Caring for a patient after mastectomy
Carolyn Weaver RN, AOCN, MSN 

Nursing2009
May 2009 
Volume 39 Number 5
Pages 44 - 48

BREAST CANCER is the most common cancer in women in the United States, and the second leading cause of cancer death in women after lung cancer. In 2008, about 182,460 women were expected to be diagnosed with either invasive or noninvasive breast cancer.1 Because most breast cancers are diagnosed at an early stage, thanks to the success of mammography screening, many women have several treatment options. Breast conserving surgery (a lumpectomy or partial mastectomy followed by radiation therapy or chemotherapy) is the most common local treatment for breast cancer. However, mastectomy, which involves removal of all the breast tissue, is still performed in some situations; for example, if the tumor is 5 cm or larger, if the tumor is large compared with breast size and a lumpectomy would result in a poor cosmetic outcome, if clear margins couldn't be obtained with a reexcision of a lumpectomy site, or if the procedure is being done for breast cancer risk reduction (see Mastectomy types).1

A woman undergoing mastectomy will need more nursing care than one undergoing lumpectomy, as well as extra emotional support and extensive patient education about postoperative care. Let's look at what you'll need to know.

A quick overview

When talking about mastectomy, we need to review the role of axillary lymph node dissection. In cases of invasive breast cancer and noninvasive cancer with aggressive features, the axillary lymph nodes must be evaluated to see if the cancer has spread locally. (See Locating the lymph nodes.) If the patient doesn't have clinically positive lymph nodes and an experienced sentinel lymph node team is available, a sentinel lymph node biopsy will be done to evaluate the axillary nodes. In a sentinel lymph node biopsy, only a few lymph nodes are removed to biopsy (the average is 2.2), compared with a full axillary node dissection, in which 20 to 25 lymph nodes typically are removed.

The sentinel node or nodes are the first lymph nodes into which the tumor drains, so if the cancer has started to spread, cancer cells will be found in these nodes. If no cancer is found in the sentinel node or nodes, further lymph node surgery isn't needed.

If cancer is found in sentinel nodes, the surgeon will do a full axillary node dissection (at the same time as sentinel node biopsy or later) to determine how many other nodes are involved. Because sentinel node biopsy spares many women from more aggressive surgery, it's a major advance in the surgical treatment of breast cancer, shortening hospital stays and lowering the incidence of lymphedema, pain, paresthesias, and restriction in upper extremity range of motion.

Breast reconstruction rates following a mastectomy vary widely across the United States. (For information on normal anatomy, see Anatomy of the breast.) The preferred method is for reconstruction to be done at the time of mastectomy, but some women wait until after adjuvant treatment or even years later. A decision against reconstructive surgery may be based on various factors, such as patient preference, age, educational level, treatment plan, prognosis, and overall health or comorbidities.2 Preoperative and postoperative care is more complex for these women and depends on the type of breast reconstruction. For more on reconstructive surgery, see “Helping Your Patient after Breast Reconstruction” in the August issue of Nursing2008.

Help your patient cope with the diagnosis

A cancer diagnosis of any type is likely to create a whirlwind of emotions for the patient: fear, shock, anger, anxiety, denial, and depression. Many women are surprised by the diagnosis because they feel healthy. Patients with breast cancer, unlike those with many other cancers, rarely have unpleasant signs and symptoms at the time of diagnosis.

Assessing and being sensitive to the patient's emotional health is essential to nursing care and effective teaching. Meet with the patient and her support person in a private area outside the exam room if possible. To make the best of your limited time with her, start by asking about her concerns and fears, and find out if she has questions. Acknowledge that it's normal to feel overwhelmed and fearful and assure her that the team will be there to help her.

Assess her learning needs and readiness to learn before you begin teaching. Keep in mind that patients (and their support persons) may have different information-seeking behaviors. Some won't ask questions and want the healthcare providers to tell them what they need to know. Others want to know many details, such as recurrence and survival rates. They may ask “what if” questions, which may cause needless anxiety about a situation that may never occur.

If you feel comfortable, you can answer “what if” questions, but try to keep the patient focused on the information that's known. Encourage her to take one step at a time.



Graphic
Figure. Anatomy of the breast

Preparing for surgery

Tell your patient that after mastectomy, she'll stay in the hospital overnight. If she has breast reconstruction at the same time as the mastectomy, her hospital stay will be 2 to 4 nights, depending on the type of reconstruction.

Explain to the patient that she'll be evaluated by her healthcare provider a few weeks before the surgery. She'll have blood tests, urinalysis, and an ECG. She should tell her healthcare provider about medications and supplements she's taking, and if she's allergic to any medications, or if she has any other allergies. Her healthcare provider may direct her to discontinue some medications.

The night before surgery, she should follow her healthcare provider's instructions on when to stop eating and drinking, and should shower with an antibacterial soap. Tell the patient that surgery usually lasts 1 to 2 hours, depending on the type of mastectomy.

Tell the patient and her support person about postoperative care in the hospital and at home. This information will need to be reinforced postoperatively before discharge. Provide printed instructions for the patient to refer to later. Teaching topics include expected length of stay, routine postoperative monitoring, caring for a drainage tube, reducing the risk of lymphedema, range of motion exercises, pain management, and support groups. If she's having difficulty with decision making or expresses interest in seeing photographs of women who have had mastectomies, with or without reconstruction, it may be appropriate to show the patient these photographs.

Postoperative care and teaching

After the surgery, in addition to monitoring vital signs and other routine postoperative interventions, assess your patient for pain, bleeding, hematoma or seroma formation, and wound infection. Although infection and wound healing problems are rare, they're most likely to occur in the first 2 weeks after surgery. Follow the surgeon's protocol for dressing changes and the type of dressing used (gauze and transparent sterile dressings are typical).

Encourage your patient to look at her incisions so she can see what's normal; this will help her once she's home and has to monitor for signs and symptoms of infection, such as erythema, edema, warmth, and purulent drainage. Although she may not feel emotionally ready to look at her incisions, having you by her side for the first look can be very reassuring and comforting.3

A woman can expect to have two surgical drains if she had a modified radical mastectomy and one or two (depending on surgeon preference) if she had a simple mastectomy with or without sentinel node biopsy. As soon as she's awake and alert, begin teaching her how to milk or strip clots through the drainage tubing to maintain patency, and how to empty and measure fluid from the drainage device. Have her watch you perform drain care first before she does it herself. With the patient's permission, include a support person in the teaching session.

Pain is subjective, but most patients report the most discomfort at the drain insertion sites. If the patient had an axillary lymph node dissection, she may have more pain. Assess her pain at least every 4 hours, using a reliable, validated pain intensity rating scale. Reassess the patient when she requests pain medication and 30 to 60 minutes after administering analgesics. In the immediate postoperative period, I.V. opioids are most often used for pain management.

Once she can tolerate an oral diet, she can be prescribed oral analgesics such as oxycodone with acetaminophen or hydrocodone with acetaminophen. Some patients may need only acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). Explain that discomfort can include stiffness of the affected arm and soreness. Taking analgesics as prescribed can make her comfortable enough to perform range of motion exercises, slowly resume activities, and get adequate rest.

If the patient is taking an opioid analgesic, assess bowel function daily and initiate a bowel protocol (including a laxative and stool softener) at the start of therapy. Teach her to continue the protocol through treatment to prevent opioid-induced constipation.

Some patients experience phantom sensations (feeling as if the breast is still there), which may take years to resolve.4 A patient who's had axillary lymph nodes removed may have nerve-related sensations such as burning down the arm or around the back. These sensations usually resolve in time, but a few patients experience a severe chronic postmastectomy pain syndrome. This is characterized by persistent, continuous pain in the axilla, medial upper arm, or lateral chest wall. These patients should be referred to a pain management specialist for treatment, which may include use of gabapentin, opioids, and NSAIDs.5

Advise your patient not to use a heating pad on the surgical area. Because of altered postoperative sensation in this area, she's at a higher risk for burns.

Reducing the risk of lymphedema

Teach a patient who's had axillary lymph node dissection the signs and symptoms of lymphedema, which include swelling, tightness, heaviness, or pain in the hand, arm, or chest on the same side as the surgery. These signs and symptoms, which can be difficult to manage and extremely debilitating, may occur a few months after surgery or up to 30 years later. The fewer lymph nodes removed, the lower the risk of lymphedema; about 30% of patients who undergo axillary lymph node dissection develop lymphedema, compared with 7% for patients undergoing sentinel lymph node biopsy.6 Risk factors for lymphedema include increasing age, obesity, extensive axillary disease, radiation therapy, and injury or infection of the arm.

Most recommendations for lymphedema prevention are based on knowledge of anatomy and physiology and anecdotal reports, because few reliable studies have been done. However, recent research showed that women who gain more than 10 pounds after axillary lymph node dissection have an increased risk of lymphedema, and those who do aerobic exercise regularly have a lower risk of lymphedema.7



Graphic
Figure. Locating the lymph nodesAxillary lymph node dissection is often done concurrently with mastectomy to evaluate the local spread of the cancer.

