NURSING CARE PLAN

Assessment Nursing Diagnosis

Scientific Explanation

Planning Interventions Rationale Evaluation

Subjective:“Sobrang sakit ng sugat ko”

Objective:BP- 140/90mm/Hg

T: 36

- 21cm surgical site @ R upper breast- 8/10 pain scale- (+)Facial grimace -irritable-Inflammation on surrounding of the R breast-tenderness> 5 hours stay at the RR

Acute Pain related to post- operative incision at right breast secondary to mastectomy

Post- operative site

redness

inflammation

PAIN

Goal: The patient will be able to alleviate pain.

Short term goal:After 8 hours of nursing intervention the pt. will be able to:a.Verbalize understanding of the cause of pain.

b.Identify ways to decrease pain.

c.decrease pain from 8/10-6/10

Long term:After 2 weeks of nursing interventions patient will:

a.alleviate pain

b.participate in pharmacological treatment 

Independent:-Monitor vital sign including pain.

-Perform pain assessment by using pain scale.(0-10 numeric pain rating scale)

-Instruct patient to report un tolerable pain as soon as possible.

-Provide quiet environment and comfort measures like (Frequent position changes, Soft music and a restful environment, Use of relaxation techniques like meditation,

-Abnormal vital signs can be a cause of pain.

- To know the contributing factors.

- Only the client can judge the level and distress of pain; pain management should be a team approach that includes the client.

-The human body is believed to have energy fields that express aberrant patterns when body systems are insulted. Therapeutic Touch is thought

The patient was able to decrease pain from 8/10- 6/10

Short term goal:

After 8 hours of nursing intervention the pt. was able to:a.Verbalized understanding of the cause of pain.

b.Identified ways to decrese pain.

Long term:After 2 weeks of nursing interventions patient will:a..alleviate pain

b.participate in pharmacological treatment 

yoga,Backrubs or massage)

-Encourage deep breathing exercise and some diversional activities. (e.g watching t.v, listening to calm and soft music)

-Encourage early ambulation as soon as the pt. recovers.

-Encourage adequate rest periods (at least 6-8 hours)

Dependent:

-Administer analgesics as ordered. (Diclofenac 75 mg,)

to realign aberrant fields.

-To lessen sense of anxiety and associated pain.

-To promote circulation and determine tolerance

-

-To maintain acceptable level of pain.

Assessment Nursing Diagnosis

Scientific Explanation

Planning Interventions Rationale Evaluation

ObjectiveVs:BP- 140/90mm/Hg

T: 36

-with dry intact post-op dressing-(+) redness-(+)tenderness-21cm surgical site @ R upper breast-skin warm to touch-(-) pus- Inflammation on surrounding of site-(-) hematoma

Impaired skin integrity related to surgical incision secondary to breast removal

Incision on the Right breast

cutting /penetration of skin surface and skin layers

Trauma on the skin

Inflammation

IMPAIRED SKIN

Goal: The pt. will be able toachieve paired skin

Short term goal:

After 8 hours of nursing intervention, patient will be able to know measures on taking care of post- operative site by teaching how to::.Assess dressing and change when soaked

Hand washing before touching the wound

Long Term goal:

Independent:

>Provide dressing and drain care (Jackson Pratt)

>Teach proper hand washing (specially before touching the wound)

>Encourage and Teach patient on how to do passive exercises (such as elbow flexion/extension & other activities that use the arm with care; not to raise it too high or above the

>this helps in preventing and promoting an aseptic way of wound healing.

> to promote an aseptic way of wound healing

>this facilitates lymph flow, prevent or reduce swelling of affected part.

Goal: The pt. will be able toachieve paired skin

Short term goal:

After 8 hours of nursing intervention, patient will be able to know measures on taking care of post- operative site by:

Assess dressing and change when soaked

Always do hand washing before touching the wound

Long Term goal:

After 2 weeks of continuous nursing intervention, patient will remain free of impairment in skin integrity, as evidenced by:

healing skin without redness infection, hematoma formation or breakdown.

    

shoulder.)

>Advise patient or relative to report any untoward s/sx such as fever or redness on affected part.

Dependent:>Administer prophylactic antibiotics as prescribed. (Cefuroxime 750 mg.)

>Fever & redness are the usual signs of having an infection & early detection would limit its spread.

>Prophylaxis is a prevention of spread of infection that may further pose a risk on patient.

