A Review of the Literature
Related to Limb Precautions
After Lymph Node Dissection
L
Lynne Brophy, MSN, PMGT-BC, APRN-CNS, AOCN®, Andrea Bales, MSN, RN, CNL, OCN®, Julie K. Ziemann, MS, APRN-CNP, AOCNP®,
Kellie Navigato, RN, and Carlo Contreras, MD, FACS
BACKGROUND: Upper extremity limb precautions
are recommended for patients who undergo axillary
lymph node dissection (ALND) or sentinel lymph
node biopsy (SLNB) to lower the risk of lymph-
edema. Limb precautions involve avoiding use of
the affected arm for point-of-care testing, venipunc-
ture, and blood pressure measurement, all of which
can affect quality of life and create delays in care.
OBJECTIVES: This review provides a summary
of the evidence regarding limb precautions and
evidence-based interventions to lower the risk of
lymphedema after ALND or SLNB.
METHODS: A literature search was conducted
using CINAHL®; PubMed®; Education Resources
Information Center; History of Science, Technol-
ogy, and Medicine; Cochrane Library; and Joanna
Briggs Institute databases.
FINDINGS: Evidence supports exercising the
affected limb, maintaining a body mass index
of less than 25, and massaging to lower the risk
of lymphedema. There is limited evidence for
avoiding IV catheter placement and venipuncture
in the affected arm following ALND and SLNB.
Best practice is to assess the patient for risk factors
of lymphedema before recommending selected
evidence-based limb precautions.
KEYWORDS
lymphedema; limb precautions; lymph
node biopsy; lymph node dissection
DIGITAL OBJECT IDENTIFIER
10.1188/22.CJON.86-92
86 CLINICAL JOURNAL OF ONCOLOGY NURSING FEBRUARY 2022, VOL. 26, NO. 1
LIMB PRECAUTIONS ARE COMMONLY RECOMMENDED to prevent lymphedema,
particularly for selected breast cancer and melanoma survivors, and it is crit-
ical for nurses to consider how those precautions might affect survivorship
for these patients. Survival in these patient populations is increasing, with
five-year survival rates for all stages of breast cancer and melanoma having
increased to 84% and 93%, respectively (American Cancer Society, 2021).
Patients are often asked to follow limb precautions for the remainder of their
life, despite research findings indicating that upper extremity lymphedema
does not exert a significant effect on most patients’ functional status, which is
an aspect of health-related quality of life (Shaitelman et al., 2015). According
to the National Comprehensive Cancer Network (NCCN, 2021a, 2021b), axil-
lary lymph node dissection (ALND) or sentinel lymph node biopsy (SLNB)
is indicated for many patients with invasive breast cancer and melanoma to
stage their cancer, offer prognostic information, and guide treatment choices
(see Figure 1). These axillary operations can impair lymphatic flow, thereby
increasing the risk of lymphedema. SLNB reduces the risk of lymphedema
by about 5% as compared to 20%–30% following ALND (Asdourian et al.,
2016). Radiation therapy following surgery for breast and other cancers also
has the potential to increase the risk of secondary lymphedema if adminis-
tered to the operative nodal basin (Cormier et al., 2010; DiSipio et al., 2013).
More than 20% of women who undergo breast cancer surgery will develop
secondary lymphedema, with 70% of them developing lymphedema within
the first two years, and 90% developing lymphedema in the third year after
surgery. The risk declines to 1% incidence per year after three years postsur-
gery in women who develop lymphedema (Larocque & McDiarmid, 2019).
Women with and without factors associated with increased risk can develop
lymphedema, which may indicate the possibility of genetic predisposition
(Newman et al., 2012; Shaitelman et al., 2015).
