noninvasive (in situ), depending on the penetration of the tumor into surrounding tissue
Carcinoma of mammary lobules
Sarcoma of the breast
Most malignant form of breast cancer
Edema with dimpling of the skin the result in the skin looking like the peel of an orange is usually present
Involving infiltration of the nipple epithelium
Abnormal nipple discharge
Rash at nipple area
Dimpling of skin
Change in nipple position
Most tumors found by women themselves or their partner
Percutaneous needle biopsy
Excisional Biopsy- when the tissue from the breast lesion is removed surgically
Treatments are given every 3 to 4 weeks for 6 to 9 months. Because the drugs differ in their mechanisms of action, various combinations are used to treat cancer.
Principal breast cancer drugs include cyclosphosphamide, methotrexate, fluorouracil, doxorubicin, and paclitaxel.
Additional agents for advanced breast cancer include docetaxel, vinorelbine, mitoxantrone, and fluorouracil.
Herceptin is a monoclonal antibody directed against Her-2/neu oncogene; may be effective for patients who express this gene
Indications for chemotherapy include large tumors, positive lymph nodes, premenopausal women, and poor prognostic factors.
Chemotheraphy is also used as primary treatment in inflammatory breast cancer and as palliative treatment in metastatic disease or recurrence.
Anti-estrogens, such as tamoxifen, are used as adjuvant systemic therapy after surgery.
Hormonal agents may be used in advanced disease to induce remissions that last for months to several years.
Axillary node dissection
Palliative radiation therapy is also used to treat chest wall recurrences and some bone metastases to help control pain and prevent fractures.
family hx, breast changes, nipple discharge, use of hormone replacement, personal hx of breast cancer, previous diagnostics test and tx of cancer, menstrual hx, pregnancies, alcohol intake, physical activity, dietary hx
height and weight, breasts, lymph glands.
Risk for Infection
Risk for Injury
Disturbed Body Image
Client will not experience infection
Client will make informed treatment decisions
Family and significant others will provide appropriate support for client
Discuss woman’s knowledge of breast cancer
Encourage discussion relating to immediate concerns
Explain surgical procedure
Explain that it is normal to have decreased sensations in surgical area
Focus on immediate concerns
Listen in nonjudgmental manner
Provide opportunities for her to meet with other women who have had breast cancer
Facilitate team approach
Watch for nonverbal clues
Allow time to interact
Explain that it is normal to have periods of depression, anger, denial after surgery
If woman wishes to do so, involve the partner
Circle bleeding, drainage on dressing
Observe incision and IV sites for pain, redness, swelling, drainage
Assess drainage system for patency
Note color, amount of drainage
IV catheters on uninvolved side only
Change dressings using aseptic technique
Encourage protein rich diet
Teach woman to care for drainage system
Teach woman to watch for, report manifestations of infection
Explain that she may experience scaling, flaking, dryness, etc., particularly after radiation therapy
Instruct to avoid deodorants, talcum until incision healed
Elevate affected arm higher than shoulder
Encourage ROM in affected arm
Explain lymphedema massage, elastic compression bandage
Discuss image of self before surgery
Explain that redness, swelling in scar will fade with time
Include partner, family in discussing plan of care, ADLs if possible
Offer pamphlets, literature that might increase knowledge
Encourage woman to look at incision when she feels ready
Often reality not as frightening as imagined
If woman interested in breast reconstruction, provide material prior to surgery
Encourage to talk with plastic surgeon
Side effects from medications are minimized
Pain is managed to allow client to rest, perform essential ADLs
Age 23, two children
Age 45, very thin
Age 33, never pregnant
Age 64, positive family history
Rationale: The risk factors are double for this client due to age and family history. The other clients are not at increased risk for breast cancer.
Risk for Injury
Disturbed Body Image
Anticipatory grieving is the most appropriate at this time as the client is crying in anticipation of surgery and losing a part of her body. Disturbed body image would be the priority after surgery when the client sees herself without the breast. Fatigue and risk for injury are possible, but not priorities.
Start intravenous lines on the affected side in the antecubital area.
Keep the affected arm above the level of the heart.
Wait for the fifth postoperative day to start exercises.
Use warm, moist compresses on the arm to alleviate pain.
The arm is kept elevated after a mastectomy to reduce edema. Warm compresses encourage the inflammatory response, causing more edema. IV lines, lab draws, and, blood pressures are performed in the opposite arm because the lymph nodes have been removed. Gentle range of motion may be started immediately after surgery.