After 2 weeks of continuous nursing intervention, patient will remain free of impairment in skin integrity as evidenced by:

healing skin without redness infection, hematoma formation or breakdown.

NURSING CARE PLAN

Assessment Nursing Diagnosis

Scientific Explanation

Planning Interventions Rationale Evaluation

Objective:Vs:BP- 140/90mm/HgT: 36

- 21cm surgical site @ R upper breast

-with Jackson Pratt @ R breast>with moderate amount of drainage (27ml drainage)>light red in color>skin warm to touch> post operative dressing dry and intact> inflammation> 5 hours stay at the RR>no discharge

Risk for infection related to post surgical incision secondary to mastectomy

Surgical site @ R upper breast (21cm)

Redness

Inflammation

Close wound

Risk for infection

Goal:The pt. will be free from infection.

Short term goal:After 4 hours of nursing intervention the patient will be able to identify and demonstrate interventions to prevent or reduce risk of infection.a. proper Hand Washingb.Proper wound carec.Increase intake of protein rich foods

Long term goal:After 2-3 weeks of nursing intervention, the patient will achieve timely wound healing and be free

Independent:-Monitor temperature.

-provide health teaching on hand washing and proper wound care

-

-instruct to eat foods rich in vitamin c and protein

-observe and instruct to report signs and symptoms of infection such as fever, sore throat, swelling, pain and foul drainage- Inspect the wound for swelling,

-To detect presence of infection.- Handwashing and proper wound care are the effective ways to prevent infectionc- To promote wound healing

- 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

Goal:The pt. will be free from infection.

Short term goal:After 4 hours of nursing intervention the patient was able to identify and demonstrate interventions to prevent or reduce risk of infection.a. proper Hand Washingb.Proper wound carec.Increase intake of protein rich foods

Long term goal:After 2-3 weeks of nursing intervention, the patient will achieve timely

from signs and symptoms of infection. a.without swellingb.without unusual drainagec.without foul odor   

unusual drainage, odor redness, or separation of the suture lines

- Empty and re-establish positive pressure in close wound drains per hour

Dependent:-Administer antibiotics as ordered(Cefuroxime 750mg.)

- Positive pressure pulls fluid from the incisional area, which facilitates healing

-to prevent infection

wound healing and be free from signs and symptoms of infection.

a.without swellingb.without unusual drainagec.without foul odor

Generic Name Trade Name Frequency/Route Contraindication/Side Effects

Classification/Action Nursing Consideration

Cefuroxime

750 mg

Ecocef 1.5g 30mins prior to OR, induction of anesthesia

Contraindicated in patients with known allergy to the cephalosporin group of antibiotics.

Side Effects:nausea, vomiting, stomach pain, mild diarrhea, gas, upset stomach;cough, stuffy nose;stiff or tight muscles, muscle pain;joint pain or swelling;headache, drowsiness;feeling restless, irritable, or hyperactive;white patches or sores inside your mouth or on your lips

Class:Anti-Infectives

Action:Bind to bacterial cell wall membrane, causing cell death

Rightclientdrugdoseroute timeassessmentapproachto refuseto know the reason for the drugevaluationdocumentationdrug preparation

Inspect IM and IV injection sites frequently for signs of phlebitis.Monitor for manifestation of hypersensitivity

Generic Name Trade Name Frequency/Route Contraindication/Side Effects

Classification/Action Nursing Consideration

Diclofenac Sodium

75 mg

Voltaren 75mg. TIV stat should not be given to patients who have experienced asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs. Severe, rarely fatal, anaphylactic-like reactions to NSAIDs have been reported in such patients.

Side Effect:Stomach problems, including gas, bloating, pain, cramping, constipation, and diarrhea.Upset stomach and/or bleeding in your stomach, esophagus, or intestines.Headache and ringing in the ears.Rash.

Class:NSAID, Analgesic, Antipyretic, CNS agent

Action:it appears to be a potent inhibitor of cyclooxygenase, thereby decreasing the synthesis of prostaglandins.

Rightclientdrugdoseroute timeassessmentapproachto refuseto know the reason for the drugevaluationdocumentationdrug preparation

Observe and report for signs of bleedingMonitor blood pressure for hypertension and blood sugar for hyperglycemiaMonitor for signs and symptoms of GI irritation and ulcerationMonitor for increase serum sodium and potassium