| Mastectomy Posted: 24 Sep 2010 08:21 PM PDT 
Definition - Removal of the breast, with or without surrounding structures.
Discussion Mastectomies can be performed in four distinct methods, depending on the diagnosis and the extent of the pathologic findings. - Partial Mastectomy: Excision of breast tumor, leaving appropriate tumor-free margins.
- Subcutaneous Mastectomy: Removal of all breast tissue. Overlying the skin and nipple are left intact.
- Simple Mastectomy
- Radical Mastectomy:
- Modified radical – removal of breast and axillary lymph nodes. Most frequently performed.
- Classic radical – includes removal of the entire breast, pectoralis muscles, axillary lymph nodes, fats, fascia, and adjunct tissue.
- Extended radical – bloc removal of breast, axillary contents, pectoralis muscles, and internal mammary lymph nodes.
Position - Supine, with arms extended on armboards; folded sheets or sandbag under the affected shoulder.
Incision Site - Dependent on the proposed technique
Packs/ Drapes - Major Lap pack
- Impervious stockinette
- Extra drape sheets
- Extra Mayo tray cover
- The affected arm, once draped with stockinette, is brought through the fenestration.
Instrumentation - Major Lap tray
- Curved Crile hemostasis
- Hemoclip
- Rake retractors
- Lahey clamps
- Intraductal probes
- Minor tray
Supplies/ Equipment - Basin set
- Blades
- Needle counter
- Drainage system
- Pressure dressing
- Suture
- Solutions – saline water
- Medications
Procedure Overview 
Partial Mastectomy - The incision is usually made over the lesion. The skin is elevated and the breast mass is excised.
- Hemostasis is controlled, and the wound is irrigated with warm saline or water.
- The wound is closed in a routine fashion, and if a drain is used, it is secured.
Simple Mastectomy - The skin is incised using an elliptical incision around the breast.
- The incision is deepened with the cautery pencil or second knife, and the skin flaps are elevated.
- Kocher or Allis clamps are placed along the skin edge and retracted upward as dissection continuous.
- Once the skin flaps have been raised, the breast is freed from the chest wall at the level of the fascia.
- If the incision extends at the axilla, sharp dissection is performed.
- If a lymph node is needed for a frozen section examination, the tissue is gasped with an Allis clamp and dissected free.
- Once the breast is completely mobilized, it is removed en bloc, and placed in a basin for fixed specimen evaluation.
- The wound is irrigated with warm saline and the drainage system established.
- If a Hemo Vac drain is used, the drainage tubes are brought out of the skin flap through two stab wounds created with the Hemo Vac trocar.
- The skin is then closed, and the drains are secured with the surgeon's choice of suture and skin closure material.
 Modified Radical
- A transverse or longitudinal skin incision is performed.
- The dissection is performed and the incision is extended well into the axilla.
- The axillary contents are dissected free from the vascular and nerve structures, and are carefully removed.
- Care must be taken to avoid injury to the nerve supply to various muscles.
- After the hemostasis is achieved, the skin flaps are approximated over the drains.
- The wound is irrigated with a warm saline and closed as described for a simple mastectomy.
Perioperative Nursing Considerations - If a mastectomy is to follow a biopsy, the drape should be reinforced with clean towels, the team should change gloves, and the biopsy instruments are removed.
- Additional personnel may be needed to hold the arm during a circumferential extremity skin prep.
- Several knife maybe needed because of the fibrous nature or the tissue incised.
- Irrigation solution may be water in place of saline in order to lessen the survival of the tumor cells.
- Estrogen and progesterone may be requested.
Related posts: - ABBREVIATIONS
- Thyroidectomy
- Lymph Node Biopsy
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| Thyroidectomy Posted: 24 Sep 2010 08:10 PM PDT 
 Definition
- Removal of all or a portion of the thyroid gland.
Discussion - The procedure is usually performed to treat various disease of the thyroid gland that may not be treated effectively by chemotherapy or medication.
- A total thyroidectomy is indicated for certain carcinomas and to relieve tracheal or esophageal compression.
