Page 1281 - Saunders Comprehensive Review For NCLEX-RN

painless except in the late stages
4. Asymmetry
5. Bloody or clear nipple discharge
6. Nipple retraction or elevation
7. Skin dimpling, retraction, or ulceration
8. Skin edema or peau d’orange skin
9. Axillary lymphadenopathy
10. Lymphedema of the affected arm
11. Symptoms of bone or lung metastasis in late stage

D. Early detection: Regular BSE

1. Performing BSE
a. Perform regularly 7 to 10 days after
menses.
b. Postmenopausal clients or clients who
have had a hysterectomy should
perform BSE regularly as well.
2. Client instructions (Fig. 44-2)
E. Nonsurgical interventions
1. Chemotherapy
2. Radiation therapy
3. Hormonal manipulation via the use of medication in
postmenopausal women or other medications for
estrogen receptor–positive tumors
4. Monoclonal antibodies such as trastuzumab for
human epidermal growth factor receptor 2–positive
(HER-2 +) breast cancer
F. Surgical interventions: Surgical breast procedures, with possible
breast reconstruction (Box 44-12)
G. Postoperative interventions
1. Monitor vital signs.

2. Position the client in a semi-Fowler’s position;

turn from the back to the unaffected side, with the
affected arm elevated above the level of the heart to
promote drainage and prevent lymphedema.
3. Encourage coughing and deep breathing.
4. If a drain (usually a Jackson-Pratt) is in place, maintain
suction and record the amount of drainage and
drainage characteristics; teach the client about home
management of the drain (Fig. 44-3).
5. Assess operative site for infection, swelling, or the
presence of fluid collection under the skin flaps or in
the arm.
6. Monitor incision site for restriction of dressing,
impaired sensation, or color changes of the skin.
7. If breast reconstruction was performed, the client will

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