Psychosocial assessment

Fear

Threats to body image, intimate relationships and survival Decisions regarding treatment options

Explore clients feelings, support system, clients & familys knowledge

Clients level of education Sexuality psychologic, physiologic, relational Evaluate need for additional resources

Possible Chief Complaint

Inflammatory breast cancer of the left breast Breast CA patient recently diagnosed with left breast cancer (Inflammatory) needs port for chemotherapy Inflammatory breast cancer Left breast cancer patient with inflammatory breast carcinoma currently receiving chemo and now presents for mastectomy

EPAL TO wag nlng kaya to

Related Nsg. Diagnosis

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 related to the diagnosis of breast cancer Decisional conflict related to treatment options. Disturbed body image related to loss or alteration of the breast

PLANNING
Diagnostic exams in Breast CA
Breast Self Examination Starts from age 20. done after menstruation. Note for symmetry of the breast. Palpate the breast from periphery to the center in circular motion. Mammogram It involves x-ray examination of the breast, it is supported on flat, firm surface. It involves use of 2 x-ray films.

Biopsy It is the examination of affected tissue in detecting presence of cancer cells. Nuclear Magnetic Resonance Imaging This is viewing the structure of the breast using a high tech radiation imaging in detecting presence of mass or tumors. The use of radio waves and strong magnets to visualize the entire breast. MRIs may be used to characterize a cancer found through mammography or to take a closer look at the breasts of women who are at high risk of developing breast cancer. Ductogram A type of X-ray that helps determine the cause of nipple discharge. A ductogram can show if there is a mass inside the duct at the nipple. A ductogram also is known as a galactogram.

Surgery
This operation saves as much of your breast as possible by removing only the lump plus a surrounding area of normal tissue. Many women can have lumpectomy often followed by radiation therapy instead of mastectomy, and in most cases survival rates for both operations are similar. But lumpectomy may not be an option if a tumor is very large, deep within your breast, or if you have already had radiation therapy, have two or more widely separated areas of cancer in the same breast, have a connective tissue disease that makes you sensitive to radiation, or if you have inflammatory breast cancer. If you have a large tumor but still want to consider the possibility of lumpectomy, chemotherapy before surgery may be an option to shrink the tumor and make you eligible for the procedure. In general, lumpectomy is almost always followed by radiation therapy to destroy any remaining cancer cells. But when very small, noninvasive cancers are involved, some studies question the role and benefits of radiation therapy especially for older women. These studies haven't shown that lumpectomy plus radiation prolongs a woman's life any better than does lumpectomy alone.

Lumpectomy.

Partial or segmental mastectomy.

Another breast-sparing operation, partial mastectomy involves removing the tumor as well as some of the breast tissue around the tumor and the lining of the chest muscles that lie beneath it. In almost all cases, you'll have a course of radiation therapy following your operation, similar to if you had a lumpectomy.

Simple mastectomy.

During a simple mastectomy, your surgeon removes all your breast tissue the lobules, ducts, fatty tissue and skin, including the nipple and areola. Depending on the results of the operation and follow-up tests, you may also need further treatment with radiation to the chest wall, chemotherapy or hormone therapy.

Modified radical mastectomy. In this procedure, a surgeon removes

your entire breast, including the overlying skin, and some underarm lymph nodes (axillary lymph node dissection), but leaves your chest muscles intact. This makes breast reconstruction less complicated.

Sentinel lymph node biopsy

Because breast cancer first spreads to the lymph nodes under the arm, all women with invasive cancer need to have these nodes examined. Rather than remove as many lymph nodes as possible, surgeons now focus on finding the sentinel nodes the first nodes to receive the drainage from breast tumors and therefore the first place cancer cells will travel. If a sentinel node is removed, examined and found to be normal, the chance of finding cancer in any of the remaining nodes is small and no other nodes need to be removed. This spares many women the need for a more extensive operation and greatly decreases the risk of complications.

Axillary lymph node dissection

If the sentinel lymph node does show the presence of cancer, then your surgeon removes additional lymph nodes in your armpit (axilla). The removal of these lymph nodes does increase the risk of serious arm swelling (lymphedema), but newer surgical techniques make this complication much less likely. Knowing if cancer has spread to the lymph nodes is important in determining the best course of treatment, including whether you'll need chemotherapy or radiation therapy.

