Assessment and Management of Patients

with Breast Disorders

It would be most important for the nurse to palpate the breast to determine the presence
of a mass and to refer the patient to her primary care provider. Edema and pitting of the
skin may result from a neoplasm blocking lymphatic drainage, giving the skin an orangepeel appearance (peau dorange), a classic sign of advanced breast cancer. Evaluation of
milk production is required in lactating women. There is no indication of lactation in the
scenario. The patients knowledge of breast cancer is relevant, but is not a time-dependent
priority. This finding is not an age-related change.
The primary reason for raising the arms is to detect any dimpling. To elicit skin dimpling
or retraction that may otherwise go undetected, the examiner instructs the patient to raise
both arms overhead. Citing American Cancer Society recommendations does not address
the womans question. The purpose of raising the arms is not to elicit pain or to
redistribute adipose tissue.
A general guideline is to begin screening 5 to 10 years earlier than the age at which the
youngest family member developed breast cancer, but not before age 25 years. In families
with a history of breast cancer, a downward shift in age of diagnosis of about 10 years is
seen. Because their mother developed breast cancer at age 48 years, the daughters should
begin mammography at age 38 to 43 years.
The nurse should instruct the patient to stop taking aspirin due to its anticoagulant effect.
Limiting green leafy vegetables will decrease vitamin K and marginally increase
bleeding. Increasing fluid intake or being NPO before surgery will have no effect on
bleeding.
Tamoxifen has been shown to be a highly effective chemopreventive agent. However, it
cannot reduce the risk of cancer by 100%. It also acts to prevent osteoporosis.
Right mastectomy would be considered a prophylactic measure to reduce the risk of
cancer in the patients unaffected breast. None of the other listed interventions would be
categorized as being prophylactic rather than curative.
Pagets disease presents with erythema of the nipple and areola. Peau dorange, which is
associated with breast cancer, is caused by interference with lymphatic drainage, but does
not cause these specific signs. Nipple inversion is considered normal if long-standing; if
it is associated with fibrosis and is a recent development, malignancy is suspected. Acute
mastitis is associated with lactation, but it may occur at any age.
In the breast cancer diagnostic phase it is appropriate to acknowledge the patients
feelings of fear, concern, and apprehension. This must precede interventions such as
referrals, if appropriate. Assessment of stress management skills made be necessary, but
the nurse should begin by acknowledging the patients feelings. Fear is not necessarily
indicative of ineffective coping.
Treatment for breast cancer depends on the disease stage and type, the patients age and
menopausal status, and the disfiguring effects of the surgery. For this patient,
lumpectomy is the most likely option because the nodule is well-defined. The patient
usually undergoes radiation therapy afterward. Because a lumpectomy is possible,
mastectomy would not be the treatment of choice.

Assessment and Management of Patients

with Breast Disorders

Fine-needle aspiration and biopsy provide cells for histologic examination to confirm a
diagnosis, although falsenegative and falsepositive findings are possibilities. A breast
self-examination, if done regularly, is the most reliable method for detecting breast lumps
early, but is not diagnostic of cancer. Mammography is used to detect tumors that are too
small to palpate. Chest x-rays can be used to pinpoint rib metastasis. Neither test is
considered diagnostic of breast cancer, however.
Breast cancer tumors are typically fixed, hard, and poorly delineated with irregular edges.
A mobile mass that is soft and easily delineated is most commonly a fluid-filled benign
cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous
mass. Nipple retraction, not eversion, may be a sign of cancer.
The patient is not exhibiting clear signs of anxiety or depression. Therefore, the nurse can
probably safely approach her about talking with others who have had similar experiences.
The nurse may educate the patients spouse or partner to listen for concerns, but the nurse
should not tell the patients spouse what to do. The patient must consult with her
physician and make her own decisions about further treatment. The patient needs to
express her sadness, frustration, and fear. She cannot be expected to be optimistic at all
times.
Following an axillary dissection, the patient should avoid lifting objects greater than 5 to
10 pounds, cutting the cuticles, and undergoing venipuncture on the affected side.
Exercises of the hand and arm are encouraged and the use of a sling is not necessary.
Treatment of mastitis consists of antibiotics and local application of cold compresses to
relieve discomfort. A broad-spectrum antibiotic agent may be prescribed for 7 to 10 days.
The patient should wear a snug bra and perform personal hygiene carefully. Massage is
not recommended.
The patient should report sudden cessation of output from the drainage device, which
could indicate an occlusion. Gradual decline in output is expected. A temperature of
100.4F or greater should also be reported to rule out postoperative infection, but a
temperature of 98.5F is not problematic. Fatigue is expected during the recovery period.
The patient should report sudden cessation of output from the drainage device, which
could indicate an occlusion. Gradual decline in output is expected. A temperature of
100.4F or greater should also be reported to rule out postoperative infection, but a
temperature of 98.5F is not problematic. Fatigue is expected during the recovery period.
Late age at first pregnancy is a risk factor for breast cancer. None of the other listed
aspects of the patients health history is considered to be a risk factor for breast cancer.
Fibroadenomas are firm, round, movable, benign tumors. These masses are nontender and
are sometimes removed for biopsy and definitive diagnosis. They are not considered to be
an age-related change, even though they are benign. Radiation therapy is unnecessary and
fibroadenomas do not result from oral contraceptive use.
Generally, the lesions are nontender, fixed rather than mobile, and hard with irregular
borders. Small size is not suggestive of malignancy.
The radiation exposure of mammogram is equivalent to about 1 hour of exposure to
sunlight. Consequently, the benefits of mammography far outweigh any risks associated

