Preoperative And Postoperative Management For Patients Undergoing Reconstruction Of The Breast After Modified Radical Mastectomy

Indications and contraindications of MRM

Question:

Discuss about the Preoperative And Postoperative Management.

Patients undergoing reconstruction of the breast after modified radical mastectomy (MRM) can expect to experience lifestyle changes following the surgery. MRM is a procedure involving the removal of an entire breast including all of its tissues (American Society of Anaesthesiologists Task Force on Acute Pain Management, 2012). Historically, MRM was the known main technique of treatment of breast cancer, and as the treatments have evolved, breast conservation has been one of the most commonly used methods. Still, mastectomy is a good choice for most people with breast cancer. During MRM, postoperative education is vital in helping women cope with lifestyle changes as well as recover quickly following the surgery. Preoperative care is the care provided prior to a surgical operation while the opposite is care provided after surgery (Blaudszun et al., 2012). According to research, surgical patient who believe that they did not receive adequate pre and post-operative education on management experience dissatisfaction after a surgery and had difficulties in understanding the changes they encounter. The rationale of this essay is to discuss preoperative and postoperative management following a patient who is to undergo a bilateral total MRM and reconstruction of the breast cancer. Clients and patients will be used interchangeably throughout the essay

There are few indications to the MRM. For clients with metastatic illness, the primary mode of treatment is systemic therapy. Currently, MRM is not the primary care for people with metastatic diseases (Chou et al., 2016). Other contraindications involve people who cannot receive general anaesthesia.

A patient with MRM encounters a life-changing event; hence it is critical to start the education process in advance, especially in ambulatory setting before the surgery. Education at this time can help the client to begin the process as well as prepare for the life changes prior to hospitalisation rather than postoperative education while experiencing anxiety and pain which cannot be helpful to the patient. Apart from the physician’s explanation of the diagnosis and procedure, the client should have preoperative visits with clinicians to discuss the crucial information regarding the surgical process, what to expect during surgery or in the hospital, skills to be learned, and equipments to be used, as well as the necessary resource (Macintyre et al., 2010). This kind of education can improve the patient’s outcome as well as gratification.

However, when providing preoperative education, you should first assess what the client knows and the information he/she wants to learn to ensure that education is individualised and the mutual objectives can be set. It would also be wise to include the patient’s family or friends in education as shown plus based on clients’ preferences.

Preoperative education for patients undergoing MRM

According to Chou et al., (2016) there has been a heated discussion over the presence of lymph node dissection. However, modern indications for the first and second level  of axillary dissections in people undergoing mastectomy include; local axillary recurrence, outside clinical trials, and failed mapping for sentinel lymph nodes biopsy among other indications.  Clients need to be assessed for lymph node dissection regularly. It should be known that axillary dissection cannot be of great help to people with favourable tumour characteristics, multiple comorbidities and the elderly.

People who undergo MRM have a choice for immediate or delayed reconstruction with antilogous implants or tissues. Before the procedure, the client should see a plastic surgeon (Parvizi, 2011). However, the option for delayed or immediate reconstruction is reached in regard to the need for post-mastectomy radiation as well as choice of surgeon.

Complications linked with MRM include problems linked with wound healing such as chronic sarcoma, infection, hematoma, skin necrosis and dehiscence (Wu & Raja, 2011). However, the risk of necrosis usually entails a greater flap plus the wound edges which is commonly treated with wound care. However, people at high risks of postoperative problems are those who are diabetic, smokers, those with a history of chest wall radiation. Following axillary dissection as well as normal local healing problems, a change in the regional lymphatic system puts the client in great danger. For those going through sentinel ‘lymph node biopsy’ before axillary dissection, they are at risk of anaphylaxis linked with isosulfan contrast agent (White & Kehlet, 2010). However, anaesthesiologists and clients need to be aware of such problems which usually resolves intra operatively. People with completion axillary dissection have a greater risk of contracting lymphedema and numbness under the axilla, hypersensitisation as well as chronic pain in that region. According to Vadivelu et al., (2010), patients are encouraged to ambulate the arm to prevent reduced shoulder function as well as scarring of the muscle to avoid cording and chronic pain syndromes that can develop later on.

Anaesthesia; anaesthesia should be used without neuromuscular blocking agents of the axillary dissection and mastectomy. However, if a client is undergoing quick breast reconstruction together with MRM, a paralytic can be used following completion of the dissection of the axillary lymph node. Also, a thoracic paravertebral block is used to give procedural as well as post-procedural analgesic effects thus resulting in declining in postoperative pain quickly and after one day.

Complications linked with MRM

Positioning; clients need to be put on a table in a supine posture with their arm at a right angle with the body.

Patient education; the nurse should teach the patient deep breathing plus coughing exercises., encourage mobility as well as active body movement turning and foot and leg exercise. Other education regimens would be teaching on how to manage pain plus cognitive coping strategies (Macintyre et al., 2010).