Swelling in the affected arm
Numbness and tingling in the affected arm
Lymphedema or arm edema is a complication of mastectomy that can occur at any time, including years after the surgery. Pain is an expected outcome of surgery as is serous drainage. Numbness and tingling are not associated with mastectomy.
Caucasian women are more likely to die from breast cancer because they are often diagnosed in advanced stages.
Asian, Hispanic, and Native American women have a lower incidence of breast cancer.
Breast cancer is more prevalent in Caucasian women under 40.
African American women are more at risk for breast cancer than any other group.
Asian, Hispanic, and Native American women have a lower risk for developing breast cancer. Breast cancer is more prevalent in Caucasian women over 40. Breast cancer is more prevalent in African American women under 40. African American women are more likely to die from breast cancer because diagnosis often occurs at an advanced stage.
Reconstructive surgery may require multiple surgeries.
Reconstructed breasts do not look normal.
Silicone is known to be safe when used as an implant.
Reconstructive surgery must be completed within 3 weeks of the mastectomy.
Depending on the type of mastectomy, reconstructive surgery may require multiple surgeries, thereby increasing such risks as reaction to anesthesia and infection. Controversy still exists about the health risks of silicone use. Reconstructed breasts do look normal and the surgery may be performed immediately after mastectomy or later on.
Pain when walking
Swelling in the breasts
Edema of the ankles
The client taking Tamoxifen is at risk for developing deep vein thrombosis (DVT), and pain while walking is one of the classic symptoms of DVT. Breast swelling, chilling episodes, and edema of the ankles are not side effects associated with the use of this medication.
a. Mammography is the most reliable method for detecting breast cancer.
b. Breast cancer is the leading killer of women of childbearing age.
c. Breast cancer requires a mastectomy.
d. Men can develop breast cancer.
Men can develop breast cancer, although they seldom do. The most reliable method for detecting breast cancer is monthly self-examination, not mammography. Lung cancer causes more deaths than breast cancer in women of all ages. A mastectomy may not be required if the tumor is small, confined, and in an early stage.
a. at the end of her menstrual cycle.
b. on the same day each month.
c. on the 1st day of the menstrual cycle.
d. immediately after her menstrual period.
Premenopausal women should do their self-examination immediately after the menstrual period, when the breasts are least tender and least lumpy. On the 1st and last days of the cycle, the woman’s breasts are still very tender. Postmenopausal women because their bodies lack fluctuation of hormone levels, should select one particular day of the month to do breast self-examination.
a. Monitoring temperature
b. Ambulation three times daily
c. Monitoring the platelet count
d. Monitoring for pathological fractures
Thrombocytopenia indicates a decrease in the number of platelets in the circulating blood. A major concern is monitoring for and preventing bleeding. Option A elates to monitoring for infection, particularly if leukopenia is present. Options B and D, although important in the plan of care, are not related directly to thrombocytopenia.
a. At the onset of menstruation
b. Every month during ovulation
c. Weekly at the same time of day
d. 1 week after menstruation begins
The breast self-examination should be performed monthly 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.
a. Pain at the incisional site
b. Arm edema on the operative side
c. Sanguineous drainage in the Jackson-Pratt drain
d. Complaints of decreased sensation near the operative site
Arm edema on the operative side (lymphedema) is a complication following mastectomy and can occur immediately postoperatively or may occur months or even years after surgery. Options A, C, and D are expected occurrences following mastectomy and do not indicate a complication.
a. This is the hardest area to feel for changes.
b. Who told you that you have to do that?
c. I’m not sure why that is important, but it sounds like it is.
d. Breast tissue extends into the axilla.
a. It’s not. It’s done because the chest area is exposed.
b. To review the integrity of the skin.
c. To assess the deep lymph nodes which drain the mammary lobules.
d. To assess shoulder range of motion.
a. Has your mother or sister had breast cancer?
b. Have you ever had a mammogram?
c. Are you still menstruating?
d. Have you had any breast trauma?
a. Skin dimpling is accented in this position.
b. The nurse couldn’t palpate the axillae correctly.
c. The client has small breasts.
d. The client has large breasts.
a. Letter H
b. Back and forth technique.
c. Letter S
a. Write it in the medical record and say nothing to the client.
b. Phone for a mammogram for the client immediately.
c. Explain that this could be benign or it could mean something else. It needs to be further investigated.
