mastectomy

Patient Care. The psychological aspects of the breast must always be considered in the care of women who face the prospect of loss of breast tissue through surgery. The breast is symbolic of femininity, motherhood, and sexual attractiveness for some individuals. Psychological problems likely to be associated with mastectomy include disturbance in self-concept related to changes in body image, self-esteem, role performance, and personal identity. Newer, less mutilating surgical procedures and cosmetically successful reconstructive plastic surgery (mammaplasty) to replace surgically removed breast tissue have diminished some of the emotional trauma formerly associated with mastectomy.

Following mastectomy the patient is likely to experience such physical problems as pain, numbness, tingling, and weakness related to nerve damage and muscle atrophy. Additionally, the patient is subject to lymphedema and collections of serous fluid (seroma) associated with interruption of the flow of lymph.

In addition to routine postoperative care to prevent pulmonary and circulatory complications, the patient must be watched for the development of localized edema, especially if lymph nodes have been removed. In order to provide adequate drainage of serosanguineous fluid that could delay healing of the operative site, the surgeon may insert a flat, narrow drain with multiple openings. The device is part of a portable self-contained closed-suction system that exerts negative pressure. Systems of this kind include Hemovac and Reliavac.

The patient receives routine postoperative care, including coughing and deep-breathing exercises, to prevent respiratory complications and early ambulation to avoid circulatory stasis. When helping the patient from bed it is important to realize that her sense of balance may be impaired because of changes in upper body structures and some hesitancy to use the arm on the operative side to support herself and maintain balance.

Postoperative care should include periodic assessment of sensations (e.g., “phantom breast” sensations) and of functional limitations in the chest wall and affected arm. Additionally numbness, patterns of weakness, and paresthesias are evaluated. The patient should be taught how to recognize and report these symptoms and any changes noted, as they could indicate progressive nerve damage.

Impairment of lymph flow increases the risk of infection. Loss of sensation could predispose the patient to injury from burns, cuts, and other accidental trauma. Venipunctures are not done and blood pressure cuffs are not applied on the arm on the affected side. Prior to discharge the patient is given instruction in ways to avoid trauma: for example, do not carry a heavy handbag or other heavy articles with the affected arm, avoid excessive exposure to sun, do not pick or cut cuticles, and consult the physician or nurse before having vaccinations or injections in the affected arm. Exercises to improve mobility and lymphatic drainage are begun while the patient is in the hospital and continued by her after discharge. These exercises are described and illustrated in the booklet “Help Yourself to Recovery,” which is available from local offices of the American Cancer Society. The Cancer Society also has self-help support groups, called Reach for Recovery, for women following mastectomy.

The woman is encouraged to continue follow-up care, including a clinical breast exam every 3 to 4 months for the first 3 years, then every 6 months for 2 years, and thereafter every 6 to 12 months. Annual mammograms should be obtained and the woman should perform breast self-exams monthly.