Modified

Radical
Mastectomy
(MRM)

By: Ernie G. Bautista II; USI-BSN

DEFINITION:
• MRM is surgical procedure that the entire breast is
removed, including the skin, areola and nipple, as
well as most of the lymph nodes under the arm.
o This surgery is most commonly recommended if
the tumor is large and cancer has already spread
to the lymph nodes.
o Takes 2 to 4 hours and usually involves a one- to
two-night hospital stay. A single incision across
half the chest usually allows the surgeon to
remove the breast and the lymph nodes.
 OVERVIEW OF BREAST
CANCER
• Causes of Breast Cancer
– Exact cause: not known
• Factors that can increase a woman’s risk
– heredity, early puberty, late childbearing,
obesity, and lifestyle factors such as heavy
alcohol consumption and smoking.
– biggest risk factor for breast cancer is age
(50-60)
 OVERVIEW OF BREAST
CANCER
• Symptoms
– lump or mass; characterized by:
• painless, hard, and has uneven edges
• tender, soft, and rounded.
– Other signs of breast cancer include the
following:
• swelling of part of the breast
• Skin irritation or dimpling
• Nipple pain or the nipple turning inward
• Redness or scaliness of the nipple or breast skin
• A nipple discharge (other than breast milk)
• A lump in the underarm area
 OVERVIEW OF BREAST
CANCER
Stages: Stage Definition
• Stage 0 ~ Cancer cells remain inside the breast duct, without
invasion into normal adjacent breast tissue
• Stage I ~ Cancer is 2 centimeters or less and is confined to the
breast (lymph nodes are clear)
• Stage II ~ The tumor is over 2 centimeters but no larger than 5
centimeters
Or
There is spread to the lymph nodes under the arm
• Stage III (includes substages IIIA & IIIB) Also called locally
advanced cancer. ~ The tumor is more than 5 centimeters across
Or
The cancer is extensive in the underarm lymph nodes
Or
It has spread to other lymph nodes or tissues near the breast
• Stage IV ~ The cancer has spread—or metastasized—to other parts
of the body.
OVERVIEW OF BREAST
CANCER

Types of Mastectomy
• The usual type of operation for breast
cancer in the Philippines is the modified
radical mastectomy or MRM. The entire
breast is removed, together with the nodes
in armpit.
• However, when breast cancer is detected early,
the entire breast does not have to be removed.
This is called Breast Conserving Therapy or
BCT.
– An adequate margin is obtained around the
cancerous tissue, then the wound is closed, as seen
below the right nipple.
– Then the lymph nodes in the armpit are removed. The
breast is still intact after the removal of the cancerous
tissue.
– Around a month after operation, the patient has to
undergo radiation to the breast.
CONTENTS:
• Demographics/ Incidence (Breast Ca)

• Purposes of MRM

• Diagnosis/ Preparation

• Overview of MRM

• Aftercare

• Risks of MRM
 DEMOGRPHICS/ INCIDENCE
• Highest rates of breast cancer occur in
Western countries (>100 cases per
100,000 women);
• and the lowest among Asian countries
(10–15 cases per 100,000 women)
• Men can also have breast cancer, but the
incidence is much less when compared to
women.
 DEMOGRPHICS/ INCIDENCE
• Predisposing Factors (Breast Ca):
1. Genetic correlation (history of breast Ca)
2. Females who never breastfed a baby
3. had a child after age 30
4. started menstrual periods very early, or
experienced menopause very late
• Breast cancer is a worldwide public
health problem since there are
approximately one million new cases
diagnosed annually.
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CONTENTS
 PURPOSES OF MRM
1.) Removal of breast cancer (abnormal
cells in the breast that grow rapidly and
replace normal healthy tissue)
– This procedure leaves a chest muscle called
the pectoralis major intact.
– This sparing of the pectoralis major muscle
will avoid a disfiguring hollow defect below the
clavicle.
 PURPOSES OF MRM
2.) Allow for the option of breast
reconstruction, a procedure that is
possible, if desired, due to intact muscles
around the shoulder of the affected side.
3.) Involves removal of large multiple tumor
growths located underneath the nipple and
cancer cells on the breast margins