Lymphedema has the potential to drastically affect the lives of cancer
survivors. Damage to (through radiation therapy) or resection of lymphatic
channels can result in blocked lymphatic flow, which, in turn, can lead to
lymphedema of the affected limb, causing decreased mobility, pain, altered
sensation, numbness, and altered appearance (Centers for Disease Control
and Prevention, 2021). Available treatments for lymphedema include exer-
cise, massage, compression devices and sleeves, and liposuction, as well as
surgical options, such as lymphovenous bypass, lymphedema excision, or
tissue transfer, but there is currently no cure for lymphedema (Chang et al.,
CJON.ONS.ORG
2018; Shaitelman et al., 2015). Often, patients at risk for devel-
oping lymphedema are advised to avoid invasive procedures, such
as venipunctures and placement of indwelling venous catheters
in the affected limb, to lower this risk. Patients are also encour-
aged to avoid noninvasive procedures, such as blood pressure
measurement, in the affected limb. These restrictions are typi-
cally organized as clinical practice policies and guidelines that
direct patient care at cancer centers across the country. The
result is strict avoidance of using the affected limb for invasive
and noninvasive procedures, including venipuncture, catheter
placement, point-of-care finger-stick testing, and blood pres-
sure measurement. Adherence to these restrictions can result in
delays of care or invasive procedures to establish vascular access,
as well as increased risk of infection and venous thromboembo-
lism, healthcare spending, and inconvenience to patients.
Traditionally, patients who undergo ALND have been advised
to avoid trauma in the affected limb to reduce the risk of devel-
oping lymphedema (Cemal et al., 2011; National Lymphedema
Network, 2012; Olsen et al., 2019; Shaitelman et al., 2015). Many
clinicians also advise patients who have undergone SLNB to do
the same, with the disclosure that the incidence of lymphedema
is lower following SLNB as compared to ALND. In Chemotherapy
and Immunotherapy Guidelines and Recommendations for Practice,
Olsen et al. (2019) recommend avoiding vascular access place-
ment in areas of “impaired circulation or lymph node drainage”
and note that “no definitive guidelines exist regarding venipunc-
ture . . . for patients who have had sentinel lymph node biopsy”
(p. 211). The National Lymphedema Network, a group of health
professionals including lymphedema therapists, physical ther-
apists, and occupational therapists with a scientific interest
in lymphedema, advises asymptomatic patients to take the
following precautions: maintain a normal body weight; have reg-
ular follow-ups with a medical provider and report any signs of
lymphedema; maintain proper skin hygiene, including treating
any episodes of cellulitis urgently; follow exercise recommenda-
tions; and wear compression garments during air travel according
to manufacturer’s recommendations (National Lymphedema
Network Medical Advisory Committee, 2011a, 2011b). Patients
are also encouraged to avoid trauma, excessive constriction, and
exposure of the affected limb to extreme cold or heat (National
Lymphedema Network, 2012). Many surgeons agree with these
precautions, and a multitude of websites, chat rooms, and other
resources caution cancer survivors about the risks of lymph-
edema, such as the National Cancer Institute, American Cancer
Society, and Susan G. Komen.
In 1992, the use of SLNB as a staging tool helped to lower the
risk of lymphedema in selected patients with breast cancer and
melanoma (Nieweg et al., 2015). As early as 1998, limb precautions
began to be questioned as a standard practice following all breast
surgeries. Witte and Witte (1998) stated that “with peripheral
lymphedema, rigid practice parameters and excessive warnings
CJON.ONS.ORG FEBRUARY 2022, VOL. 26, NO. 1 CLINICAL JOURNAL OF ONCOLOGY NURSING
may raise patient fears unduly over such minor events as taking
of blood pressure, blood drawing, and air travel and interfere
with medical surgical interventions” (p. 98). With the increased
interest in evidence-based practice, a new school of thought
has emerged. By eliminating limb precautions in asymptomatic
cancer survivors, use of the affected arm for venipuncture and
IV access allows nurses administering chemotherapy and other
IV medications to insert a peripheral or central vascular access
device for this purpose. Adhering to limb precautions when
access is unavailable in the unaffected arm often causes delays in
care for subcutaneous implantable port placement or other pro-
cedures to gain vascular access. In turn, central vascular access
device placement increases the costs and risks related to care,
including infection and venous thrombosis. This shift away from
empirical limb precaution recommendations has attracted atten-
tion on patient support websites, causing patient dissatisfaction
and raising questions about whether to follow limb precautions.
