College of Nursing

Silliman University
Dumaguete City

Syllabus
On

End-Stage Renal Disease

Submitted to:
Mrs. Corazon Ordonez, BSN-RN
Clinical Instructor

Submitted by:
Marodvi Zerna

November 9, 2010
Vision
A leading Christian institution committed to total human development for the well-being of
society and environment.

Mission
 Infuse into the academic learning the Christian faith anchored on the gospel of Jesus
Christ; provide an environment where Christian fellowship and relationship can be
nurtured and promoted.
 Provide opportunities for growth and excellence in every dimension of the University
life in order to strengthen character, competence and faith.
 Instill in all members of the University community an enlightened social consciousness
and a deep sense of justice and compassion.
  Promote unity among peoples and contribute to national development.
COLLEGE OF NURSING
Silliman University
Dumaguete City

Resource Unit on End-Stage Renal Disease

Placement: Level IV, Medicine Rotation

Time Allotment: 1 hour
Topic Description: This topic focuses on breast cancer and its detrimental effects on the body. This includes the risk factors of breast cancer, diagnostic test for
the presence of the breast cancer, its brief pathophysiology as well as its possible signs and symptoms. The topic also covers the different stages and the different
kinds of breast cancer and the different management and treatment of breast cancer. The different responsibilities of a nurse towards the care of patient
undergoing mastectomy are also included in this topic.
Central Objective: Within 1 hour of ward class, the learners shall acquire deeper understanding, hasten beginning skills, and manifest positive attitude
towards the care of patients with end-stage renal disease or chronic renal failure.

Specific Content T.A. T-L Activities Evaluation

Objectives
Given varied *PRAYER
teaching- Oral Evaluation
learning I. Introduction 1 min Lecture by a Game
activities discussion
within 1 hour, II. Definition of terms Instruction:
the learners participants will
shall: III. Anatomy and Physiology choose a
number on a
Breasts are located anterior to the pectoral muscle. In many women, breast tissue extends well into the screen and
1. Define in axilla. Milk glands of the breasts are divided by connective tissue partitions into approximately 20 lobes. All of the 2 mins Lecture answer the
their own glands in each lobe produce milk by acinar cells and deliver it to the nipple via a lactiferous duct. The nipple has discussion question behind
words the approximately 20 small openings through which milk is secreted. An ampulla portion of the duct, located just that number
terminologie posterior to the nipple, serves as a reservoir for milk before breast-feeding. with a specific
s given prize.
A nipple is composed of smooth muscle that is capable of erection on manual or sucking stimulation. On
stimulation, it transmits sensations to the posterior pituitary gland to release oxytocin. Oxytocin acts to Questions:
constrict milk gland cells and push milk forward into the ducts that lead to the nipple. The nipple is surrounded 1. Define in
by a darkly pigmented area of epithelium approximately 4 cm in diameter, termed the areola; the areola their own
appears rough on the surface because it contains many sebaceous glands, called Montgomery's tubercles. words the
terminologie
2. Recall the The blood supply to the breasts is profuse; it is supplied by thoracic branches of the axillary, internal s given
anatomy mammary and intercostal arteries. This effective blood supply is important in bringing nutrients to the milk
and glands and makes possible a plentiful supply of milk for breast-feeding. However, it also aids in the metastasis
physiology of breast cancer if this is not discovered early by breast examination or mammography. 2 mins Socialized 2. Recall the
of the breast discussion with anatomy
IV. Risk Factors the use of and
visual aids physiology
1. Age and Ethnicity of the
All women are at risk for breast cancer, and the most important single risk factor is age. Risk increases breast
with age, although the rate of increase slows after menopause. The annual incidence of breast cancer in
American women 80 to 85 years of age is 15 times higher than that in women 30 to 35 years of age. African
American women under age 50 years have a higher age-specific incidence of breast cancer than that in
Caucasian women. Edwards and colleagues, in their examination of the impact of race on survival in breast
 cancer, found that not only are African American women less likely to be cured than their non-African
American counterparts, but they also survive for a shorter time until death from breast cancer. Breast cancer
incidence among Hispanic women living in North America is only 40% to 50% as great as that among non-
Hispanic white women. Asian women born in Asia have a very low lifetime risk for breast cancer, but their
daughters born in North America have the same lifetime risk of breast cancer as for American white women.

2. Ovarian and Hormonal Function

3. Name at Early menarche (first menses) and late menopause (cessation of menses) lead to an increased total lifetime
least 3 risk number of ovulatory menstrual cycles and a corresponding 30% to 50% increase in breast cancer risk. The
woman who experiences natural menopause before age 45 years has a risk for breast cancer that is half that of 5 mins Lecture 3. Name at
factors of
the woman whose menopause occurs after age 55 years. Likewise, oophorectomy before a woman reaches discussion least 3 risk
breast
menopause lowers her risk of breast cancer by approximately two thirds. Both nulliparity (no births) and age factors of
cancer
over 30 years at first live birth are associated with a nearly doubled risk of subsequent breast cancer. The use breast
of hormone-replacement therapy (HRT) has also demonstrated a small but significant increase risk for breast cancer
cancer in women who used it for more than 10 years. At present, there is no convincing evidence that oral
contraceptive use affects the risk of breast cancer. The question is difficult to address because the oral
contraceptives in use today are vastly different (in that dosages are much lower) from those used 15 and 20
years ago. Even if oral contraceptives influence the incidence of breast cancer, it would be only of historical
interest because the drugs used years ago are not comparable to those used today.

