Alyssa Hopkins, SN, SJC 4

NU 420 B Nursing Internship TheoryFebruary 23, 2011

MASTECTOMY:A Holistic Way To Heal

OBJECTIVES

*Identify surgical mastectomy options including: Modified radical mastectomy, Breast conservationsurgery, Tissue expansion, Musculotaneous flap procedures

*Discuss pre-op teaching.

*Discuss post-op teaching.

*Sentinal node biopsy procedure and teaching.

*Recognize holistic care to help a woman (or man) cope with breast cancer diagnosis and/or mastectomy.

*Discuss meaning of lymphedema.

*Discuss measurement and reduction risk of lymphedema.

*Identify treatment management strategies concerning lymphedema.

RISK FACTORS*Being female- Women account for 99% of breast cancer cases.

*Age 50 or older- Majority of cases found in women who are postmenopausal. Incidencecontinues to increase after age 60.

*Family history- Breast cancer in a first-degree relative increases the risk. BRCA-1 or BRCA-2 gene mutations result in 5%-10% of breast cancer cases.

*Personal health history of breast, colon, endometrial or ovarian cancers- Increases the risk, increases risk in other breast and increases recurrence rates.

*Early menarche (before age 12); late menopause (after age 55)- Long menstrual history mayincrease risk of breast cancer.

*Weight gain and obesity after menopause- Fat cells store estrogen.

*Exposure to ionizing radiation- Radiation is damaging to DNA.

>> Lewis, et al. (2007). P. 1349.

TYPES OF BREAST CANCER SURGERY

*Modified Radical

*Radical

*Axillary Node Dissection

*Breast Conservation Surgery

MODIFIED RADICALWHAT IS IT?

*Removal of the breast and axillary lymph nodes*Preservation of pectoralis muscle*Most commonly used with large sized tumors*Breast reconstructive surgery is an option.

SIDE EFFECTS

*Chest wall tightness*Phantom breast sensations*Arm swelling *Sensory changes

PATIENT ISSUES

*Loss of breast*Incision*Body image*Impaired arm mobility

POTENTIAL COMPLICATIONS

*Short-term: Skin flap, necrosis, seroma,hematoma, infection*Long-term: Sensory loss, muscleweakness, lymphedema

>> Lewis, et. al. (2007). P. 1353

BREAST CONSERVATION SURGERY W/ RADIATION THERAPY

WHAT IS IT?

*Wide excision of tumor, sentinal lymph node dissection and/or anterior lymph node dissection, radiation therapy.

SIDE EFFECTS

*Breast soreness*Breast edema*Skin reactions*Arm swelling*Sensory changes (breast and arm)*Fatigue*Discomfort*Chest wall tightness

POTENTIAL COMPLICATIONS: Short-term: Moist desquamation, hematoma, seroma, infectionLong-term: Fibrosis, lymphedema, pneumonitis, rib fractures

PATIENT ISSUES

*Prolonged treatment*Impaired arm mobility*Change in texture and sensitivity to breast

>> Lewis, et. al. (2007). P. 1353

TISSUE EXPANSION & BREAST IMPLANTS

WHAT IS IT?

*Expander used to slowly stretch tissue;Saline gradually injected into reservoir over weeks to months.*Insertion of implant under muculofascial layer

SIDE EFFECTS

*Discomfort*Chest wall tightness

POTENTIAL COMPLICATIONS

*Short-term: Skin flap, necrosis, wound separation, seroma, hematoma, infection*Long-term: Capsular contractions, displacement of implant

PATIENT ISSUES

*Body image*Prolonged physician visits to expand implants*Additional surgeries for nipple construction*Symmetry

>> Lewis, et. al. (2007). P. 1353

MUSCULOCUTANEOUS FLAP PROCEDURES

WHAT IS IT?

*Contains muscle, skin, blood supply.*Is transposed from latissimus dorsi to transverse rectus abdominis to chest wall

SIDE EFFECTS

*Pain related to two surgical sites and extensive surgery

POTENTIAL COMPLICATIONS

*Short-term: Delayed wound healing,Infection, skin flap necrosis, abdominal hernia, hematoma.

PATIENT ISSUES

*Prolonged postoperative recovery

>> Lewis, et. al. (2007). P. 1353

PREOPERATIVE TEACHING

*Inform patient that after her mastectomy she will be staying in the hospital for one night.

*If reconstruction occurs during surgery, stay could be 2-4 nights.

*Evaluation by healthcare provider will be done.

*Blood tests, urinalysis, and ECG will be done before surgery.

*Make healthcare provider aware of medications which are currently being taken, drug allergies, or any other allergies.

*NPO after midnight.

*Shower with antibacterial soap the night before.

*Inform patient that surgery lasts 1 to 2 hours, depending on type of mastectomy.

*Inform patient of postoperative care both in the hospital and at home.

*Possibly show photographs of women who have had mastectomy (if patient feels comfortable).

*Prior to preoperative teaching: Nurse should assess patient’s learning needs,realize that every patient is different, be ready for any type of questions.

