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Clinical Journal of Oncology Nursing logoLink to Clinical Journal of Oncology Nursing
. 2025 Jun 1;29(3):212–218. doi: 10.1188/25.CJON.212-218

Using the Ipsilateral Arm in Patients With Breast Cancer: An Evidence-Based Practice Project and Practice Change

Kathryn L Shady 1,✉
PMCID: PMC12124877  PMID: 40401833

Abstract

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.

Keywords: lymphedema prevention, ipsilateral arm, breast cancer, lymph node biopsy

ABOUT 21% OF PATIENTS WITH BREAST CANCER develop breast cancer–related lymphedema (BCRL) (Cole, 2006; Gillespie et al., 2018; Koelmeyer et al., 2022), and 80%–90% of those patients develop it within three years of surgery (Cole, 2006; Hassan et al., 2025). Nonetheless, medicine has long advised against using the ipsilateral (or affected) arm of patients with breast cancer after mastectomy, lymph node biopsy, or lymph node removal. Halsted (1921) recommended this practice in the early 1920s, believing that infection caused BCRL. Researchers reinforced this belief, and the potential that lymphatic or venous compression may trigger BCRL, through the 1950s (Guthrie & Gagnon, 1946; Holman et al., 1944). Although several researchers observed a connection between compression or infection and BCRL, the practice of avoidance was based primarily on anecdotal observations, case studies, and weak (level 4 or 5) scientific evidence (Asdourian et al., 2016; Bryant et al., 2016; Cemal et al., 2011; McLaughlin et al., 2017).

Current evidence indicates that infection and venous/lymphatic compression do not cause BCRL; however, the true causal factors or why it can develop in such a delayed fashion are not fully understood (Asdourian et al., 2016; Brophy et al., 2022; Cemal et al., 2011; Cheng et al., 2022; Cole, 2006; Ferguson et al., 2016; Larocque & McDiarmid, 2019; Mak et al., 2009; McLaughlin et al., 2017; Naranjo et al., 2021; Showalter et al., 2013). Researchers and practitioners have identified risk factors such as body mass index greater than 25–26 kg/m2 at diagnosis (Asdourian et al., 2016; Clark et al., 2005; DiSipio et al., 2013; Kilbreath et al., 2016; Larocque & McDiarmid, 2019; Mak et al., 2009; McDiarmid & Larocque, 2020; McLaughlin et al., 2017); axillary node dissection (versus sentinel node biopsy) (Asdourian et al., 2016; McDiarmid & Larocque, 2020; Winge et al., 2010); adjuvant chemotherapy and/or taxane chemotherapy (Asdourian et al., 2016; Kilbreath et al., 2016; McDiarmid & Larocque, 2020; McLaughlin et al., 2017); and radiation therapy (Koelmeyer et al., 2022; McLaughlin et al., 2017; Showalter et al., 2013). Researchers and practitioners still debate whether mastectomy and age are risk factors (Clark et al., 2005; Koelmeyer et al., 2022; Mak et al., 2009; McDiarmid & Larocque, 2020; McLaughlin et al., 2017; Winge et al., 2010).

Because of the lack of evidence-based literature or recommendations, most healthcare institutions still follow a blanket avoidance policy. Many professional body guidelines have yet to change their recommendations for patients (Bryant et al., 2016; Centers for Disease Control and Prevention, 2024; Cheng et al., 2022; Jakes & Twelves, 2015; McLaughlin et al., 2017; National Cancer Institute, 2024; Nickel et al., 2024).

The absence of clear direction and dearth of evidence have allowed blanket avoidance policies to remain, resulting in foot sticks for phlebotomy and calf use for blood pressure monitoring. Both practices can harm patients because foot sticks are painful and distressing and calf blood pressures are often falsely elevated, delaying identification and/or treatment of unstable patients (Asdourian et al., 2016; Ferguson et al., 2016; Jakes & Twelves, 2015; Lakhal et al., 2011; McDiarmid & Larocque, 2020; OncoLink, 2019; Sareen et al., 2012). In addition, blanket avoidance practices increase the need for line placement in interventional radiology, causing treatment delays, and extensive bruising and scar tissue formation from repeated use of the contralateral (unaffected) arm, which can be painful and negatively affect body image (Asdourian et al., 2016). This is particularly important for patients who go on to develop a secondary cancer or later progress to metastatic breast cancer (Valentini et al., 2011).