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CONTENTS
 DIAGNOSIS/ PREPARATION
• Modified radical mastectomy is a surgical
procedure to treat breast cancer.
• There are no real alternatives to
mastectomy.
• MRM is one of the standard treatment
recommendations for stage III breast
cancer.
 DIAGNOSIS/ PREPARATION
• In order for this procedure to be an
operable option, a definitive diagnosis of
breast cancer must be established.
1.) The first clinical sign for approximately
80% of women with breast cancer is a
mass (lump) located in the breast. (A lump
can be discovered by monthly self-examination or by a
health professional).
 DIAGNOSIS/ PREPARATION

2.) A biopsy can be performed to examine

the cells from a lump that is suspicious for
cancer
 DIAGNOSIS/ PREPARATION
3.) Staging the cancer can estimate the
amount of tumor, which is important not
only for diagnosis but for prognosis (Patients
with a type of breast cancer called ductal carcinoma in
situ (DCIS), which is a stage 0 cancer, have the best
outcome)
• Persons affected with breast cancer must
undergo the staging of the cancer to
determine the extent of cancerous growth
and possible spread (metastasis) to
distant organs.
 DIAGNOSIS/ PREPARATION
4.) Once a breast lump (mass) has been
identified by mammography or physical
examination, the patient should undergo
further evaluation to histologically
(studying the cells) identify or rule out the
presence of cancer cells.
– A procedure called fine-needle aspiration
allows the clinician to extract cells directly
from the lump for further evaluation.
 DIAGNOSIS/ PREPARATION
5.) If a diagnosis cannot be established by
fine-needle biopsy, the surgeon should
perform an open biopsy (surgical removal
of the suspicious mass).
• Preparation for surgery is imperative. The
patient should plan for both direct care
and recovery time after modified radical
mastectomy.
 DIAGNOSIS/ PREPARATION
PREOPERATIVE (Nsg. Responsibilities)
• No food or drink after midnight before the
procedure.
• Postoperative exercises (breathing
exercises)
• Advice to take a bath (remove soil and
transient microbes from the skin)
• Diminish the patient's anxiety about the
surgery (pre-op teaching, encourage
communication)
 DIAGNOSIS/ PREPARATION
Day of Surgery:
• complete preoperative assessment sheet
• assess vital signs
• provide necessary hygiene
• prepare hair and remove cosmetics
• remove prostheses
• finish preparation of patient's gastrointestinal
tract
• have patient void (if no catheter inserted)
• apply leg procedures
• perform special procedures
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– e.g., insert foley, NG tube CONTENTS
• safeguard valuables
 OVERVIEW OF MRM
• The surgeon's goal during this procedure:
– to minimize any chance of local/regional
recurrence
– avoid any loss of function
– maximize options for breast reconstruction
 OVERVIEW OF MRM
• PROCEDURE:
1.) An incision in the shape of an ellipse is
made. (Incisions are made to avoid visibility in a low
neckline dress or bathing suit.)
2.) The surgeon removes the minimum amount
of skin and tissue so that remaining healthy
tissue can be used for possible
reconstruction.
An incision in the shape of an ellipse.
 OVERVIEW OF MRM
3.) Skin flaps are made carefully and as thinly
as possible to maximize removal of diseased
breast tissues.
4.) The skin over a neighboring muscle
(pectoralis major fascia) is removed, after
which the surgeon focuses in the armpit
(axilla, axillary) region.
 OVERVIEW OF MRM
5.) In this region, the surgeon carefully identifies
vital anatomical structures such as blood
vessels (veins, arteries) and nerves.
(Accidental injury to specific nerves like the medial
pectoral neurovascular bundle will result in
destruction of the muscles that this surgery attempts
to preserve, such as the pectoralis major muscle.)
6.) In the armpit region, the surgeon carefully
protects the vital structures while removing
cancerous tissues.
 OVERVIEW OF MRM
7.) After the surgeon completes the
mastectomy, two plastic tubes each about the
width of a pen are gently sewn into place to
draw off fluids. The ends of these drains are
attached to a pocket-sized suction device.
Nursing responsibility:
Monitoring of the drains and drainage until the
drains are removed
 OVERVIEW OF MRM
8.) After axillary surgery, breast
reconstruction can be performed, if
desired by the patient.

