Article # 11
Using the Ipsilateral Arm in Patients With Breast Cancer: An Evidence-Based Practice Project and Practice Change
June 2025 • Volume 29, number 3, pages 212 - 218 • DOI: 10.1188/25.CJON.212-218
Kathryn L. Shady
Background: The ipsilateral arm is not used for blood pressure, phlebotomy, or IV access postmastectomy or post–lymph node removal or biopsy. The non–evidence-based practice of blanket forbidding of ipsilateral arm use can result in inaccurate calf blood pressure measurements, foot stick blood draw orders, and an increased need for tunneled central venous catheters.
Objectives: This project piloted a practice change and allowed for the use of the ipsilateral arm in patients with breast cancer.
Methods: The team used the Johns Hopkins Evidence-Based Practice Model to implement a practice change for hematology-oncology inpatients with breast cancer and lymph node involvement, removal, or biopsy, or mastectomy history.
Findings: Twelve months after implementation, more than 100 patients with breast cancer participated with zero incidences of resulting lymphedema. There were no foot stick orders or calf blood pressures in patients when the ipsilateral arm was used. After 16 months, the practice change became a systemwide policy.
Discussion Starting Points:
Please choose two for your response:
How does this research article compare to our practice, policy and or procedure?
What are the advantages and disadvantages to the proposed recommendations in the article?
What are the advantages and disadvantages of implementing the article recommendations on your unit and/or hospital?
Was the correct method used? Why or why not?
Marzenna Messina
ReplyDeleteOn our unit, we have many post breast surgery patients. Some of them had surgery many years ago and do not use Ipsilateral arm for BP or needle stick. This is how they were educated by providers. Nurses have limitations to BP checks and drawing blood for lab work in many of these cases. Lots of those patients have PICC or midline on the opposite arm and can't be used for BP either. Using legs can be not very accurate.
It would be beneficial to implement this article recommendation to our patients.
I would recommend providing all nurses with a tool that will help them assess the patient's knowledge regarding lymphedema and provide nurses with a tool to provide EBP education and resources to give to the patients.
How does this research article compare to practice, policy, and or procedure?
ReplyDeleteOn 6NE, our practice is to never use the ipsilateral extremity. Regardless of how long the patient had their mastectomy or lymph node removal. If the contralateral extremity cannot be used either, the LE’s are used for blood pressure monitoring. IV lines are seldom placed on the foot. The accuracy of blood pressure results vary greatly when either LE is used.
What are the advantages and disadvantages of implementing the article recommendations on your unit or hospital?
In my opinion, there would be a lot of advantages to implementing this recommendation on 6NE. We do not have new mastectomy patients/lymph nodes removal, most of our patient population have had their surgeries longer than 3 years. Per the article, studies have shown that BCRL tends to develop within the first 3 yrs post surgery. This blanketed practice was first introduced m the early 1920’s, because of lack of robust studies, practitioners continue to go along with this procedure. Although this change into practice came about after only having 100 patients in the study, it appears as though it is safe to use the ipsilateral extremity and avoid having to insert IVs in the foot, use LEs for taking BPs and blood draws
A disadvantage to putting this recommendation i to practice on 6NE would be patient satisfaction. I believe most of our patients would be upset and not agree to our EBP changes. Most are elderly and have been told for many years to not use their affected extremity, it would be difficult for them to accept new findings, especially if they are told this study only used 100 patients.
Our policy on 6NE is to utilize “arm precautions,” i.e., no blood pressure or IV draws/IVs, on the mastectomy side regardless of when surgery was.
ReplyDeleteRemoving these restrictions would benefit nursing and the patient. This would provide easier access for IVs and BP. However, most patients with a history of arm precautions are reluctant to use the arm, even with doctor approval. Education including providing research results would need to be shared with patients and a change in culture would need to occur.
Thank you for providing this article. This is interesting research and I wonder if other ministries have changed their policy. Also, do surgeons still educate their patients to avoid BP and IVs in the affected side?
(This is my post above)
DeleteWhat are the advantages and disadvantages of implementing the article recommendations on your unit and/or hospital?
ReplyDelete- An advantage of using the ipsilateral arm post mastectomy and lymph node removal would be utilizing current EBP methods into our current work practices. It is true that using calf readings for blood pressure do not always yield accurate results. And most times, placing a PIV in a lower extremity is more painful than in an upper extremity. A likely disadvantage would be the pushback we would experience from our patients who have been told to never use the affected extremity for blood pressure readings and/or labs and IV starts. This was the long practice method to provide that extra sense of precaution for lymphedema to form.
Was the correct method used? Why or why not?
-I believe the correct method was used as the study did go on for about a year according to the article. In addition, the study was run on heme/onc patients which is our unit demographic.
How does this research article compare to our practice, policy and or procedure?
ReplyDeleteOur current policy is to not use the ipsilateral arm for anything including blood pressures, labs draws, or IVs for mastectomy and lumpectomy. Patient typically inform us if they are not allowed to use that limb, per their oncologist digression. However, there have also been times where patients have not been informed if they are able to use their ipsilateral arm after receiving mastectomy and lumpectomy.
What are the advantages and disadvantages of implementing the article recommendations on your unit and/or hospital?
