Surgical Management:

Halsted radical mastectomy – breast tissue, nipple, underlying muscles, lymph nodes
(rarely performed)
Modified radical mastectomy – breast tissue, nipple, lymph nodes
Simple mastectomy – breast tissue, nipple (lymph nodes left intact)
Lumpectomy – only tumour , small amount of surrounding tissue removed
• URGICAL MANAGEMENT Breast Conserving (Stages 1 & 2)
Lumpectomy
• Lumpectomy with lymph node dissection
• Simple Mastectomy-breast tissue & usually nipple removed, lymph
nodes remain intact
• Modified radical Mastectomy-Removal of entire breast tissue and
axillary lymph nodes; pectoral muscles & nerves remain intact
• SURGICAL MANAGEMENT SENTINEL LYMPH NODE BIOPSY
• Identifies clients with axillary involvement without palpable nodes
• Dye indicates lymph node path, with first reactive nodes removed &
examined
• Absence of positive sentinel nodes prevents unnecessary radical
dissections
• POSSIBLE NURSING DIAGNOSES: MASTECTOMY
• Pain related to tissue trauma from surgery
• Skin integrity, Impaired due to surgical incision
• Mobility, Impaired Physical related to pain & tissue trauma
• Infection, Risk for related to disruption in skin integrity
• Body Image, Disturbed related to loss of breast
• Social interaction, Impaired related to changes in body image
• Knowledge, Deficient related to exercises to regain arm mobility
• MASTECTOMY:PREOPERATIVE CARE
• Include significant other
• Recognize & deal with anxiety, lack of knowledge, & body image
issues
• Review type of procedure & presence of drainage devices
• Describe location of incision
• Instruct in mobility restrictions
• Implement basic pre & post op teaching
• Provide written materials
• MASTECTOMY: POSTOPERATIVE CARE
• Anesthesia recovery
• Pain management
• Assess vital signs q30 min –q4hours
• Assess dressing for bleeding
• Wound care , observe incision for swelling , infection
• Maintain skin integrity
• Prevention of infection
• Institute measures to promote respiratory function
• Drainage tube care, usually JP’s with gentle suction
• MASTECTOMY: SPECIFIC POSTOPERATIVE CARE
• Semi-fowler’s position- HOB 30
• Elevate affected arm, DO NOT USE FOR PROCEDURES- (No BP, labs, or
injections) BE SURE TO PLACE A SIGN OVER BED!
• Early ambulation & assistance with prescribed exercises (flex, extend
fingers, lower arm, & wrist) consult physician before full arm exercises
on the affected side
• Teach drainage tube care
• MASTECTOMY: SPECIFIC POSTOPERATIVE CARE
• MASTECTOMY: POSSIBLE COMPLICATIONS
• Hematoma at incision site
• Infection
• Seroma (accumulation of serosanguineous fluid after drain removed)
• Nerve trauma
• Impaired arm mobility
• Lymphedema
• Psychological effects
• REAST RECONSTRUCTION
• May begin during the original operative procedure
• Skin flap- (autogenous reconstruction)
• Saline filled prosthesis
• Progressive tissue expander
• Nipple creation
• If not done immediately, temporary or permanent prosthesis may be
given
• TRAM flap reconstruction often used
• URGICAL MANAGEMENT Breast Conserving (Stages 1 & 2)
Lumpectomy
• Lumpectomy with lymph node dissection
• Simple Mastectomy-breast tissue & usually nipple removed, lymph
nodes remain intact
• Modified radical Mastectomy-Removal of entire breast tissue and
axillary lymph nodes; pectoral muscles & nerves remain intact
• PSYCHOSOCIAL ASSESSMENT
• Fear of cancer & prognosis
• Previous experiences with cancer
• Knowledge, education level
• Threats to body image
• Threats to sexuality and intimate relationships
• Support systems
• Need for other resources or counseling
• The nurse provides:
• Preoperative care – psychologic preparation, preoperative teaching;
assess need for drainage tube, mobility restrictions, length of hospital
stay, possibility of additional therapy; address body image issues
• Intra-operative care – circulator, scrub
• Postoperative care – avoid using affected side for B/P, injections,
blood draws; care of drainage tubes, comfort measures, client
teaching, ambulation, adls, exercise,
• BREAST BIOPSY:NURSING CARE
• Assess anxiety & fear (80% are negative)
• Education
• Prior to biopsy, avoid agents interfering with blood clotting
• NPO
• Care of biopsy site
• Avoid strenuous exercises for 1 week
• Pain management
• Supportive bra for 3-7 days
• Post test: Monitor:
• Effects of anesthesia
• Toleration of fluids, food, ambulation
• POSSIBLE NURSING DIAGNOSES
• Anxiety related to possible diagnosis of cancer
• Grieving, Anticipatory, related to loss
• Pain, Acute related to breast disease
• Sleep Pattern, Disturbed related to pain and anxiety
• Body Image, Disturbed related to possible loss of body part
• Sexual dysfunction related to body image and/or self esteem
• reast Reconstruction
• The nurse:
• Assesses incision, flap sites
• Teaches client to avoid pressure flap, suture lines
• Cares for drainage devices
• Teaches client to avoid sleeping in prone position
• Teaches client to avoid contact sports
• Teaches client to minimize pressure to breast during sexual relations
• Teaches client to refrain from driving
• Reassures client that optimal appearance may not occur for 3-6 months post – surgery
• Reviews BSE procedure
• Reminds client that mammograms should be scheduled at least yearly for the rest of her life
• Refers to ACS
• Assesses the client’s attitude toward appearance restoration
• INTERVENTIONS ANXIETY: GOAL: EFFECTIVE COPING
• Allow time for ventilation of feelings
• Active listening
• Promote client’s decision making abilities
• Active participation in choice of treatment
• Be flexible
• Utilize outside resources
• URGICAL MANAGEMENT Breast Conserving (Stages 1 & 2) Lumpectomy
• Lumpectomy with lymph node dissection
• Simple Mastectomy-breast tissue & usually nipple removed, lymph nodes
remain intact
• Modified radical Mastectomy-Removal of entire breast tissue and axillary
lymph nodes; pectoral muscles & nerves remain intact