3. Benign Breast Disease

Benign breast disease is not more common in women with other risk factors for breast cancer.
Nonproliferative lesions (such as cysts, duct ectasia, mild hyperplasia, and fibroadenoma) do not increase the
risk of breast cancer; however, cellular atypia or atypical hyperplasia (a proliferative disease) is an example of
a histologic change associated with a higher risk. Sclerosing adenosis increases the risk of breast cancer by
approximately 70%. Nearly 40% of women with a family history of breast cancer and atypical hyperplasia
subsequently have breast cancer.

4. Family History
Family history is one of the known risk factors for breast cancer. Breast cancer due to the inheritance of a
specific germline mutation from either maternal or paternal relatives is rare. In fact, breast cancer
susceptibility gene BRCA1 and BRCA2 and the p53 tumor suppressor gene have been identified in fewer than
10% of all women with breast cancer. Certain populations have a higher incidence of BRCA mutations than
the general population. Depending on the familial context, the lifetime risk of breast cancer, ovarian cancer, or
both associated with carrying a mutation ranges from 50% to 85%. Families with several affected first-degree
relatives and clients with early-onset disease have been found to harbor mutations at a higher frequency.
Women who have the BRCA 2 mutation tend to have early-onset (before age 50) breast cancer but not ovarian
cancer. Identification of the BRCA1 gene makes it possible to identify women who have a 90% to 95%
lifetime likelihood of developing breast cancer (with a 70% risk of breast cancer by age 60). Test for these
mutations exist, and research efforts to develop comprehensive genetic screening and counseling programs are
ongoing.

5. Environmental and Dietary Factors

An increased incidence of breast cancer has been reported in women who received mantle radiation for the
treatment of Hodgkin’s disease, particularly if they were younger than 20 years of age. The latency period is
between 10 and 25 years. The disease in this group typically presents more aggressively, with a high rate of
nodal involvement and bilaterality. It is for this reason that all persons who receive mantle radiation for
Hodgkin’s disease, especially those treated prior to age 20, receive a regular mammography follow-up
examination in order to detect these lesions early.

Alcohol intake is the best-established dietary risk factor for breast cancer in epidemiologic studies. The
positive correlation of alcohol intake with breast cancer risk has been established, and it appears that moderate
alcohol intake (two drinks per day) increases the risk of breast cancer by altering estrogen metabolism. Nurses
have a unique role in fostering health promotion and in teaching women about breast cancer as well as in
identifying a woman’s individual risk for breast cancer. Because some women especially those with any
family history of breast cancer greatly overestimate their risk for breast cancer, greatly overestimate their risk
for breast cancer, it is helpful to instruct women about the known risk factors and, as indicated. Counseling,
with appropriate referrals when required, should always accompany specific recommendations for clients with
significant risks.

V. Types of Breast Cancer

1. Ductal Carcinoma in Situ (DCIS)
The increased use of mammography as a screening tool has contributed to the dramatic increase in the
diagnosis of ductal carcinoma in situ (DCIS). An estimated 62,000 new cases are diagnosed annually (Jemal et
al., 2006). DCIS is characterized by the proliferation of malignant cells inside the milk ducts without
invasion into the surrounding tissue. Therefore, it is a noninvasive form of cancer(also called intraductal
 carcinoma). DCIS is frequently manifested on a mammogram with the appearance of calcifications, and it
is considered breast cancer stage 0.

If DCIS is left untreated, there is an increased likelihood that it will progress to invasive cancer .
Deciding on the best surgical treatment option can be very complex. DCIS can be categorized in terms
of its aggressiveness depending on a variety of factors , including histological subtype(comedo is more
aggressive than non comedo), size of tumor , and whether it is multicentric(present in different quadrants of
the breast). These factors, together with patient preference , are important determinants in making
treatment decisions. The most traditional treatment is total or simple mastectomy( removal of the breast
4. Differentiat only) , with a cure rate of 98% to 99%. The trend today is toward less aggressive surgery ; breast
e the 2 conservation treatment (limited surgery followed by radiation ) is being performed with increasing 4. Differentiat
types of frequency. In rare cases, lumpectomy alone is an option. 5 mins Lecture e the 2
breast discussion types of
cancer 2. Invasive Cancer breast
Types of Cancer cancer

2.1 INFILTRATING DUCTAL CARCINOMA- the most common histologic type of breast cancer ,
accounts for 75% of all cases. The tumors arise from the duct system and invade the surrounding tissues
. They often form a solid irregular mass in the breast.

2.2 INFILTRATING LOBULAR CARCINOMA- accounts for 5% to 10% of breast cancers . The
tumors arise from the lobular epithelium and typically occur as an area of ill- defined thickening
breast. They are often multicentric and can be bilateral.

2.3. MEDULLARY CARCINOMA- accounts for about 3% of breast cancers and it tends to be
diagnosed more often in women younger than 50 years . The tumors grow in a capsule inside a duct .
They can become large and may be mistaken for a firoadenoma. The prognosis is often favorable.

