204 RLE Procedures

Post Mastectomy Exercise


These exercises done by patients who underwent mastectomy or the surgical removal on one or both of breasts.


> To increase blood circulation

> To increase muscular strength.

> Prevents joints stiffness and contractures

> To restore full range of motion of the arms and shoulder.


> Checks doctor’s order

> This exercise should be performed three times a day for 20 minutes at a time

> Let patient shower with warm water prior to exercise

> Administer analgesic 30 minutes prior to exercise

> If the patient has a graft, exercises may need to be prescribed and introduces gradually.


> Rod or broom stick (1.5 – 2 meters long)

> Rope (1.5 – 2 meters long)

1. Check doctor’s order and identify the patient.

Rationale: To be sure that the exercise is not contraindicated to the patient.

2. Explain procedure to the patient.

Rationale: To gain patient’s cooperation and also give her time to prepare.

3. Assume/place patient in a standing/sitting position.

Rationale: Allow the patient to a full range of motion.

4. Ball squeezing. A rubber ball or a crumpled newspaper squeeze in the hand of the involved side.

Rationale: This does not strain the patient while preparing her for more strenuous exercise.

5. Wall climbing. The women sit/stand facing the wall with her toes next to the wall. Place both hands on the wall with uninvolved arm followed  by the involved arm.

Rationale: This increases circulation and muscular strength, prevent elbow and shoulder joint stiffness and contractures, and restore full range of motion of the shoulders and arms.

6. Pendulum or arm swinging. The points bends at the waist and swing her arms from side to side without bending the elbows.

Rationale: This will prevent shoulder joint stiffness that may result to frozen shoulder as a result of the surgery.

7. Fitting clasped hands. The patient clasps her hands and lifts them slowly over head, keeping the elbows straight.

Rationale: To restore arm and shoulder joints full range of motion and muscle strength prevents stiffness as well as increase blood circulation.

8. Elbow spread. The patient interlocks her hands behind her neck and raises her elbows to chin level, then gradually brings the elbows together.

Rationale: To restore arms ans shoulder joints  full range of motion and restore elbow strength.

9. Pulley or rope pulling. The patient pulls the string down and opposite arm is raised.

Rationale: To restore the abduction and adduction range of motion of the shoulder joints to prevent the frozen shoulder syndrome.

10. Deep breathing. The patient is placed on sitting position, her hand over the involve portion of her chest and takes a deep breath through the nose, feeling her chest expand as the breath is inhaled, as she exhaled, the chest and shoulder sags and reflex.

Rationale: To support muscles in affected side during chest expansion.

11. Make patient comfortable.

Rationale: Allowing patient to rest for the next sessions of post mastectomy exercises.

12. Chart procedure done, time and reaction of patient.

Rationale: Record and allow nurse and therapist to adjust to patient’s capability.


Kozier, Barbara, Fundamentals of Nursing. Philippines: Pearson Educations South Asia PTE LTD. 2004 pp.

204 RLE Procedures

Self Breast Examination


Involves both inspection  and palpation procedures for early detection of disease resulting in a greater chance of cure and less complex treatment.


> To detect early changes in the breast.

> To detect lumps or any abnormalities in the breast.


> Self breast examination should be done 1 week after menstruation.

> Self breast examination should be done at least once a month.


In front of a mirror:

1. Stand before a mirror. Inspect both breasts for anything unusual such as  any changes  from the nipples, puckering, dimpling or scaling of the skin.

2. Watching closely in the mirror, clasps hands behind your head and press hands forward.

3. Next, press hands firmly on hips and bow slightly toward the mirror as you pull y0ur mirrors as you pull your shoulders and elbows up.


a. Stand before a mirror

  • Inspection of breast in front of the mirror aids in visualization of the breast which can easily detect unusual changes of the breast.
  • Clasping hands behind the head and pressing forward exposes both breasts and allows the breast to hang to detect for any unusualities.This examines the lateral and under surfaces of each breast.
  • Pressing the hands firmly on hips tightens the pectoral muscles. Contraction of the pectoral muscles exaggerates signs of retraction or skin flattering. Slight bowing allows the breast to hang freely.

4. While in the shower:

5. Raise left arm. Use three or four fingers of your right hand to explore your left breast firmly, carefully and thoroughly. Beginning at the outer part edge, press the flat part of your portion. Feel any unusual lump or mass under the skin. Pay attention between the breast and armpit.

6. Gently squeeze the nipple and look for discharges.

7. Do the same with the other breast.


  • Done in the shower because soapy hands glides more easily wet skin thus palpating the breast with ease.
  • Squeezing the nipple detects for abnormal discharges.
  • To examine the other breast.

Supine Position:

8. Lie flat on your back, left arm over your head and a pillow or folded towel under your left shoulder. This position flattens the breast and makes it clear to examine. Repeat steps 4 & 5. Use the same circular motion as described earlier.


