or nurse for evaluation. Treatment consists of oral or IV antibiotics (for more severe
infections) for 1 or 2 weeks. Cultures are taken of any foul-smelling discharge.
Promoting Home and Community-Based Care
Teaching Patients Self-Care
Patients who undergo breast cancer surgery receive a tremendous amount of
information preoperatively and postoperatively. It is often difficult for the patient to
absorb all of the information, partly because of the emotional distress that often
accompanies the diagnosis and treatment. Prior to discharge, the nurse must assess the
patient's readiness to assume self-care responsibilities, and any gaps in knowledge must
be identified. Teaching may need to be reviewed and reinforced to ensure that the
patient and family are prepared to manage the necessary home care. The nurse
reiterates symptoms the patient should report, such as infection, seroma, hematoma, or
arm swelling. All teaching should be reinforced during office visits and by telephone.
Most patients are discharged 1 or 2 days after ALND and/or mastectomy (possibly later
if they have had immediate reconstruction) with surgical drains in place. Initially, the
drainage fluid appears bloody, but it gradually changes to a serosanguineous and then a
serous fluid over the next several days. The patient is given instructions about drainage
management at home (Chart 48-8). If the patient lives alone and drainage management
is difficult for her, a referral for a home care nurse should be made. The drains are
usually removed when the output is less than 30 mL in a 24-hour period (approximately
7 to 10 days). The home care nurse also reviews pain management and incision care.
Generally, the patient may shower on the second postoperative day and wash the
incision and drain site with soap and water to prevent infection. If immediate
reconstruction has been performed, showering may be contraindicated until the drain is
removed. A dry dressing may be applied to the incision each day for 7 days. The
patient should know that sensation may be decreased in the operative area because the
nerves were disrupted during surgery, and gentle care is needed to avoid injury. After
the incision has completely healed (usually after 4 to 6 weeks), lotions or creams may
be applied to the area to increase skin elasticity. The patient can begin to use deodorant
on the affected side, although many women note that they no longer perspire as much
as before the surgery.
After ALND, patients are taught arm exercises on the affected side to restore range of
motion (Chart 48-9). After SLNB, patients may also benefit from these exercises,
although they are less likely to have decreased range of motion than those who have
undergone ALND. Range of motion exercises are initiated on the second postoperative
day, although instruction often occurs on the first postoperative day. The goals of the
exercise regimen are to increase circulation and muscle strength, prevent joint stiffness
and contractures, and restore full range of motion. The patient is instructed to perform
range of motion exercises at home 3 times a day for 20 minutes at a time until full
range of motion is restored (generally 4 to 6 weeks). Most patients find that after the
drain is removed, range of motion returns quickly if they have adhered to their exercise
program.
Patient Education
Exercise After Breast Surgery Wall handclimbing. Stand facing the wall with feet apart and toes as close to the
wall as possible. With elbows slightly bent, place the palms of the hand on the
wall at shoulder level. By flexing the fingers, work the hands up the wall until
arms are fully extended. Then reverse the process, working the hands down to
the starting point.