MASTECTOMY

The choice of treatment for breast cancer depends on tumor type, size, and location, as well as clinical characteristics (staging). Therapy may include surgical intervention with/without radiation, chemotherapy, and hormone therapy. The use of gene therapy and stem cell rescue (autologous bone marrow transplantation) is under investigation. Breast reconstruction is often done at the time of cancer surgery because it does not compromise adjuvant treatment/interfere with cure of the cancer, and it improves the patient’s adjustment and acceptance. Some oncologists, however, prefer to postpone reconstruction until post-procedure therapy is completed, to reduce the risk of postoperative complications.

Types of surgery are generally grouped into three categories: radical mastectomy, total mastectomy, and more limited procedures (e.g., segmental, lumpectomy). Total (simple) mastectomy removes all breast tissue, but all or most axillary lymph nodes and chest muscles are left intact. Modified radical mastectomy (now the most common surgical option) removes the entire breast, some or most lymph nodes, and sometimes the pectoralis minor chest muscles. Major chest muscles are left intact. Radical (Halsted’s) mastectomy is a procedure that is rarely performed because it requires removal of the entire breast, skin, major and minor pectoral muscles, axillary lymph nodes, and sometimes internal mammary or supraclavicular lymph nodes. Limited procedures (i.e., lumpectomy) may be done on an outpatient basis because only the tumor and some surrounding tissue are removed. Lumpectomy is reserved for well-defined nonmetastatic tumors of less than 5 cm in size that do not involve the nipple. The procedure may be diagnostic (determines cell type) and/or curative when combined with radiation therapy.

CARE SETTING

Inpatient acute surgical unit.

RELATED CONCERNS

Cancer (for additional nursing interventions regarding cancer treatment)

Psychosocial aspects of care

Surgical intervention

Patient Assessment Database

ACTIVITY/REST

May report: Work, activity involving frequent/repetitive arm movements

Sleep style (e.g., sleeping on stomach)

CIRCULATION

May exhibit: Unilateral engorgement in affected arm (invaded lymph system)

EGO INTEGRITY

May report: Constant stressors in work/home life

Stress/fear involving diagnosis, prognosis, future expectations

FOOD/FLUID

May report: Loss of appetite, recent weight loss

PAIN/DISCOMFORT

May report: Pain in advanced/metastatic disease (localized pain rarely occurs in early malignancy)

Some experience discomfort or “funny feeling” in breast tissue

Heavy, painful breasts premenstrually usually indicate fibrocystic disease

SAFETY

May exhibit: Nodular axillary masses

Edema, erythema of involved skin

SEXUALITY

May report: Presence of a breast lump (usually painless); changes in breast symmetry or size

Changes in breast skin (pitting, dimpling), color or temperature (redness); unusual nipple discharge; itching, burning, or retracted nipple or changes in vein pattern

History of early menarche (younger than age 12); late menopause (after age 50); late first pregnancy (after age 35)

Concerns about sexuality/intimacy

May exhibit: Change in breast contour/mass, asymmetry

Dimpling, puckering of skin; changes in skin color/texture, swelling, redness or heat in breast

Retraction of nipple; discharge from nipple (serous, serosanguinous, sanguinous, watery discharge increase likelihood of cancer, especially when accompanied by lump)

TEACHING/LEARNING

May report: Family history of genetically transmitted breast cancer includes those with multiple relatives withbreast cancer (maternal and paternal), family history of ovarian cancer along with breast cancer,family history of bilateral or early-onset breast cancer, or breast cancer in a male relative. Note: Most breast cancer patients have no relatives with the disease, with only 5%–10% now thought to be attributable to hereditary factors.

Previous unilateral breast cancer, endometrial or ovarian cancer

Discharge plan DRG projected mean length of inpatient stay: 4.1 days

considerations: May need assistance with treatments/rehabilitation, decisions, self-care activities, homemaker/maintenance tasks

Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

Mammography: Visualizes internal structure of the breast, is capable of detecting nonpalpable cancers or tumors that are in early stages of development.

Galactography (ductography): Contrast mammograms obtained by injecting dye into a draining duct.

