CPR for Children

CPR for children is similar CPR for adults. The compression to ventilation ratio is 30:2. There are, however, 3 differences.

	1) If you are alone with the child give two minutes of CPR before calling 911
	2) Use the heel of one or two hands for chest compression 3) Press the sternum approximately one-third the depth of the chest

				c/f: LEARN CPR

STANDARD CPR IN ADULTS (CPR IN THREE SIMPLE STEPS)

1. CALL Check the victim for unresponsiveness. If there is no response, Call 911 and return to the victim. In most locations the emergency dispatcher can assist you with CPR instructions.
2. BLOW Tilt the head back and listen for breathing.  If not breathing normally, pinch nose and cover the mouth with yours and blow until you see the chest rise. Give 2 breaths.  Each breath should take 1 second.
3. PUMP If the victim is still not breathing normally, coughing or moving, begin chest compressions.  Push down on the chest 1½ to 2 inches 30 times right between the nipples.  Pump at the rate of 100/minute, faster than once per second.
CONTINUE WITH 2 BREATHS AND 30 PUMPS UNTIL HELP ARRIVES NOTE: This ratio is the same for one-person & two-person CPR.  In two-person CPR the person pumping the chest stops while the other gives mouth-to-mouth breathing.

Tiotropium Plus Glucocorticoid Effective in Asthma Patients

MONDAY, Sept. 20 (HealthDay News) -- The addition of the long-acting anticholinergic agent tiotropium bromide to an inhaled glucocorticoid is superior to a doubling of the dose of the glucocorticoid in improving lung function and symptoms in patients with uncontrolled asthma, and it is non-inferior to the addition of salmeterol, according to a study published online Sept. 19 in the New England Journal of Medicine to coincide with a presentation at the European Respiratory Society Annual Congress, held from Sept. 18 to 22 in Barcelona, Spain.

In a three-way, double-blind, triple-dummy crossover study, Stephen P. Peters, M.D., of Wake Forest University Health Sciences in Winston-Salem, N.C., and colleagues compared the addition of tiotropium bromide to an inhaled glucocorticoid with a doubling of the dose of the inhaled glucocorticoid or the addition of salmeterol among 210 patients with asthma.

Compared with a doubling of the dose of an inhaled glucocorticoid, the investigators found that the addition of tiotropium bromide resulted in a superior primary outcome, as measured by the morning peak expiratory flow (PEF), with a mean difference of 25.8 liters per minute. The addition of tiotropium bromide was also superior in most secondary outcomes, including evening PEF, the proportion of asthma-control days, daily symptom scores, and the forced expiratory volume in 1 second (FEV1) before bronchodilation. The addition of tiotropium bromide was also found to be non-inferior to the addition of salmeterol for all outcome measures and to increase the prebronchodilator FEV1 more than salmeterol.

"Since we could not examine either the rate of asthma exacerbations or long-term safety issues, our findings cannot be considered clinically directive. Additional studies that have sufficient statistical power to evaluate exacerbations and safety events are required to further establish the clinical efficacy of tiotropium. However, our data establish clinical equipoise to study larger cohorts of adults for longer periods of time with tiotropium as a therapy for asthma control," the authors conclude.

Boehringer Ingelheim provided the tiotropium and matching placebo for the study and had the opportunity to comment on the study design. Several authors disclosed financial ties to various pharmaceutical and/or medical device companies, including Boehringer Ingelheim.

The Life of a New Nurse in the Philippines

I graduated as a nurse from a certain University in the Philippines. I was just as excited as any Nursing graduate. Earning a bachelors degree in Nursing was really something in my country. All of those sleepless nights of studying and not to mention the sky-rocketing tuition fees spent by my parents each semester for four years.

Almost every parent hoped their son or daughter will finish up Nursing during my time and I think it continues on to the present. It is because of the promise of working abroad. The demand for nurses really perked up a few years back. I guess it was always the issue of searching for greener pastures. The promise of working abroad and earning a lot of money stirred up the ideas of most parents; believing that their son/daughter can fly to US and earn dollars after graduating and passing the Boards. I hope that was the real case...