>> Weaver. (2009). P. 44

POSTOPERATIVE TEACHING*Monitor vital signs as ordered by physician

*Monitor pain, bleeding, hematoma, seroma formation, and wound infection (wound infections most likely to occur within first two weeks).

*Follow dressing protocol (gauze and transparent dressings most typical).

*Encourage patient to look at incisions to see what is normal (benefits home care).

*Expected to have two surgical drains with modified radical mastectomy.

*Teach how to milk and strip clots through drainage tubing to maintain patency.

*Teach how to measure fluid from drainage device.

*Monitor for phantom pain.

*DO NOT use heating pad. Altered sensation may result in burns. >> Weaver. (2009). P. 44

SENTINAL NODE BIOPSYWHAT IS IT?

*Mostly used for both palpable and non-palpable T1 and T2 tumors.*Helps surgeons and healthcare team determine and identify the lymph node(s) that drain first from the tumor site (sentinal node).

HOW IS IT DONE?

*A radioisotope and/or blue dye is injected into the tumor site.*Where possible lymphatic mapping with preoperative lymphoscintigraphy in combination with intraoperative use of the gamma probe and blue dye should be used to locate the sentinel node.*It is then determined in which sentinal lymph nodes that the radioisotope or blue dye appears.*The surgeon then makes a local incision in the axilla and dissects the blue-stained and/or radioactive lymph nodes.

WHAT’S NEXT?

*Generally one to four lymph nodes are removed.*Nodes are then sent for a frozen section pathologic analysis.*If nodes are negative, no further removal is necessary.*If nodes are positive, a complete axillary dissection is typically performed. *Sentinal node biopsy has been associated with lower morbidity rates and greater accuracy as with other performed methods.

IS THIS THE RIGHT CHOICE FOR ME?

*Sentinel lymph node biopsy should be offered as a suitable alternative to axillary dissection in a woman with: -Unifocal tumour of diameter less than or equal to 3 cm-Clinically negative axilla, including consideration of imaging finding.

>> Lewis, et. al. (2007). P. 1351>> (2009) NZ Guideline Group.>>Bonema, et. al. (2002). P. 1532-1534

HOLISTIC HEALINGTIME OF DIAGNOSIS

*Many women feel fear, shock, anger, anxiety, denial and depression. They often wonder, “why me?”*As patient questions regarding fears and concerns with cancer diagnosis.*Suggest women’s support groups*Assure the patient that the healthcare team will be there for support.

POST-MASTECTOMY

*When evaluation patient after a mastectomy, all areas of functioning should be taken into account: physical, cognitive, emotional and social.*Loss of feeling of femininity, maternity and sexuality. *Family situation and marital status affect everyday functioning.

NURSES ARE HERE TO HELP

*Patients need a professional and supportive attitude from health service employees.*Women who receive better social support tend to recover more quickly, cope better, and have more selfrespect.*Extend support to patients over an extended postoperative time.*The nursing staff should have an educational role towards women after mastectomy and should be fully equipped to perform it. >> Skrzypulec, et. al. (2008). P. 613, 614, 617, 618.

WHAT ABOUT LYMPHEDEMA?WHAT IS IT?

*Occurs with the axillary lymph node dissection.*Includes swelling, tightness, heaviness, or pain in the hand, arm, or chest on the sameside as surgery. *May occur a few months to up to 30 years after surgery. *The fewer the amount of lymph nodes removed, the less chance of getting lymphedema.*About 30% of patients who undergo axillary lymph node disection develop lymphedema.*About 7% of patients who have a sentinal node biopsy develop lymphedema.

RISK FACTORS

*Increasing age*Obesity*Extensive axillary disease*Radiation therapy*Injury/infection of the arm

PATIENT PREVENTION

*Inform healthcare provider to takeBP’s on unaffected arm.*Avoid wearing tight clothing or jewelry on affected arm.*Use electric razor for shavingunderarms. *Wear sunscreen with SPF of at leastSPF 15.*Wear rubber gloves when washing dishes to avoid harsh detergents.*Sleep on back or non-surgical side.*Avoid heavy lifting for 4-6 weeks.

>> Weaver. (2009). P. 47-48

REVIEW QUESTIONS*What percentage of women account for breast cancer cases?

*Name two of the four types of major breast cancer surgery.

*What is one important precaution a patient should take to prevent lymphedema post-mastectomy?

ANY FURTHER QUESTIONS?

WORKS CITEDLewis, Sharon L., Margaret M. Heitkemper, Shannon Ruff Disksen, Patricia Graber O’Brien, and Linda

Busher. Medical-Surgical Nursing (Single Volume) Assessment and Management of Clinical Problems.St. Louis: Mosby, 2007.

Skrzypulec, Violetta., Tobor, Ewa., Drosdzol, Agnieszka., Nowosielski, Kryzysztof. “Biopsychosocialfunctioning of women after mastectomy.” Journal of Clinical Nursing (2008): 613-618.

Surgery for early invasive breast cancer. In: New Zealand Guidelines Group. Management of earlybreast cancer. Wellington (NZ): New Zealand Guidelines Group (NZGG); 2009: 29-57.

Weaver, Caroline. “Caring for a patient after mastectomy.” Nursing 2009 (2009): 44-48.