2.4 MUCINOUS CARCINOMA- accounts for about 3% of breast cancers and often presents in
postmenopausal women 75 years and older. A mucin producer , the tumor is also slow-growing and thus
the prognosis is more favorable than in many other types.

2.5 TUBULAR DUCTAL CARCINOMA- accounts for about 2% of breast cancers. Because axillary
 metastases are uncommon with this histology, prognosis is usually excellent.

2.6 INFLAMMATORY CARCINOMA- is a rare (1% to 2%) and aggressive type of breast cancer that
has unique symptoms. The cancer is characterized by diffuse edema and brawny erythema of the skin,
often referred to as peau d’ orange(resembling an orange peel) . This is due to malignant cells blocking the
lymph channels in the skin. An associated mass may or may not be present; if there is, it is often a large
area of indiscrete thickening . Inflammatory carcinoma can be congused with an infection because of its
presentation . The disease can spread to other parts of the body rapidly. Chemotherapy plays an initial role
in controlling disease progression , but radiation and surgery may also be useful.

2.7 PAGET DISEASE

Paget disease of the breast accounts for 1% of diagnosed breast cancere cases. Symptoms typically
include a scaly, erythematous, pruritic lesion of the nipple. Paget disease often represents ductal carcinoma
in situ of the nipple but may have an invasive component. Mammography should be performed followed by
a biopsy of the involved skin area.

VI. Clinical Manifestations

1. Lesions are nontender, fixed, hard with irregular borders - cancer grows into the tissue around it in an
irregular pattern, once the lesion is palpable, it is felt as an irregular, poorly defined mass.
2. Skin dippling – occurs with invasion of the dermal lymphatics because of retraction of cooper ligament
or involvement of the pectoralis fascia
3. Nipple retraction – this is due to the shortening of the mammary ducts
4. Nipple ulceration – occurs due to tumor necrosis
5. Nipple discharge - spontaneous and intermittent discharge caused by tumor
6. Heat and erythema of the breast skin – warmth is one of the signs of infection
7. Skin edema – due to the local inflammation or lymphatic obstruction

VII. Detection and Diagnosis

5. Enumerate
at least 4 A. Breast Examination
5. Enumerate
Clinical Self breast examination can detect palpable breast lumps. It needs to be thorough and should preferably be
at least 4
 manifestatio 2 mins Lecture Clinical
nsof breast performed on days 5-10 of the menstrual cycle allowing the woman to contact her physician for early discussion manifestati
cancer evaluation (http://www.wrongdiagnosis.com/c/cancer/book-diseases-12a.htm). onsof breast
cancer
Complete breast examination is usually part of routine annual care for women > 35; it can detect 7 to 10%
of cancers that cannot be seen on a mammogram. (http://www.merck.com/mmpe/sec18/ch253/ch253e.html).
This examination includes visual inspection and careful palpation (feeling) of the breasts, the armpits, and the
areas around your collarbone (http://www.emedicinehealth.com/breast_cancer/article_em.htm).

B. Mammography
6. Explain in
their own Mammography is a breast-imaging technique that can detect nonpalpable lesions and assist in diagnosing 6. Explain in
words one palpable masses. The procedure takes about 20 minutes. Two views are taken of each breast: a craniocaudal their own
diagnostic view and a mediolateral oblique view. For these views, the breast is mechanically compressed from top to words one
procedure bottom and side to side. Mammography may detect a breast tumor before it is clinically palpable (ie, smaller 10 mins Lecture diagnostic
in detecting than 1 cm); however, it has limitations and is not fool-proof. The false-negative rate ranges between 5% and discussion with procedure
breast 10%; it is generally greater in younger women with greater density of breast tissue. Some patients have very visual aids and in detecting
cancer dense breast tissue, making it difficult to detect lesions with mammography. The radiation exposure is video breast
equivalent to about 1 hour of exposure to sunlight, so patients would have to have many mammograms in a presentation cancer
year to increase their cancer risk. The benefits of this test outweigh the risks. Current mammographic screening
guidelines from the American Cancer Society recommend a mammogram every year starting at the age of 40
years.

Several studies suggest that screening for high-risk women should begin about 10 years before the age of
diagnosis of the family member with breast cancer (Hartmann, Sellers, Schaid et al., 1999). In families with a
history of breast cancer, a downward shift in age of diagnosis of about 10 years is seen (eg, grandmother
diagnosed with breast cancer at age 48, mother diagnosed with breast cancer at age 38, then daughter should
begin screening at age 28). Nurses need to provide teaching about screening guidelines for women in the
general population and those at high risk so that these women can make informed choices about screening.
Many nurses direct their efforts at educating women about the benefits of mammography. Working to
overcome barriers to screening mammography, especially among the elderly and women with disabilities, is an
important nursing intervention in the community, and nurses have an important role in the development of
educational materials targeted to specific literacy levels and ethnic groups.
 C. Ultrasonography

Ultrasonography (ultrasound) is used in conjunction with mammography to distinguish fluid-filled cysts

from other lesions (http://www.emedicinehealth.com/breast_cancer/article_em.htm). A transducer is used to
transmit high-frequency sound waves through the skin and into the breast, and an echo signal is measured. The
echo waves are interpreted electronically and then displayed on a screen. This technique is 95% to 99%
accurate in diagnosing cysts.

D. Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) of the breast is a promising tool for use in diagnosing breast
conditions. It is a highly sensitive, although not specific, test and serves as an adjunct to mammography. A coil
is placed around the breast, and the patient is placed inside the MRI machine for about 2 minutes. An injection
of gadolinium, a contrast dye, is given intravenously. MRI of the breast can be helpful in determining the exact
size of a lesion or the presence of multiple foci more precisely than mammography. Other uses include
identifying occult (undetectable) breast cancer, determining the tumor’s response to chemotherapy, and
determining the integrity of saline or silicone breast implants.

E. Biopsy

Stereotactic Biopsy
Stereotactic biopsy, also an outpatient procedure, is performed for nonpalpable lesions found on
mammography. The patient lies prone on a special table, and the breast is positioned through an opening in the
table and compressed for a mammogram. The lesion to be sampled is then located with the aid of a computer.
Next, a local anesthetic is injected into the entry site on the breast, a core needle is inserted, and samples of the
tissue are taken for pathologic examination. If the lesion is small, a clip is placed at the site of the biopsy, so
that a specific area can be visualized again as another mammogram is performed. This technique allows
accurate diagnosis and often allows the patient to avoid a surgical biopsy.

Surgical Biopsy
Surgical biopsy is the most common outpatient surgical procedure. The procedure is usually done using
local anesthesia, moderate sedation, or both. The biopsy involves excising the lesion and sending it to the
laboratory for pathologic examination.

Excisional Biopsy
Excisional biopsy is the usual procedure for any palpable breast mass. The entire lesion, plus a margin of
surrounding tissue, is removed. This type of biopsy may also be referred to as a lumpectomy.

Incisional biopsy
Incisional biopsy is performed when tissue sampling alone is required; this is done both to confirm a
diagnosis and to determine the hormonal receptor status. Complete excision of the area may not be possible or
immediately beneficial to the patient, depending on the clinical situation. This procedure is often performed in
women with locally advanced breast cancer or in cancer patients with a suspicion of recurrent disease, whose
treatment may depend on the tumor’s estrogen and progesterone receptor status. These receptors are identified
during pathologic examination of the tissue.

Breast biopsies are one of the most common ambulatory surgical procedures performed, with 80% of the
results negative for malignancy. Prior to the procedure, the nurse’s role is to provide instruction; however, it is
important for the nurse to first assess how the woman is coping with her need for the procedure and her ability
to process information about the procedure and the possible implications of the biopsy results. Anxiety and
fear are normal responses to the need for a breast biopsy, but these responses may interfere with the woman’s
ability to recall and understand the information that is provided prior to the procedure. The nurse also must
give the patient an opportunity to address issues and concerns related to the biopsy. The nurse instructs the
patient to avoid use of agents that can interfere with blood clotting and increase the risk for bleeding. The
patient may be instructed not to eat or drink after midnight.

Postoperative assessment includes monitoring the effects of the anesthesia and inspection of the dressing
covering the incision. Prior to discharge from the ambulatory surgery center or office, the patient must be able
to tolerate fluids or food, ambulate, and void.

At discharge, the nurse reviews with the patient the care of the biopsy site, pain management, and activity
restrictions. The dressing covering the incision is usually removed on the second day, but use of a supportive
bra is encouraged immediately after the procedure for 3 to 7 days to limit movement of the breast and reduce
discomfort. Follow-up after the biopsy includes a return visit to the surgeon for discussion of the final
pathology report and assessment of the healing of the biopsy site. Depending on the results of the biopsy, the
 nurse’s role varies. If the pathology report is negative for cancer, the nurse reviews incision care and explains
what to expect as the biopsy site heals (ie, changes in sensation may occur weeks or months after the biopsy
due to injury to the nerves within the breast tissue). If a diagnosis of cancer is made, the nurse’s role changes
dramatically.

F. Brachytherapy

Delivers partial breast radiation by placing a radioactive source within the lumpectomy site. This
technique can lead to an improved quality of life , because the treatments are administered over 4 to 5 days
instead of 5to 6 weeks.

VIII. Pathophysiology

Breast cancers are malignant tumors that typically begin in the ductal-lobular epithelial cells of the breast
via the lymphatic system to the axillary lymph nodes. Breast cancer is a disease of the glandular epithelium
(Black, 2002).

Pathogenesis probably involves two or three steps. First modifications of the DNA of the breast epithelial
ductal cells are caused by either genetic alterations, environmental agents, or their interactions. The initiated
changes in DNA probably occur early in a woman’s life—before full differentiation of the breast tissue.
Second, growth factors increase the rate of growth of premalignant to malignant cells—the most important of
which are estrogen and progesterone. Third is the progressive modification of specific oncogenes or the loss of
specific suppressor genes leading to advanced metastatic disease (Burke, 2004).

