NURSING CARE PLANPt. W.P.GDx: Excision Biopsy, Frozen section modified Radical Mastectomy right

Cues Nursing Diagnosis

Nursing Objective Nursing Intervention Scientific explanation

S:“”

O:Vs:BP- 140/90T: 36

- post

surgical

suture on

the Right

Breast

- with pain

scale of

8/10 at the

site of

operation - (+)Facial grimace

-Slight

irritability

Acute Pain related to post- operative incision at right breast secondary to mastectomy

Within 8 hours of nursing interventions patient will manifest a decrease in pain scale from 8/10 to 6/10:

-Verbalize understanding of the cause of pain.

-Identify ways to alleviate pain.

-Participate in care and pharmacological regimen.

-Monitor vital signs

-Perform pain assessment by using pain scale.

-Instruct patient to report un tolerable pain as soon as possible.

-Provide quiet environment and comfort measures

-Encourage deep breathing and some diversional activities.-Encourage ambulation as soon as the pt. recovers but note when pain occurs

-Encourage adequate rest periods-Administer analgesics as ordered.

-Elevated vital signs can be a sign of pain.- To assess etiology and contributing factors.

- Timely intervention is more likely to be successful in alleviating pain.

- To provide non-pharmacological pain management.

-To lessen sense of anxiety and associated muscle tension.-To promote circulation and determine tolerance

-To prevent fatigue

-To maintain acceptable level of pain.

NURSING CARE PLANPt. W.P.GDx: Excision Biopsy, Frozen section modified Radical Mastectomy right

Cues Nursing Diagnosis Nursing Objective Nursing Intervention Scientific explanation Evaluation

O:Vs:BP- 140/90T: 36

- post surgical suture

on the right breast

- presence of Jackson

Pratt

Impaired skin integrity related to surgical incision secondary to breast removal

Short term planning:

After 1-2 hours hour of nursing, patient will be able to know, verbalize and demonstrate the right measures on taking care of her post surgical skin to prevent infection.

Long Term planning:

After 3 weeks of continuous nursing intervention, patient will remain free of impairment in skin integrity, as evidenced by healing skin without redness, infection, hematoma formation or breakdown.

>Monitor vital signs, especially Temperature and BP.

>Provide and explain dressing and drain care (Jackson Pratt)

>Encourage and Teach patient on how to do exercises such as elbow flexion/extension & other activities that use the arm with care; not to raise it too high or above the shoulder.

>Advise patient or relative to report any untoward s/sx such as fever or redness on affected part.

>Administer prophylactic antibiotics as prescribed.

>elevation of temp. may be assign of infection for early detection

>this helps in preventing and promoting an aseptic way of wound healing.

>this facilitates lymph flow, prevent or reduce swelling of affected part.

>Fever & redness are the usual signs of having an infection & early detection would limit its spread.

>Prophylaxis is a prevention of spread

Short term:After 1-2 hours of nursing intervention, patient was able to verbalize and demonstrate the right measures in taking of her post surgical skin.

of infection that may further pose a risk on patient.

NURSING CARE PLANPt. W.P.GDx: Excision Biopsy, Frozen section modified Radical Mastectomy right

Cues Nursing Diagnosis

Nursing Objective Nursing Intervention Scientific explanation Evaluation

O:Vs:BP- 140/90T: 36-with surgical incision wound at the right breast-with dry intact dressing-

Risk for infection related to surgical incision site

Short term:

After 1-2 hours of

nursing intervention

the patient will be

able to identify and

demonstrate

interventions to

prevent or reduce risk

of infection.

Long term:

After 2-3 weeks of

nursing intervention,

the patient will

achieve timely wound

healing and be free

from signs and

symptoms of

infection.

-Monitor vital signs.

-Stressed proper hand washing.

-Instruct proper wound care

-Encourage to eat vitamin c rich foods

- Closely observe and instruct to report signs and symptoms of infection such as fever, sore throat, swelling, pain and drainage- Inspect the wound for swelling, unusual drainage, odor redness, or separation of the suture lines

- Empty and re-establish negative pressure in close wound drains at least once per shift-Administer antibiotics as ordered

-To detect presence of infection.

- Handwashing is the single most effective way to prevent infection- For first line defense against nosocomial infections or cross contamination- To promote wound healing

- To prevent and detect as early as possible the presence of any progressing infection

- Wound infection are accompanied by signs of inflammation and a delay in healing- Negative pressure pulls fluid from the incisional area, which facilitates healing-to prevent infection

Short term:

After 1-2 hours of

nursing

intervention the

patient has

identified

interventions to

prevent or reduce

risk of infection.

Long term:

After 2-3 weeks of

nursing

intervention, the

patient achieved

timely wound

healing and has

been free from

signs and

symptoms of

infection.