XIV.

NURSING CARE PLAN Cues Subjective: Sumasakit yung kaliwang suso ko Objective: > 5/10 Pain Scale > (+) Facial Grimace > (+) Guarding Behavior > (+) restlessness > Post Modified Radical Mastectomy Acute Pain Related to Post- Surgical Tissue Damage Nursing Diagnosis Inference Post Modified Radical Mastectomy Planning SHORT TERM: After 8 hours of nursing intervention, the patient will rate the Pain scale from 5 to 2. LONGTERM: After several weeks of nursing intervention, the patient will able to demonstrate nonphramacological methods that can relief pain. Intervention INDEPENDENT: 1.) Observe nonverbal cues and pain behavior > Observation may not be congruent with verbal reports or may be only indicator present when client is unable to verbalize > Altered Vital signs may be an indicator of acute pain. > To maintain acceptable level of pain. Rationale Evaluation SHORT TERM: After 8 hours of nursing intervention, the patient was able to rate the Pain scale from 5 to 2. LONGTERM: After several weeks of nursing intervention, the patient was able to demonstrate nonphramacological methods that can relief pain.

Actual Tissue Damage

Unpleasant Sensory / Emotional Experience

2.) Monitor skin color, temperature, vital signs. DEPENDENT: 1.) Note Clients attitude towards pain and use of pain meications.

Acute pain

2.) Administer > To maintain Analgesics as indicated acceptable level of pain.

COLLABORATIVE: 1.) Discuss with SO the ways in which they can assist the client and reduce precipitating factors that may cause / increase pain (household task) > To minimize pain and reduce precipitating Factors

Cues Subjective: pangit ko na ba? Objective: > Post operative Modified Radical Mastectomy > (+) Guarding Behavior > Not looking or not touching body parts

Nursing Diagnosis

Inference Post Surgical Modified Radical Mastectomy

Planning SHORT TERM: After 8 hours of nursing intervention, the patient will verbalize understanding of body changes and verbalize acceptance of self situation.

Intervention INDEPENDENT: 1.) Evaluate level of clients knowledge, anxiety related to situation and observe emotional state. 2.) Plan care activities with client.

Rationale

Evaluation

Disturbed Body Image related to Post-surgical Modified Radical mastectomy

Missing body parts

LONGTERM: After several weeks of nursing intervention, the patient will able to use adaptive devices and Dissatisfaction in actively pursue physical growth appearance

Altered body structure / function

3.) Maintain positive approach during care activities, avoiding expressions of disdain or revulsion. Do not take angry expressions of client/SO personally.

Distured Body Image

SHORT TERM: After 8 hours of > Indicates nursing acceptance/ non- intervention, the acceptance to the patient was able to situation. verbalize understanding of > Promotes body changes and sense of control was able to and gives verbalize message that acceptance of self client can handle situation. situation, enhancing selfLONGTERM: concept. After several > Assists weeks of nursing client/SO to intervention, the accept body patient was able to changes and feel use adaptive good about self. devices and Anger is most actively pursue often directed at growth the situation and lack of control or powerlessness individual has over what has happenednot with the individual

caregiver. DEPENDENT: 1.) Note signs of grieving / indicators of severe or prolonged depression. 2.) Discuss the availability of physical therapy / reconstructive. COLLABORATIVE: 1.) Begin counseling / other therapies > To provide early / ongoing sources of support. > to promote optimal wellness. > To evaluate need for counseling/ medications > To minimize surgery and body changes and enhance appearance

2.) Refer to Appropriate support group

Cues Subjective: Objective: > Post Modified Radical mastectomy > (+)Destruction of Skin Layers

Nursing Diagnosis

Inference Post Modified radical Mastectomy

Planning SHORT TERM: After 8 hours of nursing intervention, the patient will able to display timely healing of skin lesions, wounds or pressure without complications. LONGTERM: After several weeks of nursing intervention, the patient will able to verbalize feelings of selfesteem and ability to manage situation.

Intervention INDEPENDENT: 1.) Identify underlying condition or pathology

Rationale

Evaluation SHORT TERM: After 8 hours of nursing intervention, the patient was able to display timely healing of skin lesions, wounds or pressure withoout complications. LONGTERM: After several weeks of nursing intervention, the patient was able to verbalize feelings of self-esteem and ability to manage situation.

