INTRODUCTION:

Breast cancer treatment related post mastectomy lymphedema is a chronic progressive condition with swelling of the arm after surgery due to removal or damage to lymphnodes. Interrupts and blocks lymphatic outflow channels allowing fluid to build-up and eventually swelling on the affected arm or side.¹

The incidence varies (2-74%) across patients based on individual characteristics and type of treatment their undergo. In most cases (88-93%) lymphedema develops in the arm, while 14-27% in trunk and or breast.² One the biggest challenges is the uncertainty of its occurrence and its progressive nature makes it arduous to treat.³ Most often treatment involves multiple measures to manage, which adds up to medical costs. Thus, patients incur higher financial burden compared to those without lymphedema. There are no clear guidelines as of when to start the treatment and which management will be beneficial for each patient.⁴ Therefore, it is essential for patients to be aware of risk factors and steps to prevent it. Nurses catering for breast cancer surgery patients can play a pivotal role in effectively managing the condition by health educating high risk groups and applying current evidence-based practices in the clinical area.

Risk factors and Symptom burden:

Most notable influencing factor associated with lymphedema is axillary lymph nodes dissection (30-50%) others such as prolonged or high-volume seroma, taxane based chemotherapy, radiotherapy to axilla and skin necrosis after radiation.⁵ Obesity ≥30kg/m², tumor size >5cm, duration of axillary drainage, wound infections, limb overuse, history of lymphangitis, advanced age and low education level.⁶ Although it occurs any time postoperatively, the risk peaks 12-30 months after surgery.⁷ The symptom burden experienced by patients affects all aspects of well-being. Physical symptoms - swelling, heaviness, tightness, difficult to move arms, numbness, tingling, aching pain, arm weakness, diminished muscle strength, skin breakdown and infections.⁸ Psychological- anxiety, fear, depression, low body image and self-esteem due to marked changes in physical appearances, social stigma and isolation. Functional- difficult to cope up with roles and responsibilities, daily routines and self-care activities. Economic burden due to administration of various therapies for lymphedema.⁹

Recommendations for Risk Reduction:

Prospective Surveillance:

Regular assessment of patients before and after a breast cancer surgery is crucial for identifying patients at risk at the earliest and effectively manage before the condition becomes clinically evident and progresses to chronic stage. It also enhances patient outcomes in terms of pain reduction, functional mobility and wellbeing^10,11. Pre-operative evaluation of the patient by nurses importantly for any changes in the arms, breast and trunk on the side, range of motion, level of function, volume (at-least 3% increase in the affected arm indicates subclinical lymphedema), arm circumference tape measurement (10cm above and below on the olecranon/lateral epicondyle)^12,13. Strength, body weight, function fatigue, level of physical activity and exercises, prior physical impairments and co-morbidities to be noted to establish baseline¹⁴. Post-operatively the patient must be re-assessed and observed for signs of lymphedema in the follow-ups. Prospective surveillance at-least three assessments with initial post mastectomy lymphedema management reduces risk for chronic lymphedema. The surveillance is more beneficial for patients in high-risk groups.¹⁵

Patient Education:

Post mastectomy patients who are aware about lymphedema have shorter diagnostic delay compared to uninformed patients. Patient education and awareness on the early signs of lymphedema accelerates early detection and effective management with lower lymphedema stage and fewer infection rates¹⁴. Studies have indicated that post mastectomy patients have poor knowledge on symptoms and prevention of arm lymphedema, hence it is recommended that a pre-discharge patient education session will empower and reduce risk behaviors¹⁶. Nurses must educate patients on safe self-care practices such as care of skin and nails, prevent skin breakdown on the affected arm, muscle strain, elevate arm, arm exercises and wearing well-fitted compression garments, identifying warning signs such as swelling, tightness, heaviness and aching in the affected area, difficulty moving the arm, tight clothing/jewelry, pitting of skin when gentle pressure is applied^13,16,17. Wearing gloves during household activities, use repellent as needed, wearing loose jewelry and clothes without tight bands and elastic is advisable, avoid carrying handbags or other items on the affected arm, staying hydrated, avoiding extreme exposure to heat and sun. Keep skin clean and moisturized, Use sunscreen and wear long sleeved clothing during outdoors. Avoid blood pressure measurements and needle pricks on affected arm¹⁸.

