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.
This post contains 14 nursing care plans for patients who underwent mastectomy.
1. Risk for Injury - Mastectomy Nursing Care Plans
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 post operatively.
NDx: Risk for Injury related to change in center of gravity secondary to extensive removal of chest tissue
Assessment | Objectives | Nursing Interventions | Rationale | Desired Outcomes |
S: ØO: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. |
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| Short term:The patient shall verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situations. Long Term: The patient shall demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury. |
2. Acute Pain - Mastectomy Nursing Care Plans
NDx: Acute pain r/t postoperative incision.
ASSESSMENT | PLANNING | NURSING INTERVENTION | RATIONALE | EXPECTED OUTCOME |
S= Client may verbalize:
O= Client may manifest:
| Short term:After 3 hrs 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. |
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| Short term:After 3hrs 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. |
3. Impaired Skin Integrity - Mastectomy Nursing Care Plans
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 intergrity.
NDx: Impaired skin integrity secondary to surgery
Assessment | Objectives | Interventions | Rationale | Desired Outcomes | ||||
S= Ø O= the patient may manifest: Presence of surgical wound on the breast where incision was made Pain Numbness of surrounding areas Disruption of skin surface Redness Itchiness Poor capillary refill | SHORT TERM: After 4 hours of nursing interventions, the patient will participate in prevention measures and treatment program LONG TERM: After 1-2 days of nursing interventions, the patient will be able to display progressive improvement in wound healing. | establish rapport
monitor and record vital sign
assess incision site taking note of size, color, location, temperature, texture, consistency of wound/ lesion if possible inspect surrounding skin for erythema, induration, maceration
assess for odors and drains coming out from the skin/ area of injury
inspect skin on a daily basis, describing lesions and changes observed keep the area clean/dry, carefully dress wounds, support incision, and prevent infection use appropriate wound coverings
encourage an increase in protein and calorie intake
encourage adequate rest and sleep encourage early ambulation and mobilization
provide position changes
practice aseptic technique in cleansing/dressing and medicating lesions instruct proper disposal of soiled dressing
| to gain the trust and cooperation of the client
to obtain baseline data
to provide comparative baseline data
to assess extent of involvement
to assess early progression of wound healing, development of hemorrhage or infection
to promote timely intervention/revision of plan of care
to assist body’s natural process of repair
protect the wound and/or surrounding tissue to aid in timely wound healing for the patient
to prevent fatigue
to promote circulation and reduce risks associated with immobility to prevent bed ulcers from occuring
to reduce risk of cross-contamination
to prevent spread of infectious agent
| SHORT TERM: The patient shall participate in prevention measures and treatment program
LONG TERM: The patient shall be able to display progressive improvement in wound healing. | ||||
4. Activity Intolerance - Mastectomy Nursing Care Plans
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 post operatively.
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
Assessment | Objective | Nursing Intervention | Rationale | Expected Outcome |
S: Ө
O: Patient may manifest:
Weakness Limited range of motion Fatigue Dyspnea Decreased hemoglobin and hematocrit level Immobility Exertional discomfort Abnormal heart rate and blood pressure Pallor Cyanosis
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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. | Establish patient’s rapport
Monitor and record vital signs
Assess patient’s condition
Assess patient’s level of mobility
Assess nutritional status
Ascertain ability to stand and move about and degree of assistance necessary/ use of equipments
Provide a quite environment and encourage use of stress management
Encourage adequate rest periods
Promote comfort measures and provide for relief of pain
Plan care with rest periods between activities
Instruct SO in monitoring response to activity and in recognizing signs and symptoms
Assist client in learning and demonstrating appropriate safety measures
Encourage client to maintain positive attitudes; suggest use of relaxation techniques, such as visualization/guided imagery as appropriate
| To gain trust and cooperation of the patient
To obtain baseline data
To obtain baseline data to be use in evaluating patient’s condition
This aids in defining what patient is capable of, which is necessary before setting realistic goals
Adequate energy reserves are required for activity
To know what goals to be establish to perform wellness
Reduces stress and excess stimulation, promoting rest
Rest provides time for energy conservation and recovery
To enhance ability to participate in activities
