# Situation: A 52-year-old woman has invasive ductal carcinoma of the left breast, stage IIB (T2 N1 M0), grade 3, estrogen receptor-positive and human epidermal growth factor receptor 2 (HER2)-negative. She undergoes a modified radical mastectomy with axillary lymph node dissection and will then receive doxorubicin and cyclophosphamide every 21 days. She has no known drug allergies. On the first postoperative day, which measure should the nurse include in the care of her left arm?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629731  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 52-year-old woman has invasive ductal carcinoma of the left breast, stage IIB (T2 N1 M0), grade 3, estrogen receptor-positive and human epidermal growth factor receptor 2 (HER2)-negative. She undergoes a modified radical mastectomy with axillary lymph node dissection and will then receive doxorubicin and cyclophosphamide every 21 days. She has no known drug allergies.

On the first postoperative day, which measure should the nurse include in the care of her left arm?

## 보기

1. Elevate the arm on pillows and have her squeeze a soft ball **✔ 정답**
2. Start wall-climbing exercises to regain full shoulder motion
3. Keep the arm in a sling against the chest until the drain is out
4. Apply a warm pack to the axilla to reduce the swelling

**정답: 1**

## 해설

After axillary node dissection, the arm on the operative side is elevated on pillows to promote lymph and venous drainage, and prescribed exercises start with hand squeezing and elbow flexion. Shoulder exercises such as wall climbing are added later as ordered. Heat is avoided on the affected side because it increases lymphedema risk.

## 심화 해설

Clinical context: postoperative care after modified radical mastectomy with axillary lymph node dissection

The first postoperative day after axillary lymph node dissection (ALND) is a critical window for protecting the affected arm. The lymphatic channels that normally drain interstitial fluid from the upper extremity have been surgically interrupted, which means the arm depends on gravity and muscle pump activity to move fluid proximally. The correct nursing measure is to elevate the arm on pillows and have the patient squeeze a soft ball.

Elevation uses gravity to promote venous and lymphatic return, while gentle hand squeezing activates the forearm muscle pump to move fluid without stressing the healing axilla. This combination directly addresses the physiologic risk of fluid accumulation in the early postoperative period.

The exercise progression after ALND is deliberately staged. On the first postoperative day, only hand squeezing and elbow flexion are appropriate. Key point! Shoulder-range exercises such as wall climbing are introduced later, once the surgical drains are removed and the incision has begun to heal. Aggressive shoulder abduction or overhead reaching too early can disrupt the axillary closure, increase seroma formation, and place tension on the suture line.

Heat application to the axilla is contraindicated. Heat causes local vasodilation and increases capillary filtration, which can worsen interstitial fluid accumulation and raise the risk of breast cancer-related lymphedema (BCRL). The affected arm should also be protected from any form of thermal stress, including hot packs, heating pads, and hot water immersion.

Keeping the arm immobilized in a sling until drain removal is also incorrect. Prolonged immobility reduces the muscle pump activity that assists lymphatic drainage and can contribute to shoulder stiffness and functional impairment. The goal is protected mobility, not immobilization.

| Intervention | First postoperative day | Rationale |
| --- | --- | --- |
| Elevation on pillows | Yes | Promotes gravity-dependent venous and lymphatic drainage |
| Hand squeezing, elbow flexion | Yes | Activates muscle pump without stressing axillary incision |
| Wall-climbing shoulder exercises | No — later, as ordered | Premature shoulder motion risks seroma and wound disruption |
| Warm pack to axilla | No — avoid heat | Vasodilation increases capillary filtration and lymphedema risk |
| Sling immobilization until drain out | No | Immobility impairs lymphatic flow and promotes stiffness |

The risk of BCRL is substantial in this patient. She has undergone ALND, which is the strongest surgical risk factor for lymphedema, and her tumor is stage IIB with positive nodes. The nursing-led strategies emphasized in the literature include early symptom recognition, perioperative prevention, and patient education about arm protection . Early systematic exercise initiated within two weeks after surgery has been associated with reduced lymphedema incidence and improved functional recovery, but the exercise must be phased and therapist-guided [2]. The first phase begins with distal movements — hand and elbow — before progressing to shoulder range of motion.

Watch out! Lymphedema can develop within 12 to 24 months after surgery, not only in the immediate postoperative period . The arm on the operative side must be protected long-term from blood pressure measurement, venipuncture, constrictive clothing, and thermal injury. Complete decongestive therapy remains the mainstay of non-surgical management once lymphedema develops .

The nurse’s role on the first postoperative day is to establish a foundation for lymphatic protection: position the arm to favor drainage, initiate only the prescribed distal exercises, and educate the patient about lifelong precautions for the affected extremity.References (research sources)

- [2]The impact of early exercise intervention on the incidence and severity of lymphedema following axillary lymph node dissection in breast cancer.Research articleWang M, Zhang X, Li G, Wang A, Wu Y, Jeong DK. (2026) · DOI: 10.21037/gs-2025-1-597

## 임상 시나리오

Post-Mastectomy Arm Care: Day 1Protecting the arm after axillary lymph node dissection
On the first postoperative day, elevate the affected arm on pillows to promote lymphatic and venous return by gravity.

Begin only gentle hand exercises such as squeezing a soft ball and elbow flexion. This activates the muscle pump without stressing the healing axilla.

Delay shoulder-range exercises such as wall climbing until drains are removed and healing has progressed, as ordered.

CautionDo not apply heat to the axilla or affected arm; it causes vasodilation and increases lymphedema risk. Avoid keeping the arm in a dependent or immobilized position.

## 핵심 개념

- **Axillary lymph node dissection** — Surgical removal of lymph nodes in the axilla, which interrupts lymphatic drainage and increases the risk of lymphedema in the ipsilateral arm.
- **Muscle pump** — Mechanism by which contracting muscles compress veins and lymphatics, helping to move fluid proximally.
- **Seroma** — A collection of serous fluid that can develop under the skin after surgery, especially if the surgical site is stressed too early.
- **Lymphedema** — Swelling caused by accumulation of protein-rich fluid due to impaired lymphatic drainage.

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