Question

While preparing to insert a peripheral IV line, the nurse notices scarring near the client's left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take?

Answer 1

The nurse should not use the arm on the side of the mastectomy for IV insertion, instead choosing a site on the opposite arm to prevent complications such as lymphedema. Following patient safety protocols and providing patient-centered care are essential in this context.

Step-by-step explanation:

When preparing to insert a peripheral IV line and noticing scarring near the client's left axilla with a history of left breast cancer and modified radical mastectomy, the nurse should take specific precautions. It is important not to use the affected side for an IV insertion due to the risks associated with lymphedema, which might compromise lymphatic drainage and increase the risk of infection. Instead, the nurse should choose a site on the opposite arm for the IV line insertion.

The best practices for the nurse in this situation include:

• Understanding the history of breast cancer surgeries and treatments the patient has had.
• Avoiding blood pressure measurements, blood draws, and IV insertions on the affected side to prevent complications such as lymphedema.
• Consulting with the healthcare team if there are concerns about the safety or viability of alternative IV sites.
• Maintaining clear communication with the patient regarding care and treatment, including the reasons for using the contralateral arm.

The nurse's actions show adherence to patient safety protocols and demonstrate patient-centered care.