Breast cancer can affect one or both breasts and is usually found through a mammogram, and then diagnosed through a biopsy to determine if the cells are malignant. Breast cancer is the most common cancer in women and may rarely occur in males.
Types of Breast Cancer
There are many types of breast cancer. Identifying the type of breast cancer will determine the most effective treatment. The most common types of breast cancer are based on where the cancer originates, usually in the milk ducts or lobules. Invasive types have spread to nearby breast tissue, while noninvasive (in situ) types have not. The most common breast cancer type is invasive (infiltrating) ductal carcinoma (IDC), which makes up 80% of breast cancer cases.
Breast cancer may be further classified by the presence or absence of hormone receptors, including estrogen receptor (ER), progesterone receptor (PR), or the protein human epidermal growth factor receptor 2 (HER2). This information is important because patients with hormone-receptor-positive breast cancer can benefit from targeted therapy and hormone therapy.
Breast Cancer Staging
Breast cancer staging is another way the healthcare team plans treatment. Stages range from 0 to IV and are based on the type, location, and size of the tumor. Stage 0 is the earliest stage, while stage IV breast cancer means it has spread (metastasized) to other areas of the body and carries a poorer prognosis.
Fortunately, with advancements in detection and treatment, survival rates of breast cancer continue to improve.
Nursing Process
Nurses can expect to encounter patients with breast cancer in a variety of settings and provide support and education to patients before, during, and after treatment. Women are routinely screened for breast cancer, and nurses may be involved in educating on self-breast exams or receiving mammograms. Once diagnosed, nurses will play a crucial role in administering chemotherapy and other treatments, monitoring patients after surgery, managing side effects, and providing psychosocial support.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to breast cancer.
Review of Health History
1. Assess the patient’s general symptoms.
Early in the disease, patients may not have symptoms. As the tumor grows, the patient may report the following:
- Change in the breast’s appearance (size and shape)
- Presence of breast or axillary lump (usually found during a shower)
- Breast skin changes or dimpling
- Nipple changes or discharge
- Breast pain (rarely)
2. Determine the patient’s risk factors.
Identifying factors related to an increased risk of breast cancer is essential for screening. Assess for the following factors:
- Advancing age
- Obesity
- Dense breast tissue
- Alcohol use
- A previous breast cancer diagnosis
- Family history of breast cancer in a first-degree relative
- Genetic risk factors, such as the BRCA1 and BRCA2 genes
3. Review the patient’s reproductive history.
The patient’s reproductive history can also provide clues on potential risk factors, such as:
- Early menstruation before age 12
- Late menopause after age 55
- First pregnancy and delivery after age 30
- Never giving birth
4. Review the patient’s treatment history.
Previous radiation therapy to the chest or in early childhood increases the risk for breast cancer, as does a history of estrogen or progesterone hormone therapy.
Physical Assessment
1. Examine the breasts.
Inspect and palpate the breast with the arms raised above the head. Concerning lumps are hard, irregular, asymmetric, and fixed to the skin or muscle. Observe for additional findings, such as:
- Nipple inversion
- Nipple discharge
- Ulceration
- Redness, rashes, or swelling
- Edema or skin thickening (peau d’orange)
- Skin dimpling
- Breast pain
- Dilated veins
2. Assess the lymphatic and other systems.
Palpate the axilla, around the clavicle, and the chest to assess for lymphatic metastasis. If metastasis to other organs is suspected, evaluate for additional symptoms, such as:
Diagnostic Procedures
1. Schedule the patient for a mammogram.
Mammograms reduce the risk of mortality. Mammograms are X-rays of the breasts. Screening mammograms are performed on women without symptoms. Women who present with symptoms or who have a palpable mass receive diagnostic mammograms.
2. Prepare the patient for further breast imaging.
A positive result from breast screening tests requires further investigation. Women at a higher risk for breast cancer or who have a confirmed mass may benefit from additional noninvasive imaging. Possible tests include:
- Ultrasonography (best for younger women with palpable masses)
- Breast MRI (assists with staging and evaluates response to treatment)
- Positron emission tomography (PET) (used for staging)
- Positron emission tomography with computed tomography (PET-CT)
- Scintimammography
3. Anticipate a breast biopsy.
After a positive imaging test, a tissue sample is obtained and sent to the laboratory to confirm the presence of malignancy.