d. Nothing. It doesn’t mean a thing.
a. Refer all clients to the American Cancer Society if they have questions.
b. Inform all about the low-cost breast cancer screening program.
c. Encourage all females to increase their intake of vitamins A and E.
d. Encourage all females to complete monthly breast exam
a. Nothing. This client doesn’t need to do self examinations.
b. Suggest the client plan to conduct the exam the first day of every month.
c. Schedule the client to come into the clinic every month for the exam.
d. Schedule the client to receive a monthly phone call from the clinic as a reminder.
a. BSE will reduce the risk of dying from breast cancer.
b. performing BSE right after the menstrual period will improve comfort.
c. BSE should be done daily while taking a bath or shower.
d. annual mammograms should be scheduled in addition to BSE.
Rationale: Performing BSE at the end of the menstrual period will reduce the breast tenderness associated with the procedure. The evidence is not clear that BSE reduces breast cancer mortality. BSE should be done monthly. Annual mammograms are not routinely scheduled for women under age 40.
a. “Do you currently smoke cigarettes?”
b. “Have you ever had any breast injuries?”
c. “Is there any family history of fibrocystic breast changes?”
d. “At what age did you start having menstrual periods?
Rationale: Early menarche and late menopause are risk factors for breast cancer because of the prolonged exposure to estrogen that occurs. Cigarette smoking, breast trauma, and fibrocystic breast changes are not associated with increased breast cancer risk.
a. “If your mammogram was painful, it is especially important that you have it done annually.”
b. “An ultrasound examination of the breasts, which is not painful or a source of radiation, can be substituted for a mammogram.”
c. “Because of your age, it is even more important for you to have annual mammograms.”
d. “Unless you find a lump while examining your breasts, a mammogram every 2 years is recommended after age 60.”
Rationale: Annual mammograms are recommended for women over age 40 as long as they are in good health. The incidence of breast cancer increases in women over 60. Pain with a mammogram does not indicate any greater risk for breast cancer. Ultrasound may be used in some situations to differentiate cystic breast problems from cancer but is not a substitute for annual mammograms.
a. only a small incision is necessary, resulting in minimal breast pain and scarring.
b. if the specimen is positive for malignancy, the patient can be told at the visit.
c. if the specimen is negative for malignancy, the patient’s fears of cancer can be put to rest.
d. FNA is guided by a mammogram, ensuring that cells are taken from the lesion.
Rationale: An FNA should only be done when an experienced cytologist is available to read the specimen immediately. If the specimen is positive for malignancy, the patient can be given this information immediately. No incision is needed. If the specimen is negative for malignancy, the patient will require biopsy of the lump. FNA is not guided by mammography.
a. fibrocystic complex.
c. breast abscess.
Rationale: Fibroadenoma is the most frequent cause of breast lumps in women under 25 years of age. Fibrocystic changes occur most frequently in women ages 35 to 50. Breast abscess is associated with pain and other systemic symptoms. Breast cancer is uncommon in women younger than 25.
a. palpate the breasts for the presence of any discrete lumps.
b. explain that this is a temporary condition caused by hormonal changes.
c. refer the patient for mammography and biopsy of the breast tissue.
d. teach the patient about dietary changes to reduce the breast size.
Rationale: If discrete, circumscribed lumps are present, the patient should be referred for further testing to determine whether breast cancer is present. Gynecomastia is usually a temporary change, but it can be caused by breast cancer. Mammography and biopsy will not be needed unless lumps are present in the breast tissue. Dietary changes will not affect the condition.
a. her risk of inheriting BRCA gene mutations is small unless her mother had both ovarian and breast cancer.
b. changes in BRCA genes that normally suppress cancer growth can be passed to offspring, increasing the risk for breast cancer.
c. because her mother had breast cancer, she has inherited a 50% to 85% chance of developing breast cancer from mutated genes.
d. genetic mutations increase cancer risk only in combination with other risk factors such as obesity.
Rationale: Family history is a risk factor for breast cancer, and the nurse should discuss testing for BRCA genes with the patient. Although the BRCA gene is associated with increased risk for breast and ovarian cancer, the patient may be at risk if her mother had either one. About 5% to 10% of patients with breast cancer may have a genetic abnormality that contributes to breast cancer development. Risk factors are cumulative, but a family history alone will increase breast cancer risk.
a. cousin who was diagnosed with breast cancer at age 38.
b. mother who was diagnosed with breast cancer at age 42.
c. sister who died from ovarian cancer at age 56.
d. grandmother who died from breast cancer at age 72.
