- 1 Definition
- 2 Nursing Goals
- 3 Nursing Care Plans
- 4 Other Nursing Care Plans
Mastectomy is the surgical removal of the breast which is usually a surgical management for patients with breast cancer. This is done to prevent the metastasize of the cancer cells. Breast cancer is the most common malignancy experienced by women. Breast cancer is the uncontrolled growth of breast cells.
The nursing goal for a patient who underwent mastectomy can be: pain management, counseling due to disturbed body image, and preventing infection due to surgical incision.
Nursing Care Plans
This post contains 14 nursing care plans for patients who underwent mastectomy.
Risk for Injury
Areas involving the neck are considered to be the most vascularized parts of a person’s body. We all know that the most common complication of a surgery is excessive bleeding or hemorrhage, this was brought about by excessive blood loss intra or postoperatively.
NDx: Risk for Injury related to change in center of gravity secondary to extensive removal of chest tissue
|S: (none)O:The patient may manifest:||Short term:After 3-4 hours of nurse-patient interaction, the patient will verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situations.Long Term:After 3-4 days of nurse-patient interaction, the patient will demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.||Short term:The patient shall verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situation.Long Term:The patient shall demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.|
NDx: Acute pain r/t postoperative incision.
|S= Client may verbalize:|
O= Client may manifest:
|Short term:After 3 hours of nursing intervention, client’s pain scale will be reduce.Long term:After 1 day of nursing intervention, client will be relieve from pain and will appear more relax.||Short term:After 3 hrs of nursing intervention, client’s pain scale shall have reduce.Long term:After 1 day of nursing intervention, client shall be relieved of pain and shall appear more relaxed.|
Impaired Skin Integrity
Mastectomy, like any other surgical procedures, includes invasion of the inside body, specifically the skin and subcutaneous area. Upon incision, there will be impairment of the skin integrity causing damage, impairment of skin circulation and sensation and pain in the incision site. An incision is made in the breast. The underlying muscles are opened to expose the tumor beneath the breast. The surgeon then removes part or all of the breast while taking great care not to injure nearby blood vessels or nerves. The muscles are then repaired and the skin incision is closed with sutures that will either absorb or be removed soon after the operation. The actual incising of the skin is seen as an impairment in the skin’s integrity.
NDx: Impaired skin integrity secondary to surgery
|S= ØO= the patient may manifest:||SHORT TERM:After 4 hours of nursing interventions, the patient will participate in prevention measures and treatment programLONG TERM:After 1-2 days of nursing interventions, the patient will be able to display progressive improvement in wound healing.||SHORT TERM:The patient shall participate in prevention measures and treatment programLONG TERM: |
The patient shall be able to display progressive improvement in wound healing.
Activity intolerance refers to the insufficient physiological or psychological energy to complete desired daily activities. Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic or pulmonary –related problems. It is also common in persons who undergone surgeries and it is experienced postoperatively.
The person is suffering from a physical and psychological inability to complete daily activities caused by generalized weakness due to post-surgical procedure. Post-operative patient usually is under bed rest for a few days that may hinder them to their usual activity. Pain that may accompany post-op also inhibit the client to possible ranges of motion.
NDx: Activity intolerance related to generalized weakness
|S: ӨO: Patient may manifest:|
|Short term:After 4 hours of nursing interventions, the patient and the significant, others will be able to identify negative factors affecting activity tolerance and eliminate/reduce their effects when possible.Long term:After 3 days of nursing interventions, the patient will be able to improve his activity and perform techniques to enhance activity tolerance.|
|Short term:The patient and the significant others shall have identified negative factors affecting activity tolerance and eliminated/reduced their effects when possible.Long term:The patient shall have improved his activity and use techniques to enhance activity tolerance.|
Risk for Ineffective Breathing Pattern
Anesthesia is an artificially induced state of partial or total loss of sensation with or without loss of consciousness. Anesthesia agents can produce muscle relaxation, block transmission of pain nerve impulses and suppress reflexes. The depth and effects of anesthesia are monitored by observing changes in respiration and oxygen saturation and end tidal carbon dioxide levels, heart rate, urine output and blood pressure.
