Misconceptions with bilat mastectomies?

[fltopp1]

There seems to be a lot of controversy regarding where to do a BP and/or blood draws on a post bilat mastectomy patient. Im curious of what everyone else was taught. After looking into it, the practice of taking the BP on the thigh after a bilat mast. is because the mastectomy used to be a "Radical Mastectomy" where the tissue to include the pectoral muscle as well as all the nodes (including axillary) under the armpit were removed and the trauma to the artery could caus the artery to shink in diameter and therefore caus low readings for all the BPs after that. Today's thought process is that it causes lymphedema and thats why we refrain. Granted there is a higher possibility to cause lymphedema in the arm but this was not the main issue when the thigh BP rule came about. Some old school nurses even have stated to patients that anyone who performs a BP or stick in the arm of a mastectomy is performing mal-practice. These misconceptions that continue today are what keep this as controversial as it is. And if the patient is 300 pounds where do you find a BP cuff large enough? would the reading be accurate with the amount of cellulite in a thigh? Whats everyones thoughts on this?? And if the sentinal node was the only node removed not to include the axillary, would you do it differently??

[dudette10, MSN, RN]

I had a PM discussion with a poster here about this. It's not so much the mastectomy as it is nodal biopsy/removal.

A friend of mine had a bilateral mastectomy with R sentinel node biopsy (two removed and analyzed, the third "node" ended up being just adipose tissue and not a node at all) and chemo. Chemo was done through PIVs--twice through the left arm and twice through the right arm. No adverse effects. The doc ok'd it because a majority of nodes were still there.

Many nurses will freak out if a patient isn't on arm restrictions when the pt has had a one-sided mastectomy, regardless of node status, so I go along with it. If the patient has a b/l mastectomy, I'll ask which side the cancer was on and restrict that arm, even though I think it's going overboard if they haven't had nodes removed.

[Mulan]

.... and what about the person that has had bilateral mastectomies and bilateral amputations at the hip

[roser13, ASN, RN]

I had a PM discussion with a poster here about this. It's not so much the mastectomy as it is nodal biopsy/removal.

A friend of mine had a bilateral mastectomy with R sentinel node biopsy (two removed and analyzed, the third "node" ended up being just adipose tissue and not a node at all) and chemo. Chemo was done through PIVs--twice through the left arm and twice through the right arm. No adverse effects. The doc ok'd it because a majority of nodes were still there.

Many nurses will freak out if a patient isn't on arm restrictions when the pt has had a one-sided mastectomy, regardless of node status, so I go along with it. If the patient has a b/l mastectomy, I'll ask which side the cancer was on and restrict that arm, even though I think it's going overboard if they haven't had nodes removed.

I have had conversations with breast surgeons that correlate the above. The issue, as usual, seems to be with patients who have heard one thing most of their lives and are slow to accept the fact that research and improved surgical techniques might have created a new reality. And that's OK, of course.

My facility recognized the new guidelines for MVP, namely that antibiotic prophylaxis was no longer necessary, and stopped automatically administering antibiotics. The patients started complaining, LOUDLY, that we didn't know what we were doing. We started flushing portacaths with saline instead of heparin, again following new research & recommendations. Patients were adamant that they needed that antibiotic, and we quickly went back to heparin simply for the patient satisfaction scores.

[Karou]

When my mother had a bilateral mastectomy in January, her surgeon explicitly told her that since he only removed the sentinel lymph nodes, that she can have her BP taken on either arm. No problem. It's the same way on the med-surg floor where I work. We do sticks and BP's as long as there were not lymph nodes removed- sentinel nodes don't count. Sometimes the elderly patients don't know if they had lymph nodes removed so we avoid that extremity as if they were.

If it's difficult to get an accurate reading on a lower extremity for a patient contradicted in the upper extremities, then we can get a doctors order that it is okay to take on the upper. Sometimes the risks are outweighed by the necessity of getting an accurate reading. Of course that depends on why it's contradicted... but with lymph most doctors are okay giving that order. Once the house supervisor had to put a PIV into an arm contradicted due to lymph node removal. It was an emergency, the patient needed fluids, and no one questioned her on it. Patient was fine without adverse effects.

I have seen massive swelling/edema in a male mastectomy patient due to a BP being taken on that arm in the past. I think about that anytime we have an issue come up where we are considering using an extremity where lymph nodes were removed.

[kanzi monkey]

The risk of lymphedema increases the more extensive the node dissection. Ppx mastectomy = not an issue. Axillary node dissection = possibly an issue. If you have bilateral axillary dissections and can get a consistent BP read on the thigh, that's a fine choice. If you can't get a read on the thigh, my practice was always to check BPs on the arms judiciously. I was the responding clinician so I gave the ok for this. Depending on where you work and the culture there, it is reasonable to request an order (because not all responding clinicians are on the same page, and you don't want to find yourself arguing with a nervous intern).

If you're taking the BP in the leg, please make sure the patient is lying down. If you get a really high reading reported from an aide, check that they weren't in a chair or, say, walking with PT. I got more than a handful of pages that patient's BPs were > 190 systolic with no information or available call back, requiring me to go see the patient (in another building), get her back in bed, and take the BP

myself :/

Good times.

[classicdame, MSN, EdD]

Have been doing research on this recently for curriculum. Appears the safest thing is to get MD order to use an extremeity if in doubt. No everyone develops lymphedema. Many nurses over-inflate the cuff or leave a tourniquet on too long and that causes problems. Still best to ask MD

[dream'n, BSN, RN]

Worked closely for some years with a couple Nationally renowned breast surgeons. They stated that any risk with taking BPs or performing venipuncture in the affected arm, were theoretical at best.

[toomuchbaloney]

Worked closely for some years with a couple Nationally renowned breast surgeons. They stated that any risk with taking BPs or performing venipuncture in the affected arm were theoretical at best.[/quote']

Some of us have experience which tests that "theoretical at best" notion.

[iluvivt, BSN, RN]

There is not just one answer here. I Make a determination what is the best/safest thing to do based on my assessment of that pt ' particular situation and history. I have placed many PBS in post mastectomy side arms and even placed PICC when the benefit outweighs the risks. Since there are many cooks on a case I get an order to cover myself.

[iluvivt, BSN, RN]

The research indicating it is safe and effective to switch to ND Flush ONLY for PIVs. The current evidenced practice for all types of CVS is still to use low dose heparin. Ironically the example you gave for the port has a a higher concentration recommendation than other type of CVS except ,HD catheters, at 100 units per ml with 500 units for a final flush as well as a q month flush..With that said some chose to eliminate the use of Heparin out of fear of HIT and the use of valve catheters often marketed as saline only flush catheters...and yes you can still use heparin on those too. The increased use of positive displacement needle

less connectors also contributed to the trend. Many who did are rethinking that after dealing with frequent thrombotic occlusions!