Assessment and Management of Patients

with Breast Disorders

with the procedure. Negative consequences are insignificant, and do not accumulate later
in life.
Annual clinical breast examination is recommended for women aged 40 years and older.
Younger women may have examinations less frequently.
Instructions about BSE should be provided to men if they have a family history of breast
cancer, because they may have an increased risk of male breast cancer. It is not within the
scope of the practice of a nurse to refer a patient for a mammogram or to a surgeon; these
actions are not necessary or recommended. In the absence of symptoms or a diagnosis,
referral to a support group is unnecessary.
BSE is best performed after menses, on day 5 to day 7, counting the first day of menses
as day 1. Monthly performance is recommended.
Current practice emphasizes the importance of breast self-awareness, which is a womans
attentiveness to the normal appearance and feel of her breasts. BSE does not need to be
synchronized with the performance of mammograms. Rapport between the patient and
the care provider is beneficial, but does not necessarily determine the effectiveness of
BSE. The woman does not need to understand the pathophysiology of breast cancer to
perform BSE effectively.
Gynecomastia can also occur in older men and usually presents as a firm, tender mass
underneath the areola. In these patients, gynecomastia may be diffuse and related to the
use of certain medications. It is unrelated to fluid overload or nutrition and is not
considered an age-related change.
During the preoperative consultation, the patient should be informed of a possibility that
sensory changes of the nipple (e.g., numbness) may occur. There is no consequent
increase in breast cancer risk and it does not affect future mammography results. Chronic
pain is not an expected complication.
Ultrasound-guided core biopsy does not use radiation and is also faster and less
expensive than stereotactic core biopsy.
Incisional biopsy surgically removes a portion of a mass. This is performed to confirm a
diagnosis and to conduct special studies that will aid in determining treatment. Incisional
biopsies cannot always remove the whole mass, nor is it always beneficial to the patient
to do so. The procedure is not chosen because of the potential for pain, the possibility of
recovery from mastectomy, or the patients age.
Prior to discharge from the ambulatory surgical center or the office, the patient must be
able to tolerate fluids, ambulate, and void. The patient must have somebody to
accompany her home and would not be discharged with urinary catheter in place.
During the preoperative visit, the nurse assesses the patient for any specific educational,
physical, or psychosocial needs that she may have. This can be accomplished by
encouraging her to verbalize her fears, concerns, and questions. Reviewing her medical
history may be beneficial, but it is not the best way to ascertain her needs. Discussing
possible findings of the biopsy and possible treatment options is the responsibility of the
treating physician.

Assessment and Management of Patients

with Breast Disorders

Although many patients experience minimal pain, it is still important to assess for this
postsurgical complication. Sorrow and ineffective coping are possible, but neither is
likely to be evident in the immediate postoperative period. There is minimal risk of
trauma.
Providing the patient with realistic expectations about the healing process and expected
recovery can help alleviate fears. Offering the patient alternative treatment options is not
within the nurses normal scope of practice. Addressing survival rates may or may not be
beneficial for the patient. Written material is rarely sufficient to meet patients needs.
Each breast contains 12 to 20 cone-shaped lobes, which are made up of glandular
elements (lobules and ducts) and separated by fat and fibrous tissue that binds the lobes
together. These breast lobes do not consist of tendons, ligaments, endocrine glands, or
smooth muscle.
Gentle encouragement can help the patient progress toward accepting the change in her
appearance. The nurse should not downplay the significance of physical appearance.
Explaining that others have had similar experiences may or may not benefit the patient.
Asking the patient to describe the appearance of her breast is likely to exacerbate the
womans reluctance to do so.
If immediate reconstruction has been performed, showering may be contraindicated until
the drain is removed.
Patients who have difficulty managing their postoperative care at home may benefit from
a home health care referral. The home care nurse assesses the patients incision and
surgical drain(s), adequacy of pain management, adherence to the exercise plan, and
overall physical and psychological functioning. It is unnecessary to assess the patients
understanding of cancer at this stage of recovery. Prostheses may be considered later in
the recovery process.
A trusted ally to assist in making treatment choices is beneficial to the patients coping
ability. It is condescending and inappropriate to ask if the patient is feeling alright these
days or is concerned about the diagnosis. The patients education level is irrelevant.
Breast conservation along with radiation therapy in stage I and stage II breast cancer
results in a survival rate equal to that of modified radical mastectomy. Mastectomies are
still necessary in many cases, but are not associated with particular risk of recurrence.
Superficial thrombophlebitis of the breast (Mondor disease) is an uncommon condition
that is usually associated with pregnancy, trauma, or breast surgery. Pain and redness
occur as a result of a superficial thrombophlebitis in the vein that drains the outer part of
the breast. The mass is usually linear, tender, and erythematous. Fat necrosis is a
condition of the breast that is often associated with a history of trauma. The scenario
described does not indicate a recurrent malignancy. DVTs of the breast do not occur.
Galactography is a diagnostic procedure that involves injection of less than 1 mL of
radiopaque material through a cannula inserted into the ductal opening on the areola,
which is followed by mammography. It is performed to evaluate an abnormality within
the duct when the patient has bloody nipple discharge on expression, spontaneous nipple

Assessment and Management of Patients

with Breast Disorders
discharge, or a solitary dilated duct noted on mammography. X-ray, PET, and ultrasound
are not typically used for this purpose.