A 53-year-old patient was admitted to the surgical unit after undergoing a right modified radical mastectomy. Which of the following should the nurse include in the patient's care plan?

While assessing the surgical dressing, check the right posterior axilla

Explanation

•After a mastectomy, if there is drainage or bleeding from the surgical site, it can seep down due to gravity and may soak the posterior axillary portion of the dressing. The nurse must therefore check the right posterior axilla to detect early bleeding.

•For early-stage breast cancer that has spread to the lymph nodes, modified radical mastectomy can be helpful. Raising the arms above the head is discouraged during the early post operative recovery stage because it can put strain on the incision and cause pain.

•Position the patient in semi-fowler’s position with the arm elevated on pillows to decrease edema. Position the patient on her back or unaffected side, never on the on affected side as this could increase edema and cause pain.

•Blood pressure, venipunctures, and IV sites must not involve the use of the affected arm.

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