Purpose

Prior to 2024, healthcare providers in a large academic healthcare system in the mid-Atlantic region, ChristianaCare, which includes four emergency departments, three hospitals, and outpatient areas in and around Delaware, were not permitted to use the ipsilateral arm for blood pressures, IV placement, or phlebotomy. Staff placed orange “no blood pressures, no sticks” identification bands on that arm in accordance with policies and procedures. Supported by the chief of breast surgery, two inpatient hematology-oncology clinical nurses began an evidence-based practice project questioning the need for a blanket avoidance policy in patients with breast cancer. The team sought to determine (a) whether the ipsilateral arm could be used for blood pressures, IV placement, or phlebotomy, and (b) the safest way to implement the use of the ipsilateral arm, if possible.

Methods

The team used the Johns Hopkins Evidence-Based Practice Model to guide this evidence-based practice project and the Research Evidence Appraisal Tool to grade all literature (Johns Hopkins Center for Nursing Inquiry, 2023). The toolkit involves the creation of a PICO (population, intervention, comparison, outcome) question, search strategy, and literature review, followed by critical evidence appraisal and project implementation. The PICO question was as follows: In patients with breast cancer who have had a mastectomy, lymph node biopsy, or lymph node removal (P), does permission to use the ipsilateral arm when the contralateral arm cannot be used (I) (e.g., existing BCRL, deep vein thrombosis, pacer wire interference), compared to blanket avoidance of the arm (C), result in a decrease in foot sticks and calf blood pressure measurements (O)?

The team tested search terms in Ovid. They then used the terms yielding the most relevant research in Scopus®, CINAHL®, and Google Scholar™. Ancestral searching and using MeSH (Medical Subject Headings) terms revealed an additional 16 articles not found via database query. The Johns Hopkins Evidence-Based Practice Model uses a I–IV rating system, with I being the highest level, combined with an A–C quality system, with A being the highest, to grade literature (Johns Hopkins Center for Nursing Inquiry, 2023). The evidence demonstrates that high-level data exist to cease the blanket avoidance behaviors to prevent BCRL and repeatedly noted that avoidance practices were based on anecdotal, theoretical, and non–evidence-based practice recommendations (Asdourian et al., 2016; Bryant et al., 2016; Cemal et al., 2011; Cheng et al., 2022; Jakes & Twelves, 2015; McLaughlin et al., 2017) (see Figure 1).

FIGURE 1.

FIGURE 1

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PROJECT PROCESS DIAGRAM

Project Design: Phase 1

The team found very little statistically or clinically significant data to support the practice of blanket avoidance in the literature review, and significant data to refute it. Consequently, the team used a quality improvement design and developed a new policy recommendation stating the following: for individuals with BC status postmastectomy or post–node removal or biopsy, medical procedures (e.g., blood pressure measurements, injections, blood draws, IV placement) in the ipsilateral arm should be avoided when possible. However, if this is not possible, the ipsilateral arm should be used unless the patient has existing BCRL, deep vein thrombosis, or a peripherally inserted central catheter. The feet should not be used for blood draws, nor should the contralateral only be used repeatedly.

The team created a one-page document detailing the evidence behind the proposed policy and shared it with all interprofessional key stakeholders, including the chiefs of anesthesiology, general surgery, surgical oncology, and breast surgery; the oncology unit medical director; an oncologist/hematologist from each outpatient practice (three total); the director of the rehabilitation clinic/lymphedema clinic (physical therapy); and the vice president of acute care nursing. The team also collaborated with campus nursing leadership to design and purchase gray patient identification bands noting “limb alert” to support the change.

