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.
- 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.
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.
Preoperative Nursing Care Plan
Nursing Diagnosis: Fear/Anxiety
Related to factors:
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
Self-focus; restlessness; sympathetic stimulation
Expressed concerns regarding actual/anticipated changes in life
Expected outcome for this care plan
Fear or Anxiety Control (NOC)
Acknowledge and discuss concerns.
Demonstrate appropriate range of feelings.
Report fear and anxiety are reduced to a manageable level.
Nursing interventions with rationale
- Ascertain what information patient has about diagnosis, expected surgical intervention, and future therapies. Note presence of denial or extreme anxiety. 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.
- Explain purpose and preparation for diagnostic tests. Rationale: Clear understanding of procedures and what is happening increases feelings of control and lessens anxiety.
- 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. Rationale: 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.
- 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 opportunity to identify and clarify misconceptions and offer emotional support.
- 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. 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.
- Discuss role of rehabilitation after surgery. Rationale: 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.
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.