Breast cancer occurs because of an interaction between the environment and a defective gene. Cells
become cancerous when mutations destroy their ability to stop dividing, to attach to other cells and to stay
7. Briefly where they belong. When cells divide, their DNA is normally copied with many mistakes. The mutations
discuss the known to cause cancer, such as, BRCA1 and BRCA2, occur in the error-correcting mechanisms. These 7. Briefly
pathophysio mutations are either inherited or acquired after birth. Presumably, they allow the other mutations, which allow discuss the
logy of uncontrolled division, lack of attachment, and metastasis to distant organs. Mutations that can lead to breast 5 mins Lecture pathophysio
breast cancer have been experimentally linked to estrogen exposure (http://en.wikipedia.org/wiki/Breast_cancer). discussion logy of
cancer breast
As long as the cancer remains within the duct, it is considered noninvasive. The cancer is classified as cancer
 invasive when it penetrates the tissue surrounding the duct. Once invasive, the cancer grows into the tissue
around it in an irregular pattern; for this reason, once the lesion is palpable, it is felt as an irregular, poorly
defined mass. Breast tumor may then metastasize to distant regions of the body. Metastases from vertebral
veins can involve the vertebrae, pelvic bones, rib, and skull. The lungs, kidneys, liver, adrenal glands, ovaries,
and pituitary gland are also sites of metastasis. The finding of breast cancer in the axillary lymph nodes is an
indicator of the tumor’s ability for potential distant spread and is not merely contiguous growth into the
adjacent region of the breast. Most primary breast cancers are located in the upper outer quadrant of the breast
(Black, 2002).

IX. Staging

In the website http://www.cancer.gov/cancertopics/wyntk/breast, different stages of breast cancer were

discussed. These stages are based on the size of the cancer, whether the cancer has invaded nearby tissues, and
whether the cancer has spread to other parts of the body. In this website they have defined each stage as
follows.

Stage 0 is sometimes used to describe abnormal cells that are not invasive cancer. For example, Stage 0 is
used for ductal carcinoma in situ (DCIS). DCIS is diagnosed when abnormal cells are in the lining of a breast
duct, but the abnormal cells have not invaded nearby breast tissue or spread outside the duct.

Stage I is an early stage of invasive breast cancer. Cancer cells have invaded breast tissue beyond where
the cancer started, but the cells have not spread beyond the breast. The tumor is no more than 2 centimeters
8. Be familiar
across.
to the 8. Be familiar
different
Stage II is when the tumor is more than 2 centimeters. The tumor size is 2-5 centimeters across. In this to the
stages of
stage the cancer may or may not spread to the lymph nodes under the arm or not. different
breast
4 mins Lecture stages of
cancer
Stage III is locally advanced cancer. It is divided into Stage IIIA, IIIB, and IIIC. discussion with breast
visual aids cancer
 Stage IIIA

The tumor is more than 5 centimeters across. The cancer has spread to underarm lymph nodes that are
either alone or attached to each other or to other structures. Or the cancer may have spread to lymph
 nodes behind the breastbone.

 Stage IIIB is a tumor of any size that has grown into the chest wall or the skin of the breast. It may be
associated with swelling of the breast or with nodules (lumps) in the breast skin. The cancer may have
spread to underarm lymph nodes that are attached to each other or other structures. Or the cancer may
have spread to lymph nodes behind the breastbone.

 Stage IIIC is a tumor of any size. The cancer has spread to the lymph nodes behind the breastbone,
above or below the collarbone and under the arm.

Stage IV is distant metastatic cancer. The cancer has spread to other parts of the body, such as the bones or
liver.

X. Breast Cancer treatment with its Nursing Management

Modified radical mastectomy

Modified radical mastectomy is removal of the entire breast tissue, along with axillary lymph nodes. The
pectoralis major and pectoralis minor muscles remain intact. Before surgery, the surgeon plans an incision that
will provide maximum opportunity to remove the tumor and the affected nodes. At the same time, efforts are
made to avoid a scar that will be visible and restrictive. An objective of surgical treatment is to maintain or
restore normal function to the hand, arm, and shoulder girdle on the affected side. Skin flaps and tissue are
handled with great care to ensure proper viability, hemostasis, and drainage. After the tumor is removed,
bleeding points are ligated and the skin is closed over the chest wall. Skin grafting is performed if the skin
flaps are too small to close the wound. A nonadherent dressing (Adaptic) may be applied and covered by a
pressure dressing. Two drainage tubes may be placed in the axilla and beneath the superior skin flap, and
9. Name at portable suction devices may be used; these remove the blood and lymph fluid that collect after surgery. The 9. Name at
least 1 dressing may be held in place by wide elastic bandages or a surgical bra. least 1
common common
treatment Breast-Conserving Surgery treatment
for breast Breast-conserving surgery consists of lumpectomy, wide excision, partial or segmental mastectomy, or for breast
cancer quadrantectomy (resection of the involved breast quadrant) and removal of the axillary nodes (axillary lymph 13 mins Lecture cancer
node dissection) for tumors with an invasive component, followed by a course of radiation therapy to treat discussion with
residual, microscopic disease. The goal of breast conservation is to remove the tumor completely with clear visual aids and
margins while achieving an acceptable cosmetic result. video
presentation
The axillary lymph nodes are also eliminated through a separate semicircular incision under the the axilla. A
drain is inserted into the axilla through a separate wound to remove blood and lymph fluid (Black, 2002). A
dressing is utilized over the breast and under the arm and is fasten with wide elastic bandages or a surgical bra
(Smeltzer, 2008).

Survival rates after breast-conserving surgery correspond to those after modified radical mastectomy. But the
chance for local recurrence is greater, at 1% per year after surgery. If the patient experiences a local
recurrence, standard treatment is a completion or salvage mastectomy, in which the rest of the breast tissue is
removed. Survival rates after this procedure are equivalent to those after mastectomy (Smeltzer, 2008).