After I earned the title BSN (Bachelor of Science in Nursing), it was time to review for the Nursing Board Exam. I remembered reviewing for almost a year (I really wanted to have a place on the top 10). I also remembered the efforts of the various review centers; trying to lure as many students as possible. Nursing students are really a good source of money.

So there it was, around 2-3 months of non-stop review and it’s off to the board exams. All of the examinees are really aiming to pass the boards in any way possible. I was confident back then. I knew I was going to pass and I was also hoping to pass it with flying colors. The excitement of the boards began to ease out after the exam.

While anticipating for the results, a lot of my friends entered the Call Center industry. After a few months, the results were out, passers had their oath-taking, and we were made to think that we were closer to our goals of going to the promised lands. I immediately took the chance of applying for a nursing job in every hospital (both private and public hospitals).

It was one of the requirements that new board passers must have necessary trainings such as Intravenous insertion, Basic Life Support and the like to be able to be accepted as a nurse in any hospital.

I enrolled in all the trainings required and even had my seminars so that my resume would stand out amongst all job competitors. My efforts on applying in hospitals and clinics continued on even after I got a job from a Review and Training Center for Nurses.

I really liked to live my career as a Nurse in a hospital; caring for patients, but I was financially challenged. I couldn’t afford working as a volunteer with less or no pay at all or worst having my training in hospitals and paying for the training with no guarantee of being one of its staffs.

Those were the current situations of newly nursing graduates or board passers here in the Philippines. Wherever I go, the policy is the same: you got to be a volunteer with or without pay or pay a certain amount for on-the-job trainings. If you’ll take into consideration on the prices that these hospitals are charging Nurses, you’ll also think that it is just a way to earn money out of the poor Nurse’s pockets. Regular training costs at around 1000 Philippine peso a month.

Special areas and other well-known hospitals even charge at around 8000-15000 pesos. Do you think that’s even fair for new Nurses, whom only depend unto their parents?

What would become of those unfortunate nurses who are unable to have the money necessary for training? This is what had happened to me...

After around a year of applying in various health institutions, I grew weary. I searched for other ways of preserving my knowledge of Nursing aside from trainings and seminars. Another pathway unto the Nursing career is continuing on in Nursing Education. I decided to have my Masters degree without having any clinical experience.

I did this while I am working for a private company on a medical account. Having a Master’s degree offered a chance to be employed in a more promising job in Nursing: that is to be a Nursing lecturer or a Clinical Instructor either in the community or the hospital. I am actually doing this for a year now; working in a non-Nursing office while studying for Masters.

Another pathway is having all the exams necessary for landing job abroad. I am also planning to have those exams: IELTS, NCLEX, CGFNS and the like when I already have enough money. It seems to be a promising way to escape the fate of nurses here in the Philippines: to go abroad.

The only problem with applying for a job abroad is that it also requires clinical experience as a staff nurse. I remembered some of my friends being a volunteer for almost a year without pay or having an allowance of just around 50 pesos per day! Because of what is happening, I’m beginning to realize that Nursing is a profession made for rich people who can afford to supply an endless pool of money over trainings and seminars. I’m glad that the Philippine government is implementing some ways of giving a solution on the increasing rate of unemployment in Nursing.

Just last year, the NARS program was made to give nurses a chance to have their experiences for 6 months. Such a good opportunity for nurses, but I think it is not sufficient for answering the problems of unemployment. Nurses continue on having a really tough time here in the Philippines and I’m sure it’ll continue on for a few years more as more student Nurses are planning to add on the Nursing population explosion.

Nursing unemployment is really a grave problem these days here in the Philippines. And I think hospitals are taking advantage of new nurses, making them pay for overpricing training fees or offering them a job without pay. I’m really saddened by the way nurses are treated here in the Philippines.