• 56 SURGICAL MANAGEMENT SENTINEL LYMPH NODE BIOPSY

• Identifies clients with axillary involvement without palpable nodes
• Dye indicates lymph node path, with first reactive nodes removed & examined
• Absence of positive sentinel nodes prevents unnecessary radical dissections
• POSSIBLE NURSING DIAGNOSES: MASTECTOMY
• Pain related to tissue trauma from surgery
• Skin integrity, Impaired due to surgical incision
• Mobility, Impaired Physical related to pain & tissue trauma
• Infection, Risk for related to disruption in skin integrity
• Body Image, Disturbed related to loss of breast
• Social interaction, Impaired related to changes in body image
• Knowledge, Deficient related
• to exercises to regain arm mobility
• MASTECTOMY:PREOPERATIVE CARE
• Include significant other
• Recognize & deal with anxiety, lack of knowledge, & body image
issues
• Review type of procedure & presence of drainage devices
• Describe location of incision
• Instruct in mobility restrictions
• Implement basic pre & post op teaching
• Provide written materials
• MASTECTOMY: POSTOPERATIVE CARE
• Anesthesia recovery
• Pain management
• Assess vital signs q30 min –q4hours
• Assess dressing for bleeding
• Wound care , observe incision for swelling , infection
• Maintain skin integrity
• Prevention of infection
• Institute measures to promote respiratory function
• Drainage tube care, usually JP’s with gentle suction
• MASTECTOMY: SPECIFIC POSTOPERATIVE CARE
• Semi-fowler’s position- HOB 30
• Elevate affected arm, DO NOT USE FOR PROCEDURES- (No BP, labs, or
injections) BE SURE TO PLACE A SIGN OVER BED!
• Early ambulation & assistance with prescribed exercises (flex, extend
fingers, lower arm, & wrist) consult physician before full arm exercises
on the affected side
• Teach drainage tube care
• MASTECTOMY: SPECIFIC POSTOPERATIVE CARE
• MASTECTOMY: POSSIBLE COMPLICATIONS
• Hematoma at incision site
• Infection
• Seroma (accumulation of serosanguineous fluid after drain removed)
• Nerve trauma
• Impaired arm mobility
• Lymphedema
• Psychological effects
• BREAST RECONSTRUCTION
• May begin during the original operative procedure
• Skin flap- (autogenous reconstruction)
• Saline filled prosthesis
• Progressive tissue expander
• Nipple creation
• If not done immediately, temporary or permanent prosthesis may be
given
• TRAM flap reconstruction often used
• DISCHARGE TEACHING: CARE OF INCISION
• Light dressing, keep dry
• No lotions, ointments, deodorants
• Observe for continued redness, swelling, heat, tenderness after 1st
few weeks
• Loose fitting clothes
• ROM exercises when sutures, drains removed
• Shower after sutures, drains removed
• RE-OP 1. Explain breast cancer and treatment options 2. Reduce fear
and anxiety and improve coping abilities 3. Promote decision making
abilities 4. Provide routine pre-op care: Consent, NPO, Meds, Teaching
about breathing exercise
• Post-OP 1. Position patient: Supine Affected extremity elevated to
reduce edema
• 15 Breast Cancer NURSING INTERVENTION : Post-OP 2. Relieve pain
and discomfort Moderate elevation of extremity IM/IV injection of
pain meds Warm shower on 2 nd day post-op
• 16 Breast Cancer NURSING INTERVENTION : Post-OP 3. Maintain skin
integrity Immediate post-op: snug dressing with drainage Maintain
patency of drain (JP) Monitor for hematoma w/in 12H and apply
bandage and ice, refer to surgeon
• Breast Cancer NURSING INTERVENTION : Post-OP 3. Maintain skin
integrity Drainage is removed when the discharge is less than 30 ml in
24 H Lotions, Creams are applied ONLY when the incision is healed in
4-6 weeks
• 18 Breast Cancer NURSING INTERVENTION : Post-OP Promote activity
Support operative site when moving Hand, shoulder exercise done on
2 nd day Post-op mastectomy exercise 20 mins TID NO BP or IV
procedure on operative site
• 19 Breast Cancer NURSING INTERVENTION : Post-OP Promote activity
Heavy lifting is avoided Elevate the arm at the level of the heart On a
pillow for 45 minutes TID to relieve transient edema
• Breast Cancer NURSING INTERVENTION : Post-OP MANAGE
COMPLICATIONS Lymphedema 10-20% of patients Elevate arms,
elbow above shoulder and hand above elbow Hand exercise while