Nursing Intervention
The postoperative care of the patient undergoing a modified radical mastectomy or breast-conserving surgery
is similar because both procedures involve an alteration to the breast and removal of lymph nodes from the
axillary region. As with any surgical patient, the immediate focus is recovery from general anesthesia and pain
management. In addition, the patient who has had breast surgery may experience both physical and
psychological effects. Possible complications include the accumulation of blood (hematoma) at the incision
site and infection.

Lymphatic Mapping and Sentinel Node Biopsy

The use of lymphatic mapping and sentinel node biopsy is changing the way these patients are treated because
it provides the same prognostic information as the axillary dissection. A radiocolloid and/or blue dye is
injected into the tumor site; the patient then undergoes the surgical procedure. The surgeon uses a hand-held
probe to locate the sentinel node (the primary drainage site from the breast) and excises it, and it is examined
by the pathologist. If the sentinel node is negative for metastatic breast cancer, a standard axillary dissection is
not needed, thus sparing the patient the sequelae of the procedure (surgical drain, altered mobility of the
extremity, paresthesias, risk for lymphedema). If the sentinel node is positive, the patient undergoes the
standard axillary dissection. Reported results of this technique suggest a success rate of more than 90% in
correctly identifying the sentinel node and correctly predicting axillary metastases.

Nursing Intervention
Nurses focus on informing the patient about the expectations and possible implications. Because
patients with a negative node are spared the axillary dissection, they may be discharged home the same day.

Radiation Therapy
Radiation treatment typically begins about 6 weeks after the surgery to allow the incision to heal. If systemic
chemotherapy is indicated, radiation therapy usually begins after completion of the chemotherapy. External-
beam irradiation provided by a linear accelerator using photons is delivered on a daily basis over 5 to 7 weeks
to the entire breast region. In addition, a concentrated radiation dose or “boost” is administered to the primary
site by means of electrons.

Another approach to radiation therapy is the use of intraoperative radiation therapy (IORT), in which a single
dose of radiation is delivered to the lumpectomy site immediately after the surgeon has performed the
lumpectomy. The dosage is limited to the tumor area.

Internal radiation implantation, or brachytherapy, delivers a high dose of radiation to a localized area. The
specific radioisotope for implantation is selected on the basis of its half-life, which is the time it takes for half
of its radioactivity to decay. This internal radiation can be implanted by means of interstitial compartments.

Nursing Management
Self-care instructions for patients receiving radiation are based on maintaining skin integrity during and after
radiation therapy:

 Use mild soap with minimal rubbing.

 Avoid perfumed soaps or deodorants.
 Use hydrophilic lotions (Lubriderm, Eucerin, Aquaphor) for dryness.
 Use a nondrying, antipruritic soap (Aveeno) if itching occurs.
 Avoid tight clothes, underwire bras, excessive temperatures, and ultraviolet light.
 Important aspects of follow-up care include teaching patients to minimize exposure of the treated area to
the sun for 1 year and reassurance that minor twinges and shooting pain in the breast are normal reactions
after radiation treatment.

If a radioactive implant is used, the nurse informs the patient and family about the restrictions placed on
visitors and health care personnel and other radiation precautions.
Chemotherapy
Chemotherapy is administered to eradicate the micrometastatic spread of the disease. This is done after breast
surgery combined with radiation therapy.
Chemotherapy regimens for breast cancer combine several agents to increase tumor cell destruction and to
minimize medication resistance. The chemotherapeutic agents most often used in combination are
cyclophosphamide (Cytoxan) (C), methotrexate (M), fluorouracil (F), and doxorubicin (Adriamycin) (A).
Paclitaxel (Taxol) (T) has been recently introduced into the adjuvant chemotherapy setting, and the data from
clinical trialssuggest a slight survival benefit with its use. The combination regimen of CMF or CAF is a
common treatment protocol. AC, ACT (AC given first followed by T), and ATC, with all three agents given
together, are other regimens that may be used. Decisions regarding the chemotherapeutic protocol are based on
the patient’s age, physical status and disease status.
Common physical side effects of chemotherapy for breast cancer include nausea, vomiting, taste changes,
alopecia (hair loss), mucositis, dermatitis, fatigue, weight gain, and bone marrow suppression. In addition,
premenopausal women may experience temporary or permanent amenorrhea leading to sterility. Side effects
may vary with the chemotherapeutic agent used. CMF is generally well tolerated with only minimal side
effects. Nausea and vomiting can occur. Antiemetics and tranquilizers may provide relief, as may visual
imagery and relaxation exercises.