Nurses require best practice recommendations on how to advise
their patients regarding limb precautions. Therefore, the current
FIGURE 1.
GLOSSARY OF TERMS
AFFECTED LIMB
The affected limb is the limb in the same region or on the same side as the
area of lymph node resection and/or regional radiation therapy (i.e., if a
patient’s left axillary lymph nodes were resected, the affected limb would be
the left arm).
LYMPH NODE DISSECTION
Lymph node dissection and removal involves removing one or more of the
lymph nodes that a tumor drains to in a region after determining that they
contain cancer cells. Examples of lymph node dissection include axillary
lymph node dissection and neck or groin lymph node dissection for breast,
melanoma, head and neck, or another type of cancer.
SENTINEL LYMPH NODE BIOPSY
Sentinel lymph node biopsy is the process of identifying the key lymph
node(s) that tumor cells may have migrated to from a tumor in the breast or
other area and removal. The process begins with a surgeon injecting the pri-
mary tumor with a dye or radiopaque substance preoperatively, which travels
through the lymphatic channels that drain from the tumor site to an adjacent
area, such as the axilla. The surgeon identifies the lymph nodes in the adja-
cent area that contain the dye or radiopaque substance and removes those
lymph nodes. A rapid examination of these nodes is done by the pathologist
while the patient is still asleep. If the patient is found to have cancer in these
lymph nodes, then a lymph node dissection may be performed.
Note. Based on information from National Cancer Institute, n.d., 2019.
87
LIMB PRECAUTIONS
authors sought to discover what the evidence supports as best
practice for limb precautions.
The goal of evidence-based practice is to use the best evidence,
in combination with clinician expertise and patient preferences,
to guide care rather than relying on tradition. The avoidance of
invasive and noninvasive procedures, such as IV starts, venipunc-
ture, point-of-care testing, and blood pressure measurement in
the ipsilateral limb following ALND or SLNB, are examples of a
tradition of practice that has been taught for several generations
(Cemal et al., 2011; National Lymphedema Network, 2012; Olsen
et al., 2019; Shaitelman et al., 2015). The ONS Guidelines™ for
Cancer Treatment–Related Lymphedema offer evidence-based
management strategies but do not discuss venipuncture, point-
of-care testing, and noninvasive blood pressure monitoring in
cancer survivors who are at risk for lymphedema (Armer et al.,
2020). Best clinical practice requires a consistent policy regarding
invasive and noninvasive procedures in the ipsilateral limb after
SLND or ALND. This article summarizes the findings of a litera-
ture review that was conducted to determine the evidence for limb
precautions to prevent lymphedema after lymph node dissection.
Methods
Based on the search strategy and clinical appraisal guidelines
developed by Fineout-Overholt et al. (2010), a literature review
was conducted to evaluate the risk of lymphedema and the effects
of avoiding invasive and noninvasive procedures (including veni-
puncture, catheter placement, point-of-care finger-stick testing,
FIGURE 2.
PRISMA FLOW DIAGRAM
Articles identified through Articles identified through
database searching (n = 150) other sources (n = 3)
Articles after duplicates removed (n = 153)
Articles screened and
Articles excluded (n = 16)a
critically appraised (n = 54)
Articles included in
qualitative synthesis (N = 6)
a
38 articles remained after critical appraisal; of these, only 6 research articles were
identified and included in the qualitative synthesis.
PRISMA—Preferred Reporting Items for Systematic Reviews and Meta-Analyses
88 CLINICAL JOURNAL OF ONCOLOGY NURSING FEBRUARY 2022, VOL. 26, NO. 1
“Patients must be
evaluated individually
by providers and
nursing staff
to assess the need
for maintaining limb
precautions.”
and blood pressure measurement) in the affected limb, particu-
larly the arm, following ALND or SLNB for staging of any type
of cancer. Search terms included limb precautions, lymphedema,
prevention, axillary lymph node dissection, and sentinel lymph node
biopsy. The search was completed using the CINAHL®; PubMed®;
Education Resources Information Center; History of Science,
Technology, and Medicine; Cochrane Library; and Joanna Briggs
Institute databases. Articles were limited to those published
prior to July 2021. A total of six articles published from 1998 to
2021 were selected from the 153 articles identified and 54 articles
assessed (see Figure 2). It should be noted that no articles exam-
ining the use of upper extremity limb precautions in patients with
cancers other than breast were found.