Radiation therapy
Radiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. It's administered by a radiation oncologist at a radiation center. In general, radiation is the standard of care following a lumpectomy for both invasive and noninvasive breast cancers. Oncologists are also likely to recommend radiation following a mastectomy for a large tumor, for inflammatory breast cancer, for cancer that has invaded the chest wall or for cancer that has spread to more than four lymph nodes in your armpit. If you won't be receiving chemotherapy, radiation is usually started three to four weeks after surgery. If your doctors recommend chemotherapy, it's usually administered before you undergo radiation therapy. You'll typically receive radiation treatment five days a week for five to six consecutive weeks. The treatments are painless and are similar to getting an X-ray. Each takes about 30 minutes. The effects are cumulative, however, and you may become tired toward the end of the series. Your breast may be pink, puffy and somewhat tender, as if it had been sunburned. In a small percentage of women, more serious problems may occur, including arm swelling, damage to the lungs, heart or nerves, or a change in the appearance and consistency of breast tissue. Radiation therapy also makes it somewhat more likely that you'll develop another tumor. For these reasons, it's important to learn about the risks and benefits of radiation therapy when deciding between lumpectomy and mastectomy. You may also want to talk to a radiation oncologist about clinical trials investigating shorter courses of radiation or focal application of radiation.

Chemotherapy
Chemotherapy uses drugs to destroy cancer cells. The size of the tumor, characteristics of the cancer cells, and extent of spread of the cancer help determine your need for chemotherapy. If your cancer has a high chance of returning or spreading to another part of your body, your doctor may recommend chemotherapy after surgery to decrease the chance that the cancer will recur. This is known as adjuvant chemotherapy. If your cancer has already spread to other parts of your body, chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer is causing.

Treatment often involves receiving two or more drugs in different combinations. These may be administered intravenously, in pill form or both. You may have between four and eight treatments spread over three to six months.
Because chemotherapy affects healthy cells as well as cancerous ones, side effects are common. Your digestive tract, hair and bone marrow all composed of fast-growing cells tend to take the brunt of this toxicity, leading to hair loss, nausea, vomiting and fatigue. Not everyone has all of these side effects, however, and methods to control chemotherapy side effects have improved greatly in the past few decades. Notably, more effective drugs are now available to help prevent or reduce nausea and vomiting.

Reconstructive surgery
Reconstruction with implants. This technique uses artificial material silicone gel or saline, in an implantable, leak-proof shell to replace surgically removed breast tissue. If you don't have enough muscle and skin to cover an implant, your doctor may use a tissue expander, which is an empty implant shell that inflates as fluid is injected. It's placed under your skin and muscle, and your doctor gradually fills it with fluid usually over a period of several months. When your muscle and skin have stretched enough, the expander is removed and replaced with a permanent implant.

Reconstruction with a tissue flap. Known as a transverse rectus abdominal muscle (TRAM) flap, this surgery reconstructs your breast using tissue, including fat and muscle, from your abdomen, although surgeons sometimes may use tissue from your back or buttocks instead. Because the procedure is fairly complicated, recovery may take six to eight weeks. Complications include the risk of infection and tissue death. If you have a low percentage of body fat, this type of reconstruction may not be an option for you.

Deep inferior epigastric perforator (DIEP) reconstruction. In this procedure, fat tissue from your abdomen is used to create a naturallooking breast. But because your abdominal muscles are left intact, you're less likely to experience complications than you are with traditional TRAM flap breast reconstruction. You may also have less pain, and your healing time may be reduced.
Reconstruction of your nipple and areola. After initial surgery with either tissue transfer or an implant, you may have further surgery to make a nipple and areola. Using tissue from elsewhere in your body, your surgeon first creates a small mound to resemble a nipple. He or she may then tattoo the skin around the nipple to create an areola. Your surgeon may also take a skin graft from elsewhere on your body, place it around the reconstructed nipple to slightly raise the skin and then tattoo the skin graft.

Eto pinadaling surgery.

Breast cancer surgery Operations used to treat breast cancer include: Removing the breast cancer (lumpectomy). During lumpectomy, which may be referred to as breast-sparing surgery or wide local excision, the surgeon removes the tumor and a small margin of surrounding healthy tissue. Lumpectomy is typically reserved for smaller tumors. Removing the entire breast (mastectomy). Mastectomy is surgery to remove all of your breast tissue. Most mastectomy procedures remove all of the breast tissue the lobules, ducts, fatty tissue and some skin, including the nipple and areola (simple mastectomy). In a skin-sparing mastectomy, the skin over the breast is left intact to improve reconstruction and appearance. Removing a limited number of lymph nodes (sentinel node biopsy). To determine whether cancer has spread to your lymph nodes, your surgeon will discuss with you the role of removing the lymph nodes that receive the lymph drainage from your tumor. If no cancer is found in those lymph nodes, the chance of finding cancer in any of the remaining lymph nodes is small and no other nodes need to be removed. Removing several lymph nodes (axillary lymph node dissection). If cancer is found in the sentinel node, your surgeon will discuss with you the role of removing additional lymph nodes in your armpit. Removing both breasts. Some women with cancer in one breast may choose to have their other (healthy) breast removed (contralateral prophylactic mastectomy) if they have a very increased risk of cancer in the other breast. Discuss your breast cancer risk with your doctor, along with the benefits and risks of this procedure

