Surgery often causes pain and tenderness in the area that was operated on, which is why it is important to talk to your doctor in advance about ways to control pain. There is also a risk of infection after any surgery.
While you are in the hospital, the nursing staff will monitor you for these problems and assist with your recovery. After you return home, be sure to call your doctor if you have any pain, redness or warmth in the surgical area, swelling, fever or chills.
Bleeding after surgery is not normal. If you have any post-operative bleeding, call your doctor’s office immediately unless it has been specifically discussed with you beforehand.
Lymphedema (Swelling of an Arm or Leg)
Lymphedema can also be a side effect of surgery, particularly with breast or prostate surgery. Lymphedema is swelling of an arm or leg that sometimes occurs when lymph nodes are removed. To help you avoid lymphedema, information on stretching and gentle exercise will be included in the information you receive when you are discharged from the hospital.
Advanced lymphedema can be permanent and debilitating, so it is important to watch for early symptoms. These include swelling and/or decreased flexibility in the hand, wrist, ankle or leg. It is also important to avoid any type of trauma or increased pressure to the affected area.
How quickly you recover from surgery depends on the type of surgery you had, your general health and various other factors. Fatigue tends to be a universal experience, and can last from days to months, depending on the type of surgery. Again, talk to your nurse or doctor about any side effects or concerns you may have.
In the video below, Physical therapist, Peg Maas explains what lymphedema is and how it can be treated.
Read the transcript
Registered Nurse, Chris Yeckley demonstrates how to care for your J.P. drain after breast cancer surgery.
Read the transcript
Lymphedema: Breast Cancer Video Transcript
Hi. My name is Peg Maas and I'm a Physical Therapist here at Swedish Medical Center. The purpose of this podcast is to help you understand what lymphedema is, how it is managed, and some things you can do to reduce your chances of developing it.
Lymphedema is a condition that is commonly discussed in the course of care for women who have been treated for breast cancer. It is not unique to this population and it is not caused by the cancer itself. Anyone with insufficient lymph transport abilities, either because we were born that way or because we've been through medical procedures that compromise them, is at risk for lymphedema,
The way cancer is treated, the radiation and surgeries, puts women with breast cancer more at risk for developing lymphedema. Lymphedema is easy to understand if you think of it in terms of a traffic control issue. It's essentially the result of impaired transport of the contents of the lymphatic vessels.
To understand what we mean by this, let me start by giving you a sense of the important anatomy. Our heart pumps blood away from itself through the arteries. The arteries closest to the heart are large and the blood starts there and then the vessels get smaller and smaller as you go further from the heart. Eventually the tiniest arteries meet up with the very tiny veins and the blood travels through progressively larger and larger veins until it arrives back at the heart after passing through the lungs to pick up more oxygen. This system is a bit leaky by design. White blood cells can escape so they can do their clean up duty in the body and then they reenter the system. If they get too full or engorged though, they can't reenter the blood vessels.
That's where the lymphatic system comes in. The lymphatic system is a network of vessels into which the engorged white blood cells can easily enter. The vessels of the lymphatic system transport the body's cellular waste and along the lymphatic pathways there are nodes which act like colanders straining out the big particles. There are cells within the nodes that break down the clumps. And so what leaves the nodes is a cleaner version of what came in. Eventually the lymphatic vessels meet back up with the heart and the fluid reenters the bloodstream.
There are a couple of fascinating things to know about the lymphatic system. One is that it has its own pulse, independent of the heartbeat. The vessels gently contract and relax to move the material through them. This will be something to keep in mind when we talk about treatment of lymphedema. The second unusual thing about the lymphatic system is that it has the capability to remodel itself in response to injury. When nodes are removed or damaged, as may be the case during breast surgery or radiation, the vessels that lead to them can create new pathways and connect up the vessels that have intact nodes. This is great news in the case of people who have had nodes surgically removed or damaged by radiation. The special massage techniques used in lymphedema care specifically help to regenerate the vessels.
Now let's talk about how lymphedema occurs. Lymphedema occurs when the fluid travelling up through the lymphatic vessels gets trapped because of insufficient pathways. It's similar to when our local highways get overloaded with traffic. The fluid stops, backs up, and just as cars on the highway may exit and spill over on to the surface streets, the fluid seeps out into the nearby tissues causing swelling. The fluid that travels in the lymphatic system is very high in protein.
Protein likes to make matrices. If you think of what happens to egg whites, they are runny until you expose them to heat and then they begin to more solid. That's a matrix forming. The protein in our tissues forms matrices and firms up in the same way if it is allowed to stay still. In difficult lymphedema scenarios, the hardening of the tissues impairs adequate circulation and the tissue is not able to heal itself or clear out infections.
Not everyone who has surgery that involves the nodes will develop lymphedema. Most people will not. It turns out that we cannot predict accurately that those who have had more nodes removed will have lymphedema. Part of the issue is not how many nodes you have removed but what percentage of your total number of nodes is removed and that is not identified when surgical choices are made. The number of lymph nodes a woman may have in her under arm area ranges from six to a hundred and twenty-five. So the news of how many were removed is not a piece of data to worry about.