NDx: Risk for ineffective breathing pattern related to chemically induce muscular relaxation
|Assessment||Objective||Nursing Intervention||Rationale||Expected Outcome|
|S: ӨO: Patient may manifest:|
|Short term:After 4 hours of nursing interventions, the patient will be free from signs and symptoms of ineffective breathing pattern.Long term:After 2 days of nursing interventions, the patient will maintain a normal and effective breathing pattern.||Short term:The patient shall be free from signs and symptoms of ineffective breathing pattern.Long term:The patient shall have maintained a normal and effective breathing pattern.|
Risk for Infection
Skin is considered as a first line of defense against any foreign organism. Because of the surgical procedure the skin is impaired causing a possible entry for the organisms hence may cause infection.
Persons at risk for infection are those whose natural defense mechanisms are inadequate to protect them from the inevitable injuries and exposures that occur throughout the course of living. Infections occur when an organism invades a susceptible host. Breaks in the integument or mucous membranes allow invasion by pathogens. If the patient’s immune system cannot combat the invading organism adequately, an infection occurs.
NDx: Risk for infection related to surgical wound
|Assessment||Objective||Nursing Intervention||Rationale||Expected Outcome|
| S: ӨO: Patient may manifest:|
|Short term:After 4 hours of nursing interventions, the patient will be able to identify and demonstrate interventions to prevent or reduce risk of infection.Long term:|
After 2 days of nursing interventions, the patient will achieve timely wound healing and be free from signs and symptoms of infection.
|Short term:The patient shall have identified and demonstrated interventions to prevent or reduce risk of infection. |
The patient shall have achieved timely wound healing and free from signs and symptoms of infection.
Ineffective Therapeutic Management
With an ongoing changes in health care, patients are being expected to be co-managers of their care. They are being discharged from hospitals earlier, and are face with increasing complex therapeutic regimens to be handled in the home environment. Likewise, patients with chronic illness often have limited access to health care providers and are expected assume responsibility for managing the nuances of their disease. Patient’s with sensory perception deficits, altered cognition, financial limitations,and those lacking support system may find themselves overwhelmed and unable to follow the treatment plan. Elderly patients, who often experience most of the above problems, are specially at high risk for ineffective management of the therapeutic plan.
|S: noneO: The patient may manifest:||Short Term GoalAfter 4 hours of NPI, the will verbalize acceptance of need and desire to change actions to achieve agreed-on outcomesLong Term GoalAfter 2 days of NPI the patient will participate in problem solving of factors interfering with integration of therapeutic regimen||Short term:The shall verbalize acceptance of need and desire to change actions to achieve agreed-on outcomesLong term:The patient shall participate in problem solving of factors interfering with integration of therapeutic regimen|
Risk for Dysfunctional Grieving
Extended, unsuccessful use of intellectual and emotional responses by which individuals, families, communities attempt to work through the process of modifying self-concept based on the perception of loss. Dysfunctional grieving is a state in which an individual is unable or unwilling to acknowledge or mourn an actual or perceived loss. This may subsequently impair further growth, development, or functioning. Dysfunctional grief may be marked by a broad range of behaviors that may include pervasive denial, or a refusal to partake in self-care measures or the activities of daily living.
NDx: Risk for dysfunctional grieving r/t loss of breast
|S: noneO: The patient may manifest:||Short Term GoalAfter 4 hours of NPI the patient will verbalize a sense of beginning to deal with grief occurring from the loss of breastLong Term GoalAfter 2 days of NPI the patient will participate in therapy to learn new ways of dealing with anxiety and feelings of inadequacy|
|Short term:The patient shall verbalize a sense of beginning to deal with grief occurring from the loss of breastLong term:The patient shall participate in therapy to learn new ways of dealing with anxiety and feelings of inadequacy|
Ineffective Peripheral Tissue Perfusion
The importance of lymphatic system in maintaining fluid balance in the body. The plasma filters into the interstitial spaces from blood flowing through the capillaries. Much of this interstitial fluid is absorbed by tissue cells or reabsorbed by the blood before it flows out of the tissue. A small amount of interstitial fluid is left behind. If this would continue over even a brief period, the increased interstitial fluid would cause massive edema. This edema would causes tissue destruction or death. This problem can be avoided by the presence of lymphatic vessels that act as “drains” to collect the excess fluid and return it to the venous blood just before it reaches the heart.