Managing nutrition and fluids; the key role of withholding fluids and food before surgery can help prevent aspiration. However, in such cases, a fasting period of eight hours is recommended for meals that are fatty or fried.

Preparing for bowel procedure; enema is not ordered only when the patient is undergoing pelvic surgery. Also, preoperative skin preparation can also be done to decrease bacteria without injuring the skin.

Quick preoperative nursing intervention; this can be done through administering pre-anaesthetic drugs and maintaining preoperative records such as the consent form, final checklist and identification

A study conducted at the University of Maryland showed that continuous infusion of local anaesthetics after MRM leads to decreased analgesic consumption and has no influence on the rates of vomiting as well as nausea. A control study involved 75 women who underwent MRM, including 35 who got levobupivacaine for two days postoperatively via wound catheter as well as 40 who received saline.

Assessing the patient; regular assessment of a patients oxygen saturation pulse volume, as well as regularity, skin colour, depth plus nature of respiration as well as the intensity of consciousness,  are some of the factors that should be considered in the PACU (Wu & Raja, 2011).

Maintain a patient airway is another function that should be considered in the unit. The primary objective here is to maintain pulmonary ventilation as well as prevent hyperaemia and hypoxia. The nurse’s role here is to apply oxygen as well as assess the reparatory rate/depth and oxygen saturation.

Maintaining a cardiovascular stability; in this case, the nurse examines the client’s mental status, cardiac rhythm, vital signs, skin temperature as well as colour/urine output. The central venous pressure abbreviated as (CVP), pulmonary artery pressure (PAP) and the arterial lines should also be considered (Chou et al., 2016). The ain cardiovascular complications are shock, hypertension, haemorrhage and dysarthria.

Assessing /maintain voluntary voiding; urine retention following surgery can occur due to some reasons. Anaesthesia and opioids affect the perception of bladder fullness, and also the abdominal, hip and pelvic might increase the probability of retention of secondary to pain.

Nursing management in the PACU

Encounter activity; a vast number of surgical are encouraged to be awake most of the times. This is because early ambulation lowers the chances of postoperative complications as pneumonia, the circulatory problem as well as gastrointestinal discomfort to mention just safe.

Other nursing management in the PACU include relieving pain as well as anxiety, assessing plus maintain the surgical state as well as evaluating and managing gastrointestinal function vomiting and nausea are very common following anaesthesia

Some complications can develop as a result of postoperative procedure; they include

Shock; this is the response of the body to a decreased circulation volume of blood, cellular hypoxia as well as death plus tissue perfusion impairness (Blaudszun et al., 2012). Haemorrhage is another complication where the blood escapes from the blood vessels. Deep vein thrombosis abbreviated as DVT can also occur in lower extremities as well as pelvic vein and is very common following hip surgery. Pulmonary embolism is the obstruction of one or more arterioles by an embolus originating on the right side of the heart or in the venous system can also occur alongside urine retention and intestinal obstruction which results in partial or complete impairment to the forward flow of intestinal content (Vadivelu et al., 2010).

Conclusion

This essay has reviewed pre and postoperative management for patients with MRM. It draws attention to the main strays of this assessment where detailed history, as well as clinical examination, needs to be conducted.  Postoperative care commences immediately the procedure has ended with the client being reviewed in the recovery room. Finally, MRM plus postoperative analgesia has also been discussed showing the different complications that may arise due to postoperative surgery

References

American Society of Anesthesiologists Task Force on Acute Pain Management. (2012). Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology, 116, 248-273.

Blaudszun, G., Lysakowski, C., Elia, N., & Tramèr, M. R. (2012). Effect of Perioperative Systemic α2 Agonists on Postoperative Morphine Consumption and Pain IntensitySystematic Review and Meta-analysis of Randomized Controlled Trials. The Journal of the American Society of Anesthesiologists, 116(6), 1312-1322.

Chou, R., Gordon, D. B., de Leon-Casasola, O. A., Rosenberg, J. M., Bickler, S., Brennan, T., … & Griffith, S. (2016). Management of Postoperative Pain: a clinical practice guideline from the American pain society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ committee on regional anesthesia, executive committee, and administrative council. The Journal of Pain, 17(2), 131-157.

Macintyre, P. E., Scott, D. A., Schug, S. A., Visser, E. J., & Walker, S. M. (Eds.). (2010). Acute pain management: scientific evidence (pp. 35-45). Melbourne: ANZCA & FPM.

Parvizi, J., Miller, A. G., & Gandhi, K. (2011). Multimodal pain management after total joint arthroplasty. JBJS, 93(11), 1075-1084.

Vadivelu, N., Mitra, S., & Narayan, D. (2010). Recent advances in postoperative pain management. The Yale journal of biology and medicine, 83(1), 11.

White, P. F., & Kehlet, H. (2010). Improving Postoperative Pain ManagementWhat Are the Unresolved Issues?. The Journal of the American Society of Anesthesiologists, 112(1), 220-225.

Wu, C. L., & Raja, S. N. (2011). Treatment of acute postoperative pain. The Lancet, 377(9784), 2215-2225.