Findings
The development of lymphedema may be related to several fac-
tors, including the type of surgery (ALND versus SLNB), age, the
type of chemotherapy received, body mass index, and the pres-
ence of infection and/or cellulitis (Ahn & Port, 2016; McLaughlin
et al., 2008; Parbhooa, 2006; Winge et al., 2010). A summary of
the study findings is presented in Table 1. In a study of 936 women
with breast cancer, McLaughlin et al. (2008) found that the risk of
lymphedema in women with breast cancer in the first five years
after surgery was 5% following SLNB as compared to 16% follow-
ing ALND. Ferguson et al. (2017) recommended that patients
with a history of cellulitis, a body mass index of 25 or higher, or
a history of ALND be monitored more closely because of their
increased risk of lymphedema. Similarly, Kilbreath et al. (2016)
noted that patients with breast cancer who had a high body mass
index, had more than five lymph nodes removed, underwent
ALND, or received a taxane-based treatment were at increased
risk of developing lymphedema. In a survey, Winge et al. (2010)
found that women aged older than 70 years were more likely to
report lymphedema following ANLD or SLNB.
CJON.ONS.ORG
 Several studies suggest that there may not be a correlation
between venipunctures and IV starts and the development of
lymphedema. Multiple studies have also reported that trauma
to the affected arm, including blood pressure measurement,
venipuncture, and IV catheter placement, does not have a sig-
nificant association with lymphedema (Cheng et al., 2013; Clark
et al., 2005; Ferguson et al., 2017; Hayes et al., 2005). Winge et
al. (2010) suggested that venipuncture for a simple blood draw
was less likely to cause adverse effects and lymphedema than
catheter placement with administration of IV fluids. In the study
by Kilbreath et al. (2016), patients who had more than four
TABLE 1.
SUMMARY OF SELECTED STUDIES (N = 6)
STUDY DESIGN AND METHODS
A prospective cohort study of 1,054 women with breast cancer
Bevilacqua et al., 2012
following ALND
A prospective observational study of 188 women with breast
Clark et al., 2005 cancer who had ALND or SLNB and underwent serial measurement
for lymphedema
A prospective cohort study of 632 women with breast cancer
Ferguson et al., 2017 following SLNB or ALND who underwent serial measurement for
lymphedema
A prospective cohort study of 176 women with breast cancer
Hayes et al., 2005
following ALND or no lymph node dissection
A prospective descriptive study of 214 women with breast cancer
Kilbreath et al., 2016
who underwent ALND or SLNB
A descriptive, retrospective survey study of 348 women who
Winge et al., 2010
underwent ALND
ALND—axillary lymph node dissection; BMI—body mass index; SLNB—sentinel lymph node biopsy
CJON.ONS.ORG FEBRUARY 2022, VOL. 26, NO. 1 CLINICAL JOURNAL OF ONCOLOGY NURSING
lymph nodes removed for breast cancer were not at significantly
increased risk of lymphedema following needle punctures to the
affected arm. According to Jakes and Twelves (2015), evidence
does not support universal restrictions of limb precautions when
venous access appeared to be adequate and there was no cur-
rent lymphedema. In addition, patients who were taught to be
continuously protective of their affected arm experienced a psy-
chological burden, unnecessary anxiety, and fear of developing
lymphedema (Cheng et al., 2013).
Despite evidence, professional guidelines generally sup-
port the avoidance of venipuncture and IV catheter placement
FINDINGS
Statistically significant risk factors predictive for lymphedema were
age, BMI, ipsilateral arm chemotherapy infusions, level of ALND,
location of radiation therapy field, development of postoperative
seroma, infection, and early postoperative lymphedema. Data were
used to develop a nomogram to predict risk of lymphedema.
