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.
- Muscle weakness
- Altered mobility
- Sensory and perceptual disturbances due to anesthesia
- Risk for Injury related to change in center of gravity secondary to extensive removal of chest tissue
- The patient will verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situations.
- The patient will demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.
|Establish rapport||To gain trust and cooperation of the patient.|
|Access mood, coping abilities and personality styles||Factors may result in carelessness and increased risk-taking without consequences.|
|Identify interventions and safety devices||To promote safe physical environment and individual safety|
|Encourage participation in self-help programs, such as assertiveness training, positive self-image||To enhance self-esteem and sense of self-worth|
|Assist client during periods of ambulation when necessary||The nurse supports the client when or if client lose balance|
- Facial Grimaces
- Guarding behavior
- Sleep disturbances
- Distraction behavior
- Autonomic alteration of muscle tone
- Impaired thought process
- Acute pain r/t postoperative incision.
- Client’s pain scale will be reduce.
- Client will be relieve from pain and will appear more relax.
|Assess verbal/non-verbal reports of pain, noting location, intensity (0-10 scale), and duration||Useful in evaluating pain, choice of interventions, effectiveness of therapy|
|Place in Semi-Fowler’s position and support head/neck in neutral position with sandbags or small pillows as required in immediate postoperative phase||Prevents hyperextension of the neck and protects integrity of the suture line|
|Instruct client to use hands to support neck during movement and to avoid hyperextension of neck||Movement restriction is imposed for only a few hours postoperatively to prevent stress on the suture line and reduce muscle tension. Gentle flexing and stretching is then permitted according to pain tolerance to help prevent neck soreness|
|Keep call light and frequently needed items within easy reach||Limits stretching, muscle strains in operative area|
|Give cool liquids or soft foods such as ice cream or popsicles.||Soft foods may be tolerated better than liquids if clients experience s difficulty of swallowing|
|Encourage client to use relaxation techniques e.g., guided imagery, soft music, progressive relaxation||Helps refocus attention and assist client to manage pain more effectively|
|Administer analgesics and throat sprays/lozenges as necessary||Reduces pain and discomfort, enhances rest|
|Provide ice if indicated||Reduces tissues edema and decreased perception of pain|
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.
Patient may manifest
- Presence of surgical wound on the breast where incision was made
- Numbness of surrounding areas
- Disruption of skin surface
- Poor capillary refill
- Impaired skin integrity secondary to surgery
- The patient will participate in prevention measures and treatment program.
- The patient will be able to display progressive improvement in wound healing.
|Assess incision site taking note of size, color, location, temperature, texture, consistency of wound/lesion if possible||To provide comparative baseline data|
|Inspect surrounding skin for erythema, induration, maceration||To assess extent of involvement|
|Assess for odors and drains coming out from the skin or area of injury||To assess early progression of wound healing, development of hemorrhage or infection|
|Inspect skin on a daily basis, describing lesions and changes observed||To promote timely intervention and revision of plan of care|
|Keep the area clean or dry, carefully dress wounds, support incision, and prevent infection||To assist body’s natural process of repair|
|Use appropriate wound coverings||Protect the wound and/or surrounding tissue|
|Encourage an increase in protein and calorie intake||To aid in timely wound healing for the patient|
|Encourage adequate rest and sleep||Prevents fatigue and provides recuperation|
|Encourage early ambulation and mobilization||To promote circulation and reduce risks associated with immobility|
|Instruct on frequent position changes||To prevent bed ulcers from occurring|
|Use aseptic technique in cleansing/dressing and medicating lesions||Reduces risk of cross-contamination|
|Instruct proper disposal of soiled dressing||To prevent spread of infectious agent|
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.
- Limited range of motion
- Decreased hemoglobin and hematocrit level
- Exertional discomfort
- Abnormal heart rate and blood pressure
- Activity intolerance related to generalized weakness
- The patient and the significant, others will be able to identify negative factors affecting activity tolerance and eliminate/reduce their effects when possible.
