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MASTECTOMY: A Holistic Way To Heal. Alyssa Hopkins, SN, SJC 4 NU 420 B Nursing Internship Theory February 23, 2011. OBJECTIVES. * Identify surgical mastectomy options including: Modified radical mastectomy, Breast conservation s urgery, Tissue expansion, Musculotaneous flap procedures

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slide1

MASTECTOMY:

A Holistic Way To Heal

Alyssa Hopkins, SN, SJC 4

NU 420 B Nursing Internship Theory

February 23, 2011

slide2

OBJECTIVES

*Identify surgical mastectomy options including: Modified radical mastectomy, Breast conservation

surgery, 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.

slide3

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. Incidence

continues 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 may

increase 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.

slide4

TYPES OF BREAST CANCER SURGERY

*Modified Radical

*Radical

*AxillaryNode Dissection

*Breast Conservation Surgery

slide5

MODIFIED RADICAL

WHAT 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.

POTENTIAL COMPLICATIONS

*Short-term: Skin flap, necrosis, seroma,

hematoma, infection

*Long-term: Sensory loss, muscle

weakness, lymphedema

SIDE EFFECTS

*Chest wall tightness

*Phantom breast sensations

*Arm swelling

*Sensory changes

PATIENT ISSUES

*Loss of breast

*Incision

*Body image

*Impaired arm mobility

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

slide6

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.

PATIENT ISSUES

*Prolonged treatment

*Impaired arm mobility

*Change in texture and sensitivity to breast

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, infection

Long-term: Fibrosis, lymphedema, pneumonitis, rib fractures

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

slide7

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

slide8

MUSCULOCUTANEOUSFLAPPROCEDURES

WHAT IS IT?

*Contains muscle, skin, blood supply.

*Is transposed from latissimusdorsi to transverse

rectus abdominis to chest wall

SIDE EFFECTS

*Pain related to two surgical sites

and extensive surgery

PATIENT ISSUES

*Prolonged postoperative recovery

POTENTIAL COMPLICATIONS

*Short-term: Delayed wound healing,

Infection, skin flap necrosis, abdominal hernia, hematoma.

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

slide9

PREOPERATIVE TEACHING

*Prior to preoperative teaching: Nurse should assess patient’s learning needs,

realize that every patient is different, be ready for any type of questions.

*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).

>> Weaver. (2009). P. 44

slide10

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

slide11

SENTINAL NODE BIOPSY

WHAT 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).

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:

-Unifocaltumour of diameter less than or

equal to 3 cm

-Clinically negative axilla, including consideration of

imaging finding.

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.

>> Lewis, et. al. (2007). P. 1351

>> (2009) NZ Guideline Group.

>>Bonema, et. al. (2002). P. 1532-1534

slide13

HOLISTIC HEALING

TIME 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 self

respect.

*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.

slide14

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 same

side 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

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

PATIENT PREVENTION

*Inform healthcare provider to take

BP’s on unaffected arm.

*Avoid wearing tight clothing or

jewelry on affected arm.

*Use electric razor for shaving

underarms.

*Wear sunscreen with SPF of at least

SPF 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.

slide16

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?

slide17

WORKS CITED

  • Lewis, 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. “Biopsychosocial
    • functioning of women after mastectomy.” Journal of Clinical Nursing (2008): 613-618.
  • Surgery for early invasive breast cancer. In: New Zealand Guidelines Group. Management of early
    • breast cancer. Wellington (NZ): New Zealand Guidelines Group (NZGG); 2009: 29-57.
  • Weaver, Caroline. “Caring for a patient after mastectomy.” Nursing 2009 (2009): 44-48.