Information on continuous IV infusion via cannula, venipuncture,
and finger-stick blood tests in the affected arm were collected.
20% percent of women developed lymphedema, and 80% of
lymphedema was diagnosed by 12 months after surgery. Statistically
significant risk factors included skin puncture, a BMI of more than
26, and mastectomy.
Statistically significant risk factors for lymphedema were a BMI of
more than 25, ALND, regional lymph node irradiation, and cellulitis.
Study findings did not support an association between ipsilateral
blood draws, injections, blood pressure readings, and air travel and
lymphedema.
Risk factors predictive for lymphedema were examined, and only
lymph node dissection on the side of the nondominant arm was
discovered with the variety of measurement techniques used. Injec-
tions and blood pressure did not increase the risk of lymphedema
via all 3 measures used, leading to inconclusive results.
Findings support greater incidence of lingering lymphedema in
patients who had had more than 5 lymph nodes removed and
demonstrated lymphedema throughout the first 18 months
following surgery. Taxane-based chemotherapy, radiation therapy,
high body weight at diagnosis, and/or arm swelling at 4 weeks
postsurgery were associated with an increased risk of lymphedema
in women at 18-months postsurgery.
A survey was administered to investigate the incidence of compli-
cations after blood sampling or IV medication administration in the
affected arm. Women in the study did not avoid venipuncture in the
affected arm unless vascular access was not possible in the unaf-
fected arm. Findings support that type of surgery, venipuncture,
and/or IV push medications are not associated with patient reports
of complications, including lymphedema. Patients older than age
70 years were more likely to report lymphedema. The survey did not
gather BMI data or information on the type of medications or infu-
sion given in the affected arm or ask whether the patient underwent
radiation therapy following surgery.
89
LIMB PRECAUTIONS
in the affected limb to prevent lymphedema. The National
Lymphedema Network recommends avoiding use of the affected
arm (McLaughlin et al., 2013). Gorski et al. (2016) also sug-
gest avoiding venipuncture and IV catheter placement despite
conflicting evidence, and Jakes and Twelves (2015) encourage
this same recommendation unless it is a medical emergency. A
description of the nursing practice standard at Royal Marsden
Hospital in the United Kingdom (Cole, 2006) states that there
is insufficient evidence to support avoidance of venipuncture
following ALND as a form of lymphedema prevention, cites the
need for further research, and recognizes that the affected limb
may be used for invasive procedures after assessment of risks
and benefits. Cole (2006) recommends considering some risks,
including obesity, time since ALND, and radiation therapy to the
axilla, which are supported by current research (Clark et al., 2005;
Ferguson et al., 2017; Hayes et al., 2005; Kilbreath et al., 2016).
Discussion
Evidence to recommend upper extremity limb precautions for all
cancer survivors who have undergone ALND or SLNB, have no
risk factors for lymphedema, and show no signs of lymphedema
is insufficient. The evidence to clearly delineate the rationale for
each individual limb precaution recommendation is also lacking.
In general, the recommendation that skin puncture be avoided
seems to stem from speculation during a time when antibiotics
were not used, and infection was the predominant cause of breast
cancer–related lymphedema (Cheng et al., 2013). Most studies
during the past 60 years agree that the extent of axillary dissec-
tion correlated to the degree and incidence of lymphedema in the
affected arm (Loudon & Petrek, 2000). However, specific high-
level evidence to support the implementation of limb precautions
is not available because the majority of the literature reviewed
was descriptive. The literature search completed by the current
authors also revealed that multiple studies disagree on exactly
FIGURE 3.
REASONS TO AVOID VENI- OR VASCULAR
PUNCTURE IN THE AFFECTED LIMB
ɔ Diagnosis of lymphedema in the limb
ɔ A body mass index of more than 25
ɔ Presence or history of cellulitis in the limb
ɔ History of obstruction of lymphatics and lymph nodes by tumor in axilla
ɔ Presence of superior vena cava syndrome in distal limb
ɔ Presence of deep vein thrombosis
ɔ Presence of fistula or GOR-TEX® graft for hemodialysis in an extremity
ɔ Sequela from previous hemodialysis graft
Note. Based on information from Gorski et al., 2016; Winge et al., 2010.