elevated Refer to surgeon and physical therapist
• 21 Breast Cancer NURSING INTERVENTION : Post-OP MANAGE
COMPLICATIONS Hematoma Notify the surgeon Apply bandage wrap
(Ace wrap) and ICE pack
• Post-OP MANAGE COMPLICATIONS Infection Monitor temperature,
redness, swelling and foul-odor IV antibiotics No procedure on
affected extremity
• 23 Breast Cancer NURSING INTERVENTION : Post-OP TEACH FOLLOW-
UP care Regular check-up Monthly BSE on the other breast Annual
mammography
• Surgery: Mastectomy this is the main treatment for breast cancer especially when it is
localized without distant metstasis e.g. radical mastectomy is the removal of the whole
breast, some fatty tissue and dissection of the auxillary lymph nodes.
• Immuno-therapy
• Nursing management: A good caring attitude is necessary in optimizing the management
of cancer patients. It is important that nurses be acquainted with the burden of breast
cancer in order to cooperate with the health team in instituting measures aimed at
relieving the individual, family and community of the unpleasant outcomes. Creating
awareness in the younger age onset observed among developing countries could result
in setting screening schedule that will start at earlier years. In the multi-disciplinary
approach of the clients with breast cancer, nurses should be proactive in planning and
co-ordinating care that will be reflective of the physical, psychological and socio-
economic impact of the condition.
• Pre and post-operative management: in addition, pay special attention to exercising of the arm on the affected side of the breast.
• Psychological management:
• Reassure
• Keep open relationship with her
• Offer words of encouragement
• Encourage her to verbalize her anger and fears on her diagnosis and the effect on her life.
• Help her to identify sources of support and strength e.g. her partner, family, children etc.
• Assist her to develop a positive but realistic attitude to life.
• Nursing management of breast cancer
• Assess patient’s needs for:
• Acceptance of diagnosis
• Development of helpful coping mechanisms
• Emotional support (family/health workers)
• Education about condition and procedures
• Bodily comfort etc.
• Possible Nursing Diagnosis for mastectomy
• Pre-operatively:
• The assessment leads to identification of specific nursing problems/diagnoses such as:
• Knowledge deficit.
• Anxiety
• Fear.
• Ineffective coping.
• Decisional conflict regarding therapy.
• Post-operatively:
• Pain
• Risk of infection
• Risk of impaired adjustment.
• Disturbed body image.
• Self care deficit.
• Risk of sexual dysfunction.
• Common problems associated with breast cancer:
• Threats to physical well-being include effects of treatments
recurrence and metastasis, fatigue, arm and shoulder discomfort and
lymph-oedema (Dow,2001).
• Psychological threats – psychological distress, anxiety and fears of risk
of breast cancer for other female members of the family.
• Social crisis – social interactions, recreation, employment issues, etc.
• Spiritual crisis – loss of hope, uncertainty about the future.
• Complication of breast cancer: most breast cancer patients suffer
from depression (British Manual Journal, 2009).
• ostoperative Care • Avoidance of using the affected arm for blood
• pressure measurement, giving injections, or
• drawing blood
• • Monitoring of vital signs
• • Care of drainage tubes
• • Comfort measures
• • Mobility and diet
• • Breast reconstruction
• 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

• REAST 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

• ISSUE 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
• 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
• PATIENT ISSUES
• *Prolonged postoperative recovery
• POTENTIAL COMPLICATIONS
• *Short-term: Delayed wound healing,
• Infection, skin flap necrosis, abdominal hernia, hematoma.
• 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
• 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
• 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.
• 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

• 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.