Impaired Skin Integrity Related to Post Modified Radical Mastectomy

Altered Epidermis/ Dermis

Impaired Skin Integrity

> To identify causative / contributing 2.) Inspect surrounding factors. skin for erythema, induration, maceration. >To assess extent of DEPENDENT: involvement and injury 1.) Obtain pyschological assessment of clients emotional status, as indicated. > To determine COLLABORATIVE: impact of condition 1.) Consult with wound or stoma specialist

> To assist with developing plan of care for problematic or potentially

serious wounds

Cues Subjective: Objective: > Inappropriate / exaggerated behavior. > Statements of misconceptions.

Nursing Diagnosis

Inference Lack of Specific Information

Planning

Intervention INDEPENDENT: 1.) Determine Clients ability, readiness and barriers to learning. 2.) Provide Information relevant only to situation. 3.) Begin with the informations that the client already knows and move to complex. Use short and simple sentances COLLABORATIVE: 1.) Provide Access information for contact person

Rationale

Evaluation SHORT TERM: After 8 hours of nursing intervention, the patient was able to verbalize understanding of condition and participate in learning process LONGTERM: After several weeks of nursing intervention, the patient was able perform necessary proocedures correctly and initiate necessary lifestyle changes and participate in treatment regimen.

Deficient Knowledge Related to Lack of Information

SHORT TERM: After 8 hours of nursing intervention, the Misinterpretations/ patient will able Inacurate/ to verbalize Incomplete understanding of Information condition and prticipate in learning process Cognitive Limitations LONGTERM: After several weeks of nursing Deficient intervention, the Knowledge patient will able perform necessary procedures correctly and initiate necessary lifestyle changes and participate in treatment regimen.

> Patient may not be physically, emotionally or mentally capable at this time. > To prevent overload

> Can elevate clients interest.

2.) Identify available community resources and support groups

> To answer questions and validate informations.

> To promote wellness and discharge considerations

Cues Subjective: Objective: > (+)slowed Movement. > (+) postural instability. > (+) limited range of motion. > (+) difficulty turning. > Post Modified Radical Mastectomy

Nursing Diagnosis

Inference Prescribed Movement Restrictions

Planning

Intervention INDEPENDENT: 1.) Note situations such as surgery that may restrict movement. 2.) Observe movement when client is unaware of observation 3.) Assist client to reposition self on a regular schedule

Rationale

Evaluation SHORT TERM: After 8 hours of nursing intervention, the patient was able to verbalize understanding of situation and individual treatment regimen and safety measures. LONGTERM: After several weeks of nursing intervention, the patient was able to demonstrate techniques that enable resumption of activities.

Impaired Physical Mobility Related to Prescribed Movement Restrictions.

SHORT TERM: After 8 hours of nursing intervention, the patient will able Inability to to verbalize perform gross or understanding of fine motor skills situation and individual treatment regimen and Impaired safety measures. Physical Mobility LONGTERM: After several weeks of nursing intervention, the patient will able to demonstrate techniques that enable resumption of activities.

> To identify contributing factors. > To note any incongruencies with reports of abilities > To promote optimal level of function and prevent complications. > To prevent risk of pressure ulcer.

4.) Support affected body parts or joints using pillow

DEPENDENT: 1.) Administer medications prior to activity as needed for pain relief.

> To permit maximal effort and involvement

COLLABORATIVE: 1) Consult with physical or occupational therapist, as indicated.

in activity.

> To develop individual exercise and mobility program, and identify appropriate mobility devices.

Cues Subjective: Objective: > indesive or nonassertive behavior.

Nursing Diagnosis

Inference Post Modified Radical mastectomy

Planning SHORT TERM: After 8 hours of nursing intervention, the patient will able to acknowledge factors that lead to possibility of Low-Self-Esteem feelings.

Intervention INDEPENDENT: 1.) Note for non-verbal body language

Rationale

Evaluation SHORT TERM: After 8 hours of nursing intervention, the patient was able to acknowledge factors that lead to possibility of Low-Self-Esteem feelings.

Risk for sitational Low Self-Esteem Related to Loss of Body Parts

Loss of Body Parts

> To determine incongruencies between verbal and non-verbal communication require clarification.

