NURSING PROCESS: THE PATIENT WITH BREAST CANCER
The health history includes an assessment of the patient’s reaction to the diagnosis and her ability to cope with it. Pertinent ques-tions include the following:
· How is the patient responding to the diagnosis?
· What coping mechanisms does she find most helpful?
· What psychological or emotional supports does she have and use?
· Is there a partner, family member, or friend available to assist her in making treatment choices?
· What are the most important areas of information she needs?
· Is the patient experiencing any discomfort?
Based on the health history and other assessment data, the patient’s major preoperative nursing diagnoses may include the following:
· Deficient knowledge about breast cancer and treatment options
· Anxiety related to cancer diagnosis
· Fear related to specific treatments, body image changes, or possible death
· Risk for ineffective coping (individual or family) related to the diagnosis of breast cancer and related treatment options
· Decisional conflict related to treatment options
Based on the health history and other assessment data, the patient’s major postoperative nursing diagnoses may include the following:
· Acute pain related to surgical procedure
· Impaired skin integrity due to surgical incision
· Risk for infection related to surgical incision and presence of surgical drain
· Disturbed body image related to loss or alteration of the breast related to the surgical procedure
· Risk for impaired adjustment related to the diagnosis of cancer, surgical treatment, and fear of death
· Self-care deficit related to partial immobility of upper ex-tremity on operative side
· Disturbed sensory perception (kinesthesia) related to sensa-tions in affected arm, breast, or chest wall Risk for sexual dysfunction related to loss of body part, change in self-image, and fear of partner’s responses
· Deficient knowledge: drain management after breast surgery
· Deficient knowledge: arm exercises to regain mobility of affected extremity
· Deficient knowledge: hand and arm care after an axillary lymph node dissection
Based on the assessment data, potential complications may in-clude the following:
· Hematoma formation
The major goals for the patient may include increased knowledge about the disease and its treatment; reduction of preoperative and postoperative fears, anxiety, and emotional stress; improvement of decision-making ability; pain management; maintenance of skin integrity; improved self-concept; improved sexual function; and the absence of complications.
The patient confronting the diagnosis of breast cancer reacts with fear, dread, and anxiety. In view of the usually overwhelming emotional reactions to the diagnosis, the patient must be given time to absorb the significance of the diagnosis and any informa-tion that will help her to evaluate treatment options.
The nurse caring for the woman who has just received a diag-nosis of breast cancer needs to be knowledgeable about current treatment options and able to discuss them with the patient. The nurse should be aware of the information that has been given to the patient by the physician.
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. As appropriate, the nurse discusses with the patient medications, the extent of treatment, manage-ment of side effects, possible reactions after treatment, frequency and duration of treatment, and treatment goals. Methods to compensate for physical changes related to mastectomy (eg, pros-theses and plastic surgery) are also discussed and planned. The amount and timing of the information provided are based on the patient’s responses, coping ability, and readiness to learn.
The patient’s emotional preparation begins when the tentative di-agnosis of cancer is made. Patients who have lost close relatives to breast cancer (or any cancer) may have difficulty coping with the possible diagnosis of breast cancer because memories of loss and death can emerge during their own crisis.
The patient may have the diagnostic procedure performed in the surgeon’s office or in the hospital when she is admitted for ambulatory or same-day surgery for a biopsy. Fears and concerns are common and are discussed with the patient. If she will un-dergo a mastectomy, information about various resources and op-tions is provided. Such services include prostheses, reconstructive surgery, and groups such as Reach to Recovery. Discussion with a plastic surgeon about the various options for reconstructive surgery can be a valuable source of information and support.
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 affect various aspects of the patient’s treatment course and lifestyle. The patient is introduced to other members of the on-cology team (eg, radiation oncologist, medical oncologist, oncol-ogy nurse, and social worker) and is acquainted with the role of each in her care. After the treatment plan has been established, the nurse needs to promote preoperative physical, psychological, social, and nutritional well-being. The patient usually prefers to be active in her care and decision making. Some women find it helpful and reassuring to talk to a breast cancer survivor, some-one who has completed treatment and has been trained as a vol-unteer to talk with newly diagnosed patients.
At times, a patient may demonstrate behavior that indicates she cannot make a decision about treatment. 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. The advanced practice nurse or oncology social worker can be helpful for patients and family members in discussing some of the personal issues that may arise in relation to treatment. Some patients may need a men-tal health consultation before surgery to assist them in coping with the diagnosis and impending treatment. Such patients may have had a history of psychiatric problems or demonstrate be-havior that leads the surgeon or nurse to initiate a referral to the psychiatrist, psychologist, or psychiatric clinical nurse specialist.
