mastectomy nursing proces

MASTECTOMYDefinition

Mastectomy is the surgical removal of the breast which is usually a surgical management for patients with breast cancer. This is done to prevent the metastasize of the cancer cells. Breast cancer is the most common malignancy experienced by women. Breast cancer is the uncontrolled growth of breast cells.

Nursing Goals

The nursing goal for a patient who underwent mastectomy can be: pain management, counseling due to disturbed body image, and preventing infection due to surgical incision.

Risk for Injury

Areas involving the neck are considered to be the most vascularized parts of a person’s body. We all know that the most common complication of a surgery is excessive bleeding or hemorrhage, this was brought about by excessive blood loss intra or postoperatively.

NDx: Risk for Injury related to change in center of gravity secondary to extensive removal of chest tissue

Assessment Objectives Nursing Interventions

Rationale Desired Outcomes

S: (none)O:The patient may manifest:

edema

muscle weakness

altered mobility

sensory and perceptual disturbances due to anesthesia

Apprehension, restlessness

thirst; cold ,

Short term:After 3-4 hours of nurse-patient interaction, the patient will verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situations.Long Term:After 3-4 days of nurse-patient interaction, the patient will demonstrate behaviors,

Establish pt. Rapport

Monitor vital signs frequently.

Access mood, coping abilities and personality styles

Identify interventions and safety devices

Encourage participation in self-help programs, such as assertiveness training, positive self-image

To gain trust and cooperation of the pt.

VS could indicate possible bleeding

That may result in carelessness and increased risk-taking without consequences.

To promote safe physical environment and individual safety

To enhance self-esteem and sense of self-worth

Short term:The patient shall verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situation.Long Term:The patient shall demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

moist, pale skin

increase in pulse rate, respiration rate

drop in temperature

decrease in urinary output

lifestyle changes to reduce risk factors and protect self from injury.

Provide bibliotherapy and written resources

Assist client during periods of ambulation

Walk client’s unaffected side

Instruct the client to keep the shoulders level and the muscle relaxed when walking

For later review and self-paced learning

The nurse supports the client when or if client loose balance

The client is more likely to drift toward the side of the body that is heavier

Clients tend to accommodate for the change in the center of gravity by leaning to the side

Acute Pain

NDx: Acute pain r/t postoperative incision.

ASSESSMENT PLANNING NURSING INTERVENTIONS

RATIONALE EXPECTED OUTCOME

S= Client may verbalize:

Fear

O= Client may manifest:

Facial Grimaces

Restlessness

Guarded behavior

Irritability

Sleep disturbances

Distraction behavior

Autonomic alteration of

Short term:After 3 hours of nursing intervention, client’s pain scale will be reduce.Long term:After 1 day of nursing intervention, client will be relieve from pain and will appear more relax.

Establish rapport

Monitor vital signs

Assess verbal/non-verbal reports of pain, noting location, intensity (0-10 scale), and duration

Place in Semi-Fowler’s position and support head/neck in neutral position with sandbags or small pillows as required in immediate postoperative phase

Instruct client to use hands to support neck during movement and to avoid hyperextension

To gain trust of the patient

For baseline data

Useful in evaluating pain, choice of interventions, effectiveness of therapy

Prevents hyperextension of the neck and protects integrity of the suture line

Movement restriction is imposed for only a few hours postoperatively to

Short term:After 3 hrs of nursing intervention, client’s pain scale shall have reduce.Long term:After 1 day of nursing intervention, client shall be relieved of pain and shall appear more relaxed.

muscle tone

Diaphoresis

Self-focusing

Impaired though process

of neck

Keep call light and frequently needed items within easy reach

Give cool liquids or soft foods such as ice cream or popsicles.

