CASE STUDY 1

Name: Katina P. Serquia Class/Group: MSN104 Date: 04/18/2013 Group Members: ______________________________________________ INSTRUCTIONS: All questions apply to this case study. Your responses should
be brief and to the point. Adequate space has been provided for answers. When asked to provide several answers, they should be listed in order of priority or significance. Do not assume information that area not provided. Please print or write clearly. If your responses are not legible, it will be marked as ? and you will need to rewrite.

Scenario
B.B., a 53 years old divorced professional woman, was diagnosed with stage T1 N0 M0 infiltrating ductal breast cancer on her right side based on a lumpectomy and axillary lymph node dissection over a year ago. After her radiation theraphy (daily treatment for 6 weeks) was completed, she was placed on tamoxifen( to be taken for five years). She has been coming to the clinic every 3 months for her checkup in the year since her treatment was completed. In addition to working at the clinic, you are a volunteer consultant to the encore- YWCA support group for women who have had breast cancer, where B.B. regularly attends. The group has invited you to present breast cancer: prevention, screening, and detection guidelines at their next meeting.

1. What is tamoxifen? Why are women placed on long- termed tamoxifen therapy as a treatment for breast cancer?

Tamoxifen is an antagonist of the estrogen receptor in breast tissue via its active metabolite, hydroxytamoxifen. In other tissues such as the endometrium, it behaves as anagonist, and thus may be characterized as a mixed agonist/antagonist. Some breast cancer cells require estrogen to grow. Estrogen binds to and activates the estrogen receptor in these cells. Tamoxifen is metabolized into compounds that also bind to the estrogen receptor but do not activate it. Because of this competitive antagonism, tamoxifen acts like a key broken off in the lock that prevents any other key from being inserted, preventing estrogen from binding to its receptor. Hence breast cancer cell growth is blocked. Women are placed on long term therapy as treatment for breast cancer in order to ensure that recurrence will not likely to occur and increase the survival rates of patients. Although side effects from tamoxifen are few, patients must be examined for preexisting endometrial carcinoma before beginning drug use. Tamoxifen does not prevent the growth of endometrial tumors. Although the risk for endometrial cancer is not eradicated, the number of deaths associated with such disease exists only in few cases thus it still outweighs the risks for most patients.
2. What is an axillary lymph node dissection? Why did B.B. have an axilary lymph node dissection with her lumpectomy?

This procedure is usually done as part of a radical or modified radical mastectomy or a lumpectomy. Wherein as few as 10 or as many as 40 lymph nodes may be removed for testing. Axillary lymph node dissection may be done as part of a lumpectomy or mastectomy. These lymph nodes will be sent to the pathology lab where they will be carefully examined for cancer cells. You will need to know if your lymph nodes are negative (clear of cancer) or positive (contain cancer). This important information affects the staging of your cancer and influences your treatment options.

3. B. B. was diagnosed with stage T1 N0 M0 breast cancer. What does that mean?

The T (size) category describes the original (primary) tumor; the N (lymph node involvement) category describes whether or not the cancer has reached nearby lymph nodes; and the M (metastasis) category tells whether or not there is evidence that the cancer has traveled to other parts of the body. T1N0M0 staging means that the tumor measures up to 2 centimeters and the cancer has not spread outside the breast there is no tumor in the breast; instead, small groups of cancer cells larger than 0.2 millimeter but not larger than 2 millimeters are found in the lymph nodes or there is a tumor in the breast that is no larger than 2 centimeters, and there are small groups of cancer cells larger than 0.2 millimeter but not larger than 2 millimeters in the lymph nodes and no distant metastasis.