Sample and Setting

The team proposed initial implementation (phase 1) of the policy on the 38-bed inpatient hematology-oncology unit, where about two to five patients per week have or have had breast cancer. The average daily census of the unit is 34 patients. The unit is staffed by roughly 81 caregivers and is the inpatient area affiliated and integrated with an outpatient cancer center and National Cancer Institute Community Oncology Research Program member.

The project lead reviewed the charts of all patients admitted to the floor with a primary or secondary breast cancer (ICD-10 code C50) for the six months prior to phase 1 implementation. In total, about 150 charts were reviewed. The ChristianaCare Institutional Review Board deemed this project a quality improvement project and, therefore, exempt in December 2021.

Procedures: Phase 1

TRAINING

Immediately prior to phase 1 implementation, the team educated staff on the unit via staff meetings, flyers in the bathrooms, notes on the daily huddle boards, and reminders. The project lead also presented to the vascular access nurses and educated phlebotomists. Although training was not formally evaluated, the team made additional iterations in response to staff requests and observed difficulties with understanding the pilot change.

IMPLEMENTATION

Beginning in late October 2022, nurses screened patients with breast cancer and a history of node removal/biopsy or mastectomy to determine which arm was more appropriate to use. Nurses followed the arm use guideline of “if not the contralateral arm, then the ipsilateral arm.” Nurses placed a gray “limb alert” band on the ipsilateral arm and removed “no blood pressures, no sticks” bands if placed for limb precautions only. Staff reached out to the project lead or nursing professional development specialist with questions or concerns.

The project lead developed an algorithm to assist nurses in determining which arm was most appropriate for use in patients with bilateral mastectomies. The algorithm states where the nurse should place the band as follows:

  • ■ The side most recently removed or

  • ■ The side that was irradiated (or irradiated most recently) or

  • ■ The side that demonstrated lymphatic involvement or

  • ■ The side that was not removed prophylactically

Nurses who were still unsure were instructed to contact the project lead or patient’s oncologist for guidance.

The project lead worked with the patient and family health education team to create patient education that was accessible to readers of varying health literacy levels. This was provided to all patients and families with questions or concerns regarding the practice change. To ensure continuity of care, nurses placed an “all about limb alert” FAQ sheet in the paper chart of patients with “limb alert” bands so other departments understood what the band signified in case the patient changed units or went for a procedure. Patients’ electronic health records did not note a limb restriction (e.g., “no sticks left arm” would not be selected) because of platform limitations, unless a progress note was entered.

Data Collection

The project lead collaborated with the outpatient lymphedema clinic and outpatient oncology offices to monitor outcomes. The team conducted periodic check-ins via email to track any reports of new-onset BCRL suspected to be related to inpatient ipsilateral arm use on the hematology-oncology floor. The project lead also requested that outpatient oncology offices communicate any new-onset BCRL if the patient had recently been hospitalized and on the unit. In addition, the project lead conducted chart reviews about once every three months to note any outpatient documentation of BCRL.

After placing a “limb alert” band on a patient, nurses noted placement on a tracking log that included the patient’s room, initials, side of band placement, and reason for placement (e.g., mastectomy, lumpectomy). The project lead routinely reviewed and replaced this sheet, keeping it at the charge desk in the front of the unit. Because the sheet was used for tracking only, it was not necessary to use a validated or reliable tool.

Team Lead Oversight

The project lead and nursing professional development specialist shared a list of patients with breast cancer weekly via email. The project lead then would conduct a chart review to determine whether the patient had had a limb alert band properly placed. In instances in which there was concern of improper placement, the project lead messaged the bedside nurse to determine whether a band was in place or was needed. When on-site, the project lead reviewed the daily census sheet and visually confirmed that all patients with breast cancer had proper band placement.

Baseline Data

Preimplementation data demonstrated zero to five instances of “no blood pressures, no sticks” bands, foot sticks, and calf blood pressure measurements per month for patients with breast cancer on the unit (see Figure 2).

FIGURE 2.

