About
Swelling and edema of the affected side of the body where mastectomy and lymph node removal or biopsy has occurred due to impaired lymphatic flow through altered lymph node channels.
Tissue swelling resulting from increased lymphatic fluid accumulation and lymphatic vessel occlusion.
Assess
Swelling of tissues, especially increased in the dependant position. Usually effects the arms after axillary lymph node removal. Can also effect the genitalia.
Complications
infection, immobility of affected extremity, tissue necrosis
Diagnosis
- Risk for infection.
- Risk for injury.
- impaired tissue perfusion related to edematous condition.
- Acute pain related to tissue swelling and inflammation.
- Body image disturbance related to altered appearance of body part.
Goals
- The client will have a reduction in edema to affected body area.
- the client will remain free form infection.
- The client will have positive distal pulses with good capillary refill to the extremity affected.
- The client will state a pain level less than 4 after medication intervention.
- The client will identify strategies to reduce edema and promote lymphatic fluid drainage back into the body.
Interventions
- Assess body area affected for signs of infection, necrosis, impaired circulation, swelling, impaired movement.
- teach client how to monitor extremity for signs of impaired circulation, infection, and tissue compromise.
- Apply pressure reducing sleeves, as prescribed, to extremities.
- Encourage elevation of extremities or body parts to promote drainage of fluid back to body via gravity.
- Administer diuretics, as ordered.
- Consult with trained therapists to perform manual lymphatic drainage.
- Avoid tourniquets, blood pressure cuffs on affected extremity after lymph node removal.
- Encourage client to talk about feelings related to appearance of extremities.
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