Mastectomy is the surgical removal of one or both breasts either partially or completely. A mastectomy is usually carried out to treat or prevent breast cancer. Surgical management for patients with breast cancer usually involves lumpectomy or mastectomy. In many cases, radiation therapy is combined with surgery.
Types of breast surgery include:
- Total (simple) mastectomy – removal of breast tissue and nipple
- Modified radical mastectomy – removal of the breast, most of the lymph nodes under the arm, and often the lining over the chest muscles
- Lumpectomy – surgery to remove the tumor and a small amount of normal tissue around it
Nursing Care Plans
Providing perioperative nursing care for patients who are to undergo Mastectomy is an integral part of the therapeutic regimen. The nursing goal is to provide support, alleviating anxiety, managing pain, and providing information.
- Impaired Skin Integrity
- Acute Pain
- Situational Low Self-Esteem
- Impaired Physical Mobility
- Deficient Knowledge
- Risk for Injury
- Impaired Skin Integrity
- Activity Intolerance
- Risk for Ineffective Breathing Pattern
- Risk for Infection
- Ineffective Therapeutic Management
- Risk for Dysfunctional Grieving
- Ineffective Peripheral Tissue Perfusion
- Other Possible Nursing Care Plans
Impaired Skin Integrity
May be related to
- Surgical removal of skin/tissue; altered circulation, presence of edema, drainage; changes in skin elasticity, sensation; tissue destruction (radiation)
Possibly evidenced by
- Disruption of skin surface, destruction of skin layers/subcutaneous tissues
- Client will achieve timely wound healing, free of purulent drainage or erythema.
- Client will demonstrate behaviors/techniques to promote healing/prevent complications.
|Inspect dressings anteriorly and posteriorly for characteristics of drainage. Monitor amount of edema, redness, and pain in the incision.||Use of dressings depends on the extent of surgery and the type of wound closure. (Pressure dressings are usually applied initially and are reinforced, not changed.) Drainage occurs because of the trauma of the procedure and manipulation of the numerous blood vessels and lymphatics in the area.|
|Perform routine assessment of involved arm. Elevate hand or arm with shoulder positioned at appropriate angles (no more than 65 degrees of flexion, 45–65 degrees of abduction, 45–60 degrees of internal rotation) and forearm resting on wedge or pillow, as indicated.||Preventing or minimizing edema reduces the discomfort and complications associated with it. Elevation of affected arm facilitates drainage and resolution of edema. Note: Lymphedema is present in about 25% of patients and may develop immediately after surgery or years later.|
|Monitor temperature.||Early recognition of developing infection can enable the rapid institution of treatment.|
|Maintain in semi-Fowler’s position on the back or unaffected side; avoid letting the affected arm dangle.||Assists with drainage of fluid through use of gravity.|
|Refrain from measuring blood pressure (BP), injecting medications, or inserting IVs in the affected arm.||Increases potential of constriction, infection, and lymphedema on the affected side.|
|Observe graft site (if done) for color, blister formation; note drainage from donor site.||Color will be affected by the availability of circulatory supply. Blister formation provides a site for bacterial growth or infection.|
|Assess wound drains, periodically noting amount and characteristics of drainage.||Drainage of accumulated fluids (lymph, blood) enhances healing and reduces the susceptibility to infection. Suction devices (Hemovac, Jackson-Pratt) are often inserted during surgery to maintain negative pressure in the wound. Tubes are usually removed around the third day or when drainage ceases.|
|Encourage wearing of loose-fitting or non-constrictive clothing. Tell patient not to wear a wristwatch or other jewelry on affected arm.||Reduces pressure on compromised tissues, which may improve circulation and healing and minimize lymphedema.|
|Carry out antibiotics as indicated.||May be given prophylactically or to treat specific infection and enhance healing.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans and nursing diagnoses related to reproductive and urinary system disorders:
- Acute Glomerulonephritis | 4 Care Plans
- Acute Renal Failure | 6 Care Plans
- Benign Prostatic Hyperplasia (BPH) | 5 Care Plans
- Chronic Renal Failure | 11 Care Plans
- Hemodialysis | 3 Care Plans
- Hysterectomy (TAHBSO) | 6 Care Plans
- Mastectomy | 14+ Care Plans
- Menopause | 6 Care Plans
- Nephrotic Syndrome | 5 Care Plans
- Peritoneal Dialysis | 6 Care Plans
- Prostatectomy | 6 Care Plans
- Urolithiasis (Renal Calculi) | 4 Care Plans
- Urinary Tract Infection | 4 Care Plans
- Vesicoureteral Reflux (VUR) | 5 Care Plans