neoplastic 5

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  1. Breast cancer
    • 1 in 8 women will be dx with breast cancer
    • arise from epithelial lining of ducts or lobules
    • invasive or in situ (localized)
    • growth rates vary
  2. breast cancer
    incidence ect
    • Incidence: 227,000 new cases in 2012
    • prevalence: 2.9 survivors
    • mortality: 39, 510 US deaths 2012
  3. breast cancer
    risk factors
    • gender- women more than men
    • age- risk increases with age
    • genetic- 5-10% due to genetic mutations
    • - BRCA1 and 2genese- normally protects against CA but when mutatanted risk for cancer incre
    • - up to 80% > chance and at younger age
    • - highest in jewish women
    • - also higher risk for ovarian cancer
  4. Breast CA
    non modifiable
    • Fhx
    • - 2+ relatives with breast or ovarian cancer
    • - breast cancer before 50 in family, higher if mother or sister
    • - PMH breast ca- risk incr 3-4 x
    • ethnicity- caucasian women
  5. risk non modifiable
    • abnormal breast biopsy- papillomas, ductal hyperplasia
    • previous chest radiation- up to 12 times greater risk
    • early menes < 12 yrs old and late menopause > 55
    • DES- pts and daughters at increase risk
  6. modiable risk factors
    • children- first child after 30 or no children
    • OC use- unclear link
    • HRT- long term incre risk and late stage dx
    • breastfeeding- 1.5- 2 yrs may decreas risk
    • ETOH- risk incr with amount of consumption
  7. modifiable risk factors
    • obesity and high fat diets- especially after menopause, amt of fat in diet less clear link
    • physical activity- excerise decrease risk
  8. unproven/uncertain risk
    • antiperspirants
    • underwire bra
    • induced abortion
    • breast implants
    • hair dyes
    • night work
  9. prevention
    • modify risk factors
    • SERM- selective estrogen receptive modulators
    • - decreas risk of breast ca that are estrogen dependent
    • - tamoxifen
    • - raloxifen
    • se- hot flashes, visual changes, incre risk thrombosis
    • prophylactic surgery- angelina jolie
    • use for
    • fhx, tested positive, pmh
  10. screening breast ca
    • Clinical breast exam (CBE)
    • - review w/pcp
    • - often it should be done
    • - recommendation from
    • breast self exam (BSE)
    • - can be done if pregnant, breastfeeding, implants
    • CBE
    • - at age 20
    • - q 3yrs 20-39 q yr 40 +
    • - screening reminders
    • looking for changes to normal
  11. screening
    • mammogram 40+ gold standard
    • not 100% reliable
    • done wear deodorant, powder or cream under arms
    • if at high risk talk with MD at earlier, mammogram, additional testing or frequent exams
    • MRI most sensitve
    • magnification, 3d imaging
  12. warning signs
    • lump= palpated or mammo
    • - hard, irregular shape, nonmobile, non tender
    • larger
    • - retraction, erthema, warmth, draining, dimpling of nippls, peau d'rorange (aggressive site of breast cancer)
  13. immflammatory breast ca
    peau d'orange
    • red, warm,hot
    • thickened- peau d'oranage
    • small bumps
    • metasizes early
    • looks like an infection
  14. surgical tx
    breast ca
    • upper outter quadrant- cause of the lymph nodes
    • depends on the type, pt, mets
    • breast conservation treatment- lummpetomy, partial mastectomy
    • - doing the less invasive does the same thing-¬† benefits the same
    • modified radical mastectomy
    • - whole breast, most acillary lymph nodes, +/- lining over pectoralis major muscle removed
    • radical mastectomy
    • - breast, axillary lymph nodes, pectoralis major muscle, all fat and adjacent tissue removed
    • - taking muscle
    • - risk for complication with shoulder injury
  15. breast conservation treatment
    • surgical excision
    • axillary nodes dissection or SLND
    • XRT follows
    • chemo before XRT if evidence of systemic disease
    • test lymph nodes- cause this is where it goes first
  16. breast conservation treatment
    nursing care
    • unsually uneventful moderate pain
    • if axillary lymph node dissection, restoring arm function- see mod radial mastectomy
    • outpt procedure
    • prevention of DVT, infection, Incentive spirometry
  17. modified radical mastectomy
    • preferred over conservation if tumor is too large to leave adequate breast tissue behind
    • breast reconstruction may be done at time of surgery or may wait about 6 months
    • hospt LOS 1-2 days
  18. modified radical mastectomy
    what to expect
    • incre pain, phantom breast sensation, sensation changes- itching, pain, shooting pain, tingling- neurotin