The list of risk factors, besides the surgical removal or damage to lymph nodes, includes radiation treatment, failure to regain shoulder movement, obesity, and sedentary lifestyle. Additionally, lymphedema may be triggered by sunburn, bug bites or other trauma to the limb.
When lymphedema occurs it's usually recognizable by swelling, especially in the hand of forearm. Some people feel a heaviness or dull aching in their limb. This is not an emergency, unless it's also accompanied by redness, fever or any other signs of being ill. Even though it's not an emergency, promptly informing your health care provider will make it easier to address and begin to manage the situation.
Please understand this, lymphedema is not a sign of cancer. It is a result of the treatments we currently use for eliminating cancer.
How is lymphedema treated? People who treat lymphedema have had special training in how to evaluate and treat the condition. Currently there is no nationally recognized certification process though many institutes that train therapists issue a certificate. The people who might market themselves as lymphedema therapists are physical therapists, occupational therapists, and occasionallly massage therapists. Massage therapists are generally not covered by insurance for treating this diagnosis and they're not licensed to assess for range of motion deficits or giving any exercise prescriptions.
When it comes to arm and torso lymphedema, physical therapists and occupational therapist have overlapping skills and training. Whom you choose to see may depend partly on your insurance benefit for one discipline or the other and who you have access to. At Swedish Medical Center our team of lymphedema therapists includes both physical and occupational therapists.
A visit to a lymphedema therapist includes a thorough discussion of your history including your exercise habits, past orthopedic injuries, recent surgeries and treatments, and what your lifestyle is like in terms of hobies, job activities and other elements. We assess the movement of the limb, feel for and measure swelling, and check healing of the surgical incision.
Depending on what we find we may teach a patient how to care for herself independently or we may recommend treatment in the clinic. Sometimes treatment in the clinic means just a few visits and sometimes it means a few visits per week for several weeks. We work with the patient to figure out what their goals are and what it will take to achieve them.
The three major elements of lymphedema treatment are lymphatic drainage massage, compression, and exercise.
The massage is a unique method that's different from what people are typically accustomed to. It's a very light technique just deep enough to stretch the skin. It's not deep like swedish massage and it's not painful at all. The technique is performed rhythmically to support the natural rhythmic function of the lymphatic system. Strokes are performed in a very structured order beginning on the torso and ending on the arm and hand.
Therapists can teach you to perform a version of this yourself as a home program. In this podcast you'll learn some basic elements of this. The role of massage is to mobilize the lymphatic system to move the fluid and also to promote the development of new lymphatic connections. Blocked vessels can actually form new cross connections and may then be able to transport fluids unimpeded.
The effect of the massage will be enhanced by compression, which in essence creates an environment that is less able to accommodate extra fluid. People with lymphedema are generally encouraged to wear sleeves that provide some pressure on the tissue sorta like a girdle. There's a wide variety of products and levels of compression. The choices of compression garments are best made with the advice of the therapist who evaluates you.
There are also electric pumps that patients can purchase which are designed to perform compression and massage. Determining whether to obtain one should be done with the advice of a physical or occupational therapist with legitimate expertise.
The other essential component of treatment is exercise. Regaining full motion in your shoulder and normalizing your posture helps you lymphatic flow. Cardiovascular exercise also assists with lymphatic flow. Some women find that exercise creates a bit of swelling in their arm and others find it's a great tool to reduce swelling.
Some women need to wear compression garments for their exercise activities and others do not. Again because of the individual scenarios exercise choices are best made with the advice of a therapist and based on your particular valuation findings and preferences.
Can lymphedema be prevented? There are many questions about whether lymphedema be prevented. At this time we do not have definitive research do guide us with this. There is some indication that doing self massage as taught by a therapist may reduce the chance developing lymphedema by promoting good flow and connections for damaged vessels.
Certainly learning the precautions such as avoiding sunburn and cuts is likely to help prevent lymphatic problems and research is revealing that keeping fit is a key part. We do not recommend wearing compression garments as a form of prevention. There is preliminary research to suggest that this may actually cause an adverse lymphatic response.
Now I'm going to teach you a few strokes of lymphatic massage that are quite generic and suitable for all patients and also a breathing technique that promotes healthy lymphatic function. Before we do that though I want to recap some of the most important points we have discussed.
First, the appearance of lymphedema does not mean anything about the cancer. Second, lymphedema is not a life-threatening condition. And third, lymphedema can be successfully managed. There are many scary stories out there, but rest assured that if you address lymphedema promptly and with the correct information it is very unlikely to cause you much trouble.
Let's move into learning a breathing technique that is good for all of us but especially those with lymphatic flow issues. We are designed to be able to breathe in two quite different ways. One way is with the diaphragm, which is a muscle attached to the bottom of the rib cage. When we breathe with our diaphragm the belly expands on the in breath and flattens on the out breath. The second method is using the muscles of the neck and rib cage. Breathing this way makes the chest rise and fall. Take a moment to rest one of your hands on your abdomen and one on your chest as you breathe. Notice which hand moves more. Often the effects of stress and habits we develop over time transform our daytime breathing into chest breathing. One value of diaphragmatic breathing is that it massages some of the large vessels of the lymphatic system and promotes lymphatic transportation. Children and and pets breathe with their diaphragm when they sleep. Observing them can help you learn how to breathe this way. Crying and laughing also promote lymphatic transportation because of the abdominal activity involved. Taking at least a few minutes every day to breathe in this deep abdominal way is something you can do to help your lymphatics function at their best.