Encourage client to use relaxation techniques e.g., guided imagery, soft music, progressive relaxation

Administer analgesics and throat sprays/lozenges as necessary

Provide ice if indicated

prevent stress on the suture line and reduce muscle tension. Gentle flexing and stretching is then permitted according to pain tolerance to help prevent neck soreness

Limits stretching, muscle strains in operative area

Soft foods may be tolerated better than liquids if clients experience s difficulty of swallowing

Helps refocus attention and assist client to manage pain more effectively

Reduces pain and discomfort, enhances rest

Reduces tissues edema and decreased perception of pain

Impaired Skin Integrity

Mastectomy, like any other surgical procedures, includes invasion of the inside body, specifically the skin and subcutaneous area. Upon incision, there will be impairment of the skin integrity causing damage, impairment of skin circulation and sensation and pain in the incision site. The muscles are then repaired and the skin incision is closed with sutures that will either absorb or be removed soon after the operation. The actual incising of the skin is seen as an impairment in the skin’s integrity.

NDx: Impaired skin integrity R/T surgery

ASSESSMENT PLANNING INTERVENTIONS RATIONALE OUTCOMES

S= ØO= the patient may manifest:

Presence of surgical wound on the breast where incision was made

Pain

Numbness of surrounding areas

Disruption of skin surface

Redness

Itchiness

Poor capillary refill

SHORT TERM:After 4 hours of nursing interventions, the patient will participate in prevention measures and treatment programLONG TERM:After 1-2 days of nursing interventions, the patient will be able to display progressive improvement in wound healing.

establish rapport

monitor and record vital sign

assess incision site taking note of size, color, location, temperature, texture, consistency of wound/ lesion if possible

inspect surrounding skin for erythema, induration, maceration

assess for odors and drains coming out from the skin/ area of injury

inspect skin on a daily basis, describing lesions and changes observed

keep the area clean/dry, carefully dress wounds, support incision, and prevent infection

use appropriate wound coverings

encourage an increase in protein and calorie intake

encourage adequate rest and sleep

encourage early ambulation and mobilization

provide position changes

practice aseptic technique in cleansing/dressing and medicating lesions

to gain the trust and cooperation of the client

to obtain baseline data

to provide comparative baseline data

to assess extent of involvement

to assess early progression of wound healing, development of hemorrhage or infection

to promote timely intervention/revision of plan of care

to assist body’s natural process of repair

protect the wound and/or surrounding tissue

to aid in timely wound healing for the patient

to prevent fatigue

to promote circulation and reduce risks associated with immobility

to prevent bed ulcers from occuring

to reduce risk of cross-contamination

to prevent spread of infectious agent

SHORT TERM:The patient shall participate in prevention measures and treatment programLONG TERM:

The patient shall be able to display progressive improvement in wound healing.

instruct proper disposal of soiled dressing

Activity Intolerance

Activity intolerance refers to the insufficient physiological or psychological energy to complete desired daily activities. Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic or pulmonary –related problems. It is also common in persons who undergone surgeries and it is experienced postoperatively.

The person is suffering from a physical and psychological inability to complete daily activities caused by generalized weakness due to post-surgical procedure. Post-operative patient usually is under bed rest for a few days that may hinder them to their usual activity. Pain that may accompany post-op also inhibit the client to possible ranges of motion.

NDx: Activity intolerance related to generalized weakness

Assessment Objective Nursing Intervention Rationale Expected Outcome

S: ӨO: Patient may manifest:

Weakness

Limited range of motion

Fatigue

Dyspnea

Decreased hemoglobin and hematocrit level

Immobility

Exertional discomfort

Abnormal heart rate and blood pressure

Short term:After 4 hours of nursing interventions, the patient and the significant, others will be able to identify negative factors affecting activity tolerance and eliminate/reduce their effects when possible.Long term:After 3 days of nursing interventions, the patient will be able to improve his activity and

1. Establish patient’s rapport

2. Monitor and record vital signs

3. Assess patient’s condition

4. Assess patient’s level of mobility

5. Assess nutritional status

6. Ascertain ability to stand and move about and degree of assistance necessary/ use of equipment

7. Provide a quite environment and encourage use of stress

1. To gain trust and cooperation of the patient

2. To obtain baseline data

3. To obtain baseline data to be use in evaluating patient’s condition

4. This aids in defining what patient is capable of, which is necessary before setting realistic goals

5. Adequate energy reserves are required for activity

6. To know what

Short term:The patient and the significant others shall have identified negative factors affecting activity tolerance and eliminated/reduced their effects when possible.Long term:The patient shall have improved his activity and use techniques to enhance activity tolerance.