FIGURE 2

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PREIMPLEMENTATION DATA PER MONTH FOR PATIENTS WITH BREAST CANCER

Note. There were 0 instances during the postimplementation phase.

Results

Phase 1 Results

More than 100 unique patients participated in phase 1 during the one-year pilot implementation, and there were zero incidences of errant “no blood pressures, no sticks” bands instead of “limb alert” bands, zero incidences of foot sticks, and zero incidences of calf blood pressures. Errant incidences were defined as incidences in which a patient had a “no blood pressures, no sticks” band that was not exchanged for a “limb alert” band (when appropriate) during their admission. The most significant outcome of phase 1 was zero reports of BCRL. These results continued through 2024.

Phase 2 Project Design

With overwhelmingly positive results, the project lead engaged executive nurses and medical leadership to progress to phase 2 of the project. In phase 2, the project lead implemented and published the policy systemwide across three hospitals, four emergency departments, and all outpatient campuses and practices.

Phase 2 Procedures

To start, the project lead distributed about 900 “limb alert” bands across the campuses in packets that included patient and staff education, a copy of the new policy, and a letter to the nurse manager detailing how to reach the project lead with questions and FAQs. The project lead assisted in modifying all official policies to reflect the updated ipsilateral arm use change and is amending systemwide standard patient education. The system is working to incorporate the newly created patient education into preoperative packets for all patients prior to lymph node removal, biopsy, or mastectomy.

Phase 2 Results

As of one year postimplementation of phase 2, the team has received zero reports of BCRL. Because of the size of the health system and the small project team, they could not track foot sticks and calf blood pressures beyond the hematology-oncology unit. Some staff, particularly those who do not care for individuals with breast cancer frequently, are still experiencing a learning curve. However, the practice changes have quickly been adopted in the intensive care units and surgical procedure areas.

Discussion

This evidence-based practice project sought to determine whether blanket avoidance policies for ipsilateral arm use in patients with breast cancer reflected current evidence, and then piloted a practice change of using the ipsilateral arm when the contralateral arm was unable to be used. More than two years after initial implementation, the project has found zero incidences of BCRL related to use of the ipsilateral arm for blood pressure measurement, IV insertion, and/or phlebotomy, further strengthening the argument against blanket avoidance policies for patients with breast cancer after lymph node removal, biopsy, or mastectomy (Asdourian et al., 2016; Cemal et al., 2011; Cheng et al., 2022; Cole, 2006; Ferguson et al., 2016; Jakes & Twelves, 2015; Lakhal et al., 2011; Mak et al., 2009; McDiarmid & Larocque, 2020; McLaughlin et al., 2017; Naranjo et al., 2021; OncoLink, 2019; Showalter et al., 2013). Most of the existing literature comes from literature reviews and non-nursing journals; this evidence-based practice project adds to the nursing literature and emphasizes the integral role that nurses have in moving nursing science forward.

A notable impact of this policy change has been on the hematology-oncology floor and intensive care units, as well as in the operating room. Although this project did not collect qualitative data, patients have anecdotally reported to the project lead a decreased fear of using that arm, and appreciation for being able to choose which arm to use for blood draws and the avoidance of foot sticks. These improved patient experiences underscore the power of nurse-driven practice change.

Limitations

The team encountered minimal barriers in the implementation process, mainly because of frequent staffing changes within the phlebotomy department, and by nurses not remembering the practice change. To facilitate the change, the project lead sent phlebotomy more frequent reminders via email, and nursing leaders and nursing professional development specialists received more thorough education about the practice change. The “limb alert” bands are also in clean supply rooms to serve as a visual reminder to staff. Patients have overwhelmingly accepted the practice change, and refusal to permit ipsilateral arm use has been very rare.

The project originally began in early 2020 and took four years to complete because it was driven by bedside nurses. The inability to leave bedside staffing throughout the COVID-19 pandemic resulted in delays and staffing and leadership turnover. Because of the prolonged hiatus, the team had to reengage key stakeholders and remind them about their prior involvement once it was resumed. In some cases, entirely new stakeholders were brought in because of leadership changes.