4. What risk factors for breast cancer will you include in your group presentation? A risk factor is anything that makes it more likely you'll get a particular disease. But having one or even several risk factors doesn't necessarily mean you'll develop cancer many women who develop breast cancer have no known risk factors other than simply being women. The following factors that are associated with an increased risk of breast cancer that will be include ion the presentation would be: Being female. Women are much more likely than men are to develop breast cancer. Increasing age. Your risk of breast cancer increases as you age. Women older than 55 have a greater risk than do younger women. A personal history of breast cancer. If you've had breast cancer in one breast, you have an increased risk of developing cancer in the other breast. A family history of breast cancer. If you have a mother, sister or daughter with breast cancer, you have a greater chance of being diagnosed with breast cancer. Still, the majority of people diagnosed with breast cancer have no family history of the disease. Inherited genes that increase cancer risk. Certain gene mutations that increase the risk of breast cancer can be passed from parents to children. The most common gene mutations are referred to as BRCA1 and BRCA2. These genes can greatly increase your risk of breast cancer and other cancers, but they don't make cancer inevitable. Radiation exposure. If you received radiation treatments to your chest as a child or young adult, you're more likely to develop breast cancer later in life. Obesity. Being overweight or obese increases your risk of breast cancer because fat tissue produces estrogen that may help fuel certain cancers. Beginning your period at a younger age. Beginning your period before age 12 increases your risk of breast cancer. Beginning menopause at an older age. If you began menopause after age 55, you're more likely to develop breast cancer. Having your first child at an older age. Women who give birth to their first child after age 35 may have an increased risk of breast cancer. Postmenopausal hormone therapy. Women who take hormone therapy medications that combine estrogen and progesterone to treat the signs and symptoms of menopause have an increased risk of breast cancer. Drinking alcohol. Drinking alcohol increases the risk of breast cancer. Experts recommend no more than one alcoholic beverage a day for women.
5. What will you teach the group about early detection of breast cancer?

We all know that the prognosis of the client depends on early detection and early management of the disease. Therefore, I will likely teach this group about breast self examination as one of the simplest yet effective screening tool to detect any structural changes as well as the presence of lumps that should not be there.
6. What educational equipment can help women learn how to perform BSE correctly and how to detect lumps?

New educational equipment that can help woman learn how to perform BSE and how to detect lumps would be the BREASTOLOGY BAG. It contains a set of 6 different soft

sculpture breasts. Each breast tells a story about breast health! One breast simulates the feel of a harmful lump and another simulates the feeling of fibrocystic lumpiness. You will learn the basics about how to feel for breast changes after seeing and feeling each breast and reading the simple teaching instructions printed on the back of each one. These friendly and non-threatening soft sculpture breasts will teach you, your clients, and friends, how to feel for breast changes. Teach your fingertips to develop a lasting impression for how your breasts normally feel so that you will easily recognize problems. Dont allow feeling awkward or anxious keep you from learning breast self -exam. The Breastology Bag is the perfect interactive breast selfexam teaching tool for group learning and for individuals. Ideal for health educators and healthcare professionals to use in education or on display. The cost-effective Breastology Bag is a valuable addition to any healthcare or wellness facility in promoting breast health awareness.

7. Describe the technique for performing BSE correctly. Using a "search pattern" can help you perform BSE more thoroughly. -To use the "line" technique, start under the arm and move your fingers downward slowly until they are below the breast. Then move your fingers slightly toward the middle, and slowly move back up. Continue going up and down until you cover the whole breast. -To use the "wedge" pattern, start at the outer edge of the breast, and move your fingers toward the nipple and back to the edge. Check the entire breast by covering one small wedge at a time. -You can also use a "circle" pattern by beginning at the outer edge of your breast and moving your fingers slowly around the whole breast in a circle. Keep feeling the breast in smaller circles, gradually working toward the nipple. Whichever pattern you prefer, remember to apply it up to the collar bone and out to the armpit. Step 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips. Here's what you should look for: Breasts that are their usual size, shape, and color Breasts that are evenly shaped without visible distortion or swelling If you see any of the following changes, bring them to your doctor's attention: Dimpling, puckering, or bulging of the skin A nipple that has changed position or an inverted nipple (pushed inward instead of sticking out) Redness, soreness, rash, or swelling Step 2: Now, raise your arms and look for the same Step 5: Finally, feel your breasts while you are standing or sitting. changes. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4. Step 3: While you're at the mirror, look for any signs of fluid coming out of one or both nipples (this could be a watery, milky, or yellow fluid or blood). Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few finger pads of your hand, keeping the fingers flat and together. Use a circular motion, about the size of a quarter. Cover the entire breast from top to bottom, side to side from your collarbone to the top of your abdomen, and from your armpit to your cleavage. Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger

circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lawn. This up-and-down approach seems to work best for most women. Be sure to feel all the tissue from the front to the back of your breasts: for the skin and tissue just beneath, use light pressure; use medium pressure for tissue in the middle of your breasts; use firm pressure for the deep tissue in the back. When you've reached the deep tissue, you should be able to feel down to your ribcage.
8. One of the women in the group shows you how the arm on the side that had the breast cancer is more swollen than the other arm. She said she is having a lot of trouble with this. What do you think is happening? How will you explain this to her? What will you advise her?

Based from the scenario above, I think the client is experiencing Lymphedema. I will explain this phenomenon to her by letting her understand the mechanism of how our lympathic system works thebey allowing her to understand what will likely happen if this system is damaged. Since lymphedema occurs when lymph is not able to flow through the body the way that it should, the client is then advice the following: Keep skin and nails clean and cared for, to prevent infection. Avoid blocking the flow of fluids through the body. Studies have shown that carefully controlled exercise is safe for patients with lymphedema Try to avoid gaining weight. Keep blood from pooling in the affected limb. Try to avoid muscle strain Try to avoid burns and high heat.
9. B.B. raises her hand and tells you she heard she should ever have her BP taken in her affected arm (the right arm in her case). You remember that you told her this in the office, but you realize she was probably too anxious or tired to remember exactly what you said. What will you advise her and the other woman present?

I will advise the clients that they should avoid constriction. Constriction or squeezing of the arm may increase the pressure in nearby blood vessels. This may lead to increased fluid and swelling (much like water building up behind a dam). Some women have linked this with the start of lymphedema. Lymphedema has also been linked with air travel, possibly because of air pressure changes. Tips they should follow include: Wear loose jewelry, clothing, and gloves. Avoid anything that forms a snug band around your arm or wrist. Do not use shoulder straps when carrying briefcases and purses. Wear a loose-fitting bra with padded straps that do not dig into your shoulder. After mastectomy, use a lightweight prosthesis (breast form). A heavy prosthesis may put too much pressure on the area. Have your blood pressure taken on the unaffected arm. If both arms are affected, blood pressure can be taken on your thigh. On long or frequent airplane flights, wear a compression sleeve. A well-fitted compression sleeve may help prevent swelling. But careful fitting is required, since any garment that is too tight near the top can actually reduce the lymph flow. Ask your doctor or physical therapist if you should be fitted for a sleeve to wear during air travel. You may also want to discuss ways to safely raise your arm above the level of your heart and exercise it during long flights.
10. B.B. also says she was told to watch for infection in the affected arm. She asks why thats important. What will you tell her?

I will tell the client that our body responds to infection by sending extra fluid and white blood cells to fight the infection. If lymph nodes and vessels are missing or damaged, it is harder for the body to move this extra fluid, which can trigger lymphedema. Good hygiene and careful skin care may reduce the risk of lymphedema by helping you avoid infections.
11. What are some other things breast cancer survivors can do to manage or prevent lymphedema? (List four.)

The goal of treatment is to control the swelling and other problems caused by lymphedema.Damage to the lymph system cannot be repaired. Treatment is given to control the swelling caused bylymphedema and keep other problems from developing or getting worse. The following measures are observed and can be used: Compression device-Compression devices are pumps connected to a sleeve that wraps around the arm or leg and applies pressure on and off. The sleeve is inflated and deflated on a timed cycle. This pumping action may help move fluid through lymph vessels and veins and keep fluid from building up in the arm or leg. Compression devices may be helpful when added to combine therapy. The use of these devices should be supervised by a trained professional because too much pressure can damage lymph vessels near the surface of the skin.