Pallor

Cyanosis

perform techniques to enhance activity tolerance.

management8. Encourage

adequate rest periods

9. Promote comfort measures and provide for relief of pain

10. Plan care with rest periods between activities

11. Instruct SO in monitoring response to activity and in recognizing signs and symptoms

12. Assist client in learning and demonstrating appropriate safety measures

13. Encourage client to maintain positive attitudes; suggest use of relaxation techniques, such as visualization/guided imagery as appropriate

goals to be establish to perform wellness

7. Reduces stress and excess stimulation, promoting rest

8. Rest provides time for energy conservation and recovery

9. To enhance ability to participate in activities

10. To reduce fatigue11. To indicate need

to other activity level

12. To prevent injuries

13. To enhance sense of well-being

Risk for Ineffective Breathing Pattern

Anesthesia is an artificially induced state of partial or total loss of sensation with or without loss of consciousness. Anesthesia agents can produce muscle relaxation, block transmission of pain nerve impulses and suppress reflexes. The depth and effects of anesthesia are monitored by observing changes in respiration and oxygen saturation and end tidal carbon dioxide levels, heart rate, urine output and blood pressure.

NDx: Risk for ineffective breathing pattern related to chemically induce muscular relaxation



Use of accessory muscle to breathe

Nasal flaring

Altered chest excursion

Increase anterior posterior diameter

Purse lip breathing

Decrease inspiration/

expiration

Short term:After 4 hours of nursing interventions, the patient will be free from signs and symptoms of ineffective breathing pattern.Long term:After 2 days of nursing interventions, the patient will maintain a normal and effective breathing pattern.



3. Use pulse oximetry to monitor oxygen saturation and pulse rate

4. Monitor vital capacity in patients with neuromuscular weakness and observe trends

5. Instruct client to deep breathe during walking hours or use an incentive spirometer

6. Splint incision to reduce discomfort

7. Administer oxygen as prescribed

8. Instruct client to self-administer analgesia before deep breathing and coughing if a patient-controlled analgesia pump is available



3. To detect changes in oxygenation

4. Monitoring detects changes early

5. Deep breathing distends alveoli and promotes increased gas diffusion

6. Pain or fear of pain interferes with deep breathing

7. Supplemental oxygen provides a higher concentration than found in room air

8. Pain is more adequately controlled when an analgesic is given before severe pain develops

Short term:The patient shall be free from signs and symptoms of ineffective breathing pattern.Long term:The patient shall have maintained a normal and effective breathing pattern.

Risk for Infection

Skin is considered as a first line of defense against any foreign organism. Because of the surgical procedure the skin is impaired causing a possible entry for the organisms hence may cause infection.

NDx: Risk for infection related to surgical wound

Assessment Objective Nursing Intervention Rationale Expected

Outcome


Pallor

Weakness

With dry and intact dressing on the excised area

Swelling over the incision area

Short term:After 4 hours of nursing interventions, the patient will be able to identify and demonstrate interventions to prevent or reduce risk of infection.Long term:

After 2 days of nursing interventions, the patient will achieve timely wound healing and be free from signs and symptoms of infection.



3. Stress proper hand washing technique

4. Provide regular catheter care

5. Instruct on proper wound care

6. Encourage to eat vitamin C rich foods

7. Emphasized necessity of taking antibiotics as directed

8. Closely observe and instruct to report signs and symptoms of infection such as fever, sore throat, swelling, pain and drainage

9. Inspect the wound for swelling, unusual drainage, odor redness, or separation of the suture lines

10. Empty and re-establish negative pressure in close wound drains at least once per shift



3. Patients with poor nutritional status may be anergic or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection

4. For first line defense against nosocomial infections or cross contamination

5. To maintain optimal nutritional status

6. To promote wound healing

7. To boost the immune system

8. To prevent and detect as early as possible the presence of any progressing infection

9. Wound infection are accompanied by signs of inflammation and a delay in healing

10. Negative pressure pulls fluid from the incisional area, which facilitates healing

Short term:The patient shall have identified and demonstrated interventions to prevent or reduce risk of infection.