To reduce fatigue
To indicate need to other activity level
To prevent injuries
To enhance sense of well-being
|
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. |
5. Risk for Ineffective Breathing Pattern - Mastectomy Nursing Care Plans
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 induced muscular relaxation
Assessment | Objective | Nursing Intervention | Rationale | Expected Outcome |
S: Ө
O: Patient may manifest:
Use of accessory muscle to breathe Nasal flaring Altered chest excursion Increase anterior posterior diameter Purse lip breathing Decrease inspiration/ expiration
| 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. | Establish patient’s rapport
Monitor and record vital signs
Use pulse oximetry to monitor oxygen saturation and pulse rate
Monitor vital capacity in patients with neuromuscular weakness and observe trends
Instruct client to deep breathe during walking hours or use an incentive spirometer
Splint incision to reduce discomfort
Administer oxygen as prescribed
Instruct client to self-administer analgesia before deep breathing and coughing if a patient-controlled analgesia pump is available | To gain trust and cooperation of the patient
To obtain baseline data
To detect changes in oxygenation
Monitoring detects changes early
deep breathing distends alveoli and promotes increased gas diffusion
Pain or fear of pain interferes with deep breathing
Supplemental oxygen provides a higher concentration than found in room air
Pain is more adequately controlled when an analgesic is given before severe pain develops | 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. |
6. Risk for Infection - Mastectomy Nursing Care Plans
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: Ө
O: Patient may manifest: Pallor Weakness With dry and intact dressing on the excised area Swelling over the incision area
|
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. |
Establish patient’s rapport
Monitor and record vital signs
Stress proper hand washing technique
Provide regular catheter care
Instruct on proper wound care
Encourage to eat vitamin C rich foods
Emphasized necessity of taking antibiotics as directed
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 seperation of the suture lines
Empty and re-establish negative pressure in close wound drains at least once per shift |
To gain trust and cooperation of the patient
To obtain baseline data
Patients with poor nutritional status may be anergic or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection
For first line defense against nosocomial infections or cross contamination
To maintain optimal nutritional status
To promote wound healing
To boost the immune system
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
|
Short term:
The patient shall have identified and demonstrated interventions to prevent or reduce risk of infection.
Long term:
The patient shall have achieved timely wound healing and free from signs and symptoms of infection. |
7. Ineffective Therapeutic Management - Mastectomy Nursing Care Plans
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, patient’s 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.
NDx: Ineffective therapeutic regimen management r/t lack of knowledge of preventive measures
Assessment | Objective | Nursing Intervention | Rationale | Expected Outcome |
S: 0 O: The patient may manifest: unable to meet the goals of a treatment knowledge defiitof prescribed regimen perceived seriousness difficulties with prescribed regimen | Short Term Goal After 4 hrs of NPI, the will verbalize acceptance of need and desire to change actions to achieve agreed-on outcomes
Long Term Goal After 2 days of NPI the patient will participate in problem solving of factors interfering with integration of therapeutic regimen | Establish patient rapport
Monitor and record vital sign
Assess for related factors that may negatively affect success with following regimen
Assess patients confidence or her ability to perform desired behavior
Assess patient’s ability to learn or remember the desired health related activity
Assess patients ability to perform the desired activity
Use therapeutic communication skills Provide positive reinforcement for efforts
Promote client and SO participation in planning and evaluating the process
Assist client to develop strategies for monitoring terapeutic regimen
Identify home- and community-based nursing service | to gain patient trust and cooperation
to obtain baseline data
patient’s received seriousness and threat of disease affect his or her compliance with the program
positive conviction that one can be advised successfully executive a behavior is correlated with performance and successful outcomes
cognitive impairments need to be alternative plan can be advised
patient’s with limited financial may unable to purchase special foods
to assist client to problem-solve solution
to encourage continuation of desired behaviors
enhances commitment to plan, optimizing outcomes
promotes early recognition of changes, allowing proactive response
for assessment, follow-up care, and education in clients home | Short term: The shall verbalize acceptance of need and desire to change actions to achieve agreed-on outcomes
Long term:
