Name of Patient: J. L.
Age/Sex: 62 - F Room/Bed #:
Chief Complaint: Breast Mass
Diagnosis (if discharged):
DATE & CUES NEE NURSING
TIME D DIAGNOSIS
F S: “nagasakit ang Acute Pain related to
dalom kag gilid sang C Post Surgical Tissue
E
akong nga totoy” as O Damage as
B verbalized by the G evidenced by 2/3 pain
patient. N scale, grimaced face
R evidenced by:
I and guarding
U With pain scale of 2/3 T behavior.
1 – mild pain I a. From pain scale
A of 2/3 to 1/3
2 – moderate pain V Rationale:
R 3 – severe pain E A Modified Radical
- PMastectomy is a
Y
P procedure that
E removes the entire
O: R breast – including the
@
 (+) grimaced face C skin, breast tissue,
 (+) guarding E areola, and nipple –
1:00 PM
behavior P along with most of
 (+) restlessness T your underarm lymph
nodes. A doctor will
 Post Modified U
A make an incision
Radical
L across your chest to
Mastectomy
remove the breast
tissue. This surgery
can cause your arm
to feel stiff and sore.
309-3
Physician: Dr. Lim Alexander Uy
PATIENT INTERVENTION IMPLEMENTATIO EVALUATION
OUTCOME N
That within 2 hours 1. Consider reports of February 1, 2020 @ 3 pm
of nursing care the pain and stiffness, the
patient will be free duration and intensity. 2 GOAL PARTIALLY MET
from pain as
After 2 hours of nursing care
Rationale:
the goal was partially met as
Aids in identifying the evidenced by:
degree of discomfort.
The amount of tissue,
a. From 2/3 pain scale to 1/3
muscle and lymphatic with verbalization of “kirot kirot
1 – mild pain system removed can na lang gamay”
2 – moderate affect the amount of
pain pain experienced. b. (-) grimaced face
3 – severe pain
2. Note reports of 3 c. (+) guarding behavior
b. (-) grimaced face numbness and
d. (+) restlessness
swelling.
c. (-) guarding e. Client appeared relaxed
behavior Rationale: and able to rest properly.
Destruction of nerves in
d. (-) restlessness the axillary region
causes numbness in
e. Client will appear upper arm which may
relaxed and able be more intolerable. 4
to rest
appropriately 3. Reposition as
Reference: indicated: semi
Ranchod, Y. (2018, Fowler’s and lateral
June 28). What Is sims’
Modified Radical
Mastectomy? Rationale:
Retrieved February May relieve pain. Semi
12, 2020, from Fowler’s position
https://www.healthli relieves abdominal
ne.com/health/modi muscle tension and
fied-radical- arthritic back muscle
mastectomy tension whereas lateral
Sims’ relieve dorsal
pressure.

4. Provide additional
comfort measures such
as: backrub, heat or
cold applications.

Rationale: 5
Improves circulation,
reduces muscle tension
and anxiety associated
with pain.

5. Encourage use of
relaxation techniques
such as: deep
breathing exercises,
guided imagery,
visualization and
music.
Rationale:
Relieves muscle and 1
emotional tension;
enhances sense of
control and may
improve coping
abilities.

6. Administer
medications as
indicated: Analgesics
IV, NSAIDS [aspirin,
diflunisal (dolobid), and
naproxen (Anaprox)]

Rationale:
Analgesics given
through IV reaches the
pain centers
immediately, providing
more effective relief
with small doses of
medication. NSAIDs
are useful for mild to
moderate pain or as
adjuncts to opioid
therapy when pain is
moderated to severe.

7. Monitoring of side
effects of the
medication given and
provide patient
education.

Rationale:
Adverse effects of
analgesics such as
nausea can be
worsened by the
presence of emesis.
Vomiting can impact
the patient’s overall 6
health.

8. Encourage to use
affected arm for
personal hygiene such
as: feeding, combing
hair, and washing face)

Rationale:
Increase circulation,
helps minimize edema
and maintains strength
and function of the arm
and hand.

9. Provide emotional
support to the patient

Rationale:
Regardless of the
mechanism of pain
relief, addressing a
patient’s emotional and
psychological health
plays an integral part in
post-mastectomy pain
management.

10. Discuss the normal

effects of the surgery to
the patient.

Rationale:
Provides reassurance
that sensations are not
imaginary and that
relief can be obtained.

Reference:
Gregorio, G. (2018,
June 15). Pre and post
of care for mastectomy.
Retrieved February 12,
2020, from
https://www.slideshare.
net/GianneGregorio/pre
.
-and-post-of-care-for-
mastectomy

Vera, M. (2019, June

2). 13 Surgery
(Perioperative Client)
Nursing Care Plans.
Retrieved February 12,
2020, from
https://nurseslabs-
com.cdn.ampproject.or
g/v/s/nurseslabs.com/1
3-surgery-
perioperative-client-
nursing-care-plans/?
amp=&usqp=mq331AQ
CKAE=&_js_v=0.1#Ac
ute-Pain