- The patient will be able to improve his activity and perform techniques to enhance activity tolerance.
|Assess patient’s level of mobility||This aids in defining what patient is capable of, which is necessary before setting realistic goals|
|Assess nutritional status||Adequate energy reserves are required for activity|
|Ascertain ability to stand and move about and degree of assistance necessary/ use of equipment||To determine what goals to be establish to perform wellness|
|Provide a quiet environment and encourage use of stress management||Reduces stress and excess stimulation, promoting rest|
|Encourage adequate rest periods||Reduces stress and excess stimulation, promoting rest|
|Promote comfort measures and provide for relief of pain||Rest provides time for energy conservation and recovery|
|Plan care with rest periods between activities||To enhance ability to participate in activities|
|Instruct SO in monitoring response to activity and in recognizing signs and symptoms||To reduce fatigue|
|Assist client in learning and demonstrating appropriate safety measures||To prevent injuries|
|Encourage client to maintain positive attitudes; suggest use of relaxation techniques, such as visualization/guided imagery as appropriate||To enhance sense of well-being|
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.
- Risk for ineffective breathing pattern related to chemically induce muscular relaxation
- The patient will be free from signs and symptoms of ineffective breathing pattern.
- The patient will maintain a normal and effective breathing pattern.
|Use pulse oximetry to monitor oxygen saturation and pulse rate||To detect changes in oxygenation|
|Monitor vital capacity in patients with neuromuscular weakness and observe trends||Monitoring detects changes early|
|Instruct client to deep breathe during waking hours or use an incentive spirometer||Deep breathing distends alveoli and promotes increased gas diffusion|
|Splint incision to reduce discomfort||Pain or fear of pain interferes with deep breathing|
|Administer oxygen as prescribed||Supplemental oxygen provides a higher concentration than found in room air|
|Instruct client to self-administer analgesia before deep breathing and coughing if a patient-controlled analgesia pump is available||Pain is more adequately controlled when an analgesic is given before severe pain develops|
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.
- Risk for infection related to surgical wound
- The patient will be able to identify and demonstrate interventions to prevent or reduce risk of infection.
- The patient will achieve timely wound healing and be free from signs and symptoms of infection.
|Stress proper hand washing technique||Handwashing is the single most effective way to prevent infection|
|Provide regular catheter care||To reduce risk of infection|
|Instruct on proper wound care||For first line defense against nosocomial infections or cross contamination|
|Encourage to eat vitamin C rich foods||To promote wound healing|
|Emphasized necessity of taking antibiotics as directed||To boost the immune system|
|Closely observe and instruct to report signs and symptoms of infection such as fever, sore throat, swelling, pain and drainage||To prevent and detect as early as possible the presence of any progressing infection|
|Inspect the wound for swelling, unusual drainage, odor redness, or separation of the suture lines||Wound infection are accompanied by signs of inflammation and a delay in healing|
|Empty and re-establish negative pressure in close wound drains at least once per shift||Negative pressure pulls fluid from the incisional area, which facilitates healing|
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.
- Unable to meet the goals of a treatment
- Knowledge deficit of prescribed regimen
- Perceived seriousness
- Difficulties with prescribed regimen
- Ineffective therapeutic management
- The will verbalize acceptance of need and desire to change actions to achieve agreed-on outcomes
- The patient will participate in problem solving of factors interfering with integration of therapeutic regimen
|Assess for related factors that may negatively affect success with following regimen||Patient’s perceived seriousness and threat of disease affect his or her compliance with the program|
|Assess patients confidence or her ability to perform desired behavior||Positive conviction that one can be advised successfully executive a behavior is correlated with performance and successful outcomes|
|Assess patient’s ability to learn or remember the desired health related activity||Cognitive impairments need to be alternative plan can be advised|
|Assess patients ability to perform the desired activity||Patient’s with limited financial may unable to purchase special foods|
|Use therapeutic communication skills||To assist client to problem-solve solution|
|Provide positive reinforcement for efforts||To encourage continuation of desired behaviors|
|Promote client and SO participation in planning and evaluating the process||Enhances commitment to plan, optimizing outcomes|
|Assist client to develop strategies for monitoring therapeutic regimen||Promotes early recognition of changes, allowing proactive response|
|Identify home- and community-based nursing service||For assessment, follow-up care, and education in clients home|
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.