4. Review the stage of the breast cancer.
Once imaging and biopsies are completed, the healthcare provider can determine staging. This system includes tumor size (T), lymph node involvement (N), and metastasis (M). This anatomical information, coupled with the presence or absence of HER2, ER, or PR hormone receptors, helps guide clinical decision-making and prognosis.
5. Assist with additional testing.
The following laboratory tests may be performed:
- Blood tests
- Complete blood count (CBC)
- Complete metabolic panel (CMP)
- Liver function panel
The following imaging may be necessary for patients with advanced breast cancer to assess for metastasis:
- Bone scan
- CT scan of the abdomen and pelvis
- CT scan of the chest
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient suffering from breast cancer.
1. Prepare for the removal of the tumor.
Surgery is often recommended to remove the tumor and any affected lymph nodes, and for some patients, it is a curative treatment. The following surgical procedures are used to treat breast cancer:
- Lumpectomy
- Mastectomy
- Sentinel node biopsy
- Axillary lymph node dissection (removal of lymph nodes from the underarm)
- Breast reconstruction
Monitor the site and any drains present post-surgically for signs of abnormal bleeding, poor healing, excessive pain, or infection.
2. Prepare the patient for further treatment.
To reduce the risk of local recurrence and metastatic spread, the following treatments may be combined with surgery for the best outcome:
- Radiation therapy
- Chemotherapy
- Hormone therapy
- Targeted therapy
- Immunotherapy
Ensure the patient is educated on what to expect when receiving treatments, including potential side effects and expected outcomes.
3. Manage treatment side effects.
Patients respond to breast cancer therapy in different ways. Consider medications, nonpharmacologic interventions, counseling, hygiene practices, and alternative medicine to manage the following side effects:
- Increased risk for infection
- Anemia
- Bleeding tendencies
- Pain
- Dry, itchy, peeling skin
- Hair loss
- Chemo brain (memory loss)
- Loss of appetite
- Nausea and vomiting
- Weakness
- Fatigue
- Mouth sores
- Dry mouth
- Changes in taste
- Diarrhea
- Scarring
4. Instruct on bone health.
Many women who are diagnosed with breast cancer are postmenopausal, which already increases the risk for osteoporosis. This, combined with chemotherapy and other medications, increases the incidence of bone density loss and fractures. Encourage the following recommendations to reduce the risk of fractures and support bone health:
- Biphosphonate medications
- Vitamin D supplementation
- Weight-bearing exercise
5. Provide emotional support.
A strong support system (such as family, friends, and caregivers) is crucial for the patient facing a cancer diagnosis. Provide opportunities to listen and offer support. Offer resources to counseling and support groups.
6. Monitor for lymphedema.
Swelling in the arm may occur after treatment and is usually worse in women who have had a large number (or all) of the axillary lymph nodes removed. Monitor for signs of swelling, heaviness, or tightness in the arm and educate on solutions such as lymphatic massage, resistance exercise, and compression sleeves. Newer research suggests that blood pressure cuffs, venipunctures, and IV catheters to the arm after breast cancer surgery and lymph node removal do not contribute to lymphedema.
7. Encourage activities to improve the quality of life.
Encourage the patient to participate in yoga, exercise, meditation, and massage, which have been proven to reduce fatigue and anxiety and improve overall quality of life.
8. Counsel about follow-up.
Most patients who undergo breast conservation surgery will need to have a mammogram 6 months post-op and then every 6-12 months thereafter.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for breast cancer, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for breast cancer.
Acute Pain
Pain associated with breast cancer can be caused by tissue damage from the cancer. It can also be caused by the treatment measures used to fight the cancer.
Nursing Diagnosis: Acute Pain
Related to:
- Tumor advancement causing inflammation and compression on nerves and bones
- Chemotherapy
- Radiation
- Surgery
As evidenced by:
- Verbalization of pain
- Body language/guarding behavior
- Facial grimacing
- Changes in vital signs
- Agitation/restlessness
Expected outcomes:
- Patient will verbalize pain is reduced or controlled.