Long term:

The patient shall have achieved timely wound healing and free from signs and symptoms of infection.

Ineffective Therapeutic Management

With an ongoing changes in health care, patients are being expected to be co-managers of their care. They are being discharged from hospitals earlier, and are face with increasing complex therapeutic regimens to be handled in the home environment. Likewise, patients with chronic illness often have limited access to health care providers and are expected assume responsibility for

managing the nuances of their disease. Patient’s with sensory perception deficits, altered cognition, financial limitations,and those lacking support system may find themselves overwhelmed and unable to follow the treatment plan. Elderly patients, who often experience most of the above problems, are specially at high risk for ineffective management of the therapeutic plan.


S: noneO: The patient may manifest:

unable to meet the goals of a treatment

knowledge deficit of prescribed regimen

perceived seriousness

difficulties with prescribed regimen

Short Term GoalAfter 4 hours of NPI, the will verbalize acceptance of need and desire to change actions to achieve agreed-on outcomesLong Term GoalAfter 2 days of NPI the patient will participate in problem solving of factors interfering with integration of therapeutic regimen

1. Establish patient rapport

2. Monitor and record vital sign

3. Assess for related factors that may negatively affect success with following regimen

4. Assess patients confidence or her ability to perform desired behavior

5. Assess patient’s ability to learn or remember the desired health related activity

6. Assess patients ability to perform the desired activity

7. Use therapeutic communication skills

8. Provide positive reinforcement for efforts

9. Promote client and SO participation in planning and evaluating the

1. to gain patient trust and cooperation

2. to obtain baseline data

3. patient’s received seriousness and threat of disease affect his or her compliance with the program

4. positive conviction that one can be advised successfully executive a behavior is correlated with performance and successful outcomes

5. cognitive impairments need to be alternative plan can be advised

6. patient’s with limited financial may unable to purchase special foods

7. to assist client to problem-solve

Short term:The shall verbalize acceptance of need and desire to change actions to achieve agreed-on outcomesLong term:The patient shall participate in problem solving of factors interfering with integration of therapeutic regimen

process10. Assist client to

develop strategies for monitoring therapeutic regimen

11. Identify home- and community-based nursing service

solution8. to encourage

continuation of desired behaviors

9. enhances commitment to plan, optimizing outcomes

10. promotes early recognition of changes, allowing proactive response

11. for assessment, follow-up care, and education in clients home

Risk for Dysfunctional Grieving

Extended, unsuccessful use of intellectual and emotional responses by which individuals, families, communities attempt to work through the process of modifying self-concept based on the perception of loss. Dysfunctional grieving is a state in which an individual is unable or unwilling to acknowledge or mourn an actual or perceived loss. This may subsequently impair further growth, development, or functioning. Dysfunctional grief may be marked by a broad range of behaviors that may include pervasive denial, or a refusal to partake in self-care measures or the activities of daily living.

NDx: Risk for dysfunctional grieving r/t loss of breast


S: noneO: The patient may manifest:

mild to moderated decrease in mood

”acting out” behavior

Short Term GoalAfter 4 hours of NPI the patient will verbalize a sense of beginning to deal with grief occurring from the loss of breastLong Term GoalAfter 2 days of NPI the patient will participate in

1. Establish patient rapport2. Monitor and record vital

sign3. Assess clients ability to

manage activities of daily living and period of time since loss has occurred

4. Note stage of grief is experiencing

5. Acknowledge client’s sense of relief when death follows a long and

1. The nurse presence provide support. Ensuring privacy demonstrate for the client’s dignity

2. Numbing the mind

Short term:The patient shall verbalize a sense of beginning to deal with grief occurring from the loss of breastLong term:The patient shall participate in therapy to learn new ways of dealing with anxiety and