In addition to the breathing technique there are two very basic lymphatic massage strokes that you can start to do. First, find the indentation behind your collarbone. Put the flat part of your fingers there and make small circles pressing only with enough pressure to stretch the skin. Do five to ten repetitions. Second, apply the palm of your hand to your underarm area. This is best done directly on your skin and not through clothes. Create a large area of contact as if you were using a washcloth and making circular movements. Again taking the skin as you make the circles stretching it and releasing it as you circle repeating five to ten times.
These are just two of the steps of the self massage of lymphatic drainage. The other steps for a complete program would be selected based on your assessment by a trained lymphedema therapist. You can begin doing those and it will support your lymphatic flow. If you want to learn a complete routine ask your physician to refer you to a lymphedema therapist. Understanding the basics of lymphedema helps you make informed choices for your own care.
There are many providers in the Swedish Medical Center system who can guide you. Take care.
Drain Management Video Transcript
Hello. My name is Chris Yeckley, and I'm a registered nurse with breast cancer surgical team here at the Swedish Cancer Institute. Today I'm going to talk with you about the care and management of your Jackson Pratt drain known commonly as a JP drain. You may have had this drain placed after your breast cancer surgery.
I'm here today with Karen and together we will discuss the JP drain. After our conversation you will understand better what a JP drain is and how to care for it once you're home from hospital.
The JP drain is a wound drainage system that allows fluids to be removed from your surgical site. The drain is inserted during surgery to prevent a large collection of fluid under your skin. The JP drainage tubing coming from your incision area is connected to a small plastic suction bulb. This bulb is pinned to your hospital gown or clothing.
How does the JP drain work?
When the bulb is squeezed it makes a suction that pulls extra fluid into the bulb.
When do I empty the bulb?
After surgery the nurses will empty your drain in the hospital three times a day or as often as they did to keep the bulb less than one-third full. Sometimes you might see a blood clot in the tubing this is normal. The nurse will show you how to milk or strip the tubing a few times a day to keep the tube open and working properly. At home you'll write down how much drainage you emptied over one day or 24 hours on a chart. We will go over this again in this podcast. Continue to empty your drain at least three times a day or more if needed to keep the bulb compressed and no more than one-third full.
How do I empty a JP drain?
First, wash your hands before emptying the drain. Milk or strip the tubing while the bulb is capped, then open the plug attached to the top of the bulb. Pour the contents into a small measuring cup and write down the amount on your chart. Then, to start the suction, squeeze the bulb and cap the plug on the bulb while you are still squeezing it.
What should the drainage look like?
Over time the amount of drainage is less and the color will slowly change from red to pink and then yellow and watery.
What should I do if my JP drain isn't working?
Check to see that the bulb is compressed, the plug is closed, there aren't any clots in the tubing, and finally, try stripping the tubing a few times with the plug closed.
How do I care for the skin where the drain comes out?
You may shower with the drain in place and gently pat the area dry with a clean towel. If you notice a small amount of fluid that has leaked out around the drain this is normal. Tape a clean gauze pad over the area where the drain comes out. Changed the gauze at least once a day or more if needed.
What supplies will I need at home?
You'll need a measuring cup, Some 2 x 2 gauze pads in one inch tape.
When should I call my doctor?
Call the doctor if the skin around the drain becomes red or swollen, or bleeding happens, or if there is yellow puss or thick drainage coming from around your drain. Call your doctor if the drain tubing seems plugged up or no fluid is coming into the bulb or if the bulb ball will not stay compressed.
When the amount of drainage you empty over one or two days, twenty-four to forty-eight hours, is less than thirty milliliters or one ounce, make an appointment to have the drain removed.
This is a copy of the JP drain recording sheet. On the back is a chart for you to record your output. At home you also need some gauze and some tape. As mentioned, we want you to periodically milk, what we call milk, or strip the line. There may be an occasional clot in the line that we want you to milk down to the bulb itself.
When you open the JP drain be aware not to touch in here so that you don't get any germs that travel in the bulb up the line.
You'll empty into the cup and on the side of the car it's scored with numbers: ten cc's, twenty cc's, and so on. You'll empty the cup then down the drain and just rinse the cup out for reuse and record the drainage on the sheet, remembering to do a twenty four-hour total.
In conclusion, here are some useful hints to remember when you have a JP drain.
Make sure you empty the bulb at least three times a day or as needed.
Do not allow it to get more than one-third full.
Strip the JP drain tubing at least three times a day.
Finally, call your doctor when the day's total amount from the drain is three cc's or less.
If you follow these instructions you should not have any problems with your JP drain. These hints are also written on the handout. If you have any further questions or concerns please contact your physician or refer to the handout titled Swedish Nursing Services Jackson Pratt JP Drain.
Thank you for the listening to the Plugged in to Your Health Cancer podcast program.