Ultrasound: May be helpful in distinguishing between solid masses and cysts and in women whose breast tissue is dense; complements findings of mammography.

Xeroradiography: Reveals increased circulation around tumor site.

Thermography: Identifies rapidly growing tumors as “hot spots” because of increased blood supply and corresponding higher skin temperature.

Diaphanography (transillumination): Identifies tumor or mass by differentiating the way that tissues transmit and scatter light. Procedure remains experimental and is considered less accurate than mammography.

CT scan and magnetic resonance imaging (MRI): Scanning techniques can detect breast disease, especially larger masses, or tumors in small, dense breasts that are difficult to examine by mammography. These techniques are not suitable for routine screening and are not a substitute for mammography.

Positron emission tomography (PET) scintimammography: Helps detect malignant tissue outside the breast; may help determine status of lymph nodes to reduce the need for biopsy. Also can provide information regarding makeup of malignant tumors to guide treatment choices.

Breast biopsy (fine-needle aspiration, core sampling needle biopsy, or excisional): Provides definitive diagnosis of mass and is useful for histological classification, staging, and selection of appropriate therapies.

Sentinel node biopsy: May eliminate need for axillary dissection in small breast tumors, limiting damage to lymph ducts and nerves.

Hormone receptor assays: Reveal whether cells of excised tumor or biopsy specimens contain hormone receptors (estrogen and progesterone). In malignant cells, the estrogen-plus receptor complex stimulates cell growth and division. About two-thirds of all women with breast cancer are estrogen-receptor positive and tend to respond favorably to the addition of hormone therapy, which extends the disease-free period and increases survival time.

Chest x-ray, liver function studies, CBC, and bone scan: Help determine presence and location of metastasis.

Breast cancer genes: Researchers have now discovered BRCA-1 and BRCA-2. It is believed that if these genes are mutated, they may cause a high percentage of inherited-type breast cancers. The tests are not widely performed at this time.

NURSING PRIORITIES

1. Assist patient/SO in dealing with stress of situation/prognosis.

2. Prevent complications.

3. Establish individualized rehabilitation program.

4. Provide information about disease process, procedure, prognosis, and treatment needs.

DISCHARGE GOALS

1. Dealing realistically with situation.

2. Complications prevented/minimized.

3. Exercise regimen initiated.

4. Disease process, surgical procedure, prognosis, and therapeutic regimen understood.

5. Plan in place to meet needs after discharge.

PREOPERATIVE

NURSING DIAGNOSIS: Fear/Anxiety [specify level] May be related to Threat of death, e.g., extent of disease Threat to self-concept: change of body image; scarring, loss of body part, sexual attractiveness Change in health status Possibly evidenced by Increased tension; apprehension; feelings of helplessness/inadequacy Decreased self-assurance Self-focus; restlessness; sympathetic stimulation Expressed concerns regarding actual/anticipated changes in life DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Fear [or] Anxiety Control (NOC) Acknowledge and discuss concerns. Demonstrate appropriate range of feelings. Report fear and anxiety are reduced to a manageable level.

ACTIONS/INTERVENTIONS Anxiety Reduction (NIC) Independent Ascertain what information patient has about diagnosis, expected surgical intervention, and future therapies. Note presence of denial or extreme anxiety. Explain purpose and preparation for diagnostic tests. Provide an atmosphere of concern, openness, and availability, as well as privacy for patient/SO. Suggest that SO be present as much as possible/desired. Encourage questions and provide time for expression of fears. Tell patient that stress related to breast cancer can persist for many months and to seek help/support.

RATIONALE Provides knowledge base for the nurse to enable reinforcement of needed information, and helps identify patient with high anxiety, low capacity for information processing, and need for special attention. Note: Denial may be useful as a coping method for a time, but extreme anxiety needs to be dealt with immediately. Clear understanding of procedures and what is happening increases feelings of control and lessens anxiety. Time and privacy are needed to provide support, discuss feelings of anticipated loss and other concerns. Therapeutic communication skills, open questions, listening, and so forth facilitate this process. Provides opportunity to identify and clarify misconceptions and offer emotional support.

