Mastectomy Nursing Care Plans

Your mastectomy patient comes back from the OR with a drain or two, a pressure dressing, and an arm you have to protect for the rest of their life. The affected side is now off-limits for blood pressures, blood draws, injections, and IVs, because a compromised lymphatic system turns a small injury into lymphedema. Beyond the wound, you are managing pain, phantom breast sensations, and a person looking at a changed body for the first time.

Mastectomy is the surgical removal of one or both breasts, partially or completely, to treat or prevent breast cancer. The common procedures are total (simple) mastectomy (breast tissue and nipple), modified radical mastectomy (the breast, most of the axillary lymph nodes, and often the lining over the chest muscles), and lumpectomy (the tumor plus a margin of normal tissue). Radiation is often combined with surgery.

Nursing Problem Priorities

1. Promote wound healing and prevent infection
2. Manage pain and discomfort
3. Support body image and emotional adjustment
4. Restore arm mobility and prevent lymphedema
5. Teach self-care and discharge management
6. Connect the patient with support groups and counseling

Nursing Assessment

Assess for:

• Pain or discomfort at the surgical site
• Anxiety, fear, or emotional distress about the surgery or changed body image
• Fatigue or difficulty performing activities of daily living
• Questions about wound healing, drainage, signs of infection, or followup care
• Surgical incision(s) and drains; redness, swelling, or drainage at the wound
• Vital signs, including temperature, heart rate, and blood pressure
• Tenderness, hardness, or abnormal masses on palpation of the site
• Range of motion and ability to perform self-care
• Stiffness or numbness in the chest, shoulder, or arm; reluctance to move the affected arm
• Limited ROM, decreased muscle mass or strength, altered skin elasticity and sensation

Nursing Goals

The patient acknowledges and discusses their concerns, reports fear and anxiety reduced to a manageable level, and moves toward accepting the change without losing self-esteem. The wound heals on schedule, free of purulent drainage, erythema, or infection. Pain and discomfort drop to a tolerable level, and the patient rests and sleeps adequately. The patient regains strength and an effective range of motion in the affected arm, demonstrates the exercises and self-care needed to prevent complications, and verbalizes the disease process, lifestyle changes, and followup care.

Nursing Interventions and Actions

1. Reducing Fear and Anxiety

Fear here is specific and namable: death, pain, disfigurement, the partner's reaction. Let the patient point at it and you can work with it.

Assess the patient's fear and how they are coping with it. Shows whether their coping strategies are working.

Document verbal and nonverbal expressions of fear, and compare the two. Physiologic complaints intensify as fear rises, and mismatches reveal misperceptions of the situation.

Ask directly what they are afraid of. A patient who cannot say "I'm afraid" may still take the opening later if they know someone will listen.

Gauge how much the fear is blocking ADLs. Persistent, immobilizing fear may need anti-anxiety medication.

Keep a calm, steady manner and provide continuity of care. Stability and an ongoing relationship build the trust needed to talk about fear.

As the fear eases, have the patient trace the events that set it off. Naming the triggers opens up alternative responses.

Find out what the patient already knows about the diagnosis, planned surgery, and future therapy, and note denial or extreme anxiety. Gives you a base to reinforce and flags who needs extra attention. Brief denial can be a useful coping method; extreme anxiety needs handling now.

Give the patient and their support person time and privacy together, present as much as possible. They need room to discuss anticipated loss and other concerns, supported by open questions and active listening.

Invite questions and let the patient express fear. Warn that breast-cancer stress can run for many months, and to seek help and support. Clarifies misconceptions and offers emotional support.

Assess available support and offer resources such as Reach to Recovery and the YWCA Encore program. Arrange a visit from a woman who has recovered from a mastectomy. A peer who has been through it models recovery and a normal future.

Factor rehabilitation into the plan from the start. Rehab addresses the physical, social, emotional, and vocational needs that bring the patient back to function.

2. Wound Care, Drains, and Infection Control

The incision breaks the skin barrier and opens a door for infection, and the surgery's manipulation of blood vessels and lymphatics means drainage you have to track.

Assess the incision for size, color, temperature, texture, and drainage, and inspect surrounding skin for erythema, induration, and maceration. Gives baseline data and the extent of involvement.

Inspect the wound daily for swelling, unusual drainage, odor, redness, or separation of the suture line. Infection shows as inflammation and stalled healing.

Inspect dressings front and back for drainage, and monitor edema, redness, and pain at the incision. Apply pressure dressings first and reinforce them rather than change them. Drainage follows the trauma of surgery and the many blood vessels and lymphatics disturbed in the area.

Check wound drains for amount and character of drainage, and empty and re-establish negative pressure at least once per shift. Suction devices (Hemovac, Jackson-Pratt) hold negative pressure in the wound and are usually pulled around the third day or when drainage ceases. Draining lymph and blood speeds healing and cuts infection risk.

If a graft was done, watch the graft and donor sites for color, blister formation, and drainage. Color tracks the circulatory supply; blisters invite bacterial growth.

