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Problem: Impaired skin integrity related to mechanical trauma to the skin secondary to MRM

Nursing Scientific Expected


Assessment Planning Interventions Rationale
Diagnosis Explanation Outcome
S=Ø Impaired skin Modified radical Short term: 1. Assess skin, 1. Establish Short term:
integrity mastectomy is note color,
After 4 es After the
related to usually the turgor, and
O= mechanical treatment of hours of NI, sensation. compara nursing
trauma to the choice. This is
The patient the patient tive interventions,
skin the most
manifested: secondary invasive of the will baseline the patient
to MRM three
> Disruption of verbalize an providing shall have
treatment
skin surface at
options understandi opportun verbalized an
the right upper
described here,
extremity. ng on how ity for understandin
but despite this
> Wound is
it is the most to maintain 2. Describe timely g on how to
7cm in
common and
diameter proper care intervent maintain
surgical measure
> localized
procedure for with her wounds and ion proper care
edema on operable breast observe
wound 2. Establish with her
cancer. This is changes.
operative site
largely because es wound
>localized it provides an
Long term: compara
effective
erythema
treatment and After 3 days tive
>facial mask is also the least
of NI, the baseline
disfiguring
>guarding
breast removal patient will providing Long term:
behavior procedure. In a
display opportun After the
modified
The patient
radical timely 3. Demonstrat ity for nursing
may manifest: mastectomy e good skin
wound timely interventions,
the entire hygiene,
> altered
breast is healing AEB e.g., wash intervent the patient
mental status removed, as thoroughly
intact skin, ion shall have
well as the and pat dry
> altered LOC
lymph nodes on decreased carefully. displayed
> changes in the same side.
erythema 3. Maintaini timely wound
The large chest
motor
muscle known and ng clean, healing AEB
response as the
absence of dry skin intact skin,
pectoralis
> paralysis of
major is not purulent provides decreased
extremities removed, which
discharge a barrier erythema and
means the
> necrosis
chest wall is to absence of
still covered
infection. purulent
and protected