Rationale: A significant family history of breast cancer means that the patient has a first-degree relative who developed breast cancer, especially if the relative was premenopausal.
a. The postoperative survival rate for each is about the same, but there is a decreased rate of cancer recurrence after mastectomy.
b. The lumpectomy and radiation will preserve the breast, but this method can cause changes in breast sensitivity.
c. The hair loss associated with post-lumpectomy chemotherapy is not acceptable to some patients.
d. The treatment period for the mastectomy is shorter, and breast reconstruction can provide a normal-appearing breast.
Rationale: The impact on breast function and appearance is less with lumpectomy and radiation, but there is some effect on breast sensitivity. The rate of cancer recurrence is the same for the two procedures. Chemotherapy may be used after either lumpectomy or mastectomy, but it is not always needed. The treatment period is shorter after mastectomy, but breast reconstruction does not provide a normal-appearing breast.
a. anxiety related to prospect of additional cancer therapy.
b. fear related to uncomfortable side effects of chemotherapy.
c. decisional conflict related to lack of knowledge about prognosis and treatment options.
d. risk for ineffective health maintenance related to reluctance to consider additional treatment.
Rationale: The patient’s statements indicate that she is having difficulty making a decision about treatment because of a lack of understanding about prognosis and treatment. Although she may have some anxiety and fear, these are not the priorities at this time. The patient expresses concerns about chemotherapy rather than reluctance to consider additional treatment.
a. teach the patient about the need to monitor serum electrolyte levels.
b. ask the patient to call the health care provider before using any over-the-counter (OTC) pain relievers.
c. instruct the patient to call if she notices ankle swelling.
d. have the patient schedule frequent eye examinations.
Rationale: Herceptin can lead to ventricular dysfunction, so the patient is taught to self-monitor for symptoms of heart failure. There is no need to monitor serum electrolyte levels. OTC pain relievers do not interact with Herceptin. Changes in visual acuity may occur with tamoxifen, but not with Herceptin.
a. raloxifene (Evista).
b. estradiol (Estrace).
c. trastuzumab (Herceptin).
d. tamoxifen (Nolvadex).
Rationale: Tamoxifen is used for estrogen-dependent breast tumors in premenopausal women. Raloxifene is used to prevent breast cancer, but it is not used post-mastectomy to treat breast cancer. Estradiol will increase the growth of estrogen-dependent tumors. Trastuzumab is used to treat tumors that have the HER-2/neu antigen.
a. teaching the patient to use the ordered patient-controlled analgesia (PCA) every 10 minutes for the best pain relief.
b. insisting that the patient examine the surgical incision when the dressings are removed.
c. posting a sign at the bedside warning against blood pressures or venipunctures in the right arm.
d. encouraging the patient to obtain a permanent breast prosthesis as soon as she is discharged from the hospital.
Rationale: The patient is at risk for lymphedema and infection if blood pressures or venipuncture are done on the right arm. The patient is taught to use the PCA as needed for pain control rather than at a set time. The nurse allows the patient to examine the incision and participate in care when the patient feels ready. Permanent breast prostheses are usually obtained about 6 weeks after surgery.
a. “I should keep my left arm supported in a sling when I am up until my incision is healed.”
b. “I may expose my left arm to the sun for several hours each day to increase circulation and promote healing.”
c. “I can do whatever exercises and activities I want as long as I do not elevate my left hand above my head.”
d. “I will continue to exercise my left arm with finger-walking up the wall or combing my hair.”
Rationale: The patient should continue with arm exercises to regain strength and range of motion. The left arm should be elevated to the level of the heart when the patient is up. Sun exposure is avoided because of the risk of sunburn. The left hand should be elevated at or above heart level to reduce swelling and lymphedema.
a. “Would you like to talk about how you are feeling right now?”
b. “I can see you are really upset. Would you like to be alone for a while?”
c. “The important thing is that the tumor was found and is going to be removed.”
d. “With this surgery you will have very little change in the appearance of your breast.”
Rationale: The nurse encourages the patient to express feelings about the diagnosis and surgery. The response beginning, “I can see you are really upset” may indicate that the nurse is uncomfortable being with the patient while she is upset. The response beginning, “The important thing is that the tumor was found” places the nurse’s value system above the patient’s current concerns. And the response, “With this surgery you will have very little change in the appearance of your breast” does not address all the patient’s possible concerns and is not true.
a. “I will avoid reaching over the stove with my left hand.”
b. “I will need to do breast self-examination on my right breast monthly.”
c. “I will keep my left arm elevated until I go to bed.”
d. “I will remember to use my right arm and to rest the left one.”