Ongoing nursing assessment of pain and discomfort is important because patients experience differing degrees of pain intensity. Some 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. Intra-venous or intramuscular opioid analgesic agents are another method to manage pain in the initial postoperative phase. After the patient is taking fluids and food and the anesthesia has cleared sufficiently (usually by the next morning), oral analgesic agents can be effective in relieving pain. Patient teaching before dis-charge then becomes important in managing discomfort after surgery because pain intensity varies widely. Patients should be encouraged to take analgesic agents (opioid or nonopioid anal-gesic medications such as acetaminophen) before exercises or at bedtime and also to take a warm shower twice daily (usually al-lowed on the second postoperative day) to alleviate the discom-fort that comes from referred muscle pain.
In the immediate postoperative period, the patient will have a snug but not tight dressing or a surgical bra packed with gauze over the surgical site and one or more drainage tubes in place. A particular concern is preventing fluid from accumulating under the chest wall incision or in the axilla by maintaining the patency of the sur-gical drains. The dressings and drains should be inspected for bleeding and the extent of drainage monitored regularly.
If a hematoma develops, it usually occurs within the first 12 hours after surgery; thus, monitoring the incision is important. A hematoma could cause necrosis of the surgical flaps, although this complication is rare in breast surgery patients. If either of these complications occurs, the surgeon should be notified, and the patient should have an Ace wrap placed around the incision and an ice pack applied. Initially, the fluid in the surgical drain appears bloody, but it gradually changes to a serosanguinous and then a serous fluid during the next several days. The drain is usu-ally left in place for 7 to 10 days and is then removed after the output is less than 30 mL in a 24-hour period. The patient is dis-charged home with the drains in place; therefore, teaching of the patient and family is important to ensure correct management of the drainage system (Chart 48-6).
Dressing changes present an opportunity for the nurse and pa-tient to discuss the incision, particularly how it looks and feels and the progressive changes in its appearance. The nurse explains the care of the incision, sensations to expect, and the possible signs and symptoms of an infection. 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. The patient needs to know that sensation is decreased in the op-erative area because the nerves were disrupted during surgery and that gentle care is needed to avoid injury. After the incision is completely healed (usually 4 to 6 weeks), lotions or creams may be applied to the area to increase skin elasticity. After the incision is fully healed, the patient may again use deodorant on the af-fected side, although many women note that they no longer per-spire as much as before the surgery.
During teaching sessions, the nurse can address the patient’s per-ception of the body image changes and physical alteration of the breast. Patients may initially be uncomfortable looking at the sur-gical incision. No matter how prepared a patient may be, the view of her incision and absence of her breast is often difficult for her. Exploring this sensitive area must be a careful nursing action, and cues provided by the patient must be respected and sensitively handled. Privacy is a consideration when assisting the woman to view her incision fully for the first time and allows the patient to express her feelings safely to the nurse. Asking the patient what she perceives, acknowledging her feelings, and allowing her to ex-press her emotions are important nursing actions. 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 pro-vider who is available for support. With short hospital stays, many women will view the incision for the first time with the home care nurse or ambulatory care nurse at the time of postoperative follow-up visits.
Ongoing assessment of the patient’s concerns related to the diag-nosis of cancer, the consequences of surgical treatment, and fear of death is important in determining her progress in adjusting and the effectiveness of her coping strategies. 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. The patient and spouse may benefit from a wide network of available community resources, including the American Cancer Society’s Reach to Recovery program, advocacy groups, or a spiritual advisor. Encouraging the patient to discuss issues and concerns with other patients who have had breast can-cer may help her to understand that her feelings are normal and that other women who have had breast cancer can provide in-valuable support and understanding.
Another important aspect of promoting the patient’s adjust-ment and coping includes answering questions and addressing her concerns about the treatment options that may follow sur-gery. 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. Refocusing the pa-tient on the recovery from surgery, while addressing her concerns and answering her questions, can be helpful. Being knowledge-able about the plan of care and encouraging the patient to ask questions of the appropriate members of the health care team will also promote coping during recovery.
A few women require additional support to adjust to the di-agnosis and the changes that it brings. If a woman displays in-effective coping, counseling or consultation with a mental health practitioner may be indicated.
Table 48-6 summarizes the needs of and nursing interventions for patients and their partners at various stages of the breast can cer experience. Chart 48-7 provides insights into ways to initiate conversations with patients and their partners in different phases of therapy.
Ambulation is encouraged when the patient is free of postanes-thesia nausea and is tolerating fluids. The nurse supports the pa-tient on the nonoperative side. Exercises (hand, shoulder, arm, and respiratory) are initiated on the second postoperative day, al-though instruction occurs on the first postoperative day. The goals of the exercise regimen are to increase circulation and mus-cle strength, prevent joint stiffness and contractures, and restore full range of motion. Hand exercises are also important for the same reasons.
