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
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.
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.
TYPES OF BREAST CANCER SURGERY
*Modified Radical
*Radical
*Axillary Node Dissection
*Breast Conservation Surgery
MODIFIED RADICAL
WHAT IS IT?
POTENTIAL COMPLICATIONS
*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.
*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
BREAST CONSERVATION SURGERY W/ RADIATION THERAPY
WHAT IS IT?
PATIENT ISSUES
*Wide excision of tumor, sentinal lymph node
dissection and/or anterior lymph node dissection,
radiation therapy.
*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
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
PATIENT ISSUES
*Short-term: Skin flap, necrosis, wound separation,
seroma, hematoma, infection
*Long-term: Capsular contractions,
displacement of implant
*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
PATIENT ISSUES
*Pain related to two surgical sites
and extensive surgery
*Prolonged postoperative recovery
POTENTIAL COMPLICATIONS
*Short-term: Delayed wound healing,
Infection, skin flap necrosis, abdominal hernia, hematoma.
>> Lewis, et. al. (2007). P. 1353
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
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 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).
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 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.
WHAT ABOUT LYMPHEDEMA?
>> Weaver. (2009). P. 47-48
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.
PATIENT PREVENTION
RISK FACTORS
*Increasing age
*Obesity
*Extensive axillary disease
*Radiation therapy
*Injury/infection of the arm
*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.
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 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.