ACTIONS/INTERVENTIONS Anxiety Reduction (NIC) Independent Assess degree of support available to patient. Give information about community resources, such as Reach to Recovery, YWCA Encore program. Encourage/provide for visit with a woman who has recovered from a mastectomy. Discuss role of rehabilitation after surgery.

RATIONALE Can be a helpful resource when patient is ready. A peer who has experienced the same process serves as a role model and can provide validity to the comments, hope for recovery/normal future. Rehabilitation is an essential component of therapy intended to meet physical, social, emotional, and vocational needs so that patient can achieve the best possible level of physical and emotional functioning.

POSTOPERATIVE

NURSING DIAGNOSIS: Skin/Tissue Integrity, impaired May be related to Surgical removal of skin/tissue; altered circulation, presence of edema, drainage; changes in skin elasticity, sensation; tissue destruction ­(radiation) Possibly evidenced by Disruption of skin surface, destruction of skin layers/subcutaneous tissues DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Wound Healing: Primary Intention (NOC) Achieve timely wound healing, free of purulent drainage or erythema. Demonstrate behaviors/techniques to promote healing/prevent complications.

ACTIONS/INTERVENTIONS Incision Site Care (NIC) Independent Assess dressings/wound for characteristics of drainage. Monitor amount of edema, redness, and pain in the incision. Perform routine assessment of involved arm. Elevate hand/arm with shoulder positioned at appropriate angles (no more than 65 degrees of flexion, 45–65 degrees of abduction, 45–60 degrees of internal rotation) and forearm resting on wedge or pillow, as indicated.

RATIONALE Use of dressings depends on the extent of surgery and the type of wound closure. (Pressure dressings are usually applied initially and are reinforced, not changed.) Drainage occurs because of the trauma of the procedure and manipulation of the numerous blood vessels and lymphatics in the area. Preventing or minimizing edema reduces the discomfort and complications associated with it. Elevation of affected arm facilitates drainage and resolution of edema. Note: Lymphedema is present in about 25% of patients and may develop immediately after surgery or years later.

ACTIONS/INTERVENTIONS Incision Site Care (NIC) Independent Monitor temperature. Place in semi-Fowler’s position on back or unaffected side; avoid letting the affected arm dangle. Avoid measuring blood pressure (BP), injecting medications, or inserting IVs in affected arm. Inspect donor/graft site (if done) for color, blister formation; note drainage from donor site. Assess wound drains, periodically noting amount and characteristics of drainage. Encourage wearing of loose-fitting/nonconstrictive clothing. Tell patient not to wear wristwatch or other jewelry on affected arm. Collaborative Administer antibiotics as indicated.

RATIONALE Early recognition of developing infection can enable rapid institution of treatment. Assists with drainage of fluid through use of gravity. Increases potential of constriction, infection, and lymphedema on affected side. Color will be affected by availability of circulatory supply. Blister formation provides a site for bacterial growth/infection. Drainage of accumulated fluids (e.g., lymph, blood) enhances healing and reduces the susceptibility to infection. Suction devices (e.g., Hemovac, Jackson-Pratt) are often inserted during surgery to maintain negative pressure in wound. Tubes are usually removed around the third day or when drainage ceases. Reduces pressure on compromised tissues, which may improve circulation/healing and minimize lymphedema. May be given prophylactically or to treat specific infection and enhance healing.

NURSING DIAGNOSIS: Pain, acute May be related to Surgical procedure; tissue trauma, interruption of nerves, dissection of muscles Possibly evidenced by Reports of stiffness, numbness in chest area, shoulder/arm pain; alteration of muscle tone Self-focusing; distraction/guarding behaviors DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Pain Level (NOC) Express reduction in pain/discomfort. Appear relaxed, able to sleep/rest appropriately.