  • Lying flat on bed distributes breast evenly on chest. The folded towel exposes the breast further. For  thorough examination of the breast.
  • To examine the other breast.


1. Observe the nipple and areola for ulceration, nodules, swelling and discharges.

2. Palpate the areola for nodule and tenderness.


  • To detect any abnormalities.
  • To detect any abnormalities.


Kozier, Barbara, Fundamentals of Nursing. Philippines: Pearson Education South Asia PTE LTDF. 2004. pp.986-987

204 RLE Procedures



Crutches are artificial supports and assists patients who need aid in walking because of disease, injury, or a birth defect.


> To assist client who cannot bear  any weight on one leg.

> To assist client who have full weight bearing on both legs.

> Prevent injury to client who has difficulty in ambulation.


> Assess client’s physical limitations to determine safety and comfort.

> Take time to show patients how to walk with crutches for them to learn

> Maintain proper body mechanics.


> Gait belt                                         > Tape measure

> Crutches                                        > Sturdy footwear, properly fitted

Crutch Walking

1. Inform the client you will be teaching crutch ambulation.

Rationale:  Reduces anxiety. Helps increase comprehension and cooperation, promotes client independence.

2. Assess the client for strength, mobility, ROM, visual acuity, perceptual difficulties and balance. Note: nurse and therapist often collaborate on this assessment.

Rationale: Helps determine the clients capabilities and amount of assistance required.

3. Adjust crutches to fit the client. With the client supine, measure from the heel to the axilla. With the client standing, set the crutch position at a 4-5 inches lateral to the client and 4-6 inches in front of the client. The crutch pad should fit 1.5 – inches below the axilla (3 finger width). The hand grip should be adjusted to allow for  the client to have elbows bent at 30 degree flexion.

Rationale: Provide broad base of support for the client. Space between the crutch pad and axilla prevents pressure on radial nerves. The elbow flexion allows for space between the crutch pad and axilla.

4. Lower the height of the bed.

Rationale: Allows the client to sit with feet on the floor for stability.

5. Have the client dangle legs. Assess for vertigo.

Rationale: Allows for stabilization of blood pressure, thus preventing orthostatic hypotension.

6. Instruct the client to position crutches lateral to and forward to feet. Demonstrate correct positioning.

Rationale: Increases client comprehension and cooperation.

7. Apply the gait belt around the client’s waist if needed.

Rationale: Provides support, promotes client safety.

8. Assist the client to a standing position with crutches.

Rationale: Standing for a few minutes will assist in preventing orthostatic hypotension.

Four-Point Gait

9. a. Position crutches to the side and in front of each foot.

b. Move the right crutch forward 4 to 6 inches.

c. Move the left foot forward, even with the left crutch.

d. Move the left crutch forward 4 to 6 inches.

e. Move the right foot forward, even with the left crutch.

f. Repeat the four-point gait.

Rationale: The four point gait provides greater stability. Weight bearing is on three points at all times. The client must be able to bear weight with both legs.

Three-Point Gait

10. a. Advance both crutches and the weaker leg forward together.

b. Move the stronger leg forward, even with crutches.

c. Repeat three-point gait.

Rationale: The three point gait provides a strong base of support. This gait can be used if the client has a weak or non-weight-bearing leg.

Two-Point Gait

11. a. Move left crutch and right leg forward 4 – 6 inches.

b. Move right crutch and left leg forward 4 – 6 inches.

c. Repeat two-point gait.

Rationale: The two pint gait provides a strong base of support. The client must be able to bear on both legs. This gait is faster than four-point gait.

Walking UP stairs

12.a.  Instruct the client to position the crutches as if walking.

b. Place the strong leg on the first step.

c. Pull weak leg up and move the crutches up to the first step.

d. Repeat for all steps

Rationale: Prevents weight bearing on the weaker leg.

Walking DOWN stairs

13. a. Position the crutches as if walking.

b. Place weight on the strong leg.

c. Move crutches down the next lower step.

d. Place partial weight on hands and crutches.

e. Move the weak leg down to the step with crutches.

f. Put the total weight on arms and crutches.

g. Move strong leg same step as weak leg and crutches.

h. Repeat for all steps.

Rationale: Prevents weight bearing on weaker leg.

14. Set realistic goals.

Rationale: Crutch walking takes up to 10 times the energy required for unassisted ambulation.

15. Consult with a physical therapist.

Rationale: The physical therapist is the expert on the health care team for crutch-walking techniques.

16. Wash hands.

Rationale: Reduces the transmission of microorganisms.


Kozier, Barbare, Fundamentals of Nursing. Philippines: Pearson Education South Asia PTE LTD. pp. 1102-1104