Because of the quality improvement design of this project, descriptive or inferential statistics were not collected, nor was statistical analysis performed, limiting generalizability. Once implemented systemwide, the size of the health system prohibited the project lead from being able to follow patient outcomes beyond the hematology-oncology unit. Additional research and data are needed to further strengthen this work, increasing the contributions by nurses in lymphedema literature.

Implications for Nursing Practice

This innovative, nurse-driven policy change has decreased painful procedures and increased patient empowerment across a large mid-Atlantic health system. Patients continue to be open to the change and are provided with updated education throughout the health system.

The impetus for this project came from the questions “Why do we do this?” and “Is it really necessary?” It seemed counterintuitive for new patients with leukemia who had undergone a mastectomy 30 years ago to have an arm that medical staff could not use, particularly if they had not developed BCRL. Two practicing clinical nurses approached system experts, analyzed existing literature, and were shocked to discover that avoidance policies were developed with weak evidence. With that, the team immediately pushed for change.

Clinical nurses may not feel empowered to affect policies and/or practices that directly involve patient care. However, the reality is that clinical nurses are uniquely positioned to ask questions about things that bother patients or just do not make sense and innovate changes or new policies.

The lack of consistent messaging regarding ipsilateral arm use across medical societies and large providers of patient information underscores the need for clear and consistent direction. By empowering clinical nurses and arming patients with consistent and up-to-date information, oncology nurses can continue to provide exceptional patient care and improve the experiences of patients on their cancer care journey.

Conclusion

Given the success and acceptability of this project, the team recommends that institutions review policies and patient education to reflect an evidence-based position on ipsilateral arm use in patients with breast cancer. The team implores appropriate medical societies to ensure position statements are updated and clear regarding ipsilateral arm use to empower patients and improve patient care. This includes providers of patient education, such as health systems, that need to reevaluate published material that perpetuates blanket avoidance (Cancer Research UK, 2023; Johns Hopkins Medicine, 2025; National Cancer Institute, 2024).

IMPLICATIONS FOR PRACTICE.

  • ■ Consider that blanket avoidance policies for breast cancer–related lymphedema do not constitute best practice for patients with breast cancer; removing blanket avoidance policies increases patient confidence in arm use and decreases patient discomfort.

  • ■ Initiate projects that have the capacity to significantly affect patient care and address notable clinical issues.

  • ■ Ask questions about your practice(s) and check the literature.

PROFESSIONAL DEVELOPMENT ACTIVITY.

EARN 1 CONTACT HOUR

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ONS members can earn free nursing continuing professional development (NCPD) for reading this article and completing an evaluation online. To do so, visit www.ons.org/publications-research/cjon/ncpd to link to this article and then access its evaluation link after logging in. ONS is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

Certified nurses can claim no more than 1 total ILNA point for this program. Up to 1 ILNA point may be applied to Care Continuum OR Treatment. See www.oncc.org for complete details on certification.

QUESTIONS FOR DISCUSSION

USE THIS ARTICLE FOR JOURNAL CLUB

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Journal club programs can help to increase your ability to evaluate the literature and translate those research findings to clinical practice, education, administration, and research. Use the following questions to start the discussion at your next journal club meeting.

  • ■ What did this article teach you about the evidence on use of the ipsilateral arm in patients with breast cancer?

  • ■ What is your organization’s policy on this topic?

  • ■ What next steps can you take to incorporate this evidence into practice or research?

Visit https://bit.ly/3VvkYJU for details on creating and participating in a journal club. Photocopying of this article for discussion purposes is permitted.

Footnotes

The author gratefully acknowledges Courtney Crannell, DNP, RN-BC, OCN®, Tracy Curry, MSN, RN, OCN®, Amanda Ellis, MSN, RN, OCN®, and Kristen Otlowski, BSN, RN, OCN®, all of whom provided invaluable support for this project.

The author takes 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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