90 CLINICAL JOURNAL OF ONCOLOGY NURSING FEBRUARY 2022, VOL. 26, NO. 1
which risk factors are significant to the development of lymph-
edema and which must be avoided (Clark et al., 2005; Ferguson et
al., 2017; Hayes et al., 2005; Kilbreath et al., 2016; McLaughlin et
al., 2013). Based on the literature review, there is no clear answer
on how venipunctures, point-of-care testing, and placement of
vascular access devices in cancer survivors who have undergone
ALND or SLNB affect the risk of developing lymphedema, and it
is apparent that more research is needed.
To date, no randomized controlled trial of avoidance of inva-
sive or noninvasive procedures in the ipsilateral limb versus no
limb precautions has been published. Carrying out a random-
ized controlled trial presents considerable challenges because of
the high morbidity associated with lymphedema, which can be
incurable in advanced stages. However, because of their inherent
limitations, large retrospective registry and descriptive studies do
not provide sufficient evidence to support or refute precautions.
Position papers from the National Lymphedema Network (2012)
recommend precautions based on individualized patient assess-
ment. If limb precautions are integrated into care, clinicians must
consider that they are based on a limited number of descriptive
studies. Synthesis of the evidence to date reveals interventions
that are associated with decreased risk of lymphedema but does
not provide a clear recommendation regarding limb precaution
measures, such as avoidance of venipuncture, point-of-care
testing, vascular access, and blood pressure measurement.
The highest-level contemporary evidence supporting use of
limb precautions comes in the form of expert opinion expressed
in position papers from the National Lymphedema Network and
results of descriptive studies. Patient preferences vary, with some
patients not valuing limb precautions, and others wanting to avoid
lymphedema at all costs (McLaughlin et al., 2013). The evidence
is insufficient to generate a singular, universally accepted prac-
tice guideline. Because of the risks associated with randomized
controlled trials, prospective cohort studies present an attractive
option to investigate the risk of lymphedema, with respect to the
patient’s body mass index and history of cellulitis in the affected
limb. Integral to such a study is the use of a standard method
of measuring lymphedema; unfortunately, there is no univer-
sally accepted gold standard (Shaitelman et al., 2015). Current
methods of measuring lymphedema include limb circumference
measurement, perometry, water displacement, symptom assess-
ment, bioimpedance, and patient self-report (Clark et al., 2005;
Kilbreath et al., 2016; McDuff et al., 2019; McLaughlin et al., 2013;
Shaitelman et al., 2015).
Implications for Practice and Research
Available evidence does not support or refute the avoidance of
venipuncture and IV starts in the affected arm in all patients
who have undergone ALND or SLNB. The Oncology Nursing
Society guidelines on the management of lymphedema offer
an evidence-based approach to surveillance of cancer survivors
CJON.ONS.ORG

who are at an increased risk for lymphedema following cancer
treatment, and interventions to prevent lymphedema in cancer
survivors are well described (Armer et al., 2020). Further investi-
gation is needed to inform policy on limb precautions and future
clinical guidelines that must be based both on lymphedema risk
factors and patient preferences. In patients without lymphedema
and with no arm injury (e.g., cellulitis, broken skin), noninvasive
blood pressure measurement, venipuncture, and IV insertion
are likely safe to perform in the ipsilateral arm. Patients must be
evaluated individually by providers and nursing staff to assess
the need for maintaining limb precautions. Patients who undergo
ALND or SLNB should be monitored for signs of lymphedema by
a certified lymphedema therapist, possibly for as many as four
years (Bucci et al., 2021).
In addition, overcoming strict limb precaution policies
within the community will require patient and provider educa-
tion. Patients should be taught to report signs and symptoms
of cellulitis or lymphedema to prompt early intervention. If the
unaffected arm is no longer a viable source for vascular access,
venipuncture and blood pressure measurement may be done in
the affected arm if there is no other medical reason barring use of
the arm (see Figure 3). A prospective approach to vascular access
planning with the insertion of a long-term vascular access device
may be indicated for patients who have undergone bilateral axil-
lary dissection and radiation therapy, putting them at potentially
increased risk of lymphedema. Patient education materials are
helpful when they reflect policy developed collaboratively by
nursing staff and providers working with these patients.