ACTIONS/INTERVENTIONS Pain Management (NIC) Independent Assess reports of pain and stiffness, noting location, duration, and intensity (0–10 scale). Note reports of numbness and swelling. Be aware of verbal and nonverbal cues. Discuss normality of phantom breast sensations. Assist patient to find position of comfort. Provide basic comfort measures (e.g., repositioning on back or unaffected side, back rub) and diversional activities. Encourage early ambulation and use of relaxation techniques, guided imagery, Therapeutic Touch. Splint/support chest during coughing and deep-breathing exercises. Give appropriate pain medication on a regular schedule before pain is severe and before activities are scheduled. Collaborative Administer narcotics/analgesics as indicated.

RATIONALE Aids in identifying degree of discomfort and need for/effectiveness of analgesia. The amount of tissue, muscle, and lymphatic system removed can affect the amount of pain experienced. Destruction of nerves in axillary region causes numbness in upper arm and scapular region, which may be more intolerable than surgical pain. Note: Pain in chest wall can occur from muscle tension, be affected by extremes in heat and cold, and continue for several months. Provides reassurance that sensations are not imaginary and that relief can be obtained. Elevation of arm, size of dressings, and presence of drains affect patient’s ability to relax and rest/sleep effectively. Promotes relaxation, helps refocus attention, and may enhance coping abilities. Facilitates participation in activity without undue discomfort. Maintains comfort level and permits patient to exercise arm and to ambulate without pain hindering efforts. Provides relief of discomfort/pain and facilitates rest, participation in postoperative therapy.

NURSING DIAGNOSIS: Self-Esteem, situational low May be related to Biophysical: disfiguring surgical procedure Psychosocial: concern about sexual attractiveness Possibly evidenced by Actual change in structure/body contour Verbalization of fear of rejection or of reaction by others, change in social involvement Negative feelings about body, preoccupation with change or loss, not looking at body, nonparticipation in therapy DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Self-Esteem (NOC) Demonstrate movement toward acceptance of self in situation. Recognize and incorporate change into self-concept without negating self-esteem. Set realistic goals and actively participate in therapy program.

ACTIONS/INTERVENTIONS Self-Esteem Enhancement (NIC) Independent Encourage questions about current situation and future expectations. Provide emotional support when surgical dressings are removed. Identify role concerns as woman, wife, mother, career woman, and so forth. Encourage patient to express feelings, e.g., anger, hostility, and grief. Discuss signs/symptoms of depression with patient/SO. Provide positive reinforcement for gains/improvement and participation in self-care/treatment program. Review possibilities for reconstructive surgery and/or prosthetic augmentation.

RATIONALE Loss of the breast causes many reactions, including feeling disfigured, fear of viewing scar, and fear of partner’s reaction to change in body. May reveal how patient’s self-view has been altered. Loss of body part, disfigurement, and perceived loss of sexual desirability engender grieving process that needs to be dealt with so that patient can make plans for the future. Note: Grief may resurface when subsequent procedures are done (e.g., fitting for prosthesis, reconstructive procedure) if postponed. Common reaction to this type of procedure that needs to be recognized and acknowledged to seek timely intervention as indicated. Encourages continuation of healthy behaviors. If feasible, reconstruction provides less disfiguring/"near-normal” cosmetic result. Variations in skin flap may be done for facilitation of reconstructive procedure, which is often performed at the same time as the mastectomy. The associated emotional boost may help patient get through the more complex surgical recovery process and adjunctive therapies. Note: On occasion, reconstruction may not be done for 3–6 mo. A prolonged delay may result in increased tension in relationships and impair patient’s incorporation of changes into self-concept.

ACTIONS/INTERVENTIONS Self-Esteem Enhancement (NIC) Independent Ascertain feelings/concerns of partner regarding sexual aspects, and provide information and support. Discuss and refer to support groups, including Men in Our Lives for SO, as appropriate. Collaborative Provide temporary soft prosthesis, if indicated.

RATIONALE Negative responses directed at patient may actually reflect partner’s concern about hurting patient, fear of cancer/death, difficulty in dealing with personality/behavior changes in patient, or inability to look at operative area. Provides a place to exchange concerns and feelings with others who have had a similar experience, and identifies ways SO can facilitate patient’s recovery. Prosthesis of nylon and Dacron fluff may be worn in bra until incision heals if reconstructive surgery is not performed at the time of mastectomy. This may promote social acceptance and allow patient to feel more comfortable about body image at the time of discharge.

