Question

The nurse is caring for the client with a mastectomy. Which action would be contraindicated? A. Taking the blood pressure in the side of the mastectomy B. Elevating the arm on the side of the mastectomy C. Positioning the client on the unaffected side D. Performing a dextrostix on the unaffected side

Short answer

Answer: A. Taking the blood pressure in the side of the mastectomy.

Step-by-step solution

A. Taking the blood pressure in the side of the mastectomy

Taking the blood pressure on the side of the mastectomy is contraindicated because it can cause lymphedema, which is swelling caused by a build-up of lymph fluid. This can increase pain and lead to other complications.

B. Elevating the arm on the side of the mastectomy

Elevating the arm on the side of the mastectomy is not contraindicated. In fact, this action is recommended as it can help reduce swelling, promote drainage of lymph fluid, and improve the range of motion in the arm.

C. Positioning the client on the unaffected side

Positioning the client on the unaffected side is not contraindicated and can provide comfort to the client. This position allows for optimal healing and proper lymphatic drainage from the affected arm.

D. Performing a dextrostix on the unaffected side

Performing a dextrostix (a blood glucose monitoring test) on the unaffected side is not contraindicated. This should not cause any issues for the client since it is being done on the opposite side of the mastectomy. Based on the analysis of each action, the contraindicated action when caring for a client with a mastectomy is: A. Taking the blood pressure in the side of the mastectomy

Key concepts

Post-Mastectomy Care

After a mastectomy, the care provided to the patient is crucial for recovery and preventing complications. It is important for nurses and other caregivers to understand the measures to be taken in post-mastectomy care.

One essential aspect of post-mastectomy care is the management of the affected arm. Elevating the arm can help reduce swelling by promoting lymphatic drainage and is highly recommended. Additionally, exercises may be prescribed by a physical therapist to help increase the range of motion and improve flexibility, ultimately aiding in the recovery process.

Furthermore, sensory changes, including numbness or pain, may be experienced by the patient. Nurses should educate patients on self-care techniques, such as gentle skin care and the use of non-restrictive clothing, to avoid irritation or pressure on the surgery site. Pain management strategies, including the use of prescribed medications or alternative methods such as relaxation techniques, are also vital components of post-mastectomy care.

Lymphedema Prevention

Lymphedema prevention is a critical aspect of post-mastectomy care that requires precise nursing interventions to minimize the risk of developing this condition. Lymphedema, characterized by the accumulation of lymph fluid and swelling in the tissues, most commonly affects the arm on the side of the body where the mastectomy was performed.

Key strategies to prevent lymphedema include avoiding blood pressure measurements, blood draws, and injections on the affected side, as highlighted in our exercise solution. Other preventative measures include:

• Wearing a properly fitted compression sleeve.
• Encouraging regular gentle exercises to facilitate lymph flow.
• Maintaining skin hygiene to prevent infections.
• Avoiding tight clothing, which can restrict lymphatic flow.

Nursing interventions will prioritize educating patients about recognizing early symptoms of lymphedema and instructions to seek medical advice promptly should any signs of swelling or discomfort occur.

Nursing Interventions

Nursing interventions play an integral role in the care and recovery of patients post-mastectomy. These planned actions aim to improve the patient's overall health status and mitigate potential risks associated with the surgery.

Nurses should regularly assess the surgical site for signs of infection or healing complications, such as increased redness, warmth, or discharge. Pain management is another critical intervention; nurses must ascertain the effectiveness of analgesics and adjust the pain management plan as required, always considering the patient's feedback.

Patient education is a cornerstone of nursing interventions. Nurses educate about the importance of arm exercises, signs of infection, lymphedema prevention strategies, and the need for follow-up appointments. Emotional support is also provided, acknowledging that recovery from a mastectomy can be emotionally challenging, and referral to a support group or counselor might be beneficial. These interventions foster a holistic approach to patient care, addressing both the physical and psychological needs of the patient.