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Difficulty: MediumBasic Care and Comfort

A client is recovering on the surgical unit 24 hours after a right-sided modified radical mastectomy with axillary lymph node dissection. The client reports mild incisional pain and a feeling of "heaviness" in the right arm. Which nursing intervention is most appropriate to promote comfort and minimize postoperative complications?

  1. A
    Position the client in a right lateral recumbent position to provide splinting for the surgical incision.
  2. B
    Secure the right arm in a tight immobilization sling against the chest wall to prevent accidental movement.
  3. Elevate the right arm on several pillows to ensure it rests above the level of the right atrium.Answer
  4. D
    Direct the unlicensed assistive personnel to apply a warm, moist compress to the right axillary region.

Answer

The most appropriate intervention is to elevate the right arm on several pillows to ensure it rests above the level of the right atrium.
Following a mastectomy that involves the removal of axillary lymph nodes, the natural drainage of lymphatic fluid from the arm is compromised. Elevating the affected arm on pillows so that it is positioned above the level of the heart utilizes gravity to assist in venous and lymphatic return. This simple positional intervention effectively reduces peripheral edema, alleviates the subjective feeling of heaviness, and promotes physical comfort without compromising the surgical site.

Step-by-Step Solution

1
Assess the client's postoperative status and reported symptoms.
The client underwent a right mastectomy with axillary node removal and is currently experiencing right arm heaviness.
Identifying the specific surgical procedure and recognizing related physiological symptoms dictates the appropriate comfort and risk-reduction interventions.
2
Evaluate the physiological impact of axillary lymph node dissection.
Removal of axillary nodes impairs the normal lymphatic drainage pathways from the right arm, leading to fluid accumulation and a feeling of heaviness.
Understanding the mechanism of postoperative lymphedema is essential for selecting a mechanical intervention to counteract fluid pooling.
3
Select the intervention that best promotes lymphatic return and overall comfort.
Elevating the affected arm above the level of the heart using pillows is chosen as the primary non-pharmacologic intervention.
Elevation utilizes gravity to facilitate venous and lymphatic return back into central circulation, effectively reducing the feeling of heaviness and preventing severe postoperative swelling.

Key Concept

Postoperative Mastectomy Positioning and Lymphedema Prevention
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Topics

Basic Care and Comfort

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