Laser therapy-Laser therapy may help decrease lymphedema swelling and skin hardness after a mastectomy. A hand-held, battery-powered device is used to aim low-level laser beams at the area with lymphedema. Combined therapy-Combined physical therapy is a program of massage, bandaging, exercises, and skin care managed by a trained therapist. At the beginning of the program, the therapist gives many treatments over a short time to decrease most of the swelling in the limb with lymphedema. Then the patient continues the program at home to keep the swelling down. Combined therapy is also called complex decongestive therapy. Bandages-Once the lymph fluid is moved out of a swollen limb, bandaging (wrapping) can help prevent the area from refilling with fluid. Bandages also increase the ability of the lymph vessels to move lymph along. Lymphedema that has not improved with other treatments is sometimes helped with bandaging.

CASE STUDY 1
Name: Karl Mark P. Serquia Class/Group: MSN104 Date: 04/18/2013 Group Members: ______________________________________________ INSTRUCTIONS: All questions apply to this case study. Your responses should
be brief and to the point. Adequate space has been provided for answers. When asked to provide several answers, they should be listed in order of priority or significance. Do not assume information that area not provided. Please print or write clearly. If your responses are not legible, it will be marked as ? and you will need to rewrite.

Scenario
B.B., a 53 years old divorced professional woman, was diagnosed with stage T1 N0 M0 infiltrating ductal breast cancer on her right side based on a lumpectomy and axillary lymph node dissection over a year ago. After her radiation theraphy (daily treatment for 6 weeks) was completed, she was placed on tamoxifen( to be taken for five years). She has been coming to the clinic every 3 months for her checkup in the year since her treatment was completed. In addition to working at the clinic, you are a volunteer consultant to the encore- YWCA support group for women who have had breast cancer, where B.B. regularly attends. The group has invited you to present breast cancer: prevention, screening, and detection guidelines at their next meeting.

1. What is tamoxifen? Why are women placed on long- termed tamoxifen therapy as a treatment for breast cancer? Tamoxifen is an anti-estrogen drug that is widely used to treat

breast cancer. Its occasionally used to treat some other cancers. These side effects can happen as a result of other hormonal treatment. Tamoxifen is a nonsteroidal antiestrogen that has become the frontline endocrine therapy for all stages of breast cancer. The drug is the only single-agent therapy that, when used in an adjuvant fashion, produces a survival advantage in postmenopausal women. Women are maintained in long term tamoxifen therapy because survival rates is longer when the estrogen receptor content of the primary tumor is higher, although receptor-poor patients still have a survival advantage from adjuvant tamoxifen equivalent to that noted with combination chemotherapy. The added advantages of tamoxifen are maintenance of bone density and a decrease in fatal myocardial infarction. Although side effects from tamoxifen are few, patients must be examined for preexisting endometrial carcinoma before beginning drug use. Tamoxifen does not prevent the growth of endometrial tumors. Although the risk for
endometrial cancer is not eradicated, the number of deaths associated

with such disease exists only in few cases thus it still outweighs the risks for most patients. 2. What is an axillary lymph node dissection? Why did B.B. have an axillary lymph node dissection with her lumpectomy?

Axillary lymph node dissection is a surgery to remove a tumor (lump) in a breast and a small amount of normal tissue around it. It is a type of breast-conserving surgery. This is usually done together with your mastectomy or lumpectomy. Our patient with lumpectomy had also undergone axillary lymph node dissection in order to diagnose properly on what areas are affected and to what extent is the spread of the cancer cells.
3. B. B. was diagnosed with stage T1 N0 M0 breast cancer. What does that mean?