Normal results
If no complications develop, the surgical
area should completely heal within three
to four weeks.
OVERVIEW OF MRM

After MRM
 OVERVIEW OF MRM
 After mastectomy, some women may
undergo breast reconstruction (which can
be done during mastectomy). Recent
studies have indicated that women who
desire cosmetic reconstructive surgery
have a higher quality of life and better
sense of well-being than those who do not
utilize this option.
 OVERVIEW OF MRM
INTRAOPERATIVE (Nsg Responsibilities)
Certified registered nurse anesthetist/
Anesthetiologist
administers anesthetic drugs to induce
and maintain anesthesia
administers other medications as
indicated to support the patient's
physical status during surgery
 OVERVIEW OF MRM
Circulating nurse
1. sets up the operating room
• ensures that necessary supplies and equipment are
readily available, safe and functional
• makes up the operating room bed with gel and heating
pads
2. greets the patient
3. assists the operating room team in transferring
the client onto the operating room bed
4. positions the patient on the operating room bed
5. performs the surgical skin preparation
 OVERVIEW OF MRM
6. opens and dispenses sterile supplies during surgery
7. manages catheters, tubes, drains and specimens
8. assesses the amount of urine and blood loss and reports
these findings to the surgeon and anesthesia
personnel
9. maintains a safe, aseptic environment
– monitors traffic in the operating room
– ensures that the surgical team maintains sterile technique and a
sterile field
10. notes length of surgery
11. performs "sharps", sponge, and instrument count
12. documents all care, events, findings, and patient's
responses during surgery
 OVERVIEW OF MRM
Scrub Nurse
1. Helps set up the sterile field
2. Helps assist draping the client
3. Anticipate and hand instruments to the
surgeon

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 AFTERCARE
• After breast cancer surgery, women
should undergo frequent testing to ensure
early detection of cancer recurrence.
• It is recommended that annual
mammograms, physical examination, or
additional tests (biopsy) be performed
annually.
• Also include psychotherapy since
mastectomy is emotionally traumatic.
 AFTERCARE
• Affected women may be worried or have
concerns about appearance, the
relationship with their sexual partner, and
possible physical limitations.
– Community-centered support groups usually
made up of former breast cancer surgery
patients can be a source of emotional support
after surgery.
 AFTERCARE
• Surgeon will prescribe medication to
prevent pain. (PRN)
• Fatigue is to be expected following the
surgery.
Nursing Responsibility:
Encourage patients to plan a lighter schedule,
with the possibility of daily naps
 AFTERCARE
POSTOPERATIVE (Nsg. Responsibilities)
1.) Watch out for complications of general
anesthesia (see RISKS)
 AFTERCARE
2. Nursing Interventions in a post-op mrm
a. Respiratory status
Interventions:
» encourage patient to perform
respiratory exercises
» encourage early ambulation
» assist patients who are restricted to
bed to turn every 1 to 2 hours
» suction as necessary
 AFTERCARE
b. circulatory status
Interventions:
– encourage patient to perform leg
exercises
– apply leg procedures
– encourage early ambulation
– position patient in bed so that blood
supply is not interrupted to extremities
– administer anticoagulants as ordered
– promote adequate fluid intake
 AFTERCARE
c. Gastrointestinal status
Interventions:
– assist patient to assume a normal
position during defecation
– progress diet as ordered and tolerated
– encourage early ambulation
– promote adequate fluid intake
– administer fiber supplements, stool
softeners, enemas, rectal
suppositories, and rectal tubes as
ordered
 AFTERCARE
d. Urinary status
Interventions:
– assist patient to assume normal
position during voiding
– check the patient frequently to
determine need to void
– monitor I & O
 AFTERCARE
e. Wound status
Interventions:
– change dressings as ordered utilizing
aseptic technique

g. Comfort
Interventions:
– administer pain medications as ordered
(especially for the first 24-48 hours)
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 RISKS
• The procedure is performed under general
anesthesia, which itself carries risk.
1.) edema, or swelling of the arm (usually mild)
2.) numbness in the arm or difficulty moving
shoulder muscles. (due to damaged nerve)
3.) risk of developing a lump scar (keloid) after
surgery
4.) If surgery did not remove all the cancer cells
and that further treatment may be necessary
(with chemotherapy and/or radiotherapy)
 RISKS
5. worst risk is recurrence of cancer
• Immediate signs of risk following surgery
include:
– fever,
– redness in the incision area,
– unusual drainage from the incision, and
– increasing pain
Nursing Responsibility:
If any of these signs develop, call the surgeon
immediately
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