MASTECTOMY POWERPOINTx

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Alyssa Hopkins, SN, SJC
4

NU 420 B Nursing Internship Theory

February 23, 2011


MASTECTOMY:

A Holistic Way To Heal

OBJECTIVES

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

s
urgery, 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

c
ontinues 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

N
ode Dissection


*Breast Conservation Surgery

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.


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, muscle

weakness,
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
, infection

Long
-
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 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?

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



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

u
nderarms.

*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.




>> 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 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

f
unctioning 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.