NDx: Ineffective tissue perfusion (lymphedema) r/t compromised flow of lymphatic fluid
|Assessment||Desired Goal||Nursing Interventions||Rationale||Expected outcome|
|SOOThe patient may manifest:=weak pulses= edema= drowsiness|
= altered sensations
= changes in LOC
|Short Term:After 3-4 hours of nursing interventions, the patient will be able to demonstrate relaxation techniques.Long Term:After 3-4 days of nursing interventions, the patient will be able to demonstrate an improved perfusion by regaining strength, strong pulse and maintain alertness.||1. establish rapport2. monitor and record VS3.assess signs of decreased tse perfusion|
4. identify changes related to systemic or peripheral alterations in circulation.
5. evaluate signs of infection when immune system is compromised
6. observe for signs of pulmonary emboli.
7. assess lower extremities, noting skin texture, presence of edema, ulcerations
8. encourage early ambulation if possible
9. elevate HOB
10. Provide quiet, relaxing environment
11. caution pt to avoid activities that could increase cardiac workload.
12. teach relaxation techniques like deep breathing
13. encourage pt. to rest
14. position pt. on a semi-fowler’s position
15. keep environment allergen free for the pt.
16. educate on proper hand washing
17. encourage pt. to eat nutritious foods
|1. to gain pt’s trust2. to have a baseline data3. to plan for effective treatment and give prompt care. |
4. to asses predisposing factors
5. to determine other possible related factors.
6. to assess for contributing factors
7. to note degree of impairment involved
8. to enhance venous return
9. to increase gravitational blood flow
10. To prevent additional stress to pt.
11. to maximize tse perfusion
12. to facilitate rest and recuperation and proper oxygenation
13. to enable the body to recuperate and repair
14. to facilitate proper chest expansion
15. to prevent presence which may cause increased mucus secretion
16. to prevent infection
17. to meet daily caloric requirement and facilitate repair with body tissue
|Short Term:Patient shall able to demonstrate relaxation techniquesLong Term:|
Patient shall able to demonstrate an improved perfusion by regaining strength, strong pulse and maintain alertness.
Fear is a strong and unpleasant emotion caused by the awareness or anticipation of pain or danger. This emotion is primarily externally motivated and source-specific, that is the individual experiencing the fear can identify the person, place or thing precipitating this feeling. The factors that precipitate fear are, to some extent, universal, fear of death, pair and bodily injury or defect are common to most people.
NDx: Fear r/t diagnosis of cancer as manifested by insomnia and crying
|S: ӨO: Patient may manifest:|
|Short term:After 4 hours of nursing interventions, the patient will demonstrate understanding through the use of effective coping behaviors and resourcesLong term:|
After 2 days of nursing interventions, the patient will display appropriate range of feelings and lessened fear..
|Short term:The patient shall demonstrate understanding through the use of effective coping behaviors and resourcesLong term: |
The patient shall display appropriate range of feelings and lessened fear..
Other Nursing Care Plans
Sleep Pattern Disturbance
Pain is a discomfort that is caused by the stimulation of the nerve endings. Since pain is experience by the patient there are times that he can’t control it that makes him unable to sleep and sudden wake up due to pain cause interruption to sleep causing sleep disturbance.
Body temperature elevated usually occurs in response to an infection or inflammation temperature usually controlled by the Hypothalamus the thermostat for the body. Entry of microorganism can cause an alteration in the hypothalamic set point. Body temperature elevation occurs when the body’s immune response is triggered by pyrogens (fever- producing substances) and interleukin 1, a part of the innate immune system, and product by the phagocytic cells. These chemicals stimulate the cells of the hypothalamus to produce prostaglandin E, thus increasing the temperature set point. Turning up the heat is the body’s way of fighting the microorganism and making the body less comfortable place for them. When this condition occurs, many physiological stresses take place. Some of these include increased cell metabolism, increased heart rate, increased cardiac output. This process prevails until the body temperature matches the thermal point
Impaired Physical Mobility
Mastectomy includes incision of vital parts such as skin, subcutaneous fats, and some muscles, that causes damage to these parts which leads to impairment of neuromuscular responses of the body, that eventually causes the body to impair it’s mobility.
Disturbed Body Image
Mastectomy as a surgical procedure involves the removal of one or both of the client’s breasts. Upon removal, there is a potential of developing a low self-esteem and social stigma due to the surgical removal of the breast creating a disturbed body image because the breast particularly for women is a sign of femininity.