Arm Elevation:

Elevation of the arms above heart level for 45 minutes several times a day allows gravity drain lymphatic fluid and reduces swelling. The affected arm should be supported and elevated using pillows^4,19. Elevate arm with shoulder positioned at appropriate angles (no more than 65 degrees of flexion, 45-65 degrees of abduction, 45-60 degrees of internal rotation) and forearm resting on wedge or pillow²⁰. Studies have reported short term benefits with arm elevation. Early lymphedema (stage 1) subsides with elevation as they are mild form, soft and pits with no dermal fibrosis. However later stages of lymphedema do not reduce swelling with elevation and requires additional treatments²¹. Nurses must emphasize to patients on arm positioning and elevation after surgery.

Arm Exercises:

Incorporating lymphedema exercises can be of great help for patients after a mastectomy. When exercising the muscles in body act like a pump to lymphatic vessels and moves fluid out of the swollen area. It is important to start slow, gentle with low-impact exercises for 10-20 minutes a day this allows lymphatic system adapt to physical activity and avoids lymphedema exacerbation. Wearing an elastic bandage or compression garments when exercising is effective.^22,23

Deep breaths:

Place hands on the belly and gently press inward, while taking a deep breath. Slowly breathe out and feel the belly expand. Repeat the exercise 4-5 times

Neck Rotations:

Stand straight and look over the shoulder to the right and then back. Then, look over the shoulder to the left and come back. Repeat 8-10 times each direction. The exercise gently activates head and neck lymphnodes.

Shoulder rolls:

Bring shoulders up toward the ears and roll them back down. Continue to move shoulders in a circular motion. Switch the direction of the movement and repeat 8-10 times in each direction.

Shoulder Circles:

Lift one of the arms up and move it in large circles up and over the head. Do the circles in different directions and switch the arms. Repeat 8-10 times on both sides. If feeling pain or tightness do the circles smaller as tolerable.

Shoulder Retraction:

Squeeze the shoulder blades together and then extend arms out in-front of you. Move back and forth squeezing shoulder blades together and then extending the arms. Repeat 8-10 times, the exercise opens up the chest and allows the shoulders to stretch.²⁴

Elbow Bends:

With palm facing up-ward bend the arm at the elbow, aiming to touch the shoulder. Go back to the start position, repeat 8-10 times with each arm.

Wrist rotation:

Rotate wrist back and forth, can bend at the elbows or exercise with straight arms. The exercise stimulates forearms, repeat 8-10 times.

Grip squeeze/Finger bend:

Squeeze the fist and then open the hand, straightening out the fingers. If fingers are swollen perform motion as tolerated. Repeat 8-10 times.

Finger stretch: Place forearm on a flat surface (table/lap), slowly spread fingers apart then bring them back together. Repeat 8-10 times in each arm [25].

Compression sleeves:

Wearing a compression sleeve exerts pressure on the affected area and moves accumulated fluids through lymphatic channels, drains the excess lymph reducing swelling and pain. Day time or a night time sleeves either of them are available as ready-made or custom made to individual measurements. The sleeves are tighter at the bottom than at the top that creates a graded pressure to facilitate lymph flow up-wards and out of the arm. Sleeves apply resting pressure (pressure is high when the arm is at rest), they range from low to high pressure sleeves classified from class 1 to class 4. The sleeves can exert pressure as less as 15 mmHg to as high as 60 mmHg depending on their class. Severe lymphedema requires class 3 or 4 sleeves and milder cases require class 1 or 2 sleeves. A day time sleeve should be worn at day time, even while exercising and taken off at night, be cautioned not to wear while sleeping as the compression can be too high and hurt the arm²⁶. Study has reported that prophylactic use of compression sleeves reduces arm swelling in women with high risk for mastectomy related lymphedema²⁷ The nurse should emphasize on the importance and use of compression sleeves, ensure the sleeves fit properly without any loose areas covering the entire arm. Causing no discomfort, numbness, tingling or pain allowing the arm move freely. Instruct to remove the sleeves if symptoms develop and consult. Put the sleeves as a first thing in the morning, pulling it over the hand and easing it up-ward. Do not roll sleeve at the top while wearing it, as this will restrict blood flow and cause more swelling. Do not wear if the skin is fragile, damaged, pitted or cellulitis. Avoid using moisturizer before wearing sleeves and replace every 3-6 months.²⁸

Simple Lymphatic Drainage (SLD) Techniques:

SLD is a massage technique to allow lymphatic fluid move away from the congested areas towards healthy lymphnodes for effective drainage. The massage uses light pressure and rhythmic strokes to increase the flow of lymph. It is done daily for several weeks depending on severity of the symptoms. The techniques are suitable to be performed by the individual at home. Nurses can perform the massage and also teach patients the techniques^29,30. Gently massage on bare skin, do not use moisturizes or oils. With each movement, hand should be in contact with the skin. Stretch the skin and release so the skin moves back. During massage there should be no skin reddening or pain, perform for 15-20 minutes daily. Always massage in upward direction towards the armpit and chest. Do not massage areas with infection. If underwent recent radiotherapy, wait for 6 weeks before start massaging the area^{4,14,18, 30,31}.