Rationale: The patient should avoid any activity that might injure the left arm, such as reaching over a burner. Breast self-examination should be done to the right breast and the left mastectomy site. The left arm should be elevated when the patient is lying down also. The left arm should be used to improve range of motion and function.
a. “I am not sure how my husband will react when I tell him about this cancer.”
b. “I am ready to die if that is God’s plan for me.”
c. “I need to know all the options before making a decision about treatment.”
d. “I will do whatever the doctor thinks is best.”
Rationale: One goal for the patient with breast cancer is active participation in the decision-making process. The response beginning, “I am not sure how my husband will react” indicates that the goal of satisfaction with the support provided by significant others is still unmet. The response, “I am ready to die if that is God’s plan for me” suggests that the patient may not be willing to have treatment. The response, “I will do whatever the doctor thinks is best” indicates that the patient is not participating actively in treatment decisions.
a. Administering an analgesic 30 minutes before the scheduled arm exercises
b. Teaching the patient how to avoid injury to the right arm
c. Assessment of the patient’s range of motion for the right arm
d. Evaluation of the patient’s understanding of discharge instructions about drain care
Rationale: LPN/LVN education and scope of practice include administration and evaluation of the effects of analgesics. Assessment, teaching, and evaluation of a patient’s understanding of instructions are more complex tasks that are more appropriate to RN-level education and scope of practice.
“Breast exams should begin around age 30.”
“Breast exams should be done one week prior to the menstrual cycle.”
“Breast exams should incorporate both feeling and looking at the breasts.”
“Breast exams should be done during the middle of the menstrual cycle.”
Breast exams should incorporate both feeling and looking at the breasts. Premenstrual swelling and tenderness of the breasts may be present one week prior. Breast self-examination should begin as early as possible, preferably when the individual is an adolescent.
Timing of the symptoms
Birth control method
Method of breast self-examination
The breast undergoes regular cyclical changes in response to hormonal stimulation. The nurse will want to determine when the swelling and tenderness occurs within the menstrual cycle. Birth control method, method of BSE, and diet history may contribute to the database, but do not have priority.
Instruct the client to take Tylenol prior to the mammogram.
Instruct the client to schedule the mammogram for two weeks after menses.
Instruct the client to refrain from using deodorant.
Instruct the client to avoid caffeine for 5-7 days prior.
In order to obtain an accurate interpretation, the client must avoid lotions, powders, deodorants, or other cosmetics on the day of the exam. The other responses may assist the woman in preventing discomfort.
Age 57, has taken estrogen replacement therapy for 10 years, 5 feet, 2 inches tall, 210 pounds
Gravida 4, Para 4, regular menstrual cycle, uses Depo- Provera for birth control
Menarche at age 13, drinks a glass of wine three times per week, sister with uterine cancer
Age 45, African-American, lives in federally funded housing
Women over 50 who have taken estrogen replacement therapy for more than five years and are obese after menopause are at greater risk for breast cancer. The other women do not exhibit risk factors.
a. breast self-examination.
c. fine needle aspiration.
d. chest X-ray.
a. Vision changes
b. Hearing loss
a) complaints of dull, achy, pain
b) palpation of a mobile mass
c) presence of an inverted nipple
d) area of discoloration skin
– inversion of nipple is one of the manifestations of breast cancer. A cancerous lesion is non-mobile.
a) applying direct manual pressure to the site
b) stopping the administration of the medication
c) administering an available antidote as prescribed
d) leaving the needle in place and aspirating any residual medication
– General recommendations for managing extravasation of a chemotherapeutic agent include stopping the infusion, leaving the needle in place and attempting to aspirate any residual medication from the site, administering an antidote if available, and assessing the site for complications. Direct pressure is not applied to the site because it could further injure tissues exposed to the chemotherapeutic agent.
Elevate the client’s right arm on pillows
Place the client’s right arm in a dependent sling
Keep the client’s right arm on the bed beside her
Place the client’s right arm across her body
1. determine when the client had chemo last
2. ask the client is she received Adriamycin
3. post a message at the head of the bed to not use the right arm
4. examine the chest wall for cancer sites