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The focus of nursing care for a patient with a mastectomy during the 2- to 3-day hospital stay will be directed toward early surgical recovery. Teach pain management, mobility, adequate circulation, and self-care activities to prepare the patient for discharge. In the immediate postoperative period, keep the head of the bed elevated 30 degrees, with the affected arm elevated on a pillow to facilitate lymph drainage. Instruct the patient not to turn on the affected side. Place a sign at the head of the bed immediately after surgery with directions for no blood pressures, blood draws, injections, or intravenous lines on the arm of the operative side; this should help prevent circulatory impairment.

Emphasize the importance of ambulation and using the operative side within 24 hours. Initially, the arm will need to be supported when the patient is out of bed. As ambulation progresses, encourage the patient to hang her arm at her side normally, keeping her shoulders back to avoid the hunchback position and to prevent contractures. Within 24 hours, begin with exercises that do not stress the incision.

154 Breast Cancer

Teach the patient how to empty the drainage device (Hemovac or other), measure the drainage accurately, and observe for the color and consistency of the drainage. Create a flow sheet for record keeping in the hospital, and send it home with the patient to use until the drain is removed. At the dressing change, begin teaching the dressing change procedure and the indications of complications such as infection (purulent drainage, redness, pain), presence of fluid collection, or hematoma formation at the incision. Be sensitive to the patient's reactions upon seeing the incision for the first time with full realization that her breast is gone. Explain that phantom breast sensations and numbness at the operative site along the inner side of the armpit to the elbow are normal for several months because of interruptions of nerve endings.

Women may have feelings of loss not only of their breast but also of lifestyle, social interactions, sexuality, and even life itself. Patients often feel more comfortable expressing their feelings with nurses than with family members or the physician. Effective coping requires expression of feelings. Discuss the services and goals of Reach to Recovery (psychological and physical support). If the patient is willing, arrange for an in-hospital visit or early home visit.

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