# A nurse is caring for a client who underwent a radical mastectomy 24 hours ago. Which nursing intervention should be the priority?

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> subject: Adult Health

## 문제

A nurse is caring for a client who underwent a radical mastectomy 24 hours ago. Which nursing intervention should be the priority?

## 보기

1. Encourage early ambulation to prevent complications
2. Position the affected arm in elevation **✔ 정답**
3. Remove the surgical dressing to assess the incision site
4. Administer pain medication before physical therapy

**정답: 2**

## 해설

Positioning the affected arm in elevation is the priority to prevent lymphedema, a serious complication after radical mastectomy due to lymph node removal. Other interventions like ambulation, dressing removal, or pain management are important but secondary to lymphedema prevention.

## 심화 해설

Understanding the Priority: Preventing Lymphedema After Radical Mastectomy

Following a radical mastectomy, which involves the removal of breast tissue, underlying chest muscle, and axillary lymph nodes, the body's normal lymphatic drainage pathways are disrupted. This disruption creates a high-risk state for lymphedema, a chronic and potentially debilitating condition characterized by protein-rich fluid accumulation in the interstitial spaces of the affected arm. The immediate postoperative period is critical for establishing practices that minimize this risk.

Analyzing the Correct Intervention: Arm Elevation

Positioning the affected arm in elevation is the priority because it directly addresses the physiological challenge of impaired lymphatic and venous return from the extremity. After axillary lymph node dissection, the arm relies heavily on collateral lymphatic vessels and passive drainage mechanisms. Elevation uses gravity to promote the flow of lymph and venous blood back toward the central circulation, effectively reducing hydrostatic pressure in the capillaries and preventing fluid from pooling in the arm and hand. This simple, non-pharmacological intervention is a cornerstone of immediate postoperative care to reduce edema, pain, and the risk of developing long-term lymphedema.

Why Other Options Are Not the Priority

- Encouraging early ambulation: While early ambulation is an essential nursing intervention to prevent general postoperative complications like atelectasis, pneumonia, and deep vein thrombosis, it is not the highest priority for a client who has undergone a radical mastectomy. The most immediate and specific risk related to this surgery is lymphedema, which is directly mitigated by arm elevation. Ambulation does not specifically protect the affected arm from fluid accumulation.

- Removing the surgical dressing: The surgical dressing applied in the operating room is typically left intact for the first 24 to 48 hours to protect the wound, absorb drainage, and provide compression. Removing it prematurely to "assess the incision site" would violate surgical asepsis, increase the risk of infection, and disrupt the healing environment. Assessment of the site is done by checking for strike-through drainage on the intact dressing, not by removing it.

- Administering pain medication before physical therapy: Pain management is a critical component of postoperative care. The provided research underscores the significance of optimizing perioperative analgesia, with studies exploring advanced regional blocks like the pectoral (PECS II) and serratus anterior plane blocks to manage post-mastectomy pain [1, 2, 3]. However, the priority at 24 hours post-op is not preparing for formal physical therapy, which often begins later. The immediate nursing action is to proactively prevent a major complication (lymphedema) through proper positioning. While pain medication would be administered, the physical positioning of the arm takes precedence as a preventive measure.

## 임상 시나리오

Post-Mastectomy Arm CareImmediate Priority to Prevent Lymphedema
Within the first 24 hours after a radical mastectomy, the priority is positioning the affected arm in elevation on a pillow. This uses gravity to promote lymphatic and venous return, reducing hydrostatic pressure and preventing fluid accumulation in the interstitial spaces.

CautionNever take blood pressure, perform venipuncture, or give injections on the affected arm. These actions can traumatize vessels, increase pressure, and trigger or worsen lymphedema.

## 핵심 개념

- **Lymphedema** — Chronic swelling caused by accumulation of protein-rich fluid in interstitial spaces due to impaired lymphatic drainage, a major risk after axillary lymph node dissection.
- **Radical Mastectomy** — Surgical removal of breast tissue, underlying chest muscle, and axillary lymph nodes, which significantly disrupts normal lymphatic drainage pathways.
- **Axillary Lymph Node Dissection** — Surgical removal of lymph nodes from the armpit area, a key part of radical mastectomy that directly impairs lymphatic return from the arm.
- **Hydrostatic Pressure** — The pressure exerted by fluid within capillaries; elevation reduces this pressure in the arm, helping to prevent fluid leakage and edema.

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