Policies,Clinical,UWMF Clinical,UWMF-wide,Clinical Policies and Procedures,Surgical

Breast Biopsy (102.121)

Breast Biopsy (102.121) - Policies, Clinical, UWMF Clinical, UWMF-wide, Clinical Policies and Procedures, Surgical



TITLE: Breast Biopsy

Effective Date: February, 2005 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education

Reviewed Nov., 2007 May 2009 November 2011

PURPOSE: To provide guidelines for setting up and assisting with breast biopsies on patients at UWMF

DEFINITION: The removal of breast tissue to examine it for the presence of disease.

POLICY: The clinical staff will utilize the following guidelines to properly set up and assist with breast

SUPPLIES: Provider’s order, Patient’s record, Permit for Operation, Sterile “breast biopsy” surgical tray,
Cautery and electrode pad, Specimen container, zinc formalin, Local anesthetic, Suture material
10cc syringe, 25G or 26 G needle, No. 15 blade, Tegaderm/steri-strips (provider preference),
Patient gown, Chux, Gowns and 2 sets sterile gloves, face shield


1. Check provider’s order and clarify any inconsistencies.

2. Wash hands and gather equipment.

3. Introduce yourself and identify the patient. Include date of birth. Verify allergies (specifically to betadine,
chloraprep and local anesthetic)

4. Using sterile technique - open surgical tray and place any additional instruments needed on tray. Cover
instruments until needed

5. Provide good light and privacy by closing curtains and door.

6. Room patient – Refer to Provider Preference List for Rooming Patients.

7. Explain procedure to the patient

8. Following the provider’s discussion with patient, have patient sign Consent for Operation and sign consent
form as witness.

9. Have the patient remove their top and bra and place gown on.

10. Assist patient to the dorsal position and make patient as comfortable as possible.

11. Elevate table and adjust lighting.


12. After provider has re-examined breast, use betadine or chloraprep to cleanse area of breast to be biopsied.
NOTE: Use alcohol if allergic to betadine or chloraprep.

13. Apply electrode pad to patient’s abdomen, attach to electrosurgical generator.

14. Attach cautery to the electrosurgical generator, push power button “on” and place setting per provider

15. Wash hands, put on sterile gloves and face shield, Assist provider (as needed).


16. Assist patient to comfortable position.

17. Place specimen in Zinc Formalin container. Label specimen, in presence of patient, with the following:
Patient name and date of birth
Specimen type
Date and time of specimen collection
Provider name

18. Remove gloves and wash hands.

19. Reinforce postoperative instructions.
Give patient “Caring for Incision – Breast Biopsy” handout
Review handout with patient
Assist patient back to waiting room
Assist patient with follow-up appointment (if needed)

20. Complete necessary lab forms.

21. Place patient sticker in Pathology log book.

22. Take labeled specimen container to the lab.

23. Apply gloves and clean all surfaces with Dispatch
Bring surgical tray and instruments to dirty utility room
Place needles in sharps containers
Discard waste and disposable equipment in proper receptacles
Wash instruments and tray in dirty utility room
Remove gloves and wash hands
Bring instruments to clean utility room

24. Wrap surgical tray and instruments and take to clean utility room.

25. Documentation (in Progress Notes section of HealthLink) in the patient’s record:
Patient education
Procedure performed, date & time completed
Name and amount of any medications given (using SmartPhrase: .medinclinic)
How the patient tolerated the procedure

Discharge instructions
Follow-up appointment (if any)

WRITTEN BY: Kelly Barman, R.N., Department of General Surgery

REVISED BY: Carol Decker, RN, MSN, Clinical Staff Education

REVIEWED BY: Kelly Meyer R.N., Department of General Surgery


Kowalak, J. P. (Ed.). (2009). Lippincott’s nursing procedures (5th ed.). Ambler, PA: Lippincott Williams &
Perry, A.G. & Potter, P.A. (2002). Clinical nursing skills & techniques. (5th ed.). St. Louis, MO: Mosby.
Perry, A.G. & Potter, P.A. (2009). Fundamentals of nursing. (7th ed.). Hall, A. & Stockert, P.A. (Eds.). St.
Louis, MO: Mosby Elsevier.


Department of Surgery Date

Medical Director Date