med surge

  1. S/S in common breast disorders
    • 1.tenderness
    • 2. pain
    • 3.breast mass
    • 4.nipple d/c
    • 5. changes in appearance
  2. Mastisis
    • inflammation of breast tissue, common in breast fedding women, 2nd or 3rd wk postpartum,
    • P&E- plugged lactiferous ducts or infection(staph) thru impaired skin, also from infrequent nursing & alternating sides
    • ASSESS.- fever, malasia, tenderness, redness, pain, swelling , firmness, crack in nipple/ areola, C&S test done thru breast milk to identify agent
    • Medical manag.- antibiotic given for 10 days, pain meds, heat to area, breast should emptied by breast pump
    • Nursing manag.-
    • *instuct to take meds as RX, & report side effect (rash, GI upset, & infection of mouth & vag.
    • *handwashin tech.
    • *bath & shower reg. & to apply lotion
    • *wear good bra
    • *avoid breast shields (trap milk & moisture around nipple)
    • *apply warm soaks to breast
    • *use breast pump till no infection
  3. breast abscess
    • localized collection of pus
    • P&E- complication of postpartum mastisis, staph most common cause
    • ASSESS- same as mastasis but with pus, C&S done
    • Med. & surg mang.- pt placed on contact isolation, IV started, abscess may ber incised, drained, packed
    • Nursing manag.-
    • *removes & reapplies dressing by aseptic tech.
    • *to avoid irratating skin nurse stops using tape & apllies binders
    • *applies zinc oxide to avoid maceration from drainage & wound compress
    • *to reduce swelling nurse supports arm & shoulder w/ pillow
    • *instuct pt not to shave until healing complete
    • *emotional support when mother away from baby
    • *help pt pump & if deciding not to breast feed anymore then allow to wear tight bra
  4. FIbrocystic breast disease
    • AKA mammary dysplegia(abnormal breast tissue) or chronic cystic mastasis- bengin, usually effects women 30/50 y/o
    • P&E- from hormonal changesduring period, caffine & nicotine aggrivate condition, can be 1 or more, estrogen released can make them grow & feel tender, condition resolved by menopause, could be mistaken to cancer
    • ASSESS- can have no symtoms, but pain, tenderness, & feelin many lumps, all more noticable before period & abate durin period, wt trainin may increase mastalgia(breast pain), dx findings are masses could be soft or firm, moveable, unlikely to cause nipple retraction, fluid aspiration or biopsy are preformed
    • Medical & Surgical manag.- partial or segmented mastectomy- of breast, axillary, lymphnodes, pectoralis majora & minora muscles & sometime sternal lymph nodes, care of areola to privide cosmetic appearence
    • Nurse manag. when fibrocystic disease
    • *Preform BSE (same techn)
    • *schedule breast exam q 6 mon.
    • *wear well fitted bra (day & end)
    • *take med as RX
    • *apply cold compresses when symtomatic
    • *avoid smokin, coffee, chocolate, & caffeinated drinks
    • *reduced activities that can cause trauma to breast
    • *consult DR. about takin vit. E or oil of evening primrose which is helpful
  5. fibroadenoma
    solid bengin breast mass composed of connective & glandular tissue, happens during late adolescence & early adulthood, sometime in older women

    P&E- unknown cause, could be influenced by hormones b/c grows durin preg. & shrinks after menpause, itz a single nodual dat grows slowly in nonperg. women until reaches fixed size, usually doesnt enlarge or regress w/ q period, not concidered precancerous

    • ASSES- painless nontender lump on breast, lesion encapsulated, mobile, & firm when palpated, if large breast may be asymmetric
    • ultrasound reveals physical characteristics like fibroadenoma versus malignant mass w/ better accuracy than mamography, when young a excisional biopsy done if mass changes or gets bigger, or if pt at hiigher risk 4 breast cancer

    Medical & surgical manage.- based on findin Dr. decides whether to observe or excise it, surgery involves removal of bengin tumor but not mastectomy, pt released after anesthesia wears off