Nursing Management
Nurses working with patients receiving chemotherapy play an important role in assisting those who have
difficulty with the side effects of treatment. Encouraging the use of medications to limit nausea, vomiting, and
mouth sores reduces discomfort during chemotherapy. Anorexia, nausea, vomiting, altered taste, and diarrhea
put the patient at risk for nutritional and fluid and electrolyte disturbances. It is important for the nurse to
assess the patient’s nutritional and fluid and electrolyte status frequently and to use creative ways to encourage
an adequate fluid and dietary intake. Taking time to explain side effects and possible solutions may alleviate
some of the anxiety of women who feel uncomfortable asking questions. The more informed a patient is about
the side effects of chemotherapy and how to manage them, the better she can anticipate and deal with them.
Many women are distressed by financial concerns and time spent away from the family, nursing support and
teaching can reduce emotional distress during treatment. Important aspects of nursing care include
communicating, facilitating support groups, encouraging patients to ask questions, and promoting trust in
health care providers. Adequate time must be scheduled for clinical appointments to allow discussion and
questions.
Suppression of the bone marrow and immune system is an expected consequence of chemotherapy. Therefore,
aseptic technique and gentle handling are indicated to prevent infection and trauma. Laboratory test results,
particularly blood cell counts, are monitored closely. Untoward changes in blood test results and signs of
infection and bleeding must be reported promptly.

Hormonal Therapy
Decisions about hormonal therapy for breast cancer are based on the outcome of an estrogen and progesterone
receptor assay of tumor tissue taken during the initial biopsy. Normal breast tissue contains receptor sites for
estrogen. About two thirds of breast cancers are estrogen dependent, or ER-positive (ER+). An ER+ assay
indicates that tumor growth depends on estrogen supply; therefore, measures that reduce hormone production
may limit the progression of the disease, and these receptors can be considered prognostic indicators. ER+
tumors may grow more slowly in general than those that do not depend on estrogen (ER−); thus, having an
ER+ tumor indicates a better prognosis. A value less than 3 fmol/mg is considered negative. Values of 3 to 10
are questionable, and values greater than 10 are considered positive. The greater the value, the more beneficial
the anticipated effect from hormone suppression can be. Patients with tumors that are positive for both
estrogen and progesterone (PR+) generally have a more favorable prognosis than patients with tumors that are
ER− and PR−. Most progesterone-receptive tumors also have a positive estrogen receptor status. The loss of
progesterone receptors can be a sign of advancing disease.

Hormonal therapy may include surgery to remove endocrine glands (eg, the ovaries, pituitary, or adrenal
glands) with the goal of suppressing hormone secretion. Oophorectomy (removal of the ovaries) is one
treatment option for premenopausal women with estrogen-dependent tumors. Tamoxifen is the primary
hormonal agent used in breast cancer treatment today.

Nursing Management
Observe for changes (hot flashes, vaginal bleeding, flare); facial hirsutism, deepening of voice; fluid retention,
Cushing’s syndrome (fullness of face, lower extremity edema, weight gain); increased blood pressure; assess
for thrombophlebitis; monitor serum calcium levels; educate patient on symptom management of hot flashes
and assure patient that most changes are temporary.

XI. Nursing Intervention

Preoperative Nursing Interventions

 1. Explaining Breast Cancer and Treatment

The nurse caring for the woman who has just received a diagnosis of breast cancer needs to be knowledgeable
about current treatment options and able to discuss them with the patient. Information about the surgery, the
location and extent of the tumor, and postoperative treatments involving radiation therapy and chemotherapy
are details that the patient needs to enable her to make informed decisions. The nurse discusses with the patient
10. Name at medications, the extent of treatment, management of side effects, possible reactions after treatment, frequency 10. Name at
least two and duration of treatment, and treatment goals. Methods to compensate for physical changes related to least two
pre-op and mastectomy (eg, prostheses and plastic surgery) are also discussed and planned (Ignatavicius, 2002). pre-op and
two post-op two post-op
2. Reducing Fear and Anxiety and Improving Coping Ability

Fears and concerns are common and are discussed with the patient. The nurse provides anticipatory teaching
and counseling at each stage of the process and identifies the sensations that can be expected during additional
diagnostic procedures. The nurse also discusses the implications of each treatment option and how it may 10 mins Lecture
affect various aspects of the patient’s treatment course and lifestyle. Some women find it helpful and discussion
reassuring to talk to a breast cancer survivor, someone who has completed treatment and has been trained as a
volunteer to talk with newly diagnosed patients (Smeltzer,2008).

3. Promoting Decision-Making Ability

Careful guidance and supportive counseling are the interventions the nurse can use to help such a patient.
Also, encouraging the patient to take one step of the treatment process at a time can be helpful
(Smeltzer,2008).

Postoperative Nursing Interventions

1. Relieving Pain and Discomfort

Women may have more generalized pain and discomfort of the chest wall, affected breast, or affected arm.
Moderate elevation of the involved extremity is one means of relieving pain because it decreases tension on
the surgical incision, promotes circulation, and prevents venous congestion in the affected extremity.
Intravenous or intramuscular opioid analgesic agents are another method to manage pain in the initial
postoperative phase. Patient teaching before discharge then becomes important in managing discomfort after
surgery because pain intensity varies widely. Patients should be encouraged to take analgesic agents (opioid or
nonopioid analgesic medications such as acetaminophen) before exercises or at bedtime and also to take a
warm shower twice daily (usually allowed on the second postoperative day) to alleviate the discomfort that
comes from referred muscle pain (Ignatavicius, 2002).

2. Maintaining Skin Integrity and Preventing Infection

A particular concern is preventing fluid from accumulating under the chest wall incision or in the axilla by
maintaining the patency of the surgical drains. The dressings and drains should be inspected for bleeding and
the extent of drainage monitored regularly. Generally, the patient may shower on the second postoperative day
and wash the incision and drain site with soap and water to prevent infection. A dry dressing should be applied
to the incision each day for 7 days. After the incision is completely healed (usually 4 to 6 weeks), lotions or
creams may be applied to the area to increase skin elasticity (Black, 2002).

