Name: B Age: 45 years old Sex: Female

Chief Complain: fearful of the possible outcome after the operation Working/Medical Diagnosis: Modified Radical Mastectomy

Assessment Nursing Diagnosis Outcome Criteria Nursing Rationale Evaluation Discharge Planning
Intervention
Subjective: Situational Low Long term goal Independent MET. The patient Medications
“gina kulbaan ako Self-Esteem related After 12-24 hours of -Encourage - Loss of the breast was able to -Instruct patient
basi ano matabo sa to disfiguring nursing intervention questions about the causes many demonstrate regarding the
akon kag kun ano surgical procedure the patient will be current situation reactions, including movement toward intake of prescribed
hambalon sang mga and concern about able to: and future feeling disfigured, acceptance of self in medication
tao sa akon kag basi sexual expectations. fear of viewing scar, situation. by providing a list of
indi na ako pag attractiveness as -Demonstrate Provide emotional and fear of the medication
planggaon sang evidenced by movement toward support when partner’s reaction MET. The patient as well as the time
akon bana kay may verbalization of fear acceptance of self in surgical dressings to change in the was able to and frequency.
lain na saakon of rejection or of situation. are removed. body. recognize and Environment
huhu” reaction by others, incorporate change - Maintain clean,
change in social -Recognize and - Identify role - May reveal how into self-concept well ventilated
Objective: involvement and incorporate change concerns as woman, patient’s self-view without negating and peaceful
Vital Signs negative feelings into self-concept wife, mother, career has been altered. self-esteem. environment.
T- 37.2°C about body, without negating woman, and so Treatment
P- 18 bpm preoccupation with self-esteem. forth. MET. The patient -Encourage patient
R- 70 bpm change or loss, not was able to set and family
BP- 130/80 mmHg looking at body, -Set realistic goals - Encourage patient - Loss of body part, realistic goals and members to engage
nonparticipation in and actively to express feelings disfigurement, and actively participate in a healthy lifestyle.
therapy. participate in a like anger, hostility, perceived loss of in a therapy - Get plenty of rest
therapy program. and grief. sexual desirability program. and sleep at night.
engender grieving -Talk with your
process that needs healthcare
to be dealt with so provider if there any
that patient can uncertainties
make plans for the Health Teaching
future. Note: Grief -Do not remove the
may resurface when dressing, steri-strips
subsequent or stitches. The
procedures are healthcare provider
done (fitting for will remove the
prosthesis, dressing in seven to
reconstructive 10 daysas well as
procedure) if the removal of the
 postponed. sutures in one to
two weeks is done
- Common reaction by the healthcare
- Open up about to this type of provider unless they
signs and symptoms procedure that absorb on their
of depression with needs to be own. If the dressing
the patient and SO. recognized and or steri-strips fall
acknowledged to off, do not attempt
seek timely to replace them.
intervention as -You may shower
indicated. one day after the
drain(s) is out and if
- Negative you have a plastic
- Ascertain feelