Perioperative Care For Breast Cancer Surgery: Challenges And Considerations

The Journey of a 38-Year-Old Woman with Recurrent Metastatic Breast Cancer

Discuss about the Nursing Assignment on perioperative care.

This paper explains the journey of a 38-year-old woman diagnosed with breast cancer explaining all the challenges incurred during the period of her treatment to her recovery. She didn’t have any major medical issues in the past and kept well before diagnosed with recurrent metastatic breast cancer.  This is also known as 4^th stage cancer, which has spread to the other parts of the body like bones, lungs, brain, etc. The perioperative period begins when the patient is informed of the need for surgery, includes the surgical procedure and recovery, and continues until the patient resumes his or her usual activities. The surgical experience can be segregated into three phases: (1) preoperative, (2) intraoperative, and (3) postoperative. The word “perioperative” is used to encompass all three phases. The perioperative nurse provides nursing care during all three phases (Arwert, Hoste and Watt 2012).

The preoperative phase begins when the patient, or someone acting on the patient’s behalf, is informed of the need for surgery and makes the decision to have the procedure. This phase ends when the patient is transferred to the operating room bed. The preoperative phase is the period that is used to physically and psychologically prepare the patient for surgery. The length of the preoperative period varies. For the patient whose surgery is elective, the period may be lengthy. For the patient whose surgery is urgent, the period is brief; the patient may have no awareness of this period. Diagnostic studies and medical regimens are initiated in the preoperative period. Information obtained from preoperative assessment and interview is used to prepare a plan of care for the patient. Nursing activities in the preoperative phase are directed toward patient support, teaching, and preparation for the procedure (Bunn, Jones and Bell-Syer 2012).

It has to be understood in this context that the preoperative phase the task of preparing the patient must begin with the laboratory tests and EKG tests that are carried out a couple of days before the surgery. However, the most important nursing activity in the preoperative phase is the patient education and motivational support. Before any severe any surgical procedure the anxiety, fear and confusion can have a significant impact on the vital signs of the patient. It is very important for the patient to be calm and collected before the surgery. Without proper psychological preparation patients often go into shock or panic attack during the surgery, which can a detrimental impact on the success outcome of the surgery. Hence, the nursing professional will need to focus on educating the patients about the surgical procedure and reassure her on the success rate and recovery timeframe of the entire thing. However, more than the psychosocial support, at this stage the patients will need cautionary education regarding the dos and donts; the patient must be educated about not consuming aspirin, ibuprofen, any other NSAID drugs or any supplements containing vitamin E as well (Clough et al. 2010). On the day of the operation as well, there is effective physiological and psychological management provided to the patient. The patent should be psychologically prepared for the surgery and must give full consent to all the activities that are going to be carried out in the surgery.

Understanding the Preoperative Phase: Physical and Psychosocial Preparation

The intra-operative phase begins when the patient is transferred to the operating room bed and ends with transfer to the postanesthesia care unit (PACU) or another area where immediate postsurgical recovery care is given. During the intraoperative period, the patient is monitored, anesthetized, prepped, and draped, and the procedure is performed. Nursing activities in the intraoperative period center will focus on patient safety, facilitation of the procedure, prevention of infection, and satisfactory physiologic response to anaesthesia and surgical intervention. The anaesthetic plan that will be given to the patient is a very important area of concern in this phase. It has to be mentioned in this context that for the cancer patients, the anaesthetic modality can lower the defences of the patient against the malignant neoplastic growth. That is the reason the anaesthetic choice for the patient needs to be mild and free from any opioid derived products (Forget et al. 2010).

The postoperative phase begins with the patient’s transfer to the recovery unit and ends with the resolution of surgical sequelae. The postoperative period may be either brief or extensive, and most commonly ends outside the facility where the surgery was performed. For patients who will remain in the hospital for an extended stay, the perioperative nurse may not provide care beyond patient transfer to the PACU, where postanesthesia care nurses assume responsibility for the patient. In an effort to better utilize nursing resources, many perioperative nurses, particularly in smaller hospitals, have been trained in postanesthesia care and are assuming responsibility for providing care in both the operating room and PACU. Care at home, if required, is delivered by home healthcare nurses. The majority of operative procedures performed today are done on an outpatient basis (Gottschalk et al. 2010).