Steps in Upper Limb Lymphatic Drainage:

Step 1: Breathing – start with deep breathing, sit with shoulders relaxed and hands placed over the abdomen. Take a deep breath and feel the stomach rising, breathe out slowly and gently press inwards with hands. Repeat for 5 times.

Step 2:

Specific exercises (10 times each both sides)

Neck: Look up, then down, left then right (5 times)

Arms:

Reach up and out then cross arm over the stomach.

Elbows: Bend and straighten

Wrists: Move up and down

Hands: Open and close fist

Step 3:

Neck – Place hands on both sides of the neck below the ears. Gently stroke the skin down towards the collar bones and release. Repeat the movements 10 times.

Step 4:

Collar bones – Place the index finger above and middle finger below the collarbones (collarbones lie between these two fingers). Gently push downwards and release. Repeat 10 times both sides.

Step 5: Armpit – Place hand in armpit, massage upwards into armpit and release (ensure the direction is always upward). Repeat 10 times both sides

Step 6: Chest (unaffected side) – Place hand over unaffected side of chest, gently stroke across the skin towards unaffected armpit (always stroke into armpit) and repeat 10 times.

Step 7: Chest (central) – Place hand on the center of the chest, stroke the skin towards unaffected armpit. Always stroke into armpit and repeat 10 times

Step 8: Chest (affected side) – Place hand on the affected side of chest, stroke across the skin towards unaffected armpit (to clear armpit). Repeat 10 times

Step 9: Back (with help) – Sit comfortably, the helper places hand on unaffected armpit and massages upwards into the armpit and then releases. Ensuring upward direction and repeat 10 times

Step 10: Back 1(with help) – helper places hands on unaffected side of the back, strokes the skin across into unaffected armpit and then releases. Repeat 10 times

Step 11: Back 2(with help) - helper places hands on the middle of the back, strokes the skin across into unaffected armpit and then releases.

Step 12: Back 3(with help) - helper places hands on the affected side of the back, strokes the skin across into unaffected armpit and then releases. Repeat 10 times.

Finishing SLD:

Step 13: Repeat step 2 – specific exercises

Step 14: Repeat step 1 – Breathing exercises for 5 times^31,32,33.

Balanced Diet and Weight Management:

Obesity plays a crucial role in lymphedema progression by exerting pressure on lymphatic vessels. Studies have reported that high body mass index has been correlated with lymphedema onset and reducing weight through calorie restriction and healthy diet patterns has proven to improve lymphedema related symptoms^34,35. There is no special diet that will reduce or cure lymphedema, however a healthy diet prevents extra weight gain and strain on lymphatic system to move fluids in the body³⁶. Nurses must educate on consuming healthy diet that helps manage lymphedema. Proteins are essential in diet, taking less proteins causes fluid seep from bloodstream into tissues making lymphedema worse. Diet recommended are lean meats such as fish, poultry, eggs, lentils, legumes. Healthy fats in foods such as olive oil, seeds, nuts, avocado, fatty fish, yoghurt, cheese. Fruits and vegetables like apples, oranges, berries, grapes, carrots, beans, broccoli, green leafy vegetables spinach and kale. Avoid sugary, caffeinated drinks, alcohol as they cause dehydration and weight gain. Limit salt intake. Drink plenty of water at-least 2 liters/day, hydration is important as it helps lymphatic system function well^37,38.

CONCLUSION:

Lymphedema a long-term complication post mastectomy is a challenging chronic condition due to its unpredictability and often demands various treatment strategies to manage the condition. Therefore, it is essential that healthcare providers focus on high-risk groups to monitor and educate patients on lymphedema. Nurses caring for patients can apply evidence-based practices in collaboration with other health care professionals to effectively manage lymphedema and create awareness on self-care practices.

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Received on 10.05.2025 Revised on 14.06.2025

Accepted on 11.07.2025 Published on 16.08.2025

Available online from August 25, 2025

Int. J. Nursing Education and Research. 2025;13(3):187-192.

DOI: 10.52711/2454-2660.2025.00039

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