- Patient will demonstrate the ability to perform ADLs due to improved comfort.
Assessment:
1. Assess pain appropriately.
Breast cancer can cause pain due to the tumor(s) or from the cancer treatments. The nurse can assess pain by asking the patient their pain level on a 0-10 scale or using a nonverbal pain scale if the patient is unable to rate.
2. Assess pain with vital signs.
Elevated blood pressure, tachycardia, and tachypnea are often seen along with complaints of pain. The nurse can assess if pain is controlled or not by assessing for changes in vital signs. Of course, pain is always subjective and the nurse will treat for pain based on the patient’s report.
3. Examine the patient’s cultural norms regarding pain expression.
Some cultures display pain openly, while others do not. The nurse can address this by assessing for pain often, using verbal and nonverbal pain scales, and remaining understanding and nonjudgmental towards the patient’s beliefs.
Interventions:
1. Administer pain medication as prescribed.
Patients being treated for breast cancer often require a combination of opioids and NSAIDs along with antiemetics for nausea caused by chemotherapy to relieve pain and discomfort.
2. Evaluate the effectiveness of pain medication.
After pain medications are administered, evaluate the effectiveness regularly. The dosage and type of medications may need to be adjusted by the physician if the patient’s pain is not controlled.
3. Provide nonpharmacological pain management.
Participating in activities such as distraction, massage, hot/cold compresses, and acupuncture may provide the patient with pain relief and relaxation.
4. Educate patients about side effects and treatment.
Inform the patient about what to expect regarding side effects of chemotherapy, radiation, and other treatments which are often uncomfortable. Educate and encourage patients to be honest about their pain and communicate regularly with their provider.
Anxiety
Fear and anxiety can be caused by the unknown that comes with a breast cancer diagnosis.
Nursing Diagnosis: Anxiety
Related to:
- Crisis (breast cancer diagnosis)
- Threat of death
- Lack of knowledge
- Unfamiliarity with treatments
- Change in health status
As evidenced by:
- Verbalization of fear or worry
- Distressed appearance: shaking, hand wringing, restlessness
- Insomnia
- Shortness of breath or heart-pounding sensation (acute panic)
- Crying
- Difficulty concentrating
- Lack of appetite
Expected outcomes:
- Patient will verbalize anxiety is decreased to a manageable level.
- Patient will verbalize ways to cope with increasing anxiety/fear.
- Patient will demonstrate ways to recognize symptoms of anxiety and fear at the onset to avoid reaching a panic state.
Assessment:
1. Assess expressions of fear/anxiety.
Assess the patient’s verbal and nonverbal expressions of fear/anxiety. Inquire about how they are feeling and evaluate nonverbal expressions.
2. Determine the cause of fear/anxiety.
Actively listen to the patient to show them they can be open about what they are feeling and will not be judged or dismissed. Support but do not provide false reassurances.
3. Assess coping strategies.
Assess the patient’s coping strategies in response to their anxiety/fear. Ask questions about what strategies are or aren’t working. Determine if new strategies need to be implemented.
Interventions:
1. Provide a calm environment.
A chaotic or stimulating environment can cause an increase in anxiety. Use a calm and supportive voice when talking with the patient. Patients can pick up on anxiety from the nurse and the surrounding environment.
2. Promote relaxation techniques.
There are a variety of relaxation techniques that may work to help a patient’s anxiety and fear. These include meditation, yoga, deep breathing, guided imagery, and talk therapy. Encourage the patient to try multiple techniques to determine what works best for them.
3. Educate patients on their diagnosis.
The fear of the unknown can come from a lack of information regarding their diagnosis. Evaluate the patient’s understanding of their diagnosis, treatment, and prognosis. Answering questions accurately and addressing misconceptions can ease fear and anxiety.
4. Evaluate support systems.
Determine what kind of support system the patient has. Encourage family support along with support groups. Support groups can include other breast cancer patients, breast cancer survivors, and caregiver groups. Support helps reduce feelings of isolation, which can cause anxiety and fear.