- Risk for dysfunctional grieving r/t loss of breast
- The patient will verbalize a sense of beginning to deal with grief occurring from the loss of breast
- The patient will participate in therapy to learn new ways of dealing with anxiety and feelings of inadequacy
|Assess clients ability to manage activities of daily living and period of time since loss has occurred||They persist and interfere with normal activities, client may need additional assistance.|
|Note stage of grief is experiencing||Stages of grief may progress in a predictable manner or may be experienced in different stages|
|Acknowledge client’s sense of relief when death follows a long and debilitating course||Sadness and loss are still there, but the death may be release and the grieving process may be soother|
|Meet with both members of the couple||To determine how they are dealing with the loss|
|Encourage client and SO to identify healthy coping skills they have used in the past||These can be used in current situation to facilitate dealing with grief|
|Refer to other sources as needed, counselling, psychotherapy, significance of loss religious references, grief support group||Depending upon meaning of the loss, individual may require on-going support to work through grief|
|Stay with client and ensure privacy during emotional periods||The nurse presence provide support. Ensuring privacy demonstrate for the client’s dignity|
|Acknowledge client’s grief and reinforce that feeling angry or sad is normal and expected||Validating client’s feelings give permission for him or her to experience true emotions|
|Encourage sharing with those who can be empathic, such as another breast cancer survivor||Sharing the significant loss with person who has survived a similar experienced provides a bond for healing.|
|Avoid administering prescribed sedatives or tranquilizers as a substitute for spending time with the client||Numbing the mind interferes with grieving|
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.
Patient may manifest:
- Altered LOC
- Weak pulses
- Ineffective tissue perfusion (lymphedema) r/t compromised flow of lymphatic fluid
- The patient will be able to demonstrate relaxation techniques.
- The patient will be able to demonstrate an improved perfusion by regaining strength, strong pulse and maintain alertness.
|Identify changes related to systemic or peripheral alterations in circulation.||To assess and determine the predisposing factors|
|Evaluate signs of infection when immune system is compromised||To determine other possible related factors.|
|Observe for signs of pulmonary emboli||To note degree of impairment involved|
|Assess lower extremities, noting skin texture, presence of edema, ulcerations||To assess for contributing factors|
|Encourage early ambulation if possible||Enhances venous return|
|Position patient on a semi-fowler’s position||Facilitates proper chest expansion|
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.
Patient may manifest:
- Dry mouth
- Narrowed focus
- Fear r/t diagnosis of cancer as manifested by insomnia and crying
- The patient will demonstrate understanding through the use of effective coping behaviors and resources.
- The patient will display appropriate range of feelings and lessened fear.
|Determine what the patient is fearful of by careful and thoughtful questioning||patient who find it unacceptable to express fear may find it helpful to know that someone is willing to listen if they decide to share their feelings at sometimes in the future|
|Compare verbal and nonverbal responses||to note congruences or misperceptions of situation|
|Assess the degree of fear and the measures patient uses to cope with that fear||This helps determine the effectiveness of coping strategies used by the pt.|
|Document behavioral and verbal expressions of fear||Physiologic symptoms and complaints will intensify as the level of fear increases|
|Determine to what degree the patients fears may be affecting his/her ability to perform ADL||Persistent, immobilizing fears may requires treatment with anti-anxiety medications|
|Maintain a calm and tolerant manner while interacting with patient||The patient’s feeling of stability increases in a calm and nonthreatening atmosphere and ongoing relationship establishes trust and a basis for communicating fearful feelings|
|Establish a working relationship through continuity of care||If home environment is unsafe, patient’s fears are not resolved and fear may becoming disabling|
|Provide safety measure within the home when indicated||Recognition and explanation of factors leading to fear are significant in developing alternative responses|
|As patient fear subsides, encourage him/her to explore specific events preceding the onset of fear||Rest improves ability to cop|
|Exercises in relaxation, meditation, or guided imagery||Exercise reduces the physiological response to 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.