Keep the wound clean and dry, dress it with aseptic technique, and dispose of soiled dressings properly. Stress handwashing. Handwashing is the single most effective way to prevent infection and cross-contamination.

Position the patient in semi-Fowler's on the back or unaffected side, and do not let the affected arm dangle. Gravity drains the fluid.

Monitor temperature, and report fever, sore throat, swelling, increasing pain, or drainage. Early recognition lets treatment start fast.

Push protein, calories, and vitamin C, and ensure rest and early ambulation. Nutrition and circulation drive wound healing.

Keep blood pressures, injections, and IVs off the affected arm, and have the patient skip a wristwatch, jewelry, and tight clothing on that side. Constriction raises the risk of infection and lymphedema on the compromised side.

Give antibiotics as ordered. For prophylaxis or treatment of a specific infection.

3. Managing Acute Pain

Assess pain and stiffness for location, duration, and intensity on a 0 to 10 scale, and note numbness, swelling, and verbal and nonverbal cues. The amount of tissue, muscle, and lymphatics removed drives the pain. Nerve destruction in the axilla causes upper-arm and scapular numbness that can be worse than the incision itself, and chest-wall pain can linger for months.

Explain that phantom breast sensations are real and treatable. Reassures the patient the sensations are not imaginary.

Help the patient find a position of comfort. Arm elevation, dressing size, and drains all affect their ability to rest and sleep.

Splint the chest during coughing and deep breathing, and offer back rubs, repositioning, early ambulation, relaxation, guided imagery, and therapeutic touch. Refocuses attention and builds coping.

Give pain medication on a schedule, before pain is severe and before activity. Steady comfort lets the patient exercise the arm and ambulate without pain hindering them.

Administer narcotics or analgesics as ordered. Relieves pain and supports rest and participation in postoperative therapy.

4. Supporting Body Image, Sexuality, and Grief

Losing a breast hits body image, sexuality, and identity at once. Expect grief, and expect it to resurface later at a prosthesis fitting or reconstruction.

Encourage questions about the present and the future, and stay present when the surgical dressing comes off. The first sight of the scar brings fear of disfigurement and of the partner's reaction.

Have the patient name their roles (partner, mother, professional) and voice anger, hostility, and grief. Reveals how their self-view has shifted, and grief has to be worked through before they can plan ahead.

Watch for depression and name it openly with the patient and support person. A common reaction that has to be acknowledged before it can be treated.

Reinforce gains and participation in self-care and treatment. Sustains healthy behavior.

Review reconstruction and prosthetic options. Reconstruction can give near-normal results and is sometimes done during the mastectomy; when delayed, it may wait 3 to 6 months, and a long delay can strain relationships and slow the patient's adjustment. Offer a temporary soft prosthesis of nylon and Dacron fluff, worn in a bra until the incision heals, to ease body-image distress at discharge.

Ask the partner about their feelings and sexual concerns, and give them information and support. A partner's withdrawal often reflects fear of hurting the patient, fear of cancer or death, or difficulty looking at the operative area, not rejection.

Suggest sexual positions that avoid chest-wall pressure, and alternatives such as cuddling and touching while the area is tender. Restores a sense of intimacy and ability to resume sexual activity.

Refer to support groups, including Men in Our Lives for partners. Peers who have lived it exchange concerns and show how a partner can help.

For grief: note the stage, meet with the couple together, and have them draw on coping skills that worked before. Stay present and ensure privacy during emotional moments, validate that anger and sadness are normal, and encourage sharing with another breast-cancer survivor. Do not substitute sedatives or tranquilizers for your time. Numbing the mind blocks grieving. Refer to counseling, psychotherapy, spiritual support, or a grief group as the meaning of the loss requires.

5. Restoring Arm Mobility and Preventing Lymphedema

The lymphatic system on the affected side is compromised, so the arm swells easily and stiffens fast. Move it early, elevate it, and protect it.

Do a routine assessment of the involved arm. Elevate the hand and arm with the shoulder at no more than 65 degrees of flexion, 45 to 65 degrees of abduction, and 45 to 60 degrees of internal rotation, forearm resting on a wedge or pillow. Elevation drains fluid and limits edema. Lymphedema is present in about 25% of patients and may appear right after surgery or years later.

Measure the upper arm and forearm if edema develops. Tracks progression and may mean holding off on advancing exercises until further healing.

Start passive ROM (elbow flexion and extension, wrist pronation and supination, finger clenching) within the first 24 hours. Early movement prevents the joint stiffness that limits mobility.

Have the patient move the fingers, and watch sensation and hand color. Lost movement points to intercostal brachial nerve trouble; discoloration means impaired circulation.

Have the patient use the affected arm for hygiene (feeding, combing hair, washing the face). Builds circulation, strength, and function without the abduction that stresses the early suture line.

Assist with ambulation and correct posture. The patient feels unbalanced at first, and a straight back keeps the shoulder from rolling forward and locking.

Advance to active arm extension and shoulder rotation in bed, pendulum swings, rope turning, and reaching fingertips behind the head. Progress to wall climbing with the fingers, clasping hands behind the head, and full abduction once healing is well established. The later exercises strain the incision, so they wait until the wound is solid.