Disturbed Body Image
Patients diagnosed with breast cancer may experience disturbed body image due to changes associated with the presence of breast tumors and following surgical procedures or other treatments.
Nursing Diagnosis: Disturbed Body Image
Related to:
- Breast/nipple changes from cancer
- Side effects from chemotherapy or radiation
- Low self-esteem
- Surgical procedures (lumpectomy or mastectomy)
- Post-operative complications
- Loss of a body part
As evidenced by:
- Removal of breasts or breast tissue
- Altered function/sensation of nipples
- Avoids looking at or touching breasts
- Change in social involvement
- Depressive symptoms
- Focus on past appearance
- Verbalizes negative feelings about appearance
- Expresses concern about rejection by others
- Preoccupied with a change in appearance
- Consistently compares oneself with others
- Expresses concerns about sexuality
- Refuses to acknowledge change
- Expresses concern about loss of identity/femininity
Expected outcomes:
- Patient will demonstrate adaptation to changes in physical appearance and body function through lifestyle changes.
- Patient will verbalize acceptance of changes in their appearance.
Assessment:
1. Review treatment options.
A breast cancer diagnosis can have a significant effect on the patient’s self-esteem and perception of self. Ensure the patient understands the outcome of surgical procedures (lumpectomy vs mastectomy).
2. Assess for side effects of the breast cancer treatment regimen.
Effects of chemotherapy, radiation, and surgery can include removal of the breast or breast tissue, breast fibrosis, permanent scars, lymphedema, hair loss, and weight loss, which can all affect the patient’s body image.
3. Monitor for verbal and nonverbal signs of disturbed body image.
The patient may or may not verbalize negative thoughts about a change in body image. The nurse should remain aware of signs such as avoiding eye contact, avoiding looking at or touching their body, or a lack of social interaction, as these may be possible indications of low self-esteem or shame related to appearance.
Interventions:
1. Encourage the patient to verbalize feelings about their body image.
The nurse can listen, acknowledge, and offer reassurance and compassion to the patient struggling with body image issues.
2. Encourage active participation in treatment planning.
The patient should be an active participant in planning surgical procedures, chemotherapy, and radiation, ensuring clarity about outcomes, side effects, and potential complications. Involvement in medical decisions helps the patient feel more in control and less fearful.
3. Refer the patient to appropriate counseling programs.
Counseling can help patients prepare for breast cancer surgery, maintain a positive psychosocial structure, resolve issues with disturbed body image, and help boost self-esteem.
4. Discuss strategies for overcoming body image issues.
Wigs, mastectomy bras, and nipple/areola tattooing are just a few possibilities to manage alterations in body image following breast cancer surgery or chemotherapy.
Impaired Skin Integrity
Treatments for breast cancer can affect the patient’s skin integrity, causing irritation, pain, and other complications, as well as increasing the susceptibility to infection.
Nursing Diagnosis: Impaired Skin Integrity
Related to:
- Effects of radiation
- Effects of chemotherapy
- Surgical incisions
- Lymphedema
- Alteration in nutritional status
- Immunocompromised status
As evidenced by:
- Skin irritation (erythema, skin peeling, itching, swelling)
- Acute pain
- Bleeding
- Hematoma
- Altered pigmentation
- Impaired circulation
Expected outcomes:
- Patient will alert the nurse to any changes in the skin, such as redness, swelling, or non-intact skin.
- Patient will exhibit optimal healing post-mastectomy or lumpectomy, as evidenced by skin color and temperature within normal limits.
Assessment:
1. Monitor skin during radiation.
Patients undergoing radiation should have the area assessed at each session for redness, skin peeling or blistering and other irritation. These are common with radiation but should be monitored. The patient should also be instructed to closely examine their skin following treatment.
2. Assess surgical incisions.
If the patient had a mastectomy or lumpectomy they will have surgical incisions and possibly drains. Assess for signs of infection such as erythema, swelling, warmth, and drainage. Note the characteristics and amount of drainage.
3. Assess for lymphedema.
Lymphedema can occur months or years following the removal of lymph nodes which disrupts the lymphatic system and causes painful swelling and damage to the skin. Along with swelling the patient may complain of tightness in the armpit area, clothing not fitting as normal, aching, and weakness.
