# A nurse is caring for a client who underwent a radical mastectomy 24 hours ago. Which assessment finding would be the priority concern requiring immediate nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540636 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client who underwent a radical mastectomy 24 hours ago. Which assessment finding would be the priority concern requiring immediate nursing intervention? ## 보기 1. Mild to moderate incisional pain rated 4/10 on the pain scale 2. Serosanguineous drainage in the Jackson-Pratt drain totaling 50 mL in 8 hours 3. Numbness and tingling in the fingers with decreased capillary refill on the affected side **✔ 정답** 4. Slight swelling around the incision site with minimal bruising **정답: 3** ## 해설 Numbness, tingling, and decreased capillary refill indicate compromised circulation and potential nerve compression, requiring immediate intervention to prevent permanent damage. Other findings are expected post-operative responses. ## 심화 해설 Clinical Reasoning & Priority Setting The correct answer is 3. Numbness and tingling in the fingers with decreased capillary refill on the affected side. This finding represents a neurovascular compromise, which is a surgical emergency requiring immediate intervention to prevent permanent loss of function. Deep Dive into the Pathophysiology and Rationale Following a radical mastectomy, the priority assessment framework must always follow the ABCs (Airway, Breathing, Circulation) and neurovascular integrity. While pain, drainage, and localized edema are expected postoperative findings, neurological and vascular deficits signal a potentially limb-threatening complication. Why Option 3 is the Priority Numbness, tingling (paresthesia), and decreased capillary refill on the operative side are classic signs of neurovascular compromise. In the context of a radical mastectomy, this is most commonly caused by brachial plexus injury or compression, or by vascular insufficiency due to tight surgical dressings, hematoma formation, or improper arm positioning. The brachial plexus is highly vulnerable during extensive axillary lymph node dissection. If circulation and nerve conduction are not restored quickly, the patient risks irreversible ischemic damage, compartment syndrome, or permanent motor and sensory deficits. This directly aligns with the spectrum of complications discussed in implant-based reconstruction literature, where vascular compromise and nerve injury require immediate reoperation or intervention to prevent reconstructive failure and systemic illness . Although the cited case report focuses on a DIEP flap, the principle of vascular supply integrity being paramount to tissue viability and limb function is directly transferable . Analysis of Other Options - Option 1: Mild to moderate incisional pain rated 4/10 is an expected finding 24 hours post-mastectomy. While it requires ongoing assessment and management with prescribed analgesics, it does not indicate a life- or limb-threatening complication. It is a comfort and safety need, not the immediate physiological priority. - Option 2: Serosanguineous drainage of 50 mL in 8 hours in a Jackson-Pratt drain is a normal and expected finding in the first 24-48 hours postoperatively. This volume indicates the drain is functioning correctly to evacuate fluid from the surgical site, preventing seroma and promoting wound healing. This finding requires routine monitoring and documentation, not emergency intervention. - Option 4: Slight swelling and minimal bruising around the incision site are normal inflammatory responses to extensive surgical tissue trauma. These are expected local findings and do not constitute a priority concern unless the swelling is rapidly expanding, tense, and associated with signs of a hematoma (which would then manifest as a circulatory issue, linking back to the priority of option 3). Clinical Application of the Evidence The narrative review on complications highlights that sequelae from breast surgery range from mild aesthetic issues to systemic illness and reconstructive failure . A neurovascular deficit falls into the severe category demanding immediate action. Furthermore, while the ultrasound study focuses on chronic lymphedema, it underscores the critical importance of assessing the superficial and deep structures of the affected limb post-oncological surgery . The nurse’s acute assessment for paresthesia and capillary refill is the frontline method for detecting early, reversible neurovascular pathology before it progresses to the chronic, non-reversible tissue changes described in the lymphedema literature . The principle of ensuring adequate vascular supply to the extremity is as critical as ensuring flap perfusion in autologous reconstruction . ## 임상 시나리오 Clinical Guide: Post-Mastectomy Neurovascular Assessment Following a radical mastectomy, vigilant monitoring for neurovascular compromise is critical due to the proximity of surgical dissection to the brachial plexus and axillary vasculature. The priority assessment is the "5 Ps": Pain, Pallor, Pulselessness, Paresthesia, and Paralysis. Any new onset of numbness, tingling, or delayed capillary refill on the affected side must be treated as a surgical emergency. Immediate Nursing Actions - Immediately assess and compare bilateral upper extremity pulses, sensation, motor function, skin color, temperature, and capillary refill. - Loosen any constrictive surgical dressings or bandages, ensuring they are not impeding circulation, and verify proper arm positioning (elevated on pillows, avoiding abduction beyond 90 degrees). - Notify the surgeon or rapid response team immediately, clearly communicating the specific neurovascular deficits observed. - Prepare for potential emergency interventions such as doppler studies, surgical decompression, or hematoma evacuation. Differentiating Expected vs. Critical Findings | Assessment Area | Expected Postoperative Finding | Critical Finding (Requires Intervention) | | --- | --- | --- | | Pain | Mild to moderate incisional pain, controlled with analgesics. | Severe, unrelenting pain, especially with passive movement of fingers/wrist (compartment syndrome sign). | | Sensation | Mild numbness near the incision site. | Progressive numbness, tingling (paresthesia), or burning in the entire arm, hand, or fingers. | | Perfusion | Capillary refill < 3 seconds, arm warm to touch. | Delayed capillary refill > 3 seconds, coolness, pallor, or diminished/absent radial pulse. | | Drainage | Serosanguineous drainage gradually decreasing in volume. | Sudden, large increase in bright red drainage or formation of a tense, expanding hematoma. | Key Clinical Pearls A tight surgical dressing is a common and easily reversible cause of neurovascular compromise. Always rule this out first. Document all findings meticulously using a standardized neurovascular chart. Patient education should include instructions to report any new numbness, tingling, color change, or increased pain immediately, even after discharge. ## 핵심 개념 - **Neurovascular Compromise** — A condition involving impaired nerve function and blood circulation to an extremity, often presenting with paresthesia, numbness, and delayed capillary refill. - **Brachial Plexus Injury** — Damage to the network of nerves that sends signals from the spine to the shoulder, arm, and hand, a risk during extensive axillary surgery. - **Capillary Refill** — A quick test to assess blood flow; a delayed return of color (greater than 2-3 seconds) indicates poor peripheral perfusion. - **Compartment Syndrome** — A serious condition caused by increased pressure within a muscle compartment, leading to compromised circulation and potential tissue necrosis. - **Jackson-Pratt Drain** — A closed-suction medical device used to remove fluids from a surgical site, commonly placed after a mastectomy to prevent seroma formation. ## 같은 주제 문제 - [A nurse is caring for a 72-year-old client who underwent a splenectomy 48 hours ago. 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