NU 420 B Nursing Internship Theory 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? *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

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

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 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

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). 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. 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

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 >> 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.

REVIEW 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 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.