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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
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
treatment and After 3 days tive
>facial mask is also the least
of NI, the baseline
breast removal patient will providing Long term:
behavior procedure. In a
display opportun After the
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
muscle known and ng clean, healing AEB
response as the
absence of dry skin intact skin,
> 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