NURSING DIAGNOSIS: Mobility, impaired physical May be related to Neuromuscular impairment; pain/discomfort; edema formation Possibly evidenced by Reluctance to attempt movement Limited range of motion (ROM); decreased muscle mass/strength DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Muscle Function (NOC) Display willingness to participate in therapy. Demonstrate techniques that enable resumption of activities. Increase strength of affected body parts.

ACTIONS/INTERVENTIONS Exercise Therapy: Muscle Control (NIC) Independent Elevate affected arm as indicated. Begin passive ROM (e.g., flexion/extension of elbow, pronation/supination of wrist, clenching/extending fingers) as soon as possible. Have patient move fingers, noting sensations and color of hand on affected side. Encourage patient to use affected arm for personal hygiene, e.g., feeding, combing hair, washing face. Help with self-care activities as necessary. Assist with ambulation and encourage correct posture. Advance exercise as indicated, e.g., active extension of arm and rotation of shoulder while lying in bed, pendulum swings, rope turning, elevating arms to touch fingertips behind head. Recommend proper breathing technique of slow, deep breaths during exercise. Progress to hand climbing (walking fingers up wall), clasping hands behind head, and full abduction exercises as soon as patient can manage. Evaluate presence/degree of exercise-related pain and changes in joint mobility. Measure upper arm and forearm if edema develops. Discuss types of exercises to be done at home to regain strength and enhance circulation in the affected arm. Coordinate exercise program into self-care and homemaker activities (e.g., dressing self, washing, dusting, mopping) and leisure activities, such as swimming.

RATIONALE Promotes venous return, lessening possibility of lymphedema. Early postoperative exercises are usually started in the first 24 hr to prevent joint stiffness that can further limit movement/mobility. Lack of movement may reflect problems with the intercostal brachial nerve, and discoloration can indicate impaired circulation. Increases circulation, helps minimize edema, and maintains strength and function of the arm and hand. These activities use the arm without abduction, which can stress the suture line in the early postoperative period. Conserves patient’s energy, prevents undue fatigue. Patient will feel unbalanced and may need assistance until accustomed to change. Keeping back straight prevents shoulder from moving forward, avoiding permanent limitation in movement and posture. Prevents joint stiffness, increases circulation, and maintains muscle tone of the shoulders and arm. Contraction of abdominal muscles helps push fluid out of the cisterna chyli (a lymphatic reservoir) and through the thoracic duct, creating a vacuum effect enhancing drainage. Because this group of exercises can cause excessive tension on the incision, they are usually delayed until healing process is well established. Monitors progression/resolution of complications. May need to postpone increasing exercises and wait until further healing occurs. Exercise program needs to be continued to regain optimal function of the affected side. Patient is usually more willing to participate or finds it easier to maintain an exercise program that fits into lifestyle and accomplishes tasks as well.

ACTIONS/INTERVENTIONS Exercise Therapy: Muscle Control (NIC) Independent Assist patient to identify signs/symptoms of shoulder tension, e.g., inability to maintain posture, burning sensation in postscapular region. Instruct patient to avoid sitting or holding arm in dependent position for extended periods. Collaborative Administer medications as indicated, e.g.: Analgesics; Diuretics. Maintain integrity of elastic bandages or custom-fitted pressure-gradient elastic sleeve. Refer to physical/occupational therapist.

RATIONALE Altered weight and support put tension on surrounding structures. Pain needs to be controlled before exercise or patient may not participate optimally and incentive to exercise may be lost. May be useful in treating and preventing fluid accumulation/lymphedema. Promotes venous return and decreases risk/effects of edema formation. Provides individual exercise program. Assesses limitations/restrictions regarding employment requirements.

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs May be related to Lack of exposure/recall Information misinterpretation Possibly evidenced by Questions/request for information; statement of misconception Inaccurate follow-through of instructions, development of preventable complications DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Knowledge: Illness Care (NOC) Verbalize understanding of disease process and potential complications. Perform necessary procedures correctly and explain reasons for actions. Initiate necessary lifestyle changes and participate in treatment regimen.