Guilt

Deviation from unusual behavior pattern

Withdrawal from others and normal activities

Behavior regression

Somatic complaints

Avoidance of affectively change topics

therapy to learn new ways of dealing with anxiety and feelings of inadequacy

debilitating course6. Meet with both members

of the couple7. Encourage client and SO to

identify healthy coping skills they have used in the past

8. Refer to other sources as needed, counselling, psychotherapy, significance of loss religious references, grief support group

9. Avoid trying to diminish the

10. Acknowledge client’s grief and reinforce that feeling angry or sad is normal and expected

11. Stay with client and ensure privacy during emotional periods

12. Avoid administering prescribed sedatives or tranquilizers as a substitute for spending time with the client

13. Encourage sharing with those who can be empathic, such as another breast cancer survivor

14. to gain patient trust and cooperation

15. to obtain baseline data16. They persist and interfere

with normal activities, client may need additional assistance.

17. stages of grief may progress in a predictable manner or may be experienced in different

interferes with grieving

3. Sharing the significant loss with person who has survived a similar experienced provides a bond for healing.

feelings of inadequacy

stages18. sadness and loss are still

there, but the death may be release and the grieving process may be soother

19. to determine how they are dealing with the loss

20. these can be used in current situation to facilitate dealing with grief

21. depending upon meaning of the loss, individual may require on-going support to work through grief

22. grief works involve dealing with the reality of a significant loss

23. validating client’s feelings give permission for him or her to experience true emotions

Ineffective Peripheral Tissue Perfusion

The importance of lymphatic system in maintaining fluid balance in the body. The plasma filters into the interstitial spaces from blood flowing through the capillaries. Much of this interstitial fluid is absorbed by tissue cells or reabsorbed by the blood before it flows out of the tissue. A small amount of interstitial fluid is left behind. If this would continue over even a brief period, the increased interstitial fluid would cause massive edema. This edema would causes tissue destruction or death. This problem can be avoided by the presence of lymphatic vessels that act as “drains” to collect the excess fluid and return it to the venous blood just before it reaches the heart.

NDx: Ineffective tissue perfusion (lymphedema) r/t compromised flow of lymphatic fluid

Assessment Desired Goal Nursing Interventions Rationale Expected outcome

SOOThe patient may manifest:=weak pulses= edema= drowsiness

= altered

Short Term:After 3-4 hours of nursing interventions, the patient will be able to demonstrate relaxation

1. establish rapport

2. monitor and record VS

3.assess signs of decreased tse perfusion

4. identify changes

1. to gain pt’s trust

2. to have a baseline data

3. to plan for effective treatment and give prompt care.

4. to asses predisposing

Short Term:Patient shall able to demonstrate relaxation techniquesLong Term:

sensations

= changes in LOC

techniques.Long Term:After 3-4 days of nursing interventions, the patient will be able to demonstrate an improved perfusion by regaining strength, strong pulse and maintain alertness.

related to systemic or peripheral alterations in circulation.

5. evaluate signs of infection when immune system is compromised

6. observe for signs of pulmonary emboli.

7. assess lower extremities, noting skin texture, presence of edema, ulcerations

8. encourage early ambulation if possible

9. elevate HOB

10. Provide quiet, relaxing environment

11. caution pt to avoid activities that could increase cardiac workload.

12. teach relaxation techniques like deep breathing

13. encourage pt. to rest

14. position pt. on a semi-fowler’s position

15. keep environment allergen free for the pt.

16. educate on proper hand washing

17. encourage pt. to eat nutritious foods

factors

5. to determine other possible related factors.