The T (size) category describes the original (primary) tumor; the N (lymph node involvement) category describes whether or not the cancer has reached nearby lymph nodes; and the M (metastasis) category tells whether or not there is evidence that the cancer has traveled to other parts of the body. T1N0M0 staging means that the cancer cells have just started to invade the tissue outside the lining of the duct or lobule, but the invading cancer cells can't measure more than 1 millimeter and with no distant metastasis. T1N0M0 is similar to Stage1 breast cancer.
4. What risk factors for breast cancer will you include in your group presentation?

o o o o o o o o o

There are different kinds of risk factors. Some factors, like a person's age or race, can't be changed. Others are linked to cancer-causing factors in the environment. Still others are related personal behaviors, such as smoking, drinking, and diet. Some factors influence risk more than others, and your risk for breast cancer can change over time due to factors such as aging or lifestyle. Gender-Simply being a woman is the main risk factor for developing breast cancer. Men can develop breast cancer, but this disease is about 100 times more common among women than men. Aging-Your risk of developing breast cancer increases as you get older. About 1 out of 8 invasive breast cancers are found in women younger than 45, while about 2 of 3 invasive breast cancers are found in women age 55 or older. Genetic risk factors-About 5% to 10% of breast cancer cases are thought to be hereditary, resulting directly from gene defects (called mutations) inherited from a parent. Family history of breast cancer-Breast cancer risk is higher among women whose close blood relatives have this disease. Having one first-degree relative (mother, sister, or daughter) with breast cancer approximately doubles a woman's risk. Having 2 first-degree relatives increases her risk about 3-fold. Race and ethnicity-Overall, white women are slightly more likely to develop breast cancer than are AfricanAmerican women, but African-American women are more likely to die of this cancer. However, in women under 45 years of age, breast cancer is more common in African- American women. Menstrual periods-Women who have had more menstrual cycles because they started menstruating early (before age 12) and/or went through menopause later (after age 55) have a slightly higher risk of breast cancer. The increase in risk may be due to a longer lifetime exposure to the hormones estrogen and progesterone. Diethylstilbestrol exposure-From the 1940s through the 1960s some pregnant women were given the drug diethylstilbestrol (DES) because it was thought to lower their chances of miscarriage (losing the baby). These women have a slightly increased risk of developing breast cancer. Recent oral contraceptive use-Studies have found that women using oral contraceptives (birth control pills) have a slightly greater risk of breast cancer than women who have never used them. This risk seems to go back to normal over time once the pills are stopped. Alcohol-The use of alcohol is clearly linked to an increased risk of developing breast cancer.

5. What will you teach the group about early detection of breast cancer? We all know that the prognosis of the client depends on early detection and early management of the disease. Therefore, I will likely teach this group about breast self examination as one of the simplest yet effective screening tool to detect any structural changes as well as the presence of lumps that should not be there.
6. What educational equipment can help women learn how to perform BSE correctly and how to detect lumps?

Everyone knows that early detection saves lives. This is one simple tool that can be used to assist with early detection. The BREAST CANCER AWARENESS NECKLACE KIT (Item 23341) appears to only be available through Health Edco (www.healthedco.com) - it's inexpensive. If your doctor doesn't have one you should

suggest that she consider this an inexpensive investment in helping educate their patients. Organizations that specialize in breast cancer awareness will also have realistic breast models with palpable lumps but these tend to be too expensive for personal use. (Regarding these beads, since men can develop breast cancer this can help them recognize what to detect during their own self examinations.) This kit was developed by the University of North Carolina Breast Cancer screening program at the University of Notch Carolina's Lineberger Comprehensive Cancer Center. This necklace consists of six different sizes of wood beads (two each except for the largest bead): 3 mm, 7 mm, 9 mm, 13 mm, 25 mm, and 37 mm. These can be strung on a cord (provided) although I've simply kept them loose and in a silky bag (not provided). Each bead is associated with a statement. The "beads on this necklace represent the size of a lump that might be found" under varying conditions: 3 mm bead represents the size of lump first found by a woman receiving a mammogram every year or two. 7 mm bead represents the size of a lump found on a woman's first mammogram (if she had been procrastinating) 9 mm represents the size of a lump found by a health care provider giving a clinical breast exam (Probably Stage I tumor) 13 mm found by a woman who performs BSE's every month (this can still be considered a Stage I tumor) 25 mm found by a woman who occasionally performs a self exam (Most likely a Stage II tumor) 37 mm found by a woman who rarely or never performs a self exam.
7. Describe the technique for performing BSE correctly.