Postmastectomy exercises (Chart 48-8) are usually performed three times daily for 20 minutes at a time until full range of mo-tion is restored (generally 4 to 6 weeks). Showering before exercis-ing loosens stiff muscles, and taking an analgesic agent 30 minutes before beginning exercise increases the patient’s ability to comply with the regimen. Also, self-care activities, such as brushing the teeth, washing the face, and combing and brushing the hair, are physically and emotionally therapeutic because they aid in restor-ing arm function and a sense of normalcy for the patient.
The nurse encourages the patient to use the muscles in both arms and to maintain proper posture. If a patient is favoring or splinting the affected side, or not standing up straight, any exer-cise will be ineffective. If a patient has skin grafts, a tense, tight surgical incision, or immediate reconstruction, exercises may need to be prescribed specifically and introduced gradually. Most patients find that after the drain is removed, range of motion re-turns quickly if they have been compliant with their exercise pro-grams. This reinforcement may be provided in the outpatient setting by the ambulatory care nurse or the home care nurse.
Patients are instructed regarding activity limitations while healing postoperatively. Generally, heavy lifting is avoided, al-though normal household and work-related activities are pro-moted to maintain muscle tone. Driving may begin after the drain is removed and when the patient has full range of motion and is no longer taking opioid analgesic agents. General guide-lines for activity focus on gradually introducing previous activi-ties (eg, bowling, weight-training) when fully healed, although checking with the physician beforehand is usually indicated.
Transient edema in the affected extremity is common during the healing period, and women are encouraged to elevate the arm above the level of the heart on a pillow for 45 minutes at a time three times daily to promote circulation. Performing the pre-scribed exercises also assists in reducing the transient edema. Pre-vention of lymphedema is taught to patients before discharge. Hand and arm care after an axillary lymph node dissection fo-cuses on the prevention of injury or trauma to the affected ex-tremity, which increases the likelihood of developing lymphedema (Chart 48-9).
Because nerves in the skin are cut during breast surgery, patients experience a variety of sensations. Common sensations are tight-ness, pulling, burning, and tingling along the chest wall, in the axilla, and along the inside aspect of the upper arm. They tend to become more noticeable and increase as the patient begins to heal. 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. Many breast surgery patients report these sensations as one of the most bothersome aspects of having the surgery.
Most breast surgery patients are physically allowed to engage in sexual activity once discharged from the hospital. However, any change in the patient’s body image and self-esteem or the part-ner’s response may increase the couple’s anxiety level and may af-fect sexual function. Some partners may have difficulty looking at the incision, whereas others appear to be unaffected and comfortable.
Either response affects the patient’s self-image, sexual-ity, and acceptance. 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 is-sues 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 com-fortable can be helpful, as are other options for expressing affec-tion (eg, hugging, kissing, manual stimulation).
Most patients and their partners adjust with minimal diffi-culty if they openly discuss their concerns; however, if problems develop or persist, referral to a psychosocial resource (psycholo-gist, psychiatrist, or psychiatric clinical nurse specialist, social worker, or sex therapist) can be helpful for the woman and her partner. To identify difficulty in sexual relationships, the ambu-latory care nurse and home care nurse must be sensitive to this issue following treatment for breast cancer and must initiate dis-cussion with the patient.
Lymphedema can occur any time after an axillary lymph node dissection. Lymphedema results if functioning lymphatic chan-nels 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. Transient edema in the postoperative period occurs until this collateral cir-culation has fully assumed functioning for the removed nodes, which generally occurs within a month by moving and exercising the affected arm. Patients need reassurance that this transient swelling is not lymphedema. Education about how to prevent lymphedema is an important part of hand and arm care after an axillary dissection. Lymphedema occurs in about 10% to 20% of patients who undergo an axillary dissection. Risk factors for lym-phedema are increasing age, obesity, presence of extensive axillary disease, radiation treatment, and injury or infection to the ex-tremity. Patients should follow these guidelines to prevent injury to the affected extremity because lymphedema is subsequently associated with a trauma of some type.
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. Em-phasis should be placed on early intervention because lymphe-dema can be manageable if treated early; however, if allowed to progress without treatment, the swelling can become painful and difficult to reverse. Management consists of arm elevation with the elbow above the shoulder and the hand higher than the elbow, along with specific exercises, such as hand pumps. A referral to a physical therapist or rehabilitation specialist may be necessary for a custom-made elastic sleeve, exercises, manual lymph drainage, or a special pump to decrease swelling.
