Presentation on theme: "NU 420 B Nursing Internship Theory"— Presentation transcript:
1NU 420 B Nursing Internship Theory MASTECTOMY:A Holistic Way To HealAlyssa Hopkins, SN, SJC 4NU 420 B Nursing Internship TheoryFebruary 23, 2011
2OBJECTIVES*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 withbreast cancer diagnosis and/or mastectomy.*Discuss meaning of lymphedema.*Discuss measurement and reduction risk of lymphedema.*Identify treatment management strategies concerning lymphedema.
3RISK 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-2gene 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
4TYPES OF BREAST CANCER SURGERY *Modified Radical*Radical*Axillary Node Dissection*Breast Conservation Surgery
5MODIFIED 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, muscleweakness, lymphedemaSIDE EFFECTS*Chest wall tightness*Phantom breast sensations*Arm swelling*Sensory changesPATIENT ISSUES*Loss of breast*Incision*Body image*Impaired arm mobility>> Lewis, et. al. (2007). P. 1353
6BREAST CONSERVATION SURGERY W/ RADIATION THERAPY WHAT IS IT?*Wide excision of tumor, sentinal lymph nodedissection and/or anterior lymph node dissection,radiation therapy.PATIENT ISSUES*Prolonged treatment*Impaired arm mobility*Change in texture and sensitivity to breastSIDE EFFECTS*Breast soreness*Breast edema*Skin reactions*Arm swelling*Sensory changes (breast and arm)*Fatigue*Discomfort*Chest wall tightnessPOTENTIAL COMPLICATIONS: Short-term: Moist desquamation,hematoma, seroma, infectionLong-term: Fibrosis, lymphedema, pneumonitis, rib fractures>> Lewis, et. al. (2007). P. 1353
7TISSUE EXPANSION & BREAST IMPLANTS WHAT IS IT?*Expander used to slowly stretch tissue;Saline gradually injected into reservoir overweeks to months.*Insertion of implant under muculofascial layerSIDE EFFECTS*Discomfort*Chest wall tightnessPOTENTIAL COMPLICATIONS*Short-term: Skin flap, necrosis, wound separation,seroma, hematoma, infection*Long-term: Capsular contractions,displacement of implantPATIENT ISSUES*Body image*Prolonged physician visits to expand implants*Additional surgeries for nipple construction*Symmetry>> Lewis, et. al. (2007). P. 1353
8MUSCULOCUTANEOUS FLAP PROCEDURES WHAT IS IT?*Contains muscle, skin, blood supply.*Is transposed from latissimus dorsi to transverserectus abdominis to chest wallSIDE EFFECTS*Pain related to two surgical sitesand extensive surgeryPATIENT ISSUES*Prolonged postoperative recoveryPOTENTIAL COMPLICATIONS*Short-term: Delayed wound healing,Infection, skin flap necrosis, abdominal hernia, hematoma.>> Lewis, et. al. (2007). P. 1353
9PREOPERATIVE 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 currentlybeing 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
10POSTOPERATIVE 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 withmodified radical mastectomy.*Teach how to milk and strip clots throughdrainage 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
11SENTINAL 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 lymphnode(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 asuitable alternative to axillary dissection in a womanwith:-Unifocal tumour of diameter less than orequal to 3 cm-Clinically negative axilla, including consideration ofimaging finding.HOW IS IT DONE?*A radioisotope and/or blue dye is injected into the tumor site.*Where possible lymphatic mapping with preoperativelymphoscintigraphy in combination with intraoperative use of thegamma probe and blue dye should be used to locate the sentinel node.*It is then determined in which sentinal lymph nodes that theradioisotope or blue dye appears.*The surgeon then makes a local incision in theaxilla 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 andgreater accuracy as with other performed methods.>> Lewis, et. al. (2007). P. 1351>> (2009) NZ Guideline Group.>>Bonema, et. al. (2002). P
13HOLISTIC HEALING TIME OF DIAGNOSIS *Many women feel fear, shock, anger, anxiety, denial anddepression. 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 areasof 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 toperform it.>> Skrzypulec, et. al. (2008). P. 613, 614, 617, 618.
14WHAT 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>> Weaver. (2009). PPATIENT PREVENTION*Inform healthcare provider to takeBP’s on unaffected arm.*Avoid wearing tight clothing orjewelry on affected arm.*Use electric razor for shavingunderarms.*Wear sunscreen with SPF of at leastSPF 15.*Wear rubber gloves when washingdishes to avoid harsh detergents.*Sleep on back or non-surgical side.*Avoid heavy lifting for 4-6 weeks.
16REVIEW QUESTIONS ANY FURTHER 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 lymphedemapost-mastectomy?ANY FURTHER QUESTIONS?
17WORKS CITEDLewis, Sharon L., Margaret M. Heitkemper, Shannon Ruff Disksen, Patricia Graber O’Brien, and LindaBusher. 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):Surgery for early invasive breast cancer. In: New Zealand Guidelines Group. Management of earlybreast cancer. Wellington (NZ): New Zealand Guidelines Group (NZGG); 2009:Weaver, Caroline. “Caring for a patient after mastectomy.” Nursing 2009 (2009):