6. to assess for contributing factors

7. to note degree of impairment involved

8. to enhance venous return

9. to increase gravitational blood flow

10. To prevent additional stress to pt.

11. to maximize tse perfusion

12. to facilitate rest and recuperation and proper oxygenation

13. to enable the body to recuperate and repair

14. to facilitate proper chest expansion

15. to prevent presence which may cause increased mucus secretion

16. to prevent infection

17. to meet daily caloric requirement and facilitate

Patient shall able to demonstrate an improved perfusion by regaining strength, strong pulse and maintain alertness.

repair with body tissue

Fear

Fear is a strong and unpleasant emotion caused by the awareness or anticipation of pain or danger. This emotion is primarily externally motivated and source-specific, that is the individual experiencing the fear can identify the person, place or thing precipitating this feeling. The factors that precipitate fear are, to some extent, universal, fear of death, pair and bodily injury or defect are common to most people.

NDx: Fear r/t diagnosis of cancer as manifested by insomnia and crying



tachypnea

tachycardia

denial

fright

fatigue

dry mouth

Narrowed focus

insomnia

crying

Short term:After 4 hours of nursing interventions, the patient will demonstrate understanding through the use of effective coping behaviors and resourcesLong term:

After 2 days of nursing interventions, the patient will display appropriate range of feelings and lessened fear..



3. Determine what the patient is fearful of by careful and thoughtful questioning

4. compare verbal and nonverbal responses

5. Assess the degree of fear and the measures patient uses to cope with that fear

6. Document behavioral and verbal expressions of fear

7. Determine to what degree



3. patient who find it unacceptable to express fear may find it helpful to know that someone is willing to listen if they decide to share their feelings at sometimes in the future

4. to note congruencies or misperceptions of situation

5. This helps determine the effectiveness of coping strategies used by the pt.

6. Physiologic symptoms and complaints will intensify as the level of fear increases

7. Persistent, immobilizing fears may requires

Short term:The patient shall demonstrate understanding through the use of effective coping behaviors and resourcesLong term:

The patient shall display appropriate range of feelings and lessened fear..

the patients fears may be affecting his/her ability to perform ADL

8. Maintain a calm and tolerant manner while interacting with patient

9. Establish a working relationship through continuity of care

10. Provide safety measure within the home when indicated

11. As patient fear subsides, encourage him/her to explore specific events preceding the onset of fear

12. Encourage rest periods

13. Exercises in relaxation, meditation, or guided imagery

treatment with anti-anxiety medications

8. The patient’s feeling of stability increases in a calm and nonthreatening atmosphere and ongoing relationship establishes trust and a basis for communicating fearful feelings

9. If home environment is unsafe, patient’s fears are not resolved and fear may becoming disabling

10. Recognition and explanation of factors leading to fear are significant in developing alternative responses

11. Rest improves ability to cop

12. Exercise reduces the physiological response to fear

Other Nursing Care Plans

Sleep Pattern Disturbance

Pain is a discomfort that is caused by the stimulation of the nerve endings. Since pain is experience by the patient there are times that he can’t control it that makes him unable to sleep and sudden wake up due to pain cause interruption to sleep causing sleep disturbance.

Hyperthermia

Body temperature elevated usually occurs in response to an infection or inflammation temperature usually controlled by the Hypothalamus the thermostat for the body. Entry of microorganism can cause an alteration in the hypothalamic set point. Body temperature elevation occurs when the body’s immune response is triggered by pyrogens (fever- producing substances) and interleukin 1, a part of the innate immune system, and product by the phagocytic cells. These chemicals stimulate the cells of the hypothalamus to produce prostaglandin E, thus increasing the temperature set point. Turning up the heat is the body’s way of fighting the microorganism and making the body less comfortable place for them. When this condition occurs, many physiological stresses take place. Some of these include increased cell metabolism, increased heart rate, increased cardiac output. This process prevails until the body temperature matches the thermal point

Impaired Physical Mobility

Mastectomy includes incision of vital parts such as skin, subcutaneous fats, and some muscles, that causes damage to these parts which leads to impairment of neuromuscular responses of the body, that eventually causes the body to impair it’s mobility.

Disturbed Body Image

Mastectomy as a surgical procedure involves the removal of one or both of the client’s breasts. Upon removal, there is a potential of developing a low self-esteem and social stigma due to the surgical removal of the breast creating a disturbed body image because the breast particularly for women is a sign of femininity.

mastectomy nursing proces

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