About
Malignancy of the breast tissue; staged according to lymph node involvement and spread to other organs. Screening and BSE ( breast self exam) are crucial to diagnosing disease early before metastasis.
Assess
Skin dimpling, edema, nipple inversion, nipple erythema, nipple erosion, scaling, thickening; changes in skin or contour of breasts, drainage, orange-lie appearance to breast tissue, palpable mass
Complications
Metastasis, infertility, blood clots, treatment related complications ( radiation- burns, organ damage, tissue inflammation; chemo- neutropenia, alopecia, infection, altered immune function, renal failure, nausea, weight loss, fatigue, malaise; surgery- DVT, PE, pneumonia, atelectasis, constipation, bowel obstruction, infection, pain), severe pain, death
Diagnosis
- Knowledge deficit related to disease process and management
- Pain related to disease process.
- Ineffective coping related to concerns and fears regarding diagnosis and treatment.
- Anticipatory grieving related to diagnosis and treatment.
- Risk for infection related to immune system dysfunction and compromise.
- Risk for injury.
Goals
- The client will identify treatment options for disease.
- The client will verbalize concerns and fears related to diagnosis and treatment options.
- The client will identify signs and symptoms that require immediate follow-up.
- The client will identify signs and symptoms of infection.
- The client will identify methods to decrease the risk of infection.
- The client will remain free form complications of treatment and disease.
Interventions
- Assess vitals, CBC with differential, pain level and location, presence of other masses, knowledge about disease and treatment options.
- Prepare client for surgery, as indicated. ( Mastectomy, partial mastectomy, lumpectomy, reconstruction, etc)
- Prepare client for additional diagnostics to rule out other malignancies.
- Encourage coughing and deep breathing exercises and incentive spirometry to prevent respiratory infections.
- Administer chemotherapy and prepare for radiation therapy as indicated by physician.
- Provide opportunities for client to verbalize concerns, feelings, and fears related to diagnosis and treatment.
- Teach client signs and symptoms of infection or complications to report immediately to health care provider.
- Teach client methods to prevent infection including hand-washing, avoiding large crowds, monitoring temperature.
- Teach client factors that can increase the likelihood of additional malignancies ( smoking, excessive sun, alcohol, carcinogens).
- Teach client potential complications related to therapy ( additional malignancy, infertility, infections, immune dysfunction, fatigue).
- Monitor for complication of treatment ( chemo, radiation therapy).
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