XI.

NURSING CARE PLAN

1. ACUTE PAIN

Nursing Diagnosis

Acute pain related to compression/destruction of nerve tissue, secondary to tumor

growth as manifested by guarding behavior, restlessness, grimacing face and report of

pain with a pain scale of 8/10 on the right breast.

Nursing Inference:

The uncontrollable growth of tumor in the breast can compress the nerve that

innervates the muscle as a result pain will be felt. In addition to the tumor growth, it also

impedes the blood flow that supplies the area, in order to generate energy; the cells will

utilizes anaerobic metabolism consequently which produces lactic acid as by product.

Lactic acid irritates nerve endings.

Nursing Goal:

After 15 - 30 minutes of rendering appropriate nursing interventions the patient will

be able to demonstrate use of relaxation techniques and report of relieved pain from 8/10

to 4/10, with minimal guarding behavior, restlessness and grimacing face.

Nursing Intervention Rationale

Administer Tramadol HCl 50 mg as Decreases pain by binding to mu-opioid

prescribed. receptors. Inhibits reuptake of serotonin
and norepinephrine in the CNS.
Provide cutaneous stimulation (cold Cold compress reduces blood flow to a
compress) particular area, which can significantly

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 reduce inflammation and swelling that
causes pain. It can temporarily reduce
nerve activity, which can also relieve pain.
Encourage the patient to do deep Deep breathing delivers greater amounts
breathing exercise. of oxygen to your body more quickly that
will help to calm down and help control
stress to reduce perception of pain.
Encourage patient to do diversional To divert the attention from pain felt.
activities such as listening to soft music
and having conversation to SO.
Provide quiet environment. Excessive stimulation can cause stress
response and consequently it causes
muscle to tense and contract which can
further aggravate pain.
Nursing Evaluation:

After 15 - 30 minutes of rendering appropriate nursing interventions the patient

was able to demonstrate use of relaxation techniques and report of relieved pain from

8/10 to 4/10, with minimal guarding behavior, restlessness and grimacing face.

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 2. FATIGUE

Nursing Diagnosis

Fatigue related to decreased hemoglobin secondary to profuse bleeding with

manifestations of easy fatigability and lack of energy

Nursing Inference:

The uncontrollable growth of tumor in the breast compresses the surrounding

tissues and increasing its pressure in a prolonged period of time. This will now cause the

ulceration of the breast tissues which now leads to profuse bleeding. Because of the

continuous blood loss there will be low levels of RBC that contains oxygen that will be

distributed to the different body parts to help them function well which will lead to easy

fatigability.

Nursing Goal:

After 8 hours of rendering appropriate nursing interventions the patient will be able

to demonstrate a decrease in physiological signs of intolerance, free from weakness and

risk of complication is prevented.

Nursing Intervention Rationale

Anticipate the need for the Packed RBCs increase oxygen-

transfusion of packed RBCs. carrying capacity of the blood.
Assist the patient to develop a A plan that balances periods of
schedule for daily activity and rest. activity with periods of rest can help
the patient complete desired

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 activities without adding to levels of
fatigue.
Identify or implement energy saving Encourages patient to do as much
technique like sitting while doing a as possible. While conserving
task. energy and preventing fatigue.
Encourage the patient to use The use of assistive devices can
assistive devices. minimize energy expenditure and
prevent injury with activities.
Elevate the head of the bed as Enhances lung expansion to
tolerated. maximize oxygenation for
cellularuptake.
Assess the need for fall risk Client may not be able to perceive
precautions. weakness and loss of balance.

Nursing Evaluation:

After 8 hours of rendering appropriate nursing interventions the patient is able to

demonstrate a decrease in physiological signs of intolerance, free from weakness and

risk of complication is prevented.

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 3. DISTURBED BODY IMAGE

Nursing Diagnosis

Disturbed body image related to loss of body part secondary to mastectomy as

manifested by fear of reaction by others and verbalization of “Mabainak pay nga rumuar

mapan mangarruba gapu ta awan toy mesa nga susokon.”

Nursing Inference:

Body image is the attitude a person has about the actual or perceived structure

or function of all or part of his or her body. This attitude is dynamic and altered through

interaction with other persons and situations. As an important part of one's self-concept,

body image disturbance can have profound impact on how individuals view their overall

selves. This involves grieving that can be a functional adaptation or maybe dysfunctional

or unresolved.

Nursing Goal:

After 6 months of imparting health teachings the patient will be able to verbalize

relief of anxiety, adaption to actual body image, acceptance of self in situation, and

verbalization of “Dyuray man naawan detoy maysa nga susok, agyaman nak latta ken

apo nga sibibiag nak pelang ita.”

Nursing Intervention Rationale

Encourage verbalization of positive or To allow the client to express herself and

negative feelings about actual or release tension on feelings.
perceived change.

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 Encourage patient to look at/touch the To begin to incorporate changes into body
affected chest part. image.
Teach patient adaptive behavior like using To help the client gain back
of adaptive equipment that conceals her confidence by concealing altered body
altered body part such as breast pads. part.
Encourage the client to participate in a Support group can help to cope better and
support group. feel less isolated by make connections
with others facing similar challenges.
Set limits on maladaptive behavior and To aid in recovery.
assist client to identify positive behaviors.
Work with client’s self-concept, avoiding Positive reinforcement encourages client
moral judgments regarding client’s efforts to continue efforts and strive for
or progress. improvement.
Maintain therapeutic communication and To facilitate good nurse-patient interaction
demonstrate positive caring in routine and also gain clients trust to cooperate.
activities.
Visit client frequently and acknowledge the Provides opportunities for listening to
individual as someone who is worthwhile. concerns and questions.

Nursing Evaluation:

After 6 months of imparting health teachings the patient was able to verbalized

relief of anxiety, adapt to actual body image, accept of self in situation, and verbalization

of “Dyuray man naawan detoy maysa nga susok, agyaman nak latta ken apo nga sibibiag

nak pelang ita.”

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 4. IMPAIRED SKIN INTEGRITY

Nursing Diagnosis

Impaired skin integrity related to disruption of skin tissue associated with the

surgical procedure as manifested by presence of surgical wound.

Nursing Inference:

Breast Cancer is the most common malignancy in women as a cause of Cancer

related death. Decrease in mortality maybe ascribed to the combined benefits of early

detection and better treatment. One of its treatment modalities is an invasive procedure

causing a breakage in the continuity of the skin as removal of the affected part is done,

leaving the skin impaired for a moment until healing of tissue takes place which happens

depending on the body’s ability to heal.

Nursing Goal:

After an hour of rendering appropriate nursing intervention the patient will be able

to demonstrate the right measures on taking care of postsurgical skin to prevent infection

and verbalization of the said health teachings.

Nursing Intervention Rationale

Administer prophylactic antibiotics such as Bind to bacterial cell wall membrane,

Cephalosporin 500 mg as prescribed.
Provide and explain care of dressing.
causing cell death and as a prevention of
spread of infection that may further
predispose a risk on patient
This helps in preventing and promoting an
aseptic way of wound healing

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 Advice the patient to bathe with lukewarm To maintain cleanliness without irritating
water and mild soap. the skin.
Encourage and teach patient on how to do This facilitates lymph flow, prevent or
exercises such as elbow flexion/extension reduce swelling of affected part.
& other activities that use the arm with
care; not to raise it too high or above the
shoulder.

Nursing Evaluation:

After an hour of rendering appropriate nursing intervention the patient was able to

demonstrate the right measures on taking care of postsurgical skin to prevent infection

and verbalization of the said health teachings.

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