Medical Surgical Nursing

support, and education as well. The patient and partner may benefit from a wide
network of available community resources, including the Reach to Recovery program
of the ACS, advocacy groups, or a spiritual advisor. Encouraging the patient to discuss
issues and concerns with other patients who have had breast cancer may help her to
understand that her feelings are normal and that other women who have had breast
cancer can provide invaluable support and understanding.
The patient may also have considerable anxiety about the treatments that will follow
surgery (i.e., chemotherapy and radiation) and their implications. Providing her with
information about the plan of care and referring her to the appropriate members of the
health care team also promote coping during recovery. Some women require additional
support to adjust to their diagnosis and the changes that it brings. If a woman displays
ineffective coping, consultation with a mental health practitioner may be indicated.
Table 48-5 summarizes the needs and nursing interventions for patients and their
partners at various stages of the breast cancer experience. Chart 48-6 provides
strategies for initiating conversations with patients and their partners during different
phases of therapy.
Improving Sexual Function
Once discharged from the hospital, most patients are physically allowed to engage in
sexual activity. However, any change in the patient's body image, selfesteem, or the
response of her partner may increase her anxiety level and affect sexual function. Some
partners may have difficulty looking at the incision, whereas others may be completely
unaffected. Encouraging the patient to openly discuss how she feels about herself and
about possible reasons for a decrease in libido (e.g., fatigue, anxiety, self-
consciousness) may help clarify issues for her. Helpful suggestions for the patient may
include varying the time of day for sexual activity (when the patient is less tired),
assuming positions that are more comfortable, and expressing affection using
alternative measures (e.g., hugging, kissing, manual stimulation).
Most patients and their partners adjust with minimal difficulty if they openly discuss
their concerns. However, if issues cannot be resolved, a referral for counseling (e.g.,
psychologist, psychiatrist, psychiatric clinical nurse specialist, social worker, sex
therapist) may be helpful. The ambulatory care nurse in the outpatient clinic or hospital
should inquire whether the patient is having difficulty with sexuality issues, because
many patients are reluctant or embarrassed to bring it up themselves.
Monitoring and Managing Potential Complications
Lymphedema
Lymphedema occurs in about 10% to 30% of patients who undergo ALND and in
about 0% to 7% of patients who have SLNB (Leidenius, Leivonen, Vironen, et al.,
2005; Wilke, McCall, Posther, et al., 2006). Risk factors for lymphedema include
increasing age, obesity, presence of extensive axillary disease, radiation treatment, and
injury or infection to the extremity (Golshan, Martin & Dowlatshahi, 2003).
Lymphedema results if functioning lymphatic channels are inadequate to ensure a
return flow of lymph fluid to the general circulation. After axillary lymph nodes are
removed, collateral circulation must assume this function. Transient edema in the
postoperative period occurs until collateral circulation has completely taken over this
function, which generally occurs within a month. Performing prescribed exercises,
elevating the arm above the heart several times a day, and gentle muscle pumping
(making a fist and releasing) can help reduce the transient edema. The patient needs
reassurance that this transient swelling is not lymphedema.
Once lymphedema develops, it tends to be chronic, so preventive strategies are vital.
After ALND, the patient is taught hand and arm care to prevent injury or trauma to the
affected extremity, thus decreasing the likelihood for lymphedema development (Chart