Additional research is needed to identify best practices
related to invasive and noninvasive procedures in cancer sur-
vivors at risk for lymphedema, with a particular focus on the
influence of elevated body mass index and history of cellu-
litis based on evidence supporting the risk of lymphedema
in these populations. Because the potential for developing
lymphedema is a patient stressor that can affect long-term
quality-of-life perception, future studies would benefit from
including patient-reported outcomes. Crucial parameters to
consider include pain perception, changes in sensation, ability
to wear clothing or jewelry, and perceived changes in body
image (Shaitelman et al., 2015). Patient accrual for a clinical trial
could be challenging because patients may not perceive balance
between the experimental (permissive use of the affected arm)
and the control (adhering to traditional limb precautions) arms.
To maximize the clinical impact, future studies must include
patients who have undergone ALND or SLNB for a variety of
cutaneous and soft tissue malignancies, not just breast cancer.
The effect of lower extremity lymphedema in cancer survivors
must also be examined because early data indicate that func-
tional status and health-related quality of life are more affected
in lower extremity lymphedema than in upper extremity lymph-
edema (Shaitelman et al., 2015).
CJON.ONS.ORG FEBRUARY 2022, VOL. 26, NO. 1 CLINICAL JOURNAL OF ONCOLOGY NURSING
IMPLICATIONS FOR PRACTICE
ɔ Refer patients with risk factors for lymphedema to a trained
professional, such as a physical therapist or certified lymphedema
therapist, for decompressive therapeutic massage education before
or soon after axillary lymph node dissection (ALND) or sentinel
lymph node biopsy (SLNB).
ɔ Teach patients to perform a prescribed home exercise program for
the affected limb (not to the point of muscle soreness) no less than
seven days after an ALND or SLNB surgical procedure.
ɔ Discuss the benefits of weight loss to decrease the risk of lymph-
edema in patients with a body mass index of more than 25 and
recommend 150 minutes of safe exercise per week to maintain a
healthy weight.
Conclusion
This literature review examined the evidence for limb precau-
tions to prevent lymphedema following lymph node dissection.
Because of the lack of high-quality evidence to support the imple-
mentation of limb precautions for all asymptomatic patients
who have undergone ALND or SLNB, the authors suggest that
nurses collaborate with the interprofessional team to seek a
more progressive approach to lowering the risk of lymphedema.
This approach for patients without lymphedema can begin with
education explaining the historical approaches to lymphedema
prevention, such as traditional limb precautions, which are not
as effective as weight management, postoperative decongestive
therapy, and exercise. Patients should be taught to report signs
and symptoms of cellulitis or lymphedema to prompt early
intervention.
Lynne Brophy, MSN, PMGT-BC, APRN-CNS, AOCN®, is a breast oncology clinical
nurse specialist in the Arthur C. James and Richard J. Solove Research Institute (The
James) and at the Stefanie Spielman Comprehensive Breast Center, both at the Ohio
State University in Columbus; and Andrea Bales, MSN, RN, CNL, OCN®, is a nurse
manager in the infusion clinic, Julie K. Ziemann, MS, APRN-CNP, AOCNP®, is a nurse
practitioner in the Division of Hematology, Kellie Navigato, RN, is a clinical nurse I
on the vascular access team in inpatient nursing, and Carlo Contreras, MD, FACS, is
an associate professor in the Department of Surgical Oncology, all at The James at
the Ohio State University. Brophy can be reached at lynne.brophy@osumc.edu, with
copy to CJONEditor@ons.org. (Submitted April 2021. Accepted August 19, 2021.)
The authors take full responsibility for this content and did not receive honoraria
or disclose any relevant financial relationships. The article has been reviewed by
independent peer reviewers to ensure that it is objective and free from bias.
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