NURSING CARE PLAN

Pt. W.P.G
Dx: Excision Biopsy, Frozen section modified Radical Mastectomy right
Cues
Nursing
Nursing Objective
Nursing Intervention
Diagnosis
S:
Acute Pain
Within 8 hours of
-Monitor vital signs

related to postnursing interventions

operative
patient will manifest
-Perform pain assessment by
O:
incision at
a decrease in pain
using pain scale.
Vs:
right breast
scale from 8/10 to
BPsecondary to
6/10:
140/90
mastectomy
-Instruct patient to report un
T: 36
-Verbalize
tolerable pain as soon as
understanding of the
possible.
cause of pain.
- post
surgical
-Provide quiet environment and
-Identify ways to
suture on
comfort measures
alleviate pain.
the Right
Breast
-Participate in care
- with
and pharmacological -Encourage deep breathing and
some diversional activities.
regimen.
pain scale
-Encourage ambulation as soon
of 8/10 at
as the pt. recovers but note
the site of
when pain occurs
operation
- (+)Facial
-Encourage adequate rest
grimace
periods
-Slight
-Administer analgesics as

Scientific explanation
-Elevated vital signs can be a sign of pain.
- To assess etiology and contributing factors.
- Timely intervention is more likely to be
successful in alleviating pain.
- To provide non-pharmacological pain
management.

-To lessen sense of anxiety and associated musc

tension.
-To promote circulation and determine toleranc

-To prevent fatigue

-To maintain acceptable level of pain.

ordered.

irritability

NURSING CARE PLAN

Cues

Pt. W.P.G
Dx: Excision Biopsy, Frozen section modified Radical Mastectomy right
Nursing Diagnosis
Nursing Objective
Nursing Intervention

O:
Vs:
BP- 140/90
T: 36
- post surgical suture
on the right breast
- presence of Jackson
Pratt

Impaired skin
integrity related to
surgical incision
secondary to breast
removal

Short term planning:

After 1-2 hours hour of
nursing, patient will be
able to know, verbalize
and demonstrate the
right measures on taking
care of her post surgical
skin to prevent
infection.
Long Term planning:
After 3 weeks of
continuous nursing
intervention, patient will
remain free of
impairment in skin
integrity, as evidenced
by healing skin without
redness, infection,

Scientific explanation Evaluation

>Monitor vital signs,

especially Temperature and
BP.

>elevation of temp.
may be assign of
infection for early
detection

>Provide and explain

dressing and drain care
(Jackson Pratt)

>this helps in
preventing and
promoting an aseptic
way of wound healing.

>Encourage and Teach

patient on how to do
exercises such as elbow
flexion/extension & other
activities that use the arm
with care; not to raise it too
high or above the shoulder.

>this facilitates lymph

flow, prevent or
reduce swelling of
affected part.

>Advise patient or relative to

report any untoward s/sx

>Fever & redness are

the usual signs of

Short term:
After 1-2 hours of nursing
intervention, patient was
able to verbalize and
demonstrate the right
measures in taking of her
post surgical skin.

hematoma formation or
breakdown.

such as fever or redness on

affected part.

having an infection &

early detection would
limit its spread.

>Administer prophylactic
antibiotics as prescribed.

>Prophylaxis is a
prevention of spread
of infection that may
further pose a risk on
patient.

NURSING CARE PLAN

Pt. W.P.G
Dx: Excision Biopsy, Frozen section modified Radical Mastectomy right
Cues
Nursing
Nursing Objective
Nursing Intervention
Diagnosis
Risk for infection Short term:
-Monitor vital signs.
O:
related to surgical After 1-2 hours of
Vs:
incision site
-Stressed proper hand washing.
BP- 140/90
nursing intervention
T: 36
the patient will be
-Instruct proper wound care
-with surgical
able
to
identify
and
incision wound
demonstrate
at the right
-Encourage to eat vitamin c rich
breast
interventions to
foods
-with dry intact
prevent or reduce risk
dressing
of infection.
- Closely observe and instruct to
report signs and symptoms of
Long term:
infection such as fever, sore throat,
swelling, pain and drainage
After 2-3 weeks of
nursing intervention, - Inspect the wound for swelling,
unusual drainage, odor redness, or
the patient will
separation of the suture lines

Scientific explanation

Evaluation

-To detect presence of infection.

Short term:

- Handwashing is the single most

effective way to prevent infection
- For first line defense against
nosocomial infections or cross
contamination
- To promote wound healing

After 1-2 hours of

nursing
intervention the
patient has
identified
interventions to
prevent or reduce

- To prevent and detect as early

as possible the presence of any
progressing infection

risk of infection.
Long term:
After 2-3 weeks of

- Wound infection are

accompanied by signs of
inflammation and a delay in

nursing
intervention, the

achieve timely

- Empty and re-establish negative

wound healing and be
pressure in close wound drains at
free from signs and
least once per shift
symptoms of
-Administer antibiotics as ordered
infection.

healing
- Negative pressure pulls fluid
from the incisional area, which
facilitates healing
-to prevent infection

patient achieved
timely wound
healing and has
been free from
signs and
symptoms of
infection.