I really hope the newly elected officers of the country would try on considering more possible solutions for this problem. Fellow nurses are now petitioning for free on-the-job trainings for nurses which are to be considered as clinical experience.

Up to this very day, I’m still not losing my grip. I’m still hopeful that I could land a job in a hospital or any health institution, passing my resume to every health institution I can find. I am doing this for the last two years and still hoping...

Pain Medication From Common Sense Perspective

Is pain scale an objective tool to measure pain level. I’ve never thought so. How often it happens when a nurse asks a patient:
- Do you have pain?
- A little bit.
- How would you rate your pain level on scale from 0 to 10?
- Eight or nine.
In this case the majority of nurses do exactly as we are brainwashed to do: document 9 and offer pain medication. The majority of patients do not refuse a pain shot even though they would not request one if a nurse does not push. Does it make sense? A little bit of pain rated as 9???
Several weeks ago I attended “Pain Control Class”. Both doctors and nurse educators talked about pain. I really loved listening doctors. And I learned that doctors did not like prescribe pain medication because of side effects. One doctor said that even though opiods can control pain well, a lot of patients still suffer of withdrawal symptoms a lot. But why patients are not informed about down the road complications? Instead we tell them, “Do not hesitate to request pain medication”. I feel that we, nurses, are pill pushes. We believe we are professionals but we do not know much about medications we give to our patients. It is even not our fault because nursing textbooks do not say anything about it. Probably because they do not want us to know the truth. They just want us to be pill pushers. I remember a 20 years old patient with stones in gallbladder. (He was a pre op) He told me he cannot sleep and requested sleeping aid. I forwarded his request to MD.
-How old is he? - asked me MD.
-Twenty, replied I.
Doctor did not tell me anything but looking at her face you could see she did not like that young pateint’s request at all. Anyway, she ordered Ambien. Why did she write that order against her conscious? Why not to go to talk to the patient to explain to him all risks and why she did not want to take that med? I thing doctors are not free in this country. They are under Big Pharma and are not free to practice common sense.
As I said not only doctors, but nurse educators talked about that topic. And their message was opposite, you know, “Do not hesitate, give pain medication. Pain level is what patient says. But this approach makes a lot of harm. Let’s have a look at my patient who had “a little bit of pain” and rated it 8. I handle this situation according to common sense. I documented “4” and did not offer pain med. The next day I came to work and found out from the report that my patient was confused, pulled out JP drains, talking about conspiracy all the time a had a sitter.
-She reported pain 8 out of 10, - told me a night nurse and I had to offer her Percocet. She took it and became confused.
- How stupid you are, - thought I about that nurse but did not tell her anything. What can you tell someone who are brainwashed by nurse educators?
Not only doctors but also nurse educators talked about pain at that class. Their message was, “Do not hesitate, give you patient pain medication”. I definitely could see that doctors and nursing theorist are on different pages: nursing theory teaches you to push pain meds as doctors do not like it to do it. By the way, I was surprised. One doctor honestly admitted that some physicians increase dose of pain medication a little every time a patient on narcotics come to appointment to make sure that the patient will come back to him.
And how do you like this statement from nursing textbooks, “Patient’s pain level is not what you think, it is what they report”. All people are different and react to pain differently. Patient can smile and still has pain 10/10. Give him narcotic to control his pain. This statement is a brainwashing. Pain shock kills, so pain 10/10 kills. But our body has a protective mechanism. When you are in severe pain you may loose conscious. So if you lose conscious but still alive it means toy pain level is 9/10. Women in labor experience pain level 8/10 does not kill. By the way, have you ever seen a woman in labor, smiling and laughing? Of course not, because even though we are all different, our reaction to pain is the same. To make a story short, only few category of patients need narcotics to control pain. They are: cancer patients, patients with gun shot wounds, some (not all) post op patients.
Once my patient requested two Percocets. It does not matter how he rated his pain because so called pain scale is not a scientific tool but when I asked he said that his pain related to constipation. I had to give him narcotic. When I visited Europe this summer I told about this case to my friend who is an experienced anesthesiologist. He had a very hard time to believe me that in America patient can get narcotics for constipation pain. And that doctor told me that only a few categories of patients need narcotics. Again they are: cancer patients, patients with gun shot wounds, some (not all) post op patients.
Have a look at a chapter about pain in any nursing textbook. One short paragraph tells you that addiction is possible and 20 pages tell you how important to give your patient pain medication. But I tell you doctors are not so easy about down the road addiction. So why nursing theory ignores this problem??? And in the Internet you can find a lot of hard breaking stories written by people who became drug edicts in hospital. I tried to find official statistic of addictions r/t hospitalization but couldn’t. Probably they do not keep track of it or keep information in secret. I only found out that in Ohio 43,000 patients become addicted each year. I could not find information about other states. But it is a lot!!! And it is not a secret that nowadays the majority of drug addicts switched from street drugs to prescription drugs. And it looks like that Big Pharma when planning production of pain meds, considers not only hospitals needs but also drug addicts needs and it is scary.
Why is it so? I think that the answer is in the Bible and Jesus is only a solution. The Bible says, “For the love of money is a root of all kinds of evil.” (1 Tim 6:10). Big Pharma loves money and for this reason they brainwash customers to believe “the more medication the better”. But it is crime and overusing narcotics is even a bigger crime. Why doctors who claim they are Christians do not speak against this madness? Why Christian nurses are silent? We all are accountable to God for this crime. I remember an instructor in nursing school read a letter to our group written by terminally ill child. I remember only one moment from that latter: a terminally ill child refused pain medication because he realized he would not live long and wanted to enjoy communication with his family. Terminally ill people need to have clear mind as long as possible to reconcile with God. But too often they are overmedicated and it is a crime/ I remember 89 years old patient. She was pain free but she had few days to live. Tube feed was discontinued and patient complained about abdominal cramping related indigestion/ (She got only about 50 ml of tube feed). She even did not requested pain medication but her family did it for her and convinced her she needs it. And doctor ordered Delauded 2 milligrams. In this case 0.2 milligrams would be more than enough. This dose made her sleepy and several of her final hours were lost. But for this huge dose, her family could have enjoy meaningful communication with her dying loved one. How does God look at all of this?

