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By: Ernie G. Bautista II; USI-BSN
• MRM is surgical procedure that the entire breast is removed, including the skin, areola and nipple, as well as most of the lymph nodes under the arm. o This surgery is most commonly recommended if the tumor is large and cancer has already spread to the lymph nodes. o Takes 2 to 4 hours and usually involves a one- to two-night hospital stay. A single incision across half the chest usually allows the surgeon to remove the breast and the lymph nodes.
OVERVIEW OF BREAST CANCER
• Causes of Breast Cancer
– Exact cause: not known
• Factors that can increase a woman’s risk
– heredity, early puberty, late childbearing, obesity, and lifestyle factors such as heavy alcohol consumption and smoking. – biggest risk factor for breast cancer is age (50-60)
characterized by: • painless. and rounded.• Symptoms OVERVIEW OF BREAST CANCER – lump or mass. – Other signs of breast cancer include the following: • • • • • • swelling of part of the breast Skin irritation or dimpling Nipple pain or the nipple turning inward Redness or scaliness of the nipple or breast skin A nipple discharge (other than breast milk) A lump in the underarm area . hard. soft. and has uneven edges • tender.
Stages: Stage Definition • Stage 0 ~ Cancer cells remain inside the breast duct. ~ The tumor is more than 5 centimeters across Or The cancer is extensive in the underarm lymph nodes Or It has spread to other lymph nodes or tissues near the breast • Stage IV ~ The cancer has spread—or metastasized—to other parts of the body. without invasion into normal adjacent breast tissue • Stage I ~ Cancer is 2 centimeters or less and is confined to the breast (lymph nodes are clear) • Stage II ~ The tumor is over 2 centimeters but no larger than 5 centimeters Or There is spread to the lymph nodes under the arm • Stage III (includes substages IIIA & IIIB) Also called locally advanced cancer. OVERVIEW OF BREAST CANCER .
OVERVIEW OF BREAST CANCER Types of Mastectomy .
The entire breast is removed. . together with the nodes in armpit.• The usual type of operation for breast cancer in the Philippines is the modified radical mastectomy or MRM.
• However. then the wound is closed. . – An adequate margin is obtained around the cancerous tissue. – Then the lymph nodes in the armpit are removed. as seen below the right nipple. the entire breast does not have to be removed. – Around a month after operation. This is called Breast Conserving Therapy or BCT. the patient has to undergo radiation to the breast. The breast is still intact after the removal of the cancerous tissue. when breast cancer is detected early.
CONTENTS: • Demographics/ Incidence (Breast Ca) • Purposes of MRM • Diagnosis/ Preparation • Overview of MRM • Aftercare • Risks of MRM .
but the incidence is much less when compared to women. • and the lowest among Asian countries (10–15 cases per 100.000 women).000 women) • Men can also have breast cancer.DEMOGRPHICS/ INCIDENCE • Highest rates of breast cancer occur in Western countries (>100 cases per 100. .
3. or experienced menopause very late • Breast cancer is a worldwide public health problem since there are approximately one million new cases diagnosed annually.DEMOGRPHICS/ INCIDENCE • Predisposing Factors (Breast Ca): 1. 2. Genetic correlation (history of breast Ca) Females who never breastfed a baby had a child after age 30 started menstrual periods very early. GO BACK TO CONTENTS . 4.
.) Removal of breast cancer (abnormal cells in the breast that grow rapidly and replace normal healthy tissue) – This procedure leaves a chest muscle called the pectoralis major intact. – This sparing of the pectoralis major muscle will avoid a disfiguring hollow defect below the clavicle.PURPOSES OF MRM 1.
PURPOSES OF MRM 2. 3. a procedure that is possible. due to intact muscles around the shoulder of the affected side.) Involves removal of large multiple tumor growths located underneath the nipple and cancer cells on the breast margins GO BACK TO CONTENTS . if desired.) Allow for the option of breast reconstruction.
DIAGNOSIS/ PREPARATION • Modified radical mastectomy is a surgical procedure to treat breast cancer. . • There are no real alternatives to mastectomy. • MRM is one of the standard treatment recommendations for stage III breast cancer.
