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Zorluk: OrtaBasic Care and Comfort

An adult client is resting in a medical-surgical unit on the first postoperative day following a right-sided modified radical mastectomy with axillary lymph node dissection. While assisting the client with morning care, the practical nurse must ensure the affected extremity is positioned correctly to prevent lymphedema. Which of the following is the most appropriate placement for the client's right arm?

  1. Elevated on a pillow so that the hand is positioned higher than the elbow, and the elbow is higher than the heartCevap
  2. B
    Placed flat on the mattress directly alongside the client's torso to maintain joint alignment
  3. C
    Secured firmly across the client's chest using a binder to prevent tension on the surgical incision
  4. D
    Supported in a dependent position slightly below the mattress level to promote arterial perfusion to the fingers

Cevap

Elevate the right arm on a pillow with the hand positioned higher than the elbow, and the elbow higher than the heart.
Following a mastectomy involving axillary lymph node dissection, the natural drainage of lymphatic fluid from the arm is significantly compromised. Elevating the arm on a pillow in a graduated slope (hand higher than elbow, elbow higher than the heart) utilizes gravity to assist the return of lymphatic fluid and venous blood to the central circulation. This prevents fluid from accumulating in the tissues of the arm, thereby reducing the risk of developing painful and debilitating lymphedema.

Adım Adım Çözüm

1
Identify the surgical procedure and its risks.
The client had a mastectomy with axillary lymph node dissection, which disrupts the normal lymphatic drainage pathways of the right arm.
Understanding the anatomical changes helps anticipate complications such as lymphedema.
2
Determine the physical principle that aids in fluid management.
Gravity can assist in draining lymphatic and venous fluid from the distal parts of the arm back toward the central circulation.
Proper positioning leverages gravity to compensate for the compromised lymphatic system.
3
Select the correct positioning strategy.
The arm should be elevated on a pillow in a graduated manner: hand higher than elbow, and elbow higher than the level of the heart.
This specific upward slope creates a clear path for fluid to drain downwards toward the body, preventing pooling and swelling.

Anahtar Kavram

Post-mastectomy Lymphedema Prevention and Positioning
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Konular

Basic Care and Comfort

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