For patients who undergo surgery in ambulatory surgery facilities, day surgery centers, or office-based surgical settings where the expectation is that they will return home on the same day they have surgery, it is not uncommon for the perioperative nurse to provide care for the patient during all three phases. Nursing activities in the immediate postoperative phase center on support of the patient’s physiologic systems. In the later stages of recovery, much of the focus is on reinforcing the essential information that the patient and other caregivers require in preparation for discharge (Gustafsson et al. 2011).

The most important focus for this patient in the post operative phase will be surgical wound management, infection control, malignancy response measurement, and psychological support. It has to be mentioned here that wound management and healing is still an unprecedented sector in case of the tumor biology. As the patient had been in the last stages of cancer, there are added risks of additional co-morbidities and iatrogenic factors. In case of the cancer surgeries often the patients are opted for radiotherapy for local regional control which can have a significant negative healing effect, the pathophysiology for this is the local tissue fibrosis and the vascular effects. And in case the patient is given chemotherapy, it can also have a severe detrimental effect on the rapidly healing tissues of the surgical wound site. The risk of various infections are also effectively higher in case of the cancer patients and the fact that the functional properties of the antibiotics is somewhat altered is another key challenge for the surgical wound management and infection control of the patient. As the patient in this case study had been 4^th stage cancer patients the chances of surgical wound healing complexities are high. In such condition the patient can be provided a advanced wound healing therapies such as the hyperbaric oxygen therapy along with the regular actinomycin D based infection control (Lacomba et al. 2010).

The Intraoperative Period: Monitoring, Anesthetization, and Facilitation

On a more elaborative note, it has to be mentioned that during mastectomy the blood vessels supplying oxygen to the breasts are cut and hence it represents extreme issues during the healing of the wounds and in case of the patients in this case as well, the delayed wound healing can be further aggravated due to this persistent issue. Two medications that can be used by the perioperative wound care nurse to facilitate better and faster wound healing free of risk of infection can be Avastin and Herceptin. Both of these targeted therapeutic agents are fact acting and can help in wound healing effectively (Lowery et al. 2012).

Pain management is another very important aspect of care provided to the patients in the PACU. the patients are generally provided severe pain management medications such as corticosteroids are administered as the anaesthesia is starting to wear off, in acute pain morphine is also administered. The drainage tube needs to be aseptically removed within 24 to 48 hours of the surgery as well.  Followed by pain management the next area of concern for the patients is nutritional status (Remmers, Holtgräwe and Pinkert 2010). The patents will remain on a strictly fluid based diet for the day of the surgery and the morning after, the IV will remain until the patent is capable of taking food via the oral route. After the perioperative nurse sure that the patent can tolerate solid food, the liquid diet will need to continue, post which light antioxidant rich and vitamin C and A rich food will continue. Last but not the least the patient will need to be provided psychosocial support to the patient, there are various external and internal factors that might lead to anxiety and postoperative depression. In this condition the patients may be provided the aid of cognitive behavioural aid and relaxation therapies and counselling to help her cope with the process and attain faster recover (McNeely et al. 2012).

Conclusion:

On a concluding note, it can be mentioned that there are a myriad of different complexities that are associated with the process of mastectomy or breast surgery. With the patient in this case being in the 4th stage of cancer the impact of the surgery can be detrimental on the patient in various areas including wound healing, infection control, pain management, nutritional status and psychosocial issues. Along with that the assignment also discussed the different additional care that needs to be taken for an advanced cancer patients as well. Hence the importance of a specialized and patient centred perioperative care plan is extremely crucial in the case of breast cancer surgeries.

References:

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