The key to this exam is to spot changes in your breasts. Many women naturally have beasts that are different sizes or heights or a tendancy toward developing harmless lumps. Look for changes that persist after your menstral cycle or any changes that concern you.
Proper technique is essential to ensure that you examine the entire Puckering or dimpling in the skin of the nipples or breast. breast. It's a good idea to ask a doctor or nurse to instruct you, and to A sore or ulcer on the breast skin that does not heal. have illustrations to guide you. Sticky or bloody nipple discharge. First, What Are We Looking For Scaling, crusting or erosion of the nipple. A painless lump in the breast or armpit. Inversion or retraction of the nipple. Unexplained pain in the breast with no lump. An increase in size of one breast. Unusual thickening of the breast skin. One breast has suddenly shifted postition/height. Swelling, redness or distortion of the breast skin. Step 1 - In front of the mirror Standing undressed in front of a mirror, look at your breasts with your arms at your sides; check each breast for anything unusual, such as puckering, dimpling, or scaliness. Remember to look beneath each breast, using your hands to lift the breasts if necessary. Clasp your hands behind your head and press them forward. You should feel your chest muscles tightening, allowing you to see the contours of your breasts. Turn from side to side so you can see the outer surfaces. Next, inspect your breasts while pressing your hands firmly on your hips and bending forward slightly, pulling your shoulders and elbows forward as well. Standing erect again, raise one arm, and use the pads of the three middle fingers of the opposite hand to feel the breast. You can use lotion or powder to help your fingers glide easily over the skin, or you can do the raised-arm part of the exam in the shower with soapy skin. Step 2 - Lying down Lie down with a pillow under your left shoulder, and put your left hand behind your head. Feel your left breast with the pads of the three middle fingers of your right hand. Start at the outer edge and work inward toward the nipple. Then squeeze your nipple gently to look for discharge. Do the same thing to your right breast with a pillow under your right shoulder. Be sure to include the area up to your collarbone and out to your armpit.

USING A "SEARCH PATTERN" CAN HELP YOU PERFORM BSE MORE THOROUGHLY. To use the "line" technique, start under the arm and move your fingers downward slowly until they are below the breast. Then move

your fingers slightly toward the middle, and slowly move back up. Continue going up and down until you cover the whole breast. To use the "wedge" pattern, start at the outer edge of the breast, and move your fingers toward the nipple and back to the edge. Check the entire breast by covering one small wedge at a time. You can also use a "circle" pattern by beginning at the outer edge of your breast and moving your fingers slowly around the whole breast in a circle. Keep feeling the breast in smaller circles, gradually working toward the nipple. Whichever pattern you prefer, remember to apply it up to the collar bone and out to the armpit.
8. One of the women in the group shows you how the arm on the side that had the breast cancer is more swollen than the other arm. She said she is having a lot of trouble with this. What do you think is happening? How will you explain this to her? What will you advise her?

I believe the client is experiencing lymphedema. Bodily fluids that are being collected in the lympathic system were not able to follow the correct flow of fluid thereby causing pooling of liquid particles in the lymph vessels. I will explain this by letting her understand the mechanism of action of our lymph vessels and allow her to understand the proper use of the lympathic system. Through this, client will be able to understand what will likely happen if the lympathic system fails. I would advise her to follow the following: DO protect your arm from sunburn. Wear a sunscreen with a high SPF. DO avoid insect bites. Wear insect repellant. DO wear gloves when gardening or doing other yard work. DO get regular exercise, but avoid repetitive motion with your arm to the point of muscle fatigue. DO NOT allow outdoor pets to scratch or bite your hand or arm. DO NOT expose at-risk limbs to the extreme heat of hot tubs. DO NOT play sports which may result in injury to your arm. DO wear gloves while doing housework. DO wear oven mitts when moving hot plates to and from the oven or burner. DO try to avoid burns from grease splatter when frying foods. DO keep your arm clean and apply moisturizing cream regularly. DO thoroughly clean and apply an over-the-counter antibiotic and bandage to any scratch or cut immediately after the injury occurs. DO dry your arm thoroughly after bathing, but DO NOT rub the arm harshly with your towel in the drying process.
9. B.B. raises her hand and tells you she heard she should ever have her BP taken in her affected arm (the right arm in her case). You remember that you told her this in the office, but you realize she was probably too anxious or tired to remember exactly what you said. What will you advise her and the other woman present?