What's on your mind? ( NCLEX Q)

Q: The charge nurse on a unit should be aware that which of the following patients may not legally sign an informed consent?

A. A 55-year-old patient who is crying about the surgery she will be undergoing
B. A 16-year-old married patient
C. A 45-year-old patient who has been sedated
D. An 80-year-old patient

Nurses Coping with Personal Grief

How many of you have felt helpless or guilty when caring for a seriously ill or dying patient? How many become overwhelmed with emotion after a particularly “bad death”, or the death of a patient you have allowed yourself to become attached to? What should nurses do to avoid the pain that such circumstances often cause? Or are there appropriate ways to deal with these feelings?

Because nurses work so closely with dying patients….providing intimate care to the whole person…including physical, emotional, and spiritual care…..sharing in conversation the patient’s fears and concerns…… we expose ourselves…our personal feelings. When patients die, we seldom allow ourselves to adequately acknowledge our own losses, or to fully comprehend the intimacy of our relationships with clients. Too often we think we are to be "pillars of strength" in times of crisis or death. While we provide supportive care to patients and families, we fail to recognize our personal need to process loss. We fail to see our need to grieve.

In order to offer compassionate care for the critically sick and for the dying, as nurses we must be able give of ourselves without being destroyed in the process. For self preservation, we may resort to ineffective coping mechanisms such as withdrawal, psychological numbing, and avoidance of personal involvement with patients. Failure to work through the grieving process leads to potential burnout.

As nurses, we strive to provide compassionate care, sharing in the grief, loss, and fear experienced by dying patients and their families. We want to do more than just go through the motions, becoming numb to the pain of others. What are some of the ways you have found to cope with the repetitive emotional strain that you face on a daily basis as you care for people in physical, emotional, and spiritual pain?