Position - Supine with rolled towel or sandbag between the scapulae, hyperextending the neck. If table is placed in reverse Trendelenberg position, a padded foot board should be used to prevent the patient from slipping down toward the end of the table.
Pack/ Drapes - Laparotomy pack with small fenestrated sheet
- Rolled sheet/ towels
Instrumentation - Major Lap tray
- Thyroid tray
- Lahey clamps
- Spring retractor
Supplies/ Equipment - Basin set
- Suction
- Blades
- Needle counter
- Dissector sponge
- Small drain
- Solutions
- Sutures
Procedure Overview - The incision is made above the sternal notch.
- The platysma muscle is incised and retracted.
- The strap muscles are separated or divided, and blunt and sharp dissections are employed until the thyroid is exposed.
- The gland is then mobilized, and all or part is removed depending on the involved pathology.
- Hemostasis is obtained, and the wound is irrigated with warm saline.
- A drain may be inserted, and the incision is closed in layers by an interrupted method.
Perioperative Nursing Consideration - The surgeon may request a fine silk suture to use to mark the incision line.
- The dressing is usually secured by a thyroid collar using a towel folded in thirds lengthwise. The towel is placed around the neck and crisscrossed in front, then fastened with tape.
- The scrub person should maintain the sterility of the back table/ Mayo until the patient is extubated and breathing is stabilized.
- An emergency tracheostomy tray will accompany the patient to the postanesthesia care unit and later to the patient's room until breathing is unlabored and the chance of airway obstruction secondary to edema has passed.
Related posts: - CHECKLIST FOR EVENING CARE
- Hemorrhoidectomy
- DUTIES OF SCRUB NURSE
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| Dilation And Curettage (D&C) Posted: 24 Sep 2010 08:01 PM PDT 
Definition - The gradual enlargement of the cervical os and the curetting (scraping) of endometrial or endocervical tissue for histologic study.
Discussion - The procedure is usually performed to:
- To diagnosed cervical or uterine malignancy.
- To control dysfunctional uterine bleeding.
- To complete an incomplete abortion.
- To aid in evaluating infertility.
- To relieve dysmenorrheal.
- Fractional D&C procedures can assist in differentiating between endocervical and endometrial lesions.
Positioning - Lithotomy; arms may be extended on armboards.
Packs/ Drapes Instrumentation Supplies/ Equipment - Padded stirrups
- Telfa
- Perineal pad
- Suction
- Lubricant
Procedure Overview - A weightened speculum is placed in the vaginal vault.
- The cervix is grasped with a tenaculum.
- A graduated sound is passed through the cervical canal into the uterine cavity to determine its depth and angulation.
- Using Hegar or Hank dilators, the surgeon begins to dilate the cervical opening, increasing the size of each dilator.
- A Telfa sponge is placed over the bill of the weighted speculum, and the uterus is gently curetted, allowing the tissue specimen to collect on the Telfa sponge.
- The small serrated curette is used to scrape the uterine walls again or when the D&C is performed to remove retained placental tissue, while the large, blunt curette and forceps are used to remove the tissue.
- If a fractional D&C is performed, endocervical curettings are obtained before the uterus is sounded, to avoid bringing endometrial cells into the cervical os.
- The weighted speculum is removed, and the perineum is dressed with a perineal pad.
Perioperative Nursing Considerations - Stirrups should be padded, and a coccygeal support placed on the table to protect the lower sacral area.
- Raise and lower the legs together and slowly to prevent disturbances caused by rapid alterations in venous return and/ or injury to the rotator hip joint.
- Instruments are set up on the black table in order of usage, a scrub person may not be necessary during the procedure.
- If a fractional D&C is performed, multiple specimens may be obtained. They should be placed in separate containers, and labeled accordingly.
Dilation And Curettage (D&C) Nursing Care Plan Related posts: - Nursing Care Plan – Dilatation and Curettage (D & C)
- Papanicolaou Test (Pap Smear)
- Nursing Care Plan – Dysfunctional Uterine Bleeding (DUB)
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