Intervention
Pre-operative

Obtain informed consent Provide good care for a breast care Be sure to know what kind of surgery to be performed in order to prepare the patient If mastectomy is scheduled:
Prevent pulmonary complications and

thromboembolism Place patient on the affected side

Post-operative

inspect dressing anteriorly and posteriorly Check circulatory status Encourage coughing exercises and turning schedule every two hours Provide psychological and emotional support Explain to the patient that she may experience phantom breast syndrome

Other Intervention
Ask your doctor about aspirin. Taking an aspirin just once a week may help protect against breast cancer, but be sure to talk to your doctor before you start. When used for long periods of time, aspirin can cause stomach irritation, bleeding and ulcers. More serious aspirin side effects include bleeding in the intestinal and urinary tracts and hemorrhagic stroke. In general, you're not a candidate for aspirin therapy if you have a history of ulcers, liver or kidney disease, bleeding disorders, or gastrointestinal bleeding. Limit alcohol. Drinking alcohol is strongly linked to breast cancer. The type of alcohol consumed wine, beer or mixed drinks seems to make no difference. To help protect against breast cancer, limit the amount of alcohol you drink to less than one drink a day or avoid alcohol completely. Maintain a healthy weight. There's a clear link between obesity weighing more than is appropriate for your age and height and breast cancer. The association is stronger if you gain the weight later in life, particularly after menopause.

Avoid long-term hormone therapy. The link between postmenopausal hormone therapy and breast cancer has been a subject of debate for years, partly because research results have been mixed. Estrogen exposure clearly contributes to breast cancer risk, but for most women, the size of the contribution over a lifetime is small particularly in the absence of other risk factors, such as family history of the disease. If you're approaching menopause and having frequent symptoms, it's probably safe to take hormones for as long as four to five years. Any longer does increase your breast cancer risk, without conferring any clear benefits. The same is true of hormone therapy after age 60.
Stay physically active. No matter what your age, aim for at least 30 minutes of exercise on most days. Try to include weight-bearing exercises such as walking, jogging or dancing. These have the added benefit of keeping your bones strong. Eat foods high in fiber. Try to increase the amount of fiber you eat to between 20 and 30 grams daily about twice that in an average American diet. Among its many health benefits, fiber may help reduce the amount of circulating estrogen in your body. Foods high in fiber include fresh fruits and vegetables and whole grains.

Emphasize olive oil. Oleic acid, the main component of olive oil, appears both to suppress the action of the most important oncogene in breast cancer and to increase the effectiveness of the drug Herceptin.

Avoid exposure to pesticides. The molecular structure of some pesticides closely resembles that of estrogen. This means they may attach to receptor sites in your body. Although studies have not found a definite link between most pesticides and breast cancer, it is known that women with elevated levels of pesticides in their breast tissue have a greater breast cancer risk.

MEDICATIONS
Targeted drugs Targeted drug treatments attack specific abnormalities within cancer cells. Targeted drugs approved to treat breast cancer include: Trastuzumab (Herceptin). Some breast cancers make excessive amounts of a protein called human growth factor receptor 2 (HER2), which helps breast cancer cells grow and survive. If your breast cancer cells make too much HER2, trastuzumab may help block that protein and cause the cancer cells to die. Side effects may include headaches, diarrhea and heart problems. Pertuzumab (Perjeta). Pertuzumab targets HER2 and is approved for use in metastatic breast cancer in combination with trastuzumab and chemotherapy. This combination of treatments is reserved for women who haven't yet received other drug treatments for their cancer. Side effects of pertuzumab may include diarrhea, hair loss and heart problems. Ado-trastuzumab emtansine (Kadcyla). This drug combines trastuzumab with a cell-killing drug. When the combination drug enters the body, the trastuzumab helps it find the cancer cells because it is attracted to HER2. The cell-killing drug is then released into the cancer cells. Adotrastuzumab emtansine may be an option for women with metastatic breast cancer who've already tried trastuzumab and chemotherapy. Lapatinib (Tykerb). Lapatinib targets HER2 and is approved for use in advanced or metastatic breast cancer. Lapatinib can be used in combination with chemotherapy or hormone therapy. Potential side effects include diarrhea, painful hands and feet, nausea, and heart problems. Bevacizumab (Avastin). Bevacizumab is no longer approved for the treatment of breast cancer in the United States. Research suggests that although this medication may help slow the growth of breast cancer, it doesn't appear to increase survival times.