It is important that we see ourselves as humans and recognize the emotional reactions that traumatic events evoke in us. Acknowledgment of our vulnerability to tragedy is a fundamental factor in the way each of us handles the senseless losses we are faced with every day in our professional lives.

Feel free to share your stories of situations that have been particularly difficult for you to deal with. We can learn from each other.

CPAP: Use It And Live

The majority of patients I encounter in the ICU/CCU who have a diagnosis of sleep apnea do not use their CPAP machines. Those who DO use them seem to have better outcomes.

I work in a cardiac intensive care unit; CCU and SICU together. As an ICU nurse, I’m well acquainted with the correlation between untreated sleep apnea and heart disease, stroke or sudden death. And I wish I had a dollar for every patient with “Obstructive Sleep Apnea” listed as a diagnosis on their chart and no CPAP with them when they’re admitted to the ICU.

Pauline (not her real name) came in for an MI, proceeded to have a CABG and then stroked while still in the ICU. Her history lists “sleep apnea.” When asked if she brought her CPAP, she proudly held up a Respironics bag. At bedtime, we opened it up and found an ancient CPAP machine and full face mask that may have fit her 100 pounds ago (did I mention that she was 5 foot 0 inches and weighed 140 kg.?) The humidifier was missing a part and the hose had toothmarks in it -- canine or feline toothmarks.

“When was the last time you used this,” I asked, thinking that maybe this is her spare and her real machine is at home on her bedside table.

“Oh, I don’t use it,” she said. “I just brought it in because the office nurse told me I ought to.”

Mentally slapping myself on the side of my head, I ask “Why don’t you use it?”

“I don’t like having all that air forced into me,” she says. Like that ventilator you’re going to be stuck with is so much more comfortable? (I’m so proud that I managed to bite my tongue before actually saying this.) Sure enough, she failed her first three extubation attempts, got trached and is now in a long term care facility on a ventilator.

Hermann has a HeartMate II ventricular assist device. He was readmitted not too long ago with a recurrent drive line infection. As part of the admission process, I went over his problem list with him -- and of course obstructive sleep apnea was listed. “Did you bring your CPAP?” I asked.

“I don’t need to use it anymore,” he said. “I have my HeartMate now!” (For all of you nurses who haven’t worked with HeartMates, they’re a left ventricular assist device. They’re used as bridge to transplant, or even destination therapy for heart failure. Blood is routed from the left ventricle through the device and is returned to the aorta.)

Worse, when I read over his clinic notes, there was a note from a nurse practitioner stating something to the effect of “Patient refuses to use CPAP at night. Instructed to use it for 2 or 3 hours during the day when he’s watching TV, so he’ll get at least some benefit from it.” Really? I doubt that the man is have sleep apnea while he’s watching TV. By definition, one needs to be sleeping to have sleep apnea.

Then there was the man who came in for semi-elective valve surgery. Once again, obstructive sleep apnea was noted on his problem list. “Did you bring your CPAP?” I asked. “Oh, no,” exclaimed his wife. “He doesn’t like it, so he never uses it.” It’s been five months and counting -- he’s still in the ICU. The hypertension he developed subsequent to the untreated sleep apnea caused left ventricular hypertrophy and then he arrested post-op . . . .

I was thrilled when last week’s patient swore he used his CPAP faithfully. “I don’t have it with me because I didn’t think I needed it in the hospital and all,” he explained. “But my wife can go home and get it.”

His wife went home and got the CPAP. Interestingly enough, neither the patient or his wife had any idea how to set it up or how the mask fittings worked. What was he using the CPAP for? A paperweight? He’s on his third admission for heart failure and they’re talking transplant now. I wonder if some of his problems could have been avoided had he been actually using the CPAP he got four years ago.

