Mastectomy Nursing Care Plan
Breast removal care addressing drains, lymphedema prevention, arm exercises and body image.
Quick answer
A Mastectomy nursing care plan centers on monitor the incision, flap viability and drain output; prevent and detect lymphedema early; restore shoulder range of motion progressively. Priority nursing diagnoses are Disturbed body image, Acute pain, Impaired physical mobility, Risk for infection. The plan below gives assessment cues, measurable goals, 3 intervention sets with rationales, and patient teaching.
Overview
Mastectomy is surgical removal of breast tissue for cancer or high genetic risk. It ranges from simple (total) mastectomy to modified radical mastectomy with axillary node dissection, and may be combined with sentinel node biopsy or immediate reconstruction.
Removing axillary lymph nodes disrupts lymph drainage, creating a lifelong risk of lymphedema and restricting how the affected arm may be used for blood pressure, venipuncture and injections. Nerve involvement can also cause numbness along the inner arm.
Nursing care balances physical recovery — drains, seroma, shoulder mobility — with the profound body image, sexuality and mortality concerns that accompany breast loss.
Key numbers to know
Affected arm rule
No blood pressure, venipuncture or injections in the arm on the surgical side after node dissection.
Drains
Jackson-Pratt drains stay until output falls below about 30 mL per 24 hours for two consecutive days.
Positioning
Elevate the affected arm on a pillow to promote lymph drainage and reduce swelling.
Exercise
Begin hand and elbow movement early; progress to shoulder abduction and external rotation as the surgeon permits.
Nursing priorities
- Monitor the incision, flap viability and drain output.
- Prevent and detect lymphedema early.
- Restore shoulder range of motion progressively.
- Manage pain and phantom or neuropathic sensations.
- Support body image, grief and partner communication.
Nursing assessment
Subjective data
- Reports of incisional pain, tightness or arm heaviness
- Expressions of loss, fear of recurrence or altered attractiveness
- Reports of numbness or tingling along the inner arm
- Questions about reconstruction, prostheses and returning to activity
Objective data
- Incision and skin-flap color, drainage and approximation
- Drain volume, color and patency
- Circumference measurements of both arms for early lymphedema
- Shoulder range of motion and grip strength
- Signs of infection: fever, spreading erythema, purulence
Related factors
- Surgical removal of breast tissue and lymph nodes
- Disrupted lymphatic drainage
- Nerve transection during dissection
- Loss of a body part associated with identity and sexuality
Key nursing diagnoses
Goals and expected outcomes
- The client will maintain intact skin flaps and remain free from infection.
- The client will regain functional shoulder range of motion.
- The client will remain free from lymphedema or report it early.
- The client will express feelings about the change in body appearance.
Nursing interventions and rationales
Wound and drain care
- Assess flaps for pallor, duskiness or excessive drainage each shift.
- Strip and empty drains as ordered, recording output and teaching the patient to do the same.
- Support the arm on a pillow with the elbow above the wrist.
- Report fever, foul drainage or a rapidly enlarging fluid collection.
Lymphedema prevention
- Post a sign and inform staff: no BP, needlesticks or IVs in the affected arm.
- Teach avoidance of tight sleeves, jewelry, heavy lifting and cuts or burns on that side.
- Measure arm circumference at set points and compare with the other side.
- Refer to lymphedema therapy for sleeves or manual drainage if swelling appears.
Mobility and psychosocial support
- Start hand-squeezing and elbow flexion on day one; add wall-climbing and pulley exercises when cleared.
- Provide analgesia before exercise sessions.
- Encourage the patient to view the incision when ready and to voice fears.
- Discuss prosthesis fitting, reconstruction options and survivor support groups.
Patient and family teaching
- Demonstrate drain care, measurement and recording before discharge.
- Review the lifelong affected-arm precautions and skin protection.
- Teach the prescribed exercise progression and when to advance.
- Emphasize follow-up imaging, oncology appointments and self-examination of the remaining breast.
How to build this plan
- 1Assess the patient. Collect subjective and objective data through interview, physical assessment, labs and chart review. Complete, accurate data is the foundation of every later step.
- 2Analyze and cluster the data. Group related cues, compare them with normal findings, and identify patterns that point to actual or potential problems.
- 3Formulate nursing diagnoses. Write the problem statement using a recognized diagnostic label plus related factors and evidence (problem related to cause as evidenced by signs).
- 4Set priorities. Rank diagnoses as high, medium or low using ABCs, Maslow's hierarchy and the patient's own stated priorities. Life-threatening problems come first.
- 5Establish goals and outcomes. Write SMART, patient-centered outcomes: specific, measurable, attainable, realistic and time-bound (short-term and long-term).
- 6Select nursing interventions. Choose independent, dependent and collaborative actions that are safe, evidence-based and matched to the outcome.
- 7Provide rationales. State the scientific reason each intervention works. Rationales are what turn a task list into clinical reasoning.
- 8Evaluate the plan. Compare the patient's actual response with the expected outcome: met, partially met or not met — then continue, revise or discontinue.
- 9Document and communicate. Record the plan and the patient's response in the health record so the whole team works from the same information.
Summarized for study use. Always follow your school's or facility's approved care plan format and current clinical policy.
Practice Mastectomy questions
These concepts are tested on the ATI proctored exams below — every set has answers and rationales.
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Care plan writing guides
Common questions
What are the nursing diagnoses for Mastectomy?
Priority nursing diagnoses for Mastectomy: Disturbed body image; Acute pain; Impaired physical mobility; Risk for infection.
What are the nursing interventions for Mastectomy?
Assess flaps for pallor, duskiness or excessive drainage each shift. Strip and empty drains as ordered, recording output and teaching the patient to do the same. Support the arm on a pillow with the elbow above the wrist. Report fever, foul drainage or a rapidly enlarging fluid collection. Post a sign and inform staff: no BP, needlesticks or IVs in the affected arm. Teach avoidance of tight sleeves, jewelry, heavy lifting and cuts or burns on that side.
What are the nursing care goals for Mastectomy?
The client will maintain intact skin flaps and remain free from infection. The client will regain functional shoulder range of motion. The client will remain free from lymphedema or report it early. The client will express feelings about the change in body appearance.
What should you assess in a patient with Mastectomy?
Reports of incisional pain, tightness or arm heaviness; Expressions of loss, fear of recurrence or altered attractiveness; Reports of numbness or tingling along the inner arm; Questions about reconstruction, prostheses and returning to activity; Incision and skin-flap color, drainage and approximation; Drain volume, color and patency; Circumference measurements of both arms for early lymphedema; Shoulder range of motion and grip strength; Signs of infection: fever, spreading erythema, purulence
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