The advantage of having this implemented in our unit is that it allows us to use more than one limb. Our patients often have difficult veins from being poked so often. Our patients get poked almost daily for lab morning. Our patients also typically have a complex IV regimen and have IV medications that are harsh on the veins, requiring multiple IVs. By implementing this article, it would allow us to utilize both limbs for IV lab draws, IVs, and blood pressure. Our patients also thrombocytopenic at times, which causes them to bruise very easily. By implementing this, our patients can also get a break from only having one limb poked all the time.
Some disadvantages would be trying to re-educate patients on using limb even with evidence based practice.
Some disadvantages would be re-educated patients who are told by their oncologist or surgeons to never use the ipsilateral arm. Another disadvantage would be getting their oncologist on board.
What are the advantages and disadvantages to the proposed recommendations in the article?
ReplyDeleteThe primary recommendation in this article is to move away from a traditional blanket avoidance policy and instead allow the use of the ipsilateral arm for medical procedures when the contralateral arm is unavailable. An advantage of this change would be the immediate reduction in painful and distressing blood draws. By utilizing the ipsilateral arm, we can avoid the clinically dangerous practice of relying on calf blood pressure measurements, which are often falsely elevated and can delay the identification of an unstable patient. This approach also prevents the extensive bruising and scar tissue that develops on a patient's contralateral arm from repeated over use. From a system perspective allowing ipsilateral access reduces the need for invasive tunneled central venous catheters and interventional radiology placements which helps avoid unnecessary treatment delays. Most importantly, the study demonstrated that this practice is safe, with zero reported incidences of lymphedema among the participants. I believe this will empower our patients as it can reduce fear and increase confidence when they are given a choice in their own care.
There are certain disadvantages and practical hurdles to implementing these recommendations. Most significantly is the steep learning curve for staff, especially for those who do not frequently care for breast cancer patients and are used to the old restrictive rules. Maintaining compliance requires constant education and visual reminders, such as the limb alert signs, to prevent staff from reverting to outdated practices. There is also a risk of confusion or inaccurate sign placement if training is not reinforced during high staff turnover, which the authors noted specifically with their phlebotomy department. Additionally, the project's quality improvement design means that it lacks the rigorous statistical analysis found in larger trials, which may limit how easily these findings can be generalized to other healthcare settings. In the article researchers felt that the reliance on outpatient clinics to self report new onset lymphedema could be a disadvantage if communication between departments is not seamless. Finally, the long timeline for implementation due to challenges of the COVID pandemic showed that moving away from deeply ingrained clinical habits is a difficult and time consuming process.
Was the correct method used? Why or why not?
The Johns Hopkins Evidence based Practice Model is an appropriate and effective methodology to use as it provides a structured framework for taking existing research and translating it into a practical bedside protocol, which is essential when moving away from long‑standing traditions rooted in narrative evidence rather than high‑quality data.
Implementing the change through a phase‑one pilot on a single 38‑bed hematology‑oncology unit allowed the team to educate staff, refine workflows, and closely monitor patient outcomes before expanding the policy. This step-by-step approach was justified by the results, more than 100 patients participated with no resulting lymphedema during the pilot period . The absence of foot sticks, calf blood pressures, and inaccurate limb restriction signs further demonstrated that the implementation strategy was safe, feasible, and clinically beneficial.
However, the design has limitations when viewed through the eyes of academic research. The project was intentionally structured as a quality improvement initiative rather than a controlled research study. Once the protocol expanded systemwide, the size of the health system prevented ongoing outcome tracking beyond the original pilot unit, reducing the ability to assess long‑term or systemwide lymphedema incidence.
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ReplyDeleteHow does this research article compare to our practice, policy and or procedure?
ReplyDeleteOn 6NE, our policy enforces "limb precautions prohibiting blood pressure monitoring, lab draws, and IV access on the ipsilateral side regardless of how much time has passed since the patient's mastectomy. Transitioning away from these blanket restrictions would significantly benefit both nurses and patients by broadening options for vascular access and blood pressure monitoring.
What are the advantages and disadvantages to the proposed recommendations in the article?
Restricting procedures like blood pressure checks, blood draws, and IV placements on the affected arm after a mastectomy or lymph node removal aims to protect compromised lymph pathways, theoretically reducing the risk of cellulitis and Breast Cancer-Related Lymphedema while giving patients peace of mind. However, recent evidence shows no direct link between these routine procedures and lymphedema onset, making strict avoidance often unnecessary. In practice, unnecessary restrictions limit viable veins, leading to painful repeated punctures in the unaffected arm, reliance on inaccurate lower-extremity blood pressures, or placement of high-risk central venous lines. Consequently, modern guidelines reserve ipsilateral arm restrictions primarily for patients with active lymphedema, allowing its use when clinical necessity outweighs theoretical risks.
How does this research article compare to our practice, policy and or procedure?
ReplyDeleteAt Providence Saint Joseph, we currently uphold the standard of not using the ipsilateral arm in patients with breast cancer. We do this to protect the extremity from lymphedema. However, this study shows it would greatly improve patient comfort and the accuracy of blood pressure readings.
What are the advantages and disadvantages to the proposed recommendations in the article?
The advantages of adopting this recommendation are that it would improve patient comfort. Oftentimes, having to insert multiple PIV’s in one arm, utilizing the calf for blood pressure measurements, has brought discomfort to the patient. In addition, having to utilize central access instead of PIV’s brings a higher risk of infection. The only disadvantage of this study is that it is a smaller study with a time span of 12 months. I do believe that, in order to change this policy, it would have to be with a larger population sample.