It may be my imagination, but I swear there’s a correlation between showing up with your CPAP and knowing how to use it and eventual outcome . . . those that bring it and use it seem to do well and transfer out of the ICU promptly. Those who don’t bring it, bring only parts of it, can’t set it up or don’t even pretend to use it usually do poorly. Maybe it’s just that those who actually use their CPAP are more compliant patients in general, and compliant patients do better, but I swear that treating sleep apnea enhances patient outcomes.

The woman I admitted today -- with obstructive sleep apnea and heart disease -- claims she “has sleep apnea, but I don’t need to use a CPAP. They told me I only had to use it at night, and I sleep during the day.” I attempted to educate her on the correlation between sleep apnea and heart disease. “Oh,” she said. “I guess I could use it, but it’s just so difficult. You have no idea how difficult it is, strapping that thing on your face and trying to go to sleep.”

I DO know how difficult it is. I strap one on every night when I go to sleep -- and in the afternoon when I take a nap, too. It’s uncomfortable, unsexy, inconvenient and unnatural. It just might save your life, though.

CPAP: Use it and live.

National Breast Cancer Awareness

Breast cancer is the most common cancer in women in the United States, aside from skin cancer. According to the American Cancer Society (ACS), an estimated 192,370 new cases of invasive breast cancer are expected to be diagnosed among women in the United States this year. An estimated 40,170 women are expected to die from the disease in 2009 alone. Today, there are about 2.5 million breast cancer survivors living in the United States.

If you're worried about developing breast cancer, or if you know someone who has been diagnosed with the disease, one way to deal with your concerns is to get as much information as possible. In this section you'll find important background information about what breast cancer is and how it develops.

Breast cancer is a malignant tumor that grows in one or both of the breasts. Breast cancer usually develops in the ducts or lobules, also known as the milk-producing areas of the breast.

Breast cancer is the second leading cause of cancer death in women (after lung cancer). Although African-American women have a slightly lower incidence of breast cancer after age 40 than Caucasian women, they have a slightly higher incidence rate of breast cancer before age 40. However, African-American women are more likely to die from breast cancer at every age. Breast cancer is much less common in males; by comparison, the disease is about 100 times more common among women. According to the American Cancer Society, an estimated 1,910 new cases of invasive breast cancer are expected to be diagnosed among men in the United States in 2009.

Types of breast cancer

There are several different types of breast cancer that can be divided into two main categories - noninvasive cancers and invasive cancers. Noninvasive cancer may also be called "carcinoma in situ." Noninvasive breast cancers are confined to the ducts or lobules and they do not spread to surrounding tissues. The two types of noninvasive breast cancers are ductal carcinoma in situ (referred to as DCIS) and lobular carcinoma in situ (referred to as LCIS).

It is known that hormones in a woman's body, such as estrogen and progesterone, can play a role in the development of breast cancer. In breast cancer, estrogen causes a doubling of cancer cells every 36 hours. The growing tumor needs to increase its blood supply to provide food and oxygen. Progesterone seems to cause stromal cells (the woman's own cells to send out signals for more blood supply to feed the tumor. (Source: Dr. V. Craig Jordan, vice president and scientific director for the medical science division at Fox Chase Cancer Center in Philadelphia as quoted in NY Times, Hormones And Cancer: By Gina Kolata, Published: December 26, 2006)

• Non-invasive breast cancer. The majority of non-invasive breast cancers are DCIS. In DCIS, the cancer cells are found only in the milk duct of the breast. If DCIS is not treated, it may progress to invasive cancer.
  
  In LCIS, the abnormal cells are found only in the lobules of the breast. Unlike DCIS, LCIS is not considered to be a cancer. It is more like a warning sign of increased risk of developing an invasive breast cancer in the same or opposite breast. While LCIS is a risk factor for invasive cancer, it doesn't actually develop into invasive breast cancer in many women.
• Invasive breast cancer. Invasive or infiltrating breast cancers penetrate through normal breast tissue (such as the ducts and lobules) and invade surrounding areas. They are more serious than noninvasive cancers because they can spread to other parts of the body, such as the bones, liver, lungs, and brain.