    • chronic pain syndrome- bc severing of nerves
    • increa impairment to arm function
    • - frozen shoulder- lining over muscle could have injured muscle
    • - lymphedema- bc of removal of lymph nodes
    • impaired body image
    • follow up
  19. axillary node involvement
    • more nodes involved a greater risk
    • - axillary we have 20-40 lymph nodes
    • - there purpose is to drain and bring fluid to the vascular system, fight off infection
    • - cant get fluids back to venous system so we have accumulation
    • traditional
    • - anywhere from 10-40 excised (small or all removed)
    • - higher number less effective lymphatic drainage and higher risk lymphedema
    • - lymphedema: heaviness, pain, decre motor function, parasthesias of hand- press on nerve
  20. Sentinel Lymph node biopsy SLNB
    • to remove as fewer lymph nodes as possible
    • sentinel lymph node: 1st lymph nodes to which cancer cells are most likely to spread
    • SLNB helps to determine extent, stage,
    • - SLN is identified, removed and examined
    • remove fewer lymph nodes than standard therapy fewer s/e
  21. axillary node involvement
    how to do SLND
    • Sentinnel lymph node dissection inject a radioisotope and or blue dye injected into the tumor site, during surgery, MD looks for the node into which this drained first "sentinal node"- where did it go- u can remove the lymph and test it. if negative u don't have to check other lymph but if positive u have to check other lymphs
    • - detects radioactivity or looks blue dye in lymph
    • - greater accuracy and lower mortality rates
  22. post op nursing
    • check LS, o2 stat, incentive spirometry, veno stocking, pillow to help with deep breathing
    • pain: meds, warm shower
    • early ambulation- dec pain, TCDB, IS, care drains and dsg
    • no ace wraps- damage area
    • teaching avoid lympedema
    • - initially edema in the arm is ok 1st month
    • - arm excerises see next slide right away in PACU
    • - never allow IV, BP, phlebotomy, affected side
    • - avoid dependent position, trauma
    • - with trauma (skin burn, mani, celluitis), cleanse, antibiotic ointment, DSD, watch for inflamm, call MD
    • avoid constictive clothing
  23. post op
    • no lifting more than 5-10 for 4-6 weeks
    • normal activities encouraged
    • walking, stationary bike
    • drive restrictions
    • - once off pain med
    • - full ROM of arm back
  24. Arm function
    • semi fowler's position w/arm elevated
    • finger and hand excerises start in PACU
    • progressive arm and shoulder excerises for ROM begin at MD discretion- us 2 days (look in book for arm exerises)
    • - to prevent contracture, maintain muscle tome and improve lymph and venous circulation
    • goal- full ROM by approx 1 month
  25. more post op
    • well-fitting prosthesis if not reconstructed
    • - camisole then fitted for size and weight
    • continue BSE and mammogram
  26. Acute lymphedema
    • elevation
    • manual massage- OT/PT
    • intermittent pneumatic compression device- drainage
    • isometric exercises- w/out moving muscle- contracting
    • diuretics- lasix, loop
    • fitted elastic pressure gradient sleeve WA- promotes drainage into venous system
    • referral: OT/PT
    • antibiotic- risk for infection
    • prevent bc it becomes chronic
  27. Breast reconstruction
    • with original surgery or later
    • ¬†cannot restore lactation, nipple sensation
    • contour and appearance can help restore body image
    • breast implants- placed under pectoralis muscle
    • - tissue expanders- filled weekly
  28. chemo- breast ca
    • quite effective at preventing recurrence
    • pre op to decrease tumor size, post op
    • combination therapy in cycles for 3-6 mon
  29. hormonal therapy
    • to remove or block sources of estrogen, starving estrogen receptor sites, inhibiting growth
    • Tamoxifen qd x 5 yrs (SERMS)
    • - hot flashes, N/V, vaginal discharge and dryness, visual changes
    • - increased evidence of uterine and endometrial Ca, PE, DVT
    • visual changes
  30. hormonal therapy
    - advance breast cancer
    • aromatase inhibitors- anastrozole (arimidex), exemestane (aromasin), aminoglutethimide (cytadren)
    • block the enzyme that synthesizes estrogen
    • used in advanced disease
  31. nursing dx
    • pain
    • impaired physical mobility
    • impaired body image
    • altered coping
    • knowledge deficit
    • at risk- fluid volume overload

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neoplastic 5
2015-11-07 21:23:34

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