ACTIONS/INTERVENTIONS Teaching: Disease Process (NIC) Independent Review disease process, surgical procedure, and future expectations. Review/have patient demonstrate care of drains/wound sites. Recommend continuation of exercises, increasing program as healing progresses, for at least a year. Discuss necessity for well-balanced, nutritious meals and adequate fluid intake. Suggest alternating schedule of frequent rest and activity periods, especially in situations when sitting/standing is prolonged. Instruct patient to protect hands and arms by wearing long sleeves and gloves when gardening; use thimble when sewing; use potholders when handling hot items; use plastic gloves when doing dishes; avoid lifting or moving heavy objects; and do not carry purse or wear jewelry/wristwatch on affected side. Demonstrate holding affected arm appropriately, e.g., not dangling the arm, swinging arms with elbows bent when walking, placing arm above heart level when sitting/lying down. Warn against having blood withdrawn or receiving IV fluids/medications or BP measurements on the affected side. Recommend wearing of a medical identification device. Demonstrate use of intermittent sequential pumping or low-stretch compression custom-made garments, as appropriate.

RATIONALE Provides knowledge base from which patient can make informed choices, including participation in radiation/chemotherapy programs. Shorter hospital stays may result in discharge with drains in place, requiring more complex care by patient/caregivers. Drains may be removed 7–10 days after surgery. Enhances development of collateral lymphatic channels, reduces the tightening of scar tissue, and maintains muscle strength and function. Note: Moderation is important because strenuous activity/exercise increases heart rate and body temperature, which can potentially increase edema. Provides optimal nutrition and maintains circulating volume to enhance tissue regeneration/healing process. Prevents/limits fatigue, promotes healing, and enhances feelings of general well-being. Positions in which arm is dangling/extended intensify stress on affected structures, creating muscle tension/stiffness, and may interfere with healing. Compromised lymphatic system causes tissues to be more susceptible to infection and/or injury, which may lead to lymphedema. Helps prevent/minimize lymphedema and “frozen shoulder.” May restrict the circulation and increase risk of infection when the lymphatic system is compromised. Prevents unnecessary trauma (e.g., BP measurements, injections) to affected arm in emergency situations. Occasionally used in managing lymphedema by promoting circulation and venous return.

ACTIONS/INTERVENTIONS Teaching: Disease Process (NIC) Independent Suggest gentle massage of healed incision with emollients. Recommend use of sexual positions that avoid pressure on chest wall. Encourage alternative forms of sexual expression (cuddling, touching) during initial healing process/while operative area is still tender. Encourage regular self-examination of remaining breast. Determine recommended schedule for mammography. Stress importance of regular medical follow-up. Identify signs/symptoms requiring medical evaluation, e.g., breast or arm red, warm, and swollen; edema, purulent wound drainage; fever/chills. Address additional concerns as indicated, e.g., ongoing therapies and expected and/or adverse side effects.

RATIONALE Stimulates circulation, promotes elasticity of skin, and reduces discomfort associated with phantom breast sensations. Promotes feelings of femininity and sense of ability to resume sexual activities. Identifies changes in breast tissue indicative of recurrent/new tumor development. Other treatment may be required as adjunctive therapy, such as radiation. Recurrence of malignant breast tumors also can be identified and managed by oncologist. Lymphangitis can occur as a result of infection, causing lymphedema. Medications, such as tamoxifen (Nolvadex) used as follow-up to surgery/radiation require ongoing involvement in care.

POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patient’s age, physical condition/presence of complications, personal resources, and life responsibilities)

In addition to surgical and cancer concerns:

Skin/Tissue Integrity, impaired—surgical removal of skin/tissue; altered circulation, presence of edema, drainage; changes in skin elasticity, sensation, tissue destruction (radiation).

Self-Esteem, situational low—biophysical; disfiguring surgical procedure; concern about sexual attractiveness.

Self-Care deficit (specify)—decreased strength/endurance, pain, muscular impairment.