DIAGNOSIS/ PREPARATION • In order for this procedure to be an operable option. a definitive diagnosis of breast cancer must be established.) The first clinical sign for approximately 80% of women with breast cancer is a mass (lump) located in the breast. 1. (A lump can be discovered by monthly self-examination or by a health professional). .
DIAGNOSIS/ PREPARATION 2.) A biopsy can be performed to examine the cells from a lump that is suspicious for cancer .
which is a stage 0 cancer. have the best outcome) • Persons affected with breast cancer must undergo the staging of the cancer to determine the extent of cancerous growth and possible spread (metastasis) to distant organs.DIAGNOSIS/ PREPARATION 3.) Staging the cancer can estimate the amount of tumor. . which is important not only for diagnosis but for prognosis (Patients with a type of breast cancer called ductal carcinoma in situ (DCIS).
DIAGNOSIS/ PREPARATION 4. – A procedure called fine-needle aspiration allows the clinician to extract cells directly from the lump for further evaluation. .) Once a breast lump (mass) has been identified by mammography or physical examination. the patient should undergo further evaluation to histologically (studying the cells) identify or rule out the presence of cancer cells.
DIAGNOSIS/ PREPARATION 5. . • Preparation for surgery is imperative. The patient should plan for both direct care and recovery time after modified radical mastectomy. the surgeon should perform an open biopsy (surgical removal of the suspicious mass).) If a diagnosis cannot be established by fine-needle biopsy.
• Postoperative exercises (breathing exercises) • Advice to take a bath (remove soil and transient microbes from the skin) • Diminish the patient's anxiety about the surgery (pre-op teaching. encourage communication) . Responsibilities) • No food or drink after midnight before the procedure.DIAGNOSIS/ PREPARATION PREOPERATIVE (Nsg.
NG tube • safeguard valuables GO BACK TO CONTENTS ..DIAGNOSIS/ PREPARATION Day of Surgery: • complete preoperative assessment sheet • assess vital signs • provide necessary hygiene • prepare hair and remove cosmetics • remove prostheses • finish preparation of patient's gastrointestinal tract • have patient void (if no catheter inserted) • apply leg procedures • perform special procedures – e.g. insert foley.
OVERVIEW OF MRM • The surgeon's goal during this procedure: – to minimize any chance of local/regional recurrence – avoid any loss of function – maximize options for breast reconstruction .
) An incision in the shape of an ellipse is made. (Incisions are made to avoid visibility in a low neckline dress or bathing suit. .) The surgeon removes the minimum amount of skin and tissue so that remaining healthy tissue can be used for possible reconstruction.) 2.OVERVIEW OF MRM • PROCEDURE: 1.
An incision in the shape of an ellipse. .
) The skin over a neighboring muscle (pectoralis major fascia) is removed. axillary) region. . 4.) Skin flaps are made carefully and as thinly as possible to maximize removal of diseased breast tissues. after which the surgeon focuses in the armpit (axilla.OVERVIEW OF MRM 3.
) In the armpit region. such as the pectoralis major muscle.) In this region. . the surgeon carefully protects the vital structures while removing cancerous tissues. the surgeon carefully identifies vital anatomical structures such as blood vessels (veins. (Accidental injury to specific nerves like the medial pectoral neurovascular bundle will result in destruction of the muscles that this surgery attempts to preserve.) 6.OVERVIEW OF MRM 5. arteries) and nerves.
Nursing responsibility: Monitoring of the drains and drainage until the drains are removed .) After the surgeon completes the mastectomy. two plastic tubes each about the width of a pen are gently sewn into place to draw off fluids.OVERVIEW OF MRM 7. The ends of these drains are attached to a pocket-sized suction device.
) After axillary surgery. breast reconstruction can be performed. the surgical area should completely heal within three to four weeks. . if desired by the patient.OVERVIEW OF MRM 8. Normal results If no complications develop.
OVERVIEW OF MRM After MRM .
some women may undergo breast reconstruction (which can be done during mastectomy).OVERVIEW OF MRM After mastectomy. Recent studies have indicated that women who desire cosmetic reconstructive surgery have a higher quality of life and better sense of well-being than those who do not utilize this option. .
