modified radical mastectomy

Modified Modified Radical Radical

MastectomyMastectomy (MRM)(MRM)

By: Ernie G. Bautista II; USI-BSNBy: Ernie G. Bautista II; USI-BSN

DEFINITION:DEFINITION:

• MRMMRM 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 OVERVIEW OF BREAST CANCERCANCER

• 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)

OVERVIEW OF BREAST OVERVIEW OF BREAST CANCERCANCER

• Symptoms– lump or mass; characterized by:

• painless, hard, and has uneven edges • tender, soft, and rounded.

– 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

OVERVIEW OF BREAST OVERVIEW OF BREAST CANCERCANCER

Stages: Stage Definition• Stage 0Stage 0 ~ Cancer cells remain inside the breast duct, without

invasion into normal adjacent breast tissue• Stage IStage I ~ Cancer is 2 centimeters or less and is confined to the

breast (lymph nodes are clear)• Stage IIStage II ~ The tumor is over 2 centimeters but no larger than 5

centimetersOr

There is spread to the lymph nodes under the arm• Stage IIIStage III (includes substages IIIA & IIIB) Also called locally

advanced cancer. ~ The tumor is more than 5 centimeters acrossOr

The cancer is extensive in the underarm lymph nodesOr

It has spread to other lymph nodes or tissues near the breast• Stage IVStage IV ~ The cancer has spread—or metastasized—to other parts

of the body.

OVERVIEW OF BREAST OVERVIEW OF BREAST CANCERCANCER

Types of Mastectomy

• The usual type of operation for breast cancer in the Philippines is the modified radical mastectomy or MRM. The entire breast is removed, together with the nodes in armpit.

• However, when breast cancer is detected early, the entire breast does not have to be removed. This is called Breast Conserving Therapy or BCT. – An adequate margin is obtained around the

cancerous tissue, then the wound is closed, as seen below the right nipple.

– Then the lymph nodes in the armpit are removed. The breast is still intact after the removal of the cancerous tissue.

– Around a month after operation, the patient has to undergo radiation to the breast.

CONTENTS:CONTENTS:• Demographics/ Incidence (Breast Ca)

• Purposes of MRM

• Diagnosis/ Preparation

• Overview of MRM

• Aftercare

• Risks of MRM

DEMOGRPHICS/ INCIDENCEDEMOGRPHICS/ INCIDENCE

• Highest rates of breast cancer occur in Western countries (>100 cases per 100,000 women);

• and the lowest among Asian countries (10–15 cases per 100,000 women)

• Men can also have breast cancer, but the incidence is much less when compared to women.

DEMOGRPHICS/ INCIDENCEDEMOGRPHICS/ INCIDENCE• Predisposing Factors (Breast Ca):

1. Genetic correlation (history of breast Ca)2. Females who never breastfed a baby 3. had a child after age 30 4. started menstrual periods very early, or

experienced menopause very late

• Breast cancer is a worldwide public health problem since there are approximately one million new cases diagnosed annually.

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PURPOSES OF MRMPURPOSES 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.

PURPOSES OF MRMPURPOSES OF MRM

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

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DIAGNOSIS/ PREPARATIONDIAGNOSIS/ 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 treatmentone of the standard treatment recommendations for stage III breast cancer.

DIAGNOSIS/ PREPARATIONDIAGNOSIS/ PREPARATION

• 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).

DIAGNOSIS/ PREPARATIONDIAGNOSIS/ PREPARATION

2.) A biopsy can be performed to examine the cells from a lump that is suspicious for cancer

DIAGNOSIS/ PREPARATIONDIAGNOSIS/ 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), 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/ PREPARATIONDIAGNOSIS/ PREPARATION

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.

DIAGNOSIS/ PREPARATIONDIAGNOSIS/ PREPARATION

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.

DIAGNOSIS/ PREPARATIONDIAGNOSIS/ PREPARATION

PREOPERATIVEPREOPERATIVE (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)

DIAGNOSIS/ PREPARATIONDIAGNOSIS/ PREPARATIONDay 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

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OVERVIEW OF MRMOVERVIEW 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

OVERVIEW OF MRMOVERVIEW 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.

An incision in the shape of an ellipse.

OVERVIEW OF MRMOVERVIEW OF MRM

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.

OVERVIEW OF MRMOVERVIEW OF MRM

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.

OVERVIEW OF MRMOVERVIEW OF MRM

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

OVERVIEW OF MRMOVERVIEW OF MRM

8.) After axillary surgery, breast reconstruction can be performed, if desired by the patient.

Normal resultsIf no complications develop, the surgical

area should completely heal within three to four weeks.

OVERVIEW OF MRMOVERVIEW OF MRM

After MRM

OVERVIEW OF MRMOVERVIEW OF MRM

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.

OVERVIEW OF MRMOVERVIEW OF MRM

INTRAOPERATIVEINTRAOPERATIVE (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

OVERVIEW OF MRMOVERVIEW OF MRM

Circulating nurse1. sets up the operating room

• ensures that necessary supplies and equipment are readily available, safe and functional

• makes up the operating room bed with gel and heating pads

2. greets the patient

3. assists the operating room team in transferring the client onto the operating room bed

4. positions the patient on the operating room bed5. performs the surgical skin preparation

OVERVIEW OF MRMOVERVIEW OF MRM

6. opens and dispenses sterile supplies during surgery7. manages catheters, tubes, drains and specimens8. assesses the amount of urine and blood loss and reports

these findings to the surgeon and anesthesia personnel

9. maintains a safe, aseptic environment– monitors traffic in the operating room– ensures that the surgical team maintains sterile technique and a

sterile field

10. notes length of surgery11. performs "sharps", sponge, and instrument count12. documents all care, events, findings, and patient's

responses during surgery

OVERVIEW OF MRMOVERVIEW OF MRM

Scrub Nurse

1. Helps set up the sterile field

2. Helps assist draping the client

3. Anticipate and hand instruments to the surgeon

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AFTERCAREAFTERCARE

• 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.

AFTERCAREAFTERCARE

• 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.

AFTERCAREAFTERCARE

• 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

AFTERCAREAFTERCARE

POSTOPERATIVEPOSTOPERATIVE (Nsg. Responsibilities)

1.) Watch out for complications of general anesthesia (see RISKS)

AFTERCAREAFTERCARE

2. Nursing Interventions in a post-op mrma. 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

AFTERCAREAFTERCARE

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

AFTERCAREAFTERCARE

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

AFTERCAREAFTERCARE

d. Urinary status

Interventions:– assist patient to assume normal

position during voiding

– check the patient frequently to determine need to void

– monitor I & O

AFTERCAREAFTERCAREe. 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)

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RISKSRISKS

• 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

surgery4.) If surgery did not remove all the cancer cells

and that further treatment may be necessary (with chemotherapy and/or radiotherapy)

RISKSRISKS5. 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 painNursing Responsibility:

If any of these signs develop, call the surgeon immediately

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