Because lymphedema is a lifelong threat, teach your patient hand and arm precautions to minimize the risk of injury, infection, and impaired circulation. Explain that even minor injuries can cause painful swelling after lymph node removal. The following recommendations may help, although some members of the healthcare team may not agree with all of them because they're not supported by research.3

* Tell healthcare providers in the future to use her unaffected arm for BP measurements, injections, or venipunctures. If she had bilateral axillary lymph node dissection, the healthcare provider should use a leg for these interventions.
* Avoid wearing tight elastic or jewelry on the affected arm.8
* Wear heavy-duty gloves for gardening to prevent hand injuries.
* Use a thimble for sewing.
* Use an electric razor for shaving your underarms.
* Wear a heavy-duty oven mitt for removing hot objects from the oven or microwave.
* Wear sunscreen with an SPF of at least 15.
* Wear long-sleeved shirts or use insect repellent to prevent insect bites.
* Wear rubber gloves when washing dishes or cleaning with harsh detergents.
* Sleep on her back or nonsurgical side.
* Carry luggage or her handbag on her nonsurgical side.
* Avoid lifting heavy objects during the first 4 to 6 weeks after surgery.
* Check with her healthcare provider about doing any strenuous activity, such as shoveling snow, with the affected arm.
Preparing for a prosthesis

Women who have a mastectomy without breast reconstruction are usually fitted for a breast prosthesis about 6 weeks after surgery, as long as their wounds are healing well and postoperative edema has resolved. One type of prosthesis can be placed inside a pocket in a bra; another type adheres to the chest wall. Contact the American Cancer Society (ACS) for a mastectomy product list for your area. This list contains contact information for various places that carry mastectomy products and information about their services. The ACS also can provide temporary, lightweight, cotton-filled breast forms for patients to use while they wait to be fitted for a long-term prosthesis.

Addressing postoperative emotional concerns

An important part of postoperative care is helping the patient cope with emotions related to breast loss and change in body image. Encourage your patient to express how she's really feeling and ask if the surgical result is what she anticipated. Tell her about the availability of support groups and the benefit of talking with others who are either going through a similar experience or have already been through it.

If your facility doesn't offer a support group or it's not convenient for the patient, she can contact the local ACS division for a list of groups in her area. Several organizations also provide patients with the option of talking over the phone with a breast cancer survivor. (Phone numbers are provided in Resources at the end of this article.)

If your facility has social workers who provide counseling, inform her of the service and refer her to it as needed. If her sadness or depression persists, encourage her to consult a mental health professional.

Fear of the unknown is another common emotion. If your patient has questions about future treatments or talks about a fear of dying, acknowledge her worries, provide information as applicable, and answer her questions to the best of your ability and comfort level. Advise her to try to concentrate on one aspect of treatment at a time, which right now is recovery from surgery.

Reassure your patient that you don't expect her to remember everything she's been taught, and that it's okay to ask questions. Emphasize that she should call her treatment team with any problems or concerns.

After facing a cancer diagnosis and undergoing a mastectomy, your patient needs a great deal of teaching and support. By understanding the procedure and helping her through the perioperative period, you can help her take the first step toward recovery.

Mastectomy types
Simple

Also called a total mastectomy. Removal of the entire breast and nipple, but not the underarm lymph nodes or muscle underneath the breast.

Modified radical

Removal of the breast and some axillary lymph nodes.

Skin sparing

Removal of the breast, taking the nipple and areola and only the skin that must be removed to prevent the spread of cancer.

Radical

Removal of the breast, all axillary lymph nodes, and the chest muscles under the breast.

REFERENCES

1. American Cancer Society. Breast Cancer Facts and Figures, 2007–2008. http://www.cancer.org/downloads/STT/BCFF-Final.pdf . [Context Link]

2. Morrow M, et al. Correlates of breast reconstruction. Cancer. 2005;104:2340–2346. [Context Link]

3. Weaver C. Providing compassionate care for mastectomy patients. LPN. 2005;1(6):14–22. [Context Link]

4. Gertz E. Remembrance of things past: post-mastectomy survivors may experience phantom pain. MAMM. 2004;6(5):34–42. http://www.mamm.com . [Context Link]

5. Jung BF, Ahrendt GM, Oaklander AL, Dworkin RH. Neuropathic pain following breast cancer surgery: proposed classification and research update. Pain. 2003;104(1–2):1–13. [Context Link]

6. Wilke LG, et al. Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial. Ann Surg Oncol. 2006;13(4):491–500. [Context Link]

7. Dell DD. Battling breast cancer. Nursing Made Incredibly Easy! 2005;3(5):4–20. [Context Link]

8. American Cancer Society. What every woman facing breast cancer should know about lymphedema: hand and arm care following surgery or radiation therapy for breast cancer axillary dissection. http://www.cancer.org/docroot/MIT/content/MIT_7_2x_Lymphedema_and_Breast_Cancer.asp . [Context Link]

RESOURCES

Breast Cancer Network of Strength http://www.networkofstrength.org Hotline: 800-221-2141 (weekdays 9 a.m.–5 p.m. Eastern) or 312-986-8228 (24-hour)

Cancer Hope Network http://www.cancerhopenetwork.org 1-877-HOPENET

Living Beyond Breast Cancer. http://lbbc.org

National Comprehensive Cancer Network Breast Cancer Guideline, 2009. http://www.nccn.org .

Susan G. Komen for the Cure http://www.komen.org