3. Promoting positive Body Image

Explaining that her feelings are a normal response to breast cancer surgery may be reassuring to the patient.
Ideally, she will see the incision for the first time when she is with the nurse or another health care provider
who is available for support (Smeltzer,2008). Alopecia is a common effect of chemotherapy, one way of
promoting a positive body image is encouraging the woman to use wigs (Black, 2002).

4. Promoting Positive Adjustment and Coping

Assisting the patient in identifying and mobilizing her support systems is important. The patient’s spouse or
partner may need guidance, support, and education as well. Encouraging the patient to discuss issues and
concerns with other patients who have had breast cancer may help her to understand that her feelings are
normal and that other women who have had breast cancer can provide invaluable support and understanding.
Another important aspect of promoting the patient’s adjustment and coping includes answering questions and
addressing her concerns about the treatment options that may follow surgery. After the surgery has been
completed, thoughts about what lies in the future in terms of additional treatment are normal, and this topic
can cause understandable anxiety. Being knowledgeable about the plan of care and encouraging the patient to
ask questions of the appropriate members of the health care team will promote coping during recovery
(Smeltzer,2008).

5. Promoting Participation in Care

Ambulation is encouraged when the patient is free of postanesthesia nausea and is tolerating fluids. The nurse
supports the patient on the nonoperative side. Exercises (hand, shoulder, arm, and respiratory) are initiated on
the second postoperative day, although instruction occurs on the first postoperative day. The goals of the
exercise regimen are to increase circulation and muscle strength, prevent joint stiffness and contractures, and
restore full range of motion (Black, 2002).

6. Managing Postoperative Sensations

Because nerves in the skin are cut during breast surgery, patients experience a variety of sensations. Common
sensations are tightness, pulling, burning, and tingling along the chest wall, in the axilla, and along the inside
aspect of the upper arm. They usually persist for several months up to a year and then begin to diminish.
Explaining to the patient that this is a normal part of healing helps to reassure her that these sensations are not
indicative of a problem. Performing the exercises may decrease the sensations. Acetaminophen (Tylenol),
taken as needed, also assists in managing the discomfort (Smeltzer,2008).

7. Improving Sexual Function

Any change in the patient’s body image and self-esteem or the partner’s response may increase the couple’s
anxiety level and may affect sexual function. Open discussion and clear communication about how the patient
sees herself and about possible decreased libido related to fatigue, anxiety, or nausea may help to clarify issues
for her and her partner. Encouraging discussion about fears, needs, and desires may reduce the couple’s stress.
Suggestions regarding varying the time of day for sexual activity (when the patient is less tired) or assuming
positions that are more comfortable can be helpful, as are other options for expressing affection (eg, hugging,
kissing, manual stimulation) (Smeltzer,2008).

8. Monitoring and Managing Potential complications

Lymphedema
Lymphedema can occur any time after an axillary lymph node dissection. Lymphedema results if functioning
lymphatic channels are inadequate to ensure a return flow of lymph fluid to the general circulation. After
removal of axillary nodes, collateral or auxiliary circulation must take over their function. If lymphedema
occurs, the patient should contact the surgeon or nurse to discuss management because she may need a course
of antibiotics or specific exercises to decrease the swelling (Black, 2002).

Hematoma Formation
Hematoma formation may occur after either mastectomy or breast conservation. The nurse monitors the
surgical site for excessive swelling and monitors the drainage device. Gross swelling or output from the drain
may indicate hematoma formation, and the surgeon should be notified promptly. Depending on the surgeon’s
assessment, an Ace wrap may be applied for compression of the surgical site along with ice packs for 24
hours, or the patient may be returned to surgery to identify the source of bleeding (Smeltzer,2008).

Infection
Infection can occur for a variety of reasons, including concurrent conditions (diabetes, immune disorders,
advanced age) and exposure to pathogens. Both preoperatively and before discharge, patients are taught to
monitor for signs and symptoms of infection (redness, foul-smelling drainage, temperature greater than
100.4°F) and to contact the surgeon or nurse for evaluation. Treatment consists of oral or intravenous
antibiotics for 1 or 2 weeks, depending on the severity of the infection (Black, 2002).

9. Promoting Home Care

Teaching Patients Self-Care

Teaching is necessary to prepare the patient and family to manage aspects of care after home discharge. It may
need to be repeated and reinforced postoperatively. Most patients are discharged 1 or 2 days after the surgery
with the drains in place. The nurse assesses the patient’s readiness to assume self-care and focuses on teaching
the patient incision care; signs to report, such as an infection; pain management; arm exercises; hand and arm
care; and management of the drainage system at home. Family members may be included in the discharge
teaching, and many women find it reassuring and helpful to have another person
assist them with management of the drainage system (Ignatavicius, 2002).

Continuing Care
Follow-up visits to the physician after diagnosis and treatment of breast cancer depend on the individual and
on postoperative treatments, stage of disease at diagnosis, late effects from cancer, and the patient’s adaptation
(Smeltzer, 2008).

*Open Forum

3 mins