosphatase levels to detect bony metastasis.
5. Chest x-rays, bone scans, or possible brain and chest CT scans detect metastasis.

Primary Nursing Diagnosis

• Body image disturbance related to significance of loss of part or all of the breast

Pharmacological Intervention

1. Chemotherapy is the primary used as adjuvant treatment postoperatively ; usually begins 4 weeks after surgery (very stressful for a patient who just finished major surgery).
   • Treatments are given every 3 to 4 weeks for 6 to 9 months. Because the drugs differ in their mechanisms of action, various combinations are used to treat cancer.
   • Principal breast cancer drugs include cyclosphosphamide, methotrexate, fluorouracil, doxorubicin, and paclitaxel.
   • Additional agents for advanced breast cancer include docetaxel, vinorelbine, mitoxantrone, and fluorouracil.
   • Herceptin is a monoclonal antibody directed against Her-2/neu oncogene; may be effective for patients who express this gene
2. Indications for chemotherapy include large tumors, positive lymph nodes, premenopausal women, and poor prognostic factors.
3. Chemotheraphy is also used as primary treatment in inflammatory breast cancer and as palliative treatment in metastatic disease or recurrence.
4. Anti-estrogens, such as tamoxifen, are used as adjuvant systemic therapy after surgery.
5. Hormonal agents may be used in advanced disease to induce remissions that last for months to several years.

Surgical Interventions

1. Surgeries include lumpectomy (breast-preventing procedure), mastectomy (breast removal), and mammoplasty (reconstructive surgery).
2. Endocrine related surgeries to reduce endogenous estrogen as a palliative measure.
3. Bone marrow transplantation may be combined with chemotherapy.

Lumpectomy

Mammoplasty

Modified Radical Mastectomy

Nursing Interventions

1. Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough, nausea, anorexia.
2. Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea and vomiting, alopecia, weight gain or loss, fatigue, stomatitis, anxiety, and depression.
3. Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. Provide psychological support to the patient throughout the diagnostic and treatment process.
4. Involve the patient in planning and treatment.
5. Describe surgical procedures to alleviate fear.
6. Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia, fatigue.
7. Administer antiemetics prophylactically, as directed, for patients receiving chemotherapy.
8. Administer I.V. fluids and hyperalimentation as indicated.
9. Help patient identify and use support persons or family or community.
10. Suggest to the patient the psychological interventions may be necessary for anxiety, depression, or sexual problems.
11. Teach all women the recommended cancer-screening procedures.

Documentation Guidelines

• Response to surgical interventions: Condition of dressing and wound, stability of vital signs, recovery from anesthesia
• Presence of complications:Pain,edema,infection,seroma,limited ROM
• Knowledge of and intent to comply with adjuvant therapies
• Reaction to cancer and body changes
• Knowledge of and intent to comply with incision care, postoperative exercises, arm precautions, follow-up care,and early detection methods for recurrence

Discharge and Home Healthcare Guidelines

PATIENT TEACHING

• The patient can expect to return home with dressings and wound drains. Instruct the patient to do the following:empty the drainage receptacle twice a day,record the amount on a flow sheet,and take this information along when keeping a doctor’s appointment; report symptoms of infection or excess drainage on the dressing or the drainage device; sponge bathe until the sutures and drains are removed; continue with daily lower arm ROM exercises until the surgeon orders more strenuous exercises; avoid caffeinated foods and drinks,nicotine,and secondary smoke for 3 weeks postoperatively. Review pain medication instructions for frequency and precautions.
• Teach precautions to prevent lymphedema after node dissection (written directions or pamphlet from American Cancer Society [ACS] is desirable for lifetime referral):
• Request no blood pressure or blood samples from affected arm.
• Do not carry packages,handbags,or luggage with the affected arm; avoid elastic cuffs.
• Protect the hand and arm from burns,sticks,and cuts by wearing gloves to do gardening and housework,using a thimble to sew,applying sunscreen and insect repellent when out-of-doors. Report swelling,pain,or heat in the affected arm immediately. Put the arm above the head and pump the fist frequently throughout the day.

FOLLOW-UP

• Prepare the patient and family for a variety of encounters with healthcare providers (radiologist, oncologist, phlebotomist). Try to provide a continuity between the providers (yourself, clinical nurse specialist, or nurse consultant system, if available) as a resource for the patient or family to call with questions.
• Provide lists and information of local community resources and support groups for emotional support:Reach to Recovery,Y-ME,Wellness Center,Can Surmount,I Can Cope; a list of businesses that specialize in breast prostheses; phone numbers for ACS and Cancer Information System