Interventions:
1. Ensure nutritional needs are met.
Altered nutrition can result in delayed wound healing. Poor intake may be further complicated by symptoms of nausea and vomiting caused by chemotherapy. Collaborate with the dietician as needed to ensure the patient receives adequate nutrients and hydration, promoting optimal skin health.
2. Educate on skin care with radiation therapy.
If the patient is undergoing radiation therapy, educate them on the potential side effects of radiation, including redness, dryness, itching, sensitivity, and peeling in the treatment area. The nurse should instruct the patient on the following skin care strategies:
- Gently pat the skin dry after showering
- Avoid direct sunlight to the affected area
- Opt for electric razors to shave the armpit
- Deodorants may be used as needed*
- Keep the skin hydrated with lotions and creams*
*These strategies may differ for each facility and provider. Nurses should follow the recommendations of their practice. Do not apply deodorants or lotions prior to radiation sessions.
3. Perform frequent assessments after breast surgery.
There is an increased risk for skin flap necrosis following mastectomy or breast reconstruction. The nurse will need to monitor the breast as directed by the surgeon for signs of duskiness, coolness, or swelling, which can indicate poor perfusion or hematoma development. Some facilities may use devices to monitor blood flow or tissue oxygenation. The nurse must immediately notify the surgeon of any abnormal findings.
4. Encourage loose clothing.
Encourage patients to wear soft, loose cotton clothing during the months they are receiving chemotherapy and/or radiation therapy to minimize friction. Avoiding tight or underwire bras helps prevent pressure and further discomfort to the sensitive skin.
Ineffective Tissue Perfusion
Breast cancer is associated with intravascular invasion, thrombus formation, and tumor formation in the breast and surrounding tissues, resulting in ineffective tissue perfusion.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Tumor presence
- Disease process
- Circulatory compromise
- Inflammatory process
As evidenced by:
- Pallor
- Edema
- Pain
- Paresthesia
- Intermittent claudication
- Altered motor function
- Altered skin characteristics
Expected outcomes:
- Patient will remain free from complications caused by circulatory compromise and decreased tissue perfusion including necrosis.
- Patient will demonstrate interventions that help reduce ineffective breast tissue perfusion.
Assessment:
1. Assess for pain and its characteristics.
Breast cancer can be painful due to metabolic imbalance, inflammatory processes, disease processes, and decreased tissue perfusion.
2. Assess for signs of decreased tissue perfusion.
Ineffective breast tissue perfusion may exhibit changes in the color of the affected site, pallor, decreased capillary refill time, pain or discomfort, decreased pulses, numbness or tingling sensation, and edema.
3. Assess and monitor side effects of breast cancer treatment.
Chemotherapy and radiation therapy are often indicated for breast cancer patients. These treatment regimens have side effects including myocardial capillary injury and increased cardiovascular complications leading to circulation problems and ineffective tissue perfusion.
Interventions:
1. Assist and prepare the patient for surgery as indicated.
Surgery (lumpectomy and mastectomy) may be indicated for patients with breast cancer depending on the severity and staging of the cancer. Surgery can increase the patient’s risk for ineffective tissue perfusion.
2. Monitor the patient’s hemodynamic status.
Monitoring the patient’s hemodynamic status ensures adequate circulation in the body and encourages prompt management of ineffective breast tissue perfusion for patients diagnosed with breast cancer.
3. Administer pain medications as indicated.
Ineffective tissue perfusion can result in ischemic pain or discomfort. Administering pain medications is vital in managing the pain, promoting comfort, and improving breast cancer patient’s quality of life.
4. Encourage exercise as tolerated.
An appropriate exercise regimen can help promote tissue perfusion and support the metabolic demands of the affected breast tissue.
5. Encourage adequate fluid intake and well-balanced meals.
Optimal nutrition and hydration help maintain circulating volume to ensure adequate tissue perfusion and regeneration and promote healing and recovery.
6. Assist in providing chemotherapy or radiation therapy.
Radiation and chemotherapy can help manage and kill breast cancer cells, promoting adequate tissue perfusion to the cancer site for healing and recovery.
References
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