14 Mastectomy Nursing Care Plans

Assessment

Objectives

Nursing Interventions

Rationale

Desired Outcomes

• edema
• muscle weakness
• altered mobility
• sensory and perceptual disturbances due to anesthesia
• Apprehension, restlessness
• thirst; cold , moist, pale skin
• increase in pulse rate, respiration rate
• drop in temperature
• decrease in urinary output

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.

1. Establish pt. Rapport
2. Monitor vital signs frequently.
3. Access mood, coping abilities and personality styles
4. Identify interventions and safety devices
5. Encourage participation in self-help programs, such as assertiveness training, positive self image
6. Provide bibliotherapyand written resources
7. Assist client during periods of ambulation
8.  Walk client’s unaffected side
9.  Instruct the client to keep the shoulders level and the muscle relaxed when walking

1. To gain trust and cooperation of the pt.
2. VS could indicate possible bleeding
3. That may result in carelessness and increased risk-taking without consequences.
4. To promte safe physical environment and individual safety
5. To enhance self-esteem and sense of self-worth
6. For later review and self-pced learning
7. The nurse supports the client when or if client loose balance
8. The lient is more likely to drift toward the side of the body that is heavier
9. Clients tend to accommodate for the change in the center of gravity by leaning to the side

Long Term:

The patient shall demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.