Hematoma formation may occur after either mastectomy or breast conservation. The nurse monitors the surgical site for excessive swelling and monitors the drainage device, if present. Gross swelling or output from the drain may indicate hematoma for-mation, and the surgeon should be notified promptly. Depend-ing 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. The nurse monitors the site and reassures the patient that this complication is rare but does occur and that she will be assisted through its management. A calm demeanor on the part of the nurse helps prevent anxiety and panic on the part of the patient.
Infection follows breast surgery in about 1 in 100 patients. In-fection can occur for a variety of reasons, including concurrent conditions (diabetes, immune disorders, advanced age) and ex-posure to pathogens. In addition, cellulitis may occur after breast surgery. 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. Cultures are taken of any foul-smelling discharge. Infections are a serious threat to women who have had breast reconstruction because they may lose the breast mound if the infection persists; there is a risk of lymphedema in women who develop an infection and have had an axillary lymph node dissection.
Patients who undergo breast surgery receive a tremendous amount of information before and after surgery. Additional teaching is necessary to prepare the patient and family to manage aspects of care after home discharge. Even though the ambulatory care nurse prepares the patient for what to expect postoperatively, the details often appear less important to the patient in light of the diagno-sis of breast cancer. Thus, teaching 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 inpatient nurse as-sesses the patient’s readiness to assume self-care and focuses on teaching the patient incision care; signs to report, such as an in-fection; 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. The ambulatory care nurse reinforces teaching by telephone follow-up and during postoper-ative visits in the office.
Referral for home care may be indicated to assist the patient and family caregiver with postoperative care at home. The home care nurse assesses the patient’s incision and drainage system, physical and psychological status, adequacy of pain management, and ad-herence to the exercise plan. In addition, the home care nurse reinforces previous teaching and communicates important phy-siologic findings or psychosocial issues to the patient’s primary care provider, nurse, or surgeon.
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. Visits every 3 months for 2 years, followed by every 6 months up to 5 years, may be then extended to annual examinations, depending on the patient’s progress and the physician’s preference. A disease-free state for as long as pos-sible is the goal. Patients are also encouraged to do BSE on the re-maining breast (and operative side if breast-conserving surgery was done) and the chest wall (after mastectomy) between ap-pointments because the risk for cancer in the remaining breast (or recurrence in the operative breast) is about 1% per year after the original diagnosis. Additional screening is done with annual mammography. Ultrasound and MRI are being used more com-monly with women who have survived breast cancer. Because it is common to ignore routine health care when a major health issue arises, the woman is reminded of the importance of partic-ipating in health promotion activities and other health screening. Because some problems with coping may not occur until the woman has returned to more usual routines, the ambulatory care nurse needs to be sensitive to this issue and encourage discussion throughout the recovery period.
Expected preoperative patient outcomes may include:
1) Exhibits knowledge about diagnosis and treatment options
a) Asks relevant questions about diagnosis and available treatments
b) States rationale for surgery and other treatment options
c) Describes advantages and disadvantages of treatment options
2) Verbalizes willingness to deal with anxiety and fears re-lated to the diagnosis and the effects of surgery on self-image and sexual functioning
3) Demonstrates ability to cope with diagnosis and treatment
a) Verbalizes feelings appropriately and recognizes nor-malcy of mood lability
b) Proceeds with treatment in timely fashion
c) Discusses impact of diagnosis and treatment on family and work
4) Demonstrates ability to make decisions regarding treat-ment options in timely fashion
Expected postoperative patient outcomes may include:
1) Reports that pain has decreased and states pain and dis-comfort management strategies are effective
2) Exhibits clean, dry, and intact surgical incisions without signs of inflammation or infection
3) Lists the signs and symptoms of infection to be reported to the nurse or surgeon
4) Verbalizes feelings regarding change in body image
5) Discusses meaning of the diagnosis, surgical treatment, and fears (especially of death) appropriately
6) Participates actively in self-care activities
a) Performs exercises as prescribed
b) Participates in self-care activities as prescribed
7) Recognizes that postoperative sensations are normal and identifies management strategies
8) Discusses issues of sexuality and resumption of sexual relations
9) Demonstrates knowledge of postdischarge recommenda-tions and restrictions
a) Describes follow-up care and activities
b) Demonstrates appropriate care of incisions and drainage system
c) Demonstrates arm exercises and describes exercise regimen and activity limitations during postoperative period
d) Describes care of affected arm and hand and lists indi-cations to contact the surgeon or nurse
10) Experiences no complications
a) Identifies signs and symptoms of reportable complica-tions (ie, redness, heat, pain, edema)
b) Describes side effects of chemotherapy and strategies to cope with possible side effects
c) Explains how to contact appropriate health care pro-viders in case of complications
Care of the patient with breast cancer is summarized in the Plan of Nursing Care.