Mastectomy

 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.

PURPOSES OF MRM
1.) 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.
2.) Allow for the option of breast reconstruction, a procedure that is possible, if desired, due to intact muscles
around the shoulder of the affected side. 3.) Involves removal of large multiple tumor growths located underneath
the nipple and cancer cells on the breast margins

DIAGNOSIS/ PREPARATION ARATION

• 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.
• In order for this procedure to be an operable option, a definitive diagnosis of breast cancer must be established.
1.) The first clinical sign for approximately 80% of women with breast cancer is a mass (lump) located in the
breast. (A lump can be discovered by monthly self-examination or by a health professional).
2.) A biopsy can be performed to examine the cells from a lump that is suspicious for cancer
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), 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.
4.) 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. – A procedure called fine-needle aspiration allows the clinician to extract cells directly from
the lump for further evaluation.
5.) If a diagnosis cannot be established by fine-needle biopsy, the surgeon should perform an open biopsy
(surgical removal of the suspicious mass). • Preparation for surgery is imperative. The patient should plan
for both direct care and recovery time after modified radical mastectomy.

PREOPERATIVE (Nsg. Responsibilities)

• No food or drink after midnight before the procedure.
• 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)

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, NG tube
• safeguard valuables

OVERVIEW OF MRM • PROCEDURE:

1.) An incision in the shape of an ellipse is made. (Incisions are made to avoid visibility in a low neckline dress or
bathing suit.)
2.) The surgeon removes the minimum amount of skin and tissue so that remaining healthy tissue can be used for
possible reconstruction.
3.) Skin flaps are made carefully and as thinly as possible to maximize removal of diseased breast tissues.
4.) The skin over a neighboring muscle (pectoralis major fascia) is removed, after which the surgeon focuses in the
armpit (axilla, axillary) region.
5.) In this region, the surgeon carefully identifies vital anatomical structures such as blood vessels (veins, arteries)
and nerves. (Accidental injury to specific nerves like the medial pectoral neurovascular bundle will result in
destruction of the muscles that this surgery attempts to preserve, such as the pectoralis major muscle.) 6.) In the
armpit region, the surgeon carefully protects the vital structures while removing cancerous tissues.
7.) 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. The ends of these drains are attached to a pocket-sized suction device.
Nursing responsibility:
 Monitoring of the drains and drainage until the drains are removed
8.) After axillary surgery, breast reconstruction can be performed, if desired by the patient.
- Normal results If no complications develop, the surgical area should completely heal within three to four weeks.

 After mastectomy, some women may undergo breast reconstruction (which can be done during 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.

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

 After breast cancer surgery, women should undergo frequent testing to ensure early detection
of cancer recurrence.
 It is recommended that annual mammograms, physical examination, or additional tests
(biopsy) be performed annually.
 Also include psychotherapy since mastectomy is emotionally traumatic.
 Affected women may be worried or have concerns about appearance, the relationship
with their sexual partner, and possible physical limitations
– Community-centered support groups usually made up of former breast cancer surgery
patients can be a source of emotional support after surgery.
 Surgeon will prescribe medication to prevent pain. (PRN)
 Fatigue is to be expected following the surgery.
 Nursing Responsibility: Encourage patients to plan a lighter schedule, with the possibility
of daily naps
 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
b. 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

c. 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, stool softeners, enemas, rectal suppositories, and rectal tubes as
ordered

d. Urinary status Interventions:

– assist patient to assume normal position during voiding
– check the patient frequently to determine need to void
– monitor I & O

e. Wound status Interventions:

– change dressings as ordered utilizing aseptic technique

g. Comfort Interventions:
– administer pain medications as ordered (especially for the first 24-48 hours)

RISKS • The procedure is performed under general anesthesia, which itself carries risk.
1.) edema, or swelling of the arm (usually mild)
2.) numbness in the arm or difficulty moving shoulder muscles. (due to damaged nerve)
3.) risk of developing a lump scar (keloid) after surgery
4.) If surgery did not remove all the cancer cells and that further treatment may be necessary
(with chemotherapy and/or radiotherapy)

5. worst risk is recurrence of cancer

• Immediate signs of risk following surgery include:
– fever,
– redness in the incision area,
– unusual drainage from the incision, and
– increasing pain Nursing Responsibility:
If any of these signs develop, call the surgeon immediately