Advise the two women to avoid allowing the skin of your at-risk arm or hand to be pierced or pressured for any reason: for example, injections, blood draws, intravenous lines, vaccines, and blood pressure. Its up to you to remind physicians and nurses about this at every appointment. You may wish to invest in a lymphedema medical alert bracelet you can wear on the affected arm. These are available for purchase through the National Lymphedema Network. Another option is a G-sleeve, a flexible garment worn on the forearm and clearly labeled no blood draws, no blood pressure, no IVs. You can put it on before doctor visits or wear it continuously during a hospital stay. If youve had breast cancer in both breasts along with underarm lymph node dissections, ask if you can have any blood draws or blood pressure measurements taken on another area of the body. To protect your arm and hand from overuse, trauma, or too much pressure: Avoid taking unusually hot baths or showers and immersing the arm and upper body in high-heat hot tubs or steam baths. If you wish to use a hot tub, keep your affected arm out of the water and limit your exposure to 15 minutes or less. Dont apply heating pads or hot compresses to the arm, neck, shoulder, or back on the affected side. Also, be cautious of other heat-producing treatments provided by physical, occupational, or massage therapists, such as ultrasound, whirlpool, fluidotherapy (which combines high heat and massage), or deep tissue massage. Heat and vigorous massage bring extra fluid into that area of the body. Avoid carrying heavy objects or shoulder bags on your at-risk arm, especially with the arm hanging downward, at least initially. As you strengthen the arm over time, you should able to carry heavier objects again. Avoid wearing tight watches, bracelets, or rings on your affected hand or arm. Avoid wearing clothing that has tight sleeves or that restrains movement.

Avoid exercises that put great pressure on the arm such as push-ups, the downward dog position in yoga, heavy weightlifting, or bowling until you and your therapist determine what your arm can handle and how to build up its strength.

10. B.B. also says she was told to watch for infection in the affected arm. She asks why thats important. What will you tell her?

I will tell the client that our body responds to infection by sending extra fluid and white blood cells to fight the infection. If lymph nodes and vessels are missing or damaged, it is harder for the body to move this extra fluid, which can trigger lymphedema. Good hygiene and careful skin care may reduce the risk of lymphedema by helping you avoid infections.
11. What are some other things breast cancer survivors can do to manage or prevent lymphedema? (List four.)

These are other things survivors can do to manage or prevent lymphedemaa. Weight loss-In patients who are overweight, lymphedema related to breast cancer may improve with weight loss. Drug therapy-Lymphedema is not usually treated with drugs. Antibiotics may be used to treat and prevent infections. Other types of drugs, such as diuretics or anticoagulants (blood thinners), are usually not helpful and may make the lymphedema worse. Exercise-Both light exercise and aerobic exercise (physical activity that causes the heart and lungs to work harder) help the lymph vessels move lymph out of the affected limb and decrease swelling. Pressure garments-Pressure garments are made of fabric that puts a controlled amount of pressure on different parts of the arm or leg to help move fluid and keep it from building up. Some patients may need to have these garments custom-made for a correct fit. Wearing a pressure garment during exercise may help prevent more swelling in an affected limb. It is important to use pressure garments during air travel, because lymphedema can become worse at high altitudes. Pressure garments are also called compression sleeves and lymphedema sleeves or stockings.