A 55-year-old individual is recovering on the surgical unit 24 hours after a right-sided modified radical mastectomy with axillary lymph node dissection. As the practical nurse organizes basic care and comfort measures for the shift, which of the following actions should be included in the plan of care? Select all that apply.
- Elevate the client's right arm on a pillow while resting in bed.Answer
- BAssist the client into a right lateral side-lying position to splint the surgical incision.
- Encourage the client to perform finger-flexion and wrist-rotation exercises with the right hand.Answer
- DPosition the right arm in a dependent position alongside the body to promote arterial perfusion.
- EInstruct the unlicensed assistive personnel (UAP) to assess the surgical wound for signs of excessive drainage.
Answer
The correct actions are to elevate the client's right arm on a pillow while resting and to encourage finger-flexion and wrist-rotation exercises with the right hand.
The correct answers involve elevating the affected right arm on a pillow and encouraging simple distal movements like finger-flexion and wrist-rotation. Following an axillary lymph node dissection, normal lymphatic drainage is disrupted, predisposing the client to lymphedema (swelling) and severe discomfort. Elevating the arm uses gravity to facilitate fluid return, thereby reducing edema and pain. Additionally, gentle distal exercises such as hand squeezing or wrist rotation promote circulation and prevent joint stiffness without placing undue stress on the fresh chest wall incision.
Step-by-Step Solution
Key Concept
Post-mastectomy basic care and comfort focuses on preventing lymphedema and pain by elevating the affected arm and promoting circulation through gentle, distal range-of-motion exercises.