BACKGROUND OF THE STUDY

A 42-year-old female patient presented at the Emergency Room of SKPH last February 18, 2024 with chief complaints of pain and
feeling of tightness around a lump in her right breast. She has a history of hypertension, diabetes mellitus and asthma.
On February 19, 2024, patient underwent a mastectomy caused by stage II invasive ductal carcinoma. This surgical procedure is
used to remove all breast tissue from a breast. It’s most often done to treat breast cancer. It can also prevent breast cancer in those
with a very high risk of developing it.

Invasive ductal carcinoma (also referred to as infiltrating ductal carcinoma) is the most common type of breast cancer, accounting for
approximately 80% of the total number of cases. Invasive ductal carcinoma occurs when cancerous cells form in a duct that carries
milk from a lobule (a gland in the breast that produces milk) to the nipple, and then spreads to tissue outside the duct. By stage 2, a
breast tumor measures 2 to 4 centimeters in diameter or cancerous cells have spread to the lymph nodes in the underarm area.

There are several types of mastectomy procedures. The most common total mastectomy, which involves removing all breast tissue,
including the nipple and areola, the breast skin and the tissues that cover the chest muscles. Usually, the surgeon will also perform a
sentinel lymph node biopsy to check for cancer spread.

Additionally, most patients who undergo a mastectomy do so because of malignancy, and their post-operation care team includes
medical oncology and possibly radiation oncology. Following mastectomy, patients may require home healthcare nursing support and
even physical or occupational therapy to maximize the return of capacity for activities of daily living.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Impaired After 4 hours of A.) Monitor site of A.) Systematic “Goal Met”
N/A Skin nursing intervention impaired skin integrity inspection can After 4 hours of
Integrity the client will be at least once daily for identify impending nursing
Objective Data: related to able to: color changes, problems early. intervention the
Disruption of skin surgical A.) Verbalized an redness, swelling, B.) Individualized client will be able
warmth, pain or other
layer removal of understanding on plan is necessary to:
signs of infection.
Guarding the how to maintain B.) Monitor status of according to A.) Verbalized an
behavior breast(mast proper care with her skin around wound. patient’s skin understanding on
Immobility of ectomy) wound. Monitor patient’s skin condition, needs, how to maintain
right arm secondary care practices, noting and preferences. proper care with
to invasive the type of soap or C.) This technique her wound.
ductal other cleansing reduces the risk of “gatawan ko den
carcinoma agents used, infection in belimpyu su pali
as temperature of water impaired skin ko endu di ko
evidenced and frequency of skin integrity. galimpangan
by damaged cleansing. D.) This is to avoid pedtagwan sa
epidermal C.) Keep a sterile adverse effects of betadine I pali ko.”
dressing technique
tissue external (Marunong na
during wound care.
D.) Don’t position the mechanical forces akong maglinis ng
patient on the site of (pressure, friction, sugat at di ko na
impaired skin integrity. and shear). na
If ordered, turn and E.) Rubbing and nakakalimutang
position patient at scratching can lagyan ng
least every 2 hours, cause further injury betadine). As
and carefully transfer and delay healing. verbalized by the
patient. F.) Wound patient.
E.) Tell patient to infections maybe
avoid rubbing and managed well and
scratching. Provide more efficiently
gloves or clip the nails
with topical agents,
if necessary.
F.) Administer although
antibiotics as ordered. intravenous
antibiotics may be
indicated.
REFERENCES;

https://www.moffitt.org/cancers/invasive-ductal-carcinoma/treatment/surgery/
https://www.breastcancer.org/treatment/surgery/mastectomy/what-to-expect