It contains the Preoperative and Postoperative Nursing Diagnosis and the interventions regading the patient undergoing surgery for the breast cancer.

1. Nursing Management of the
Patient undergoing Surgery
for Breast Cancer
Presented By : Chetna Bhatt

2. Diagnosis

3. Preoperative
Nursing
Diagnoses
 Deficient knowledge about the planned surgical
treatments .
 Anxiety related to the diagnosis of cancer .
 Fear related to specific treatments and body in changes.
 Risk for defensive or ineffective coping related to the
diagnosis of breast cancer and related treatment.
 Decisional conflict related to treatment options

4. Postoperative
Nursing
Diagnoses
 Acute pain and discomfort related to surgical procedure
 Peripheral neurovascular dysfunction related to ne Irritation in
affected arm, breast, or chest wall Based on the
 Disturbed body image related to loss or alteration of the breast
 Risk for impaired coping related to the diagnosis of cancer and
surgical treatment
 Self-care deficit related to partial immobility of upper extremity on
operative side
 Risk for sexual dysfunction related to loss of body put change in
self-image, and fear of partner's responses
 Deficient knowledge ; drain management after breast surgery , arm
exercises to regain mobility of affected extremity of affected
extremity , hand and arm care after ALND

5. Planningand
Goals
 The major goals may include increased knowledge about
the disease and its treatment reduction of preoperative
and post operative fear, anxiety, and emotional stress;
improvement of decision-making ability; pain
management; improvement in coping abilities;
improvement in sexual function; and the absence of
complications

6. Preoperative Nursing
Interventions

7. Providing
Education and
Preparation
About Surgical
Treatment
 Patients with newly diagnosed breast cancer are expected to absorb
an abundance of new information during a very emotionally difficult
time, and this may lead to difficulty in making treatment decisions. The
nurse plays a key role in reviewing treatment options by reinforcing
information provided the patient and answering any questions. The
nurse fully prepares the patient for what to expect before, during, and
after surgery. Patients undergoing breast conservation with ALND, or a
total or modified radical mastectomy, generally remain in the hospital
overnight (or longer if they have immediate reconstruction). Surgical
drains will be inserted in the mastectomy incision and in the axilla if
the patient undergoes ALND. A surgical drain is generally not needed
after SLNB. The patient should be informed that she will go home with
the drain(s) and that complete instructions about drain care will be
provided prior to discharge. In addition, the patient should be informed
that she will often have decreased arm and shoulder mobility after
ALND and that she will be shown range-of-motion exercises prior to
discharge. The patient should also be reassured that appropriate
analgesia and comfort measures will be provided to alleviate any
postoperative discomfort.

8. Reducing Fear
andAnxiety and
Improving Coping
Ability
 The nurse must help the patient cope with the physical and
emotional effects of surgery. Many fears may emerge during the
preoperative phase. These can include fear of pain, mutilation (after
mastectomy), and loss of sexual attractive concern about inability to
care for oneself and one’s family; concern about taking time off from
work; and coping with an uncertain future. Providing the patient with
realistic expectations about the healing process and expected
recovery communication and assuring the patient that she can
contact and help alleviate fears. Maintaining open communication
with the nurse at any time with questions or concerns can be a more
of comfort. The patient should also be made aware of available
resources at the treatment facility as well as in the breast cancer
community such as social workers, psychiatrist, and reassuring to
talk to a breast cancer survivor who has support groups. Some
women find it helpful to undergo similar treatments.

9. Promoting
Decision-Making
Ability
 The patient may be eligible for more than one therapeutic approach,
she may be presented with treatment options and then asked to
make a choice. This can be very frightening for some patients, and
they may prefer to have someone else make the decision for them
(e.g.. Surgeon, family member), The nurse can be instrumental in
ensuring that the patient and family members truly understand their
options. The nurse can then help the patient weigh the risks and
benefits of each option. The patient may be presented with the
option of having breast conservation treatment followed by reduction
or a mastectomy. The nurse can explore the issues with the patient
by asking questions such as the following:
 How would you feel about losing your breast!
 Are you considering breast reconstruction?
 If you choose to retain your breast, would you consider undergoing
radiation treatments 5 days a week for 5 to 6 weeks?
 Questions such as these can help the patient focus. Once the
patient’s decision is made, it is very important to support it.

10. Postoperative Nursing
Interventions

11. RelievingPain
andDiscomfort
 Many patients tolerate breast surgery quite well and have minimal
pain during the postoperative period. This is particularly true of less
invasive procedures such as breast conservation treatment with
SLNB. However, all patients must be carefully assessed, because
individual patients can have varying degrees of pain. Patients who
have had more invasive procedures, such as a modified radical
mastectomy with immediate reconstruction, may have considerably
more pain. All patients are discharged home with analgesic
medication (e.g., oxycodone and acetaminophen [Percocet|) and are
encouraged to take it if needed. An over-the-counter analgesic agent
such as acetaminophen may provide sufficient relief. Patients
sometimes complain of a slight increase in pain after the first few
days of surgery, this may occur as patients regain sensation around
the surgical site and become more active. However, patients who
report pain, must be evaluated to rule out any potential complications
such as infection or hematoma. Alternative methods of pain
management, such as taking warm showers and using distraction
methods (eg.. Guided imagery), may also be helpful.

12. Managing
Postoperative
Sensations
 Because nerves in the skin and axilla are often cut or injured
during breast surgery, patients experience a variety of sensations.
Common sensations include tenderness, soreness, numbness,
tightness, pulling, and twinges. These sensations may occur
along the chest wall, in the axilla, and along the inside aspect of
the upper arm. After mastectomy, some patients experience
phantom sensations and report a feeling that the breast or nipple
is still present. Overall, patients do not find these sensations
severe or distressing. Sensations usually persist for several
months and then begin to diminish, although some may persist
for as long as 5 years and possibly longer. Patients should be
reassured that this is a normal part of healing and that these
sensations are not indicative of a problem

13. Promoting
Positive Body
Image
 Patients who have undergone mastectomy often find it difficult to
view the surgical site for the first time. No matter how prepared the
patient may think she is, the appearance of an absent breast can be
very emotionally distressing. Ideally, the patient sees the incision for
the first time when she’s with the nurse or another health care
provider who is available. The nurse first assesses the patient’s
readiness and provides gentle encouragement. It is important to
maintain the patient’s privacy while assisting her as she views the
incision Asking the patient what she perceives, acknowledging her
feelings, and allowing her to express her emotions are important
nursing actions.Reassuring the patient that her feelings are a
normal response to breast cancer surgery may be comforting, If the
patient has not had immediate reconstruction, providing her with a
temporary breast form to place in her bra on discharge can help
alleviate feelings of embarrassment or self-consciousness

14. Promoting
Positive
Adjustment and
Coping
 Providing ongoing assessment of how the patient is
coping with her diagnosis of breast cancer and her
surgical treatment is important in determining her overall
adjustment. Assisting the patient in identifying and
mobilizing her support systems can be beneficial to her
well-being. The patient’s spouse or partner may also need
guidance, support, and education. The patient and
partner may benefit from a wide network of avail. Able
community resources, including the Reach to Recovery
program of the ACS, advocacy groups, or a spiritual advi
SOL Encouraging the patient to discuss issues and
concerns with other patients who have had breast cancer
may help her to understand that her feelings are normal
and that other women who have had breast cancer can
provide invaluable support and understanding.

15. Improving Sexual
Function
 Once discharged from the hospital, most patients are
physically allowed to engage in sexual activity. However,
any change in the patient’s body image, self-esteem, or
the response of her partner may increase her anxiety
level and affect sexual function. Some partners may have
difficulty looking at the incision, whereas others may be
completely unaffected. Encouraging the patient to openly
discuss how she feels about herself and about possible
reasons for a decrease in libido (e.g., fatigue, anxiety,
self-consciousness) may help clarify issues for her.
Helpful suggestions for the patient may include varying
the time of day for sexual activity (when the patient is less
tired), assuming positions that are more comfortable, and
expressing affection using alternative measures (e.g.,
hugging, kissing, manual stimulation).

16. Monitoring and
Managing Potential
Complications

17. Lymphedema
 Lymphedema is a complication in which there is a chronic swelling of an extremity
due to interrupted lymphatic circulation. The swelling is due to the accumulation of
protein-rich fluid in the interstitial space and is a common postoperative complication
after ALND . Lymphedema occurs after treatment for breast cancer, often affecting
both the breast and ipsilateral limb. It is associated with a painful swelling of the arm
as well as weakness, shoulder pain, and tingling sensation in the arm and shoulder.
Lymphedema results if functioning lymphatic channels are inadequate to ensure a
return flow of lymph general circulation. After axillary lymph nodes are removed,
collateral circulation must assume this function. Transient edema in the postoperative
period occurs until collateral circulation has completely taken over this function, which
generally occurs within a month. Performing prescribed exercises, elevating the arm
above the heart several times a day, and gentle muscle pumping (making a fist and
releasing) can help reduce the transient edema. The patient needs reassurance that
this transient swelling is not lymphedema.
 She is also instructed to contact her primary provider immediately if she suspects that
she has lymphedema, because early intervention provides the best chance for
control. If allowed to progress without treatment, the swelling can become more
difficult to manage Treatment may consist of a course of antibiotic agents if an
infection is present. A referral to a rehabilitation specialist (e.g., occupational or
physical therapist) may be necessary for a compression sleeve or glove, exercises,
manual lymph drainage, and a discussion of ways to modify daily activities to avoid
worsening lymphedema. Ongoing research is seeking to identify which lymph nodes
drain the arm before surgery so that they can be preserved when possible, helpins
vent the development of lymphedema

18. Hematoma or
Seroma
Formation.
 Hematoma formation (collection of blood inside a cavity) may occur after
either mastectomy or breast conservation and usually develops within
the first 12 hours after surgery. The nurse assesses for signs and
symptoms of hematoma at the surgical site, which may include swelling,
tightness, pain, and bruising of the skin. The surgeon should be notified
immediately if there is gross swelling or increased bloody output from the
drain. Depending on the surgeon’s assessment, a compression wrap
may be applied to the incision for approximately 12 hours, or the patient
may be returned to the operating room so that the incision may be
reopened to identify the source of bleeding. Some hematomas are small,
and the body absorbs the blood naturally. The patient may take warm
showers or apply warm compresses to help increase the absorption. A
hematoma usually resolves in 4 to 5 weeks.
 A seroma, a collection of serous fluid, may accumulate under the breast
incision after mastectomy or breast con reservation or in the axilla. Signs
and include symptoms may Swelling, heaviness, discomfort, and a
sloshing of fluid. Seromas may develop temporarily after the drain is
removed or if the drain is in place and becomes obstructed. Seromas
rarely Pose a threat and may be treated by unclogging the drain or
manually aspirate the fluid with a needle and syringe. Large, long-
standing seromas that have not been aspirated may lead to infection.
Small seroma that are not bothersome to the Patient usually resolve on
their own

19. Infection
 Although infection is rare, it is a risk after any surgical
procedure. This risk may be higher in patients with
conditions such as diabetes, immune disorders, and
advanced age, as well as in those with poor hygiene.
 Patients are taught to monitor for signs and symptoms of
infection (redness, warmth around incision, tenderness,
foul-smelling drainage, temperature greater than 40°C
[100.4°F], chills) and to contact the surgeon or nurse for
evaluation.
 Treatment consists of oral or IV antibiotics (for more
severe infections) for 1 or 2 weeks . Cultures are taken of
any foul-smelling discharge

20. Patient Education

21. BreastSelf-
Examination
Step I
1. Stand in front of a mirror.
2. Check both breasts for anything unusual.
3. Look for discharge from the nipple, puckering, dimpling, or scaling
of the skin.
Step 2
Step 2 and 3 are done to check for any changes in the contour of
your breasts. As you do them, you should be able to feel your
muscles tighten.
1. Watch closely in the mirror as you clasp your hands behind your
head and press your hands forward.
2. Note any change in the contour of your breasts.
Step 3
1. Next, press your hands firmly on your hips and bow slightly toward
the mirror as you pull your shoulders and elbows forward.
2. Note any change in the contour of your breasts

22. Step 4
Some women do step 4 of the examination in the shower. Your fingers will
glide easily over soapy skin, so you can concentrate on feeling for
changes inside the breast.
1. Raise your left arm.
2. Use three or four fingers of your right hand to feel your left breast firmly,
carefully, and thoroughly.
3. Beginning at the outer edge, press the flat part of your fingers in small
circles, moving the circles slowly around the breast.
4.Gradually work toward the nipple.
5. Be sure to cover the whole breast.
6. Pay special attention to the area between the breast and the underarm,
including the underarm itself.
7. Feel for any unusual lumps or masses under the skin.
8. If you have any spontaneous discharge during the month- whether or
not it is during your breast self-examination-see your primary provider.
9. Repeat the examination on your.

23. Step 5
1. Step 5 should be repeated lying down.
2. Lie flat on your back with your left arm over your head
and a pillow or folded towel under your left shoulder. (This
position flattens your breast and makes it easier to
check.)
3. Use the same circular motion described earlier.
4. Repeat on your right breast.

24. HandandArm
CareAfterAxillary
Lymph Node
Dissection
Avoid blood pressure, injections, and blood draws in affected
extremity. Use sunscreen (higher than 15 SPF) for extended
exposure to the sun.
Apply insect repellent to avoid insect bites. Wear gloves for
gardening. Use a cooking mitt for removing objects from the
oven.
Avoid cutting cuticles; push them back during manicure
Use an electric razor for shaving armpit.
Avoid lifting objects heavier than 5-10 pounds.
If a trauma or break in the skin occurs, wash the area with soap
and water, and apply an over-the-counter antibacterial ointment
(Bacitracin or Neosporin).
Observe the area and extremity for 24 hours; if redness, swelling,
or a fever occurs, call the surgeon or nurse.

25. Thank you