Dissatisfaction in LONGTERM: physical After several appearance weeks of nursing intervention, the patient will able to demonstrate Distured Body self-confidence Image by actively participating in life situation. Risk for sitational Low Self-Esteem

2.) Assess negative attitudes and/or selftalk. 3.) Identify clients basic sense of selfworth.

4.) Encourage expressions of feelings and anxiety. 5.) Active listen to clients concerns and negative verbalizations without comment/ judgement

> To detect view of situation as LONGTERM: hopeless and After several difficult. weeks of nursing intervention, the patient was able to > To assess demonstrate selfcontributing confidence by factors. actively participating in life situation. > facilitates greiving the loss body parts. > To assist client to deal with the loss or changes.

6.) Convey confidence in clients ability to cope with current situation COLLABORATIVE: 1) Promote attendance in therapy / support group.

> To recapture sense of positive self-esteem.

> To promote wellness.

Cues Subjective: Objective: >(+) powerlessness > (+) broken skin > Post Modified Radical Mastectomy.

Nursing Diagnosis

Inference Post Modified Radical mastectomy

Planning SHORT TERM: After 8 hours of nursing intervention, the patient will able to identify interventions to prevent and reduce Risk of Infection. LONGTERM: After several weeks of nursing intervention, the patient will able to achieve timely wound healing ; be free of Purulent Drainage, Erythema and be febrile.

Intervention INDEPENDENT: 1.) Note risk factors for occurence of infection (skin/tissue wounds/invasive procedures) 2.) Assess and document skin conditions around insertion of drainage 3.) Note signs and symptoms of sepsis (systemic infection) : fever, chills, altered LOC. 4.) Stress proper hand hygiene by all caregivers between therapies and clients 5.) Maintain Sterile Technique for all invasive procedures

Rationale

Evaluation

Risk for Infection Related to Broken tissue.

Traumatized tissue and broken skin

Inadequate Primary defense Increase Risk of Pathogenic Organism Invasion Risk for Infection

SHORT TERM: After 8 hours of > To assess nursing contributing / intervention, the causative factors. patient was able to identify interventions to prevent and reduce Risk of Infection. > To assess contributing / LONGTERM: causative factors. After several weeks of nursing intervention, the patient was able to achieve timely > To assess wound healing ; contributing / be free of Purulent causative factors. Drainage, Erythema and be febrile. > A first line defense against healthcare assosiated infections.

DEPENDENT: 1.) Administer medication regimen as ordered COLLABORATIVE: 1) Obtain appropriate tissue/ fluid specimens for observationand cultural sensitivities testing.

> To reduce/correct existing risk factors. > To determine effectiveness of therapy.

> To promote wellness.

Cues Subjective: Objective: >(+) disbelief feeling > (+) helplessness > (+) Pain

Nursing Diagnosis

Inference Post Modified Radical mastectomy

Planning SHORT TERM: After 8 hours of nursing intervention, the patient will able to discuss meaning of loss. LONGTERM: After several weeks of nursing intervention, the patient will able to verbalize sense of beginning to deal with grief process.

Intervention INDEPENDENT: 1.) Determine Loss that has occured and meaning to the client. Note whether loss was sudden or expected. 2.) Discuss meaning of loss to client, ActiveListening response to client without judgement. 3.) Respect clients desire for quiet, privacy, talking or silence. 4.) Meet with both members of couple.

Rationale

Evaluation SHORT TERM: After 8 hours of nursing intervention, the patient will able to discuss meaning of loss. LONGTERM: After several weeks of nursing intervention, the patient will able to verbalize sense of beginning to deal with grief process.

Risk for Complicated Grieving Related to Loss of Significant Body Part.

> To identify contributing / causative factors

Loss of Significant Body Part

Altered body structure / function

> To assist client to deal with the situation.

Dissatisfaction in physical appearance

> To assess contributing / causative factors.

Distured Body Image > To determine how they are dealing with current situation.

COLLABORATIVE:

Low-Self Esteem 1) Refer to other resources, such as counseling , psychotherapy, spiritual advisor, cancer survivor groups.

Risk for Complicated Grieving

> To promote wellness.