OVERVIEW OF MRM INTRAOPERATIVE (Nsg Responsibilities) Certified registered nurse anesthetist/ Anesthetiologist administers anesthetic drugs to induce and maintain anesthesia administers other medications as indicated to support the patient's physical status during surgery .
assists the operating room team in transferring the client onto the operating room bed 4. safe and functional makes up the operating room bed with gel and heating pads 2. greets the patient 3. sets up the operating room • • ensures that necessary supplies and equipment are readily available.OVERVIEW OF MRM Circulating nurse 1. positions the patient on the operating room bed 5. performs the surgical skin preparation .
and patient's responses during surgery . drains and specimens 8. documents all care. assesses the amount of urine and blood loss and reports these findings to the surgeon and anesthesia personnel 9. performs "sharps". notes length of surgery 11. maintains a safe. sponge. and instrument count 12. findings. tubes. manages catheters. events. aseptic environment – – monitors traffic in the operating room ensures that the surgical team maintains sterile technique and a sterile field 10. opens and dispenses sterile supplies during surgery 7.OVERVIEW OF MRM 6.
Helps assist draping the client 3. Anticipate and hand instruments to the surgeon GO BACK TO CONTENTS . Helps set up the sterile field 2.OVERVIEW OF MRM Scrub Nurse 1.
. physical examination. or additional tests (biopsy) be performed annually. • It is recommended that annual mammograms. • Also include psychotherapy since mastectomy is emotionally traumatic. women should undergo frequent testing to ensure early detection of cancer recurrence.AFTERCARE • After breast cancer surgery.
– Community-centered support groups usually made up of former breast cancer surgery patients can be a source of emotional support after surgery. and possible physical limitations. the relationship with their sexual partner. .AFTERCARE • Affected women may be worried or have concerns about appearance.
AFTERCARE • Surgeon will prescribe medication to prevent pain. Nursing Responsibility: Encourage patients to plan a lighter schedule. with the possibility of daily naps . (PRN) • Fatigue is to be expected following the surgery.
) Watch out for complications of general anesthesia (see RISKS) . Responsibilities) 1.AFTERCARE POSTOPERATIVE (Nsg.
AFTERCARE 2. Nursing Interventions in a post-op mrm a. Respiratory status Interventions: » encourage patient to perform respiratory exercises » encourage early ambulation » assist patients who are restricted to bed to turn every 1 to 2 hours » suction as necessary .
circulatory status Interventions: – encourage patient to perform leg exercises – apply leg procedures – encourage early ambulation – position patient in bed so that blood supply is not interrupted to extremities – administer anticoagulants as ordered – promote adequate fluid intake .AFTERCARE b.
rectal suppositories. and rectal tubes as ordered . stool softeners.AFTERCARE c. enemas. Gastrointestinal status Interventions: – assist patient to assume a normal position during defecation – progress diet as ordered and tolerated – encourage early ambulation – promote adequate fluid intake – administer fiber supplements.
Urinary status Interventions: – assist patient to assume normal position during voiding – check the patient frequently to determine need to void – monitor I & O .AFTERCARE d.
Comfort Interventions: – administer pain medications as ordered (especially for the first 24-48 hours) GO BACK TO CONTENTS . Wound status Interventions: – change dressings as ordered utilizing aseptic technique g.AFTERCARE e.
) If surgery did not remove all the cancer cells and that further treatment may be necessary (with chemotherapy and/or radiotherapy) .) risk of developing a lump scar (keloid) after surgery 4.) numbness in the arm or difficulty moving shoulder muscles. or swelling of the arm (usually mild) 2. (due to damaged nerve) 3. which itself carries risk. 1.) edema.RISKS • The procedure is performed under general anesthesia.
– unusual drainage from the incision. worst risk is recurrence of cancer • Immediate signs of risk following surgery include: – fever. call the surgeon immediately GO BACK TO CONTENTS .RISKS 5. – redness in the incision area. and – increasing pain Nursing Responsibility: If any of these signs develop.