Teach slow, deep breathing during exercise. Contracting the abdominal muscles pushes fluid through the cisterna chyli and thoracic duct, creating a vacuum effect that enhances drainage.

Work the exercises into self-care, homemaking, and leisure such as swimming. Patients stick with a program that fits their life.

Teach the signs of shoulder tension (inability to hold posture, burning behind the scapula), and tell the patient not to hold the arm dependent for long stretches. Altered weight and support put tension on surrounding structures.

Maintain elastic bandages or custom pressure-gradient sleeves, and demonstrate intermittent sequential pumping or low-stretch compression garments for lymphedema. Promotes venous return and decreases edema.

Continue the exercises at home for at least a year. Builds collateral lymphatic channels, limits scarring, and keeps strength, but in moderation, since strenuous activity raises heart rate and temperature and can worsen edema.

Watch circulation: assess for pulmonary emboli, check the lower extremities for skin texture, edema, and ulceration, and encourage early ambulation. Ambulation enhances venous return, and early signs of emboli need catching.

Refer to physical or occupational therapy. Provides an individual exercise program and assesses work-related limits.

Give analgesics and diuretics as ordered. Diuretics treat and prevent fluid accumulation and lymphedema.

6. Breathing and Activity Tolerance

Anesthesia depresses respiration, and postoperative weakness saps the energy for daily activity.

Use pulse oximetry to track oxygen saturation and pulse, and monitor vital capacity in patients with neuromuscular weakness. Catches early changes in oxygenation.

Have the patient deep breathe during waking hours or use an incentive spirometer, splinting the incision to ease discomfort. Distends the alveoli and improves gas diffusion; pain or fear of pain otherwise blocks deep breathing.

Give oxygen as prescribed, and have the patient self-dose analgesia before deep breathing and coughing if a patient-controlled analgesia pump is available. Pain is controlled better before it becomes severe.

Assess mobility and nutritional status before setting activity goals. You need energy reserves and a realistic baseline to set reachable goals.

Provide a quiet environment, stress management, and rest periods between activities, and relieve pain. Conserves energy for recovery.

Teach the support person to monitor the response to activity and recognize warning signs. Heads off fatigue and overexertion.

Encourage a positive attitude and relaxation techniques such as visualization or guided imagery. Enhances a sense of wellbeing.

7. Promoting Safety and Preventing Injury

Assess mood, coping, and personality style. Some traits lead to carelessness and risk-taking.

Put safety devices and a safe environment in place, and assist with ambulation when balance is off. Supports the patient if they lose balance.

Encourage self-help programs such as assertiveness training and positive self-image work. Builds self-esteem and sense of self-worth.

8. Patient Education and Discharge

Patients go home sooner and sicker, often with drains still in. Teach to that reality, and confirm they can manage it.

Have the patient demonstrate care of drains and wound sites. Shorter stays mean discharge with drains in place; drains may come out 7 to 10 days after surgery.

Teach the signs that need medical evaluation: a red, warm, swollen breast or arm, edema, purulent wound drainage, fever, or chills. Lymphangitis from infection drives lymphedema.

Review the disease process, surgery, and what comes next, including radiation and chemotherapy. Lets the patient make informed choices.

Protect the affected arm: long sleeves and gloves for gardening, a thimble for sewing, potholders for hot items, gloves for dishes, no heavy lifting, and no purse, jewelry, or wristwatch on that side. Keep blood draws, IVs, injections, and blood pressures off it, and recommend a medical-alert device. A compromised lymphatic system makes any injury a lymphedema risk, and an alert device prevents accidental trauma in an emergency.

Teach the patient to hold the arm correctly: not dangling, elbows bent when walking, and arm above heart level when sitting or lying down. Prevents lymphedema and frozen shoulder.

Suggest gentle massage of the healed incision with emollients. Stimulates circulation, keeps the skin elastic, and reduces phantom breast sensations.

Stress well-balanced, nutritious meals, adequate fluids, and alternating rest and activity, especially when sitting or standing is prolonged. Supports healing and circulating volume and limits fatigue. An arm left dangling and extended stresses the affected structures.

Teach regular self-exam of the remaining breast, and set the recommended mammography schedule. Catches recurrence or a new tumor early.

Stress regular medical followup, and review ongoing therapies and side effects. Tamoxifen (Nolvadex) often follows surgery and radiation and requires ongoing involvement in care.

For self-management, assess what could undermine adherence (perceived seriousness, confidence, ability to learn and perform the activity, finances), use therapeutic communication, reinforce effort, and involve the patient and support person in planning. Connect them with home- and community-based nursing services. These services handle followup care and education in the home, where the complex regimen actually plays out.

9. Pharmacologic Management

Analgesics (opioids or NSAIDs). Control pain before exercise so the patient participates fully and keeps the incentive to move.

Antibiotics. Given prophylactically or to treat a specific infection and support healing.

Diuretics. Treat and prevent fluid accumulation and lymphedema.