The patient shall participate in problem solving of factors interfering with integration of therapeutic regimen |
8. Risk for Dysfunctional Grieving - Mastectomy Nursing Care Plans
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 individuals 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
Assessment | Objective | Nursing Intervention | Rationale | Expected Outcome |
S: 0 O: The patient may manifest: mild to moderated decrease in mood ”acting out” behavior Guilt Deviation from unusual behavior pattern Withdrawal from others and normal activities Behavior regression Somatic complaints Avoidance of affectively change topics | Short Term Goal After 4 hrs of NPI the patient will verbalize a sense of beginning to deal with grief occurring from the loss of breast
Long Term Goal After 2 days of NPI the patient will participate in therapy to learn new ways of dealing with anxiety and feelings of inadequacy | Establish patient rapport
Monitor and record vital sign
Assess clients ability to manage activities of daily living and period of time since loss has occurred
Note stage of grief is experiencing
Acknowlege client’s sense of relief when death follows a long and delibating course
Meet with both members of the couple
Encourage client and SO to identify healthy coping skills they have used in the past Refer to other sources as needed, counseling, psychotherapy, significance of loss religious references, grief support group
Avoid trying to diminish the
Acknowledge client’sgrief and reinforce that feeling angry or sad is normal and expected
Stay with client and ensure privacy during emotional periods
Avoid administering prescribed sedatives or tranquilizers as a substitute for spending time with the client
Encourage sharing with those who can be empathic, such as another breast cancer survivor | to gain patient trust and cooperation
to obtain baseline data
they persist and interfere with normal activities, client may need additional assistance.
stages of grief may progress in a predictable manner or may be experienced in different stages
sadness and loss are still there, but the death may be release and the grieving process may be soother
to determine how they are dealing with the loss
these can be used in current situation to facilitate dealing with grief
depending upon meaning of the loss, individual may require on-going support to work through grief
grief works involve dealing with the reality of a significant loss
validating client’s feelings give permission for him or her to experience true emotions
the nurse presence provide support. Ensuring privacy demonstrate for the client’s dignity
Numbling the mind interferes with grieving
Sharing the significant loss with person who has survived a similar experienced provides a bond for healing. | Short term: The patient shall verbalize a sense of beginning to deal with grief occurring from the loss of breast
Long term:
The patient shalll participate in therapy to learn new ways of dealing with anxiety and feelings of inadequacy
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9. Ineffective Peripheral Tissue Perfusion - Mastectomy Nursing Care Plans
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 of time, the increased interstitial fluid would cause massive edema. This edema would causes tissue destruction or death This problem is 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 |
SO OThe 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 rapport
2. monitor and record VS
3.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 trust
2. to have a baseline data
3. 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 techniques
Long Term: Patient shall able to demonstrate an improved perfusion by regaining strength, strong pulse and maintain alertness. |
10. Fear - Mastectomy Nursing Care Plans
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-specifi, that is the individual experiencing the fear can identify the person, placeor thing precipitating this feeling. The factors that precipitate fearar, to some extent, universal, fear of death, pair and bodily injury or defect ar common to most people.
NDx: Fear r/t diagnosis of cancer as manifested by insomnia and crying
Assessment | Objective | Nursing Intervention | Rationale | Expected Outcome |
S: Ө
O: Patient may manifest:
tachypnea tachycardia denial fright fatigue dry mouth Narrowed focus insomnia crying
| Short term:
After 4 hours of nursing interventions, the patient will demonstrate understanding through the use of effective coping behaviors and resources
Long term:
After 2 days of nursing interventions, the patient will display appropriate range of feelings and lessened fear.. |
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| Short term: The patient shall demonstrate understanding through the use of effective coping behaviors and resources
Long term:
The patient shall display appropriate range of feelings and lessened fear.. |
Additional Nursing Care Plans and Diagnoses for Mastectomy
11. 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.
12. Hyperthermia
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
13. 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.
14. 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.
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