There are several kinds of invasive breast cancers. The most common type is invasive ductal carcinoma, which appears in the ducts and accounts for about 80 percent of all breast cancer cases. There are differences in the various types of invasive breast cancer, but the treatment options are similar for all of them.

Not all breast cancers are alike
Not all breast cancers are alike - there are different stages of breast cancer based on the size of the tumor and whether the cancer has spread. For doctor and patient, knowing the stage of breast cancer is the most important factor in choosing among treatment options. Doctors use a physical exam, biopsy, and other tests to determine breast cancer stage.

Stages of Breast Cancer
The most common system used to describe the stages of breast cancer is the AJCC/TNM (American Joint Committee on Cancer/Tumor-Nodes-Metastases) system. This system takes into account the tumor size and spread, whether the cancer has spread to lymph nodes, and whether it has spread to distant organs (metastasis).

All of this information is then combined in a process called stage grouping. The stage is expressed as a Roman numeral. After stage 0 (carcinoma in situ), the other stages are I through IV (1-4). Some of the stages are further sub-divided using the letters A, B, and C. In general, the lower the number, the less the cancer has spread. A higher number, such as stage IV (4), means a more advanced cancer.

These are the stages of breast cancer:

Stage 0 - Stage 0 is carcinoma in situ, early stage cancer that is confined to the ducts or the lobules, depending on where it started. It has not gone into the tissues in the breast nor spread to other organs in the body.

• Ductal carcinoma in situ (DCIS): This is the most common type of noninvasive breast cancer, when abnormal cells are in the lining of a duct. DCIS is also called intraductal carcinoma. DCIS sometimes becomes invasive cancer if not treated.
• Lobular carcinoma in situ (LCIS): This condition begins in the milk-making glands but does not go through the wall of the lobules. LCIS seldom becomes invasive cancer; however, having LCIS in one breast increases the risk of cancer for both breasts.

Stage I - Stage I is an early stage of invasive breast cancer. In Stage I, cancer cells have not spread beyond the breast and the tumor is no more than 2 centimeters (three-quarters of an inch) across.
Stage II - Stage II is one of the following:

• The tumor in the breast is no more than 2 centimeters (three-quarters of an inch) across. The cancer has spread to the lymph nodes under the arm.
• The tumor is between 2 and 5 centimeters (three-quarters of an inch to 2 inches). The cancer may have spread to the lymph nodes under the arm.
• The tumor is larger than 5 centimeters (2 inches). The cancer has not spread to the lymph nodes under the arm.

Stage III - Stage III may be a large tumor, but the cancer has not spread beyond the breast and nearby lymph nodes. It is locally advanced cancer.

• Stage IIIA - Stage IIIA is one of the following:
  • The tumor in the breast is smaller than 5 centimeters (2 inches). The cancer has spread to underarm lymph nodes that are attached to each other or to other structures.
  • The tumor is more than 5 centimeters across. The cancer has spread to the underarm lymph nodes.
• Stage IIIB - Stage IIIB is one of the following:
  • The tumor has grown into the chest wall or the skin of the breast.
  • The cancer has spread to lymph nodes behind the breastbone.
  • Inflammatory breast cancer is a rare type of Stage IIIB breast cancer. The breast looks red and swollen because cancer cells block the lymph vessels in the skin of the breast.
• Stage IIIC - Stage IIIC is a tumor of any size. It has spread in one of the following ways:
  • The cancer has spread to the lymph nodes behind the breastbone and under the arm.
  • The cancer has spread to the lymph nodes under or above the collarbone.

Stage IV - Stage IV is distant metastatic cancer. The cancer has spread to other parts of the body.
Recurrent cancer - Recurrent cancer is cancer that has come back (recurred) after a period of time when it could not be detected. It may recur locally in the breast or chest wall as another primary cancer, or it may recur in any other part of the body, such as the bone, liver, or lungs, which is generally referred to as metastatic cancer.