    • Nurse manag.-
    • *provide emotional support
    • *instructs pt to continue BSE
    • *to notify DR. if changes or pt gets preg.
    • if surgery done
    • *keep wound clean & covered until healed
    • *wear good bra
    • *followmed instruction on non-opiods for 1-3 days
    • *notify DR if pain swelling, wound drainage,or fever
  6. groups @ higher risk 4 breast cancer
    • *female
    • *older than 50
    • *exposure to ionizing radiationinchildhood or adolescence
    • *previous breast cancer
    • *HX of colon or endometrail cancer
    • *chronic alcohol consumption
    • *early period
    • *late menopauses
    • *obesity
    • *not having children or having them till after 30
    • *white women higher riskthan african americans, but african amerian more likely to die from it
    • *
  7. most aggressive forms of cancer
    • each normal breast has 15-20 lobes connected by ducts
    • most common malignancy is ductal carcinoma(80%), followed by infiltrating lobular carcinoma(form of breast cancer 10%), medullary carcinoma, mucinous carcinoma, tubular ductal carcinoma, & inflammatory breast cancer, the rarest but most aggressive

    some malignant breast tumors are hormone dependent meaning estrogen/progesterone increasse tumor growth
  8. S/S of breast cancer
    • painless mass, mostly in the upper outer quad, tumors may be developing in situ, w/o invading other tissue, 4 as long as 2yrs before bein palpable.
    • *bloody d/c from nipple
    • *dimpling of skin over lesion
    • *retraction of nipple
    • *peau d' orange appearance of skin
    • *difference of breasts
    • *lesion may be fixed or movable, & axillary nodes will be enlarged
    • All depend on type, duration, & location
  9. 4 mehods of tx cancer
    • 2.chemotherapy- destroy cancer cells tht have escaped sugical removal
    • 3.hormone therapy
    • 4.radiation therapy- before/after surgery, done if axillary nodes have cancer cells, chest wall involed, or tumor <5cm, side effects are fatigue, skin redness like sun burn, rash, discomfort or pain, some pt get pnuemotitis, rib fractures, breast fibrosis

    • sentinal lymph node maping- determines whether complete removal of axillary lymph nodes necessary, identifies 1st lymph node where breast cancer cell would spread, by injecting nuclear isotopearoud tumor followed by instillin blue dye, after excised then geiger counter passed over perimammary tissue to find area of most intense radioactivity
    • *leavin many normal lymphnodes reduces complication like lymphedema, delayed healin, altered skin sensation b/c of disrupted lymphatic circuation
    • *lymphedema- soft tissue swellin from accumulated lymphatic fluid mostly after breast surgery, happens b/c of removal or irritating lymph nodes AEB temp./perm., enlargement of arm & hand where breast was removed
    • *impaired lymphatic circulation predisposes disfigurement, reduced ROM, heaviness of limb, skin changes, tissue necrosis tht may req. amputation
  10. nurse manag.
    • *emotional support
    • *wound management
    • *side effects of chemo- nausea, vomitin, changes in taste, alopecia, musositis, dermatitis, fatique, wt gain, & bone marrow suppression, some pt may get short-term memory loss& difficulty in thought "chemo-brain", mouthsores
    • *how to take meds
    • home instuctions
    • *emotional support
    • *expain woud care
    • *assess availabilty of help @ home
    • *provide instruction on exercises- wall climbing, rope turning, broom/rod lifting, pulley tugging
    • *arrange follow-up appt
    • *meds info
    • *inform tht some residual numbness & tinglin on chestwall & inner arm from axillato elbow may occur & take upto 1yr to resolve
    • *application of creams if skin dries
    • *expain tht prosthesis (filled w/ fluid) looks & feels natural, & radiates body warmth
    • *advise against lifting/carrying things of 15lb & makin vigourus repeated movement
    • *discourage sleepin or wearing constitive clothing tht impairs circulation
    • *explain tht b/p, injection, blood donations, IV infusion @ arm w/ mastectony
    • *recommends wearing gloves to prevent injuries that may heal slow or become infected
    • *advise to use electric razors in axilla
    • *instruct to perform BSE on intact breast
  11. surgeries to remove malignant breast tumor
    • 1.Lumpectomy- only tumor removed, some axillary lymph nodes removed @ same time 4 microscopic exam
    • 2.Partial or segmantal mastectomy- tumor & some breast tissue & some lymph nodes removed
    • 3.Simple or total mastectomy- all breast tissue removed, no lymph node dis-section performed
    • 4.subcutaneous mastectomy- all breast tissue removed, but nipple & skin left intact
    • 5.modified radical mastectomy- breast, some lymph nodes, linning over chest muscles & da pectoralis minor muscle removed
    • 6.radical mastectomy- breast, axillary lymph nodes, & pectoralis major & minor muscles removed, in some instances sternal lymph nodes removed
  12. 2 criteria 2 select mastectomy procedures
    • 1.stage of tumor
    • decision about tx options
    • current trand is to do least disfiguring procedure
  13. 4 sites where breast cancer metastasizes
    metastasis- migration of cancer cells from 1 part of body to another, spread by direct extension, thru lymphatic system , bloodstream, & cerebrospinal fluid
    • 1.brain
    • 2.liver
    • 3.skeletal system
    • 4.pulmonary system

    S/S- pain @ site, when in bone fractures w/ or w/o trauma

    dx- radiographs of lungs, spin 2 detect metastases, also MRI, CT, lymph node disection

    • Medical manag.-
    • 1.large doses of estrogen & progesteron 4 pain, wt loss, malaise
    • 2.IM androgen(testosteron) when in bones
    • 3.radiation 2 tx regional or distant metastases to bone or chest wall
  14. breast cancer prevention
    • 1. long term follow up- annual mammogram & BSE
    • 2.bilat prophylactic mastectomy- most invasive, tell pt tht it could reduces risk but doesnt eliminate
    • 3. chemoprevention w/ tamoxifen- takin for 5yrs reduced occurance of estrogen receptor positive tumors by 69%, but not estrogen-receptor-neg. tumors

    Tamozifen- also preserves bones mineral density preventing osteoporosis, lowers LDL, increases endometrial cancer, deep vein thrombosis, pulmonary embolism, cataracts, other side effects- hot flashes, cold sweats, vag, d/c, genital itching, pain when havin sex
  15. breast reconstruction- when area of mastectomy is refashioned or to create nipple or areola
    • Artificail implants-skin & tissue on chest wall expanded to give big enough space to fill & approx. remaining breast, done by stretching chestwall over months w/ inflatable or saline filled pockets
    • *pt who concider this should know tht
    • 1.not 4 a lifetime other surgeries should expected
    • 2.changes to breast are irreversible
    • 3.rupture is silent MRI recommended 3yrs after implantation & reg. screening q 2yr thereafter
    • 4.ruptured implant needs surgical removal
    • 5.reg. lifetime MRI may not be covered by insurance

    • Autogenous Tissue- gives natural look & feel to breast, skin from rectus abdominis muscle along w/ adjoining skin & fat, other donor sites are latissimusdorsi or gluteal muscles
    • *if nipple reconstruction needed tissue taken from other nipple, ear, toe, any tissue w/ same color, like inner thigh, vag. labia, also created by pigmented tattoo
  16. Reduction mammoplasty
    • *overnight procedure where glandular breast tissue, fat, & skin removed bilat 2 reduce size of breast, most canidates wear size D cup or larger bra, irritation under breast, cant find clothing, pain in back & shoulders, low self esteem, self-conciousness
    • *incision made around nipple & tissue removed, loose skin tightened to reposition areola & nipple, pt d/c w/ bulky dressing, & sometimes sm. wound drain
  17. Opposite Breast Reduction
    Done to make healthy breast look like effected one, almost same as reduction mammoplasty
  18. Breast Lift (more technically Mastopexy)
    Ptosis or drooping corrected, happens wt loss & aging, similar to reduction mammoplasty but incision, scar line, & healing time shorter

    in some casessize & contour of breast enhanced w/ breast augumentation techn.
  19. Breast Augumentation
    • similar to breast reconstruction usin artificial saline implant
    • When caring for pt
    • *keep pt in semi-fowlers postion after surgery to promote drainage
    • *gives analgesics 4 pain
    • *inspects site for changes in color & temp
    • *to minimize stretching of tissue nurse maintains dressing & assists pt to use good bra
    • *provides info to surgery being preformed, Info includes
    • 1. have mammogram to check 4 malignancies before cosmetic surgery
    • 2.continue BSE & clinical breast exams(inspection & palpation) by DR
    • 3.expect reduce sensation in nipple, scarring, & temp discomfort when movin arms & shoulders after surgery
    • 4.wear soft bra for 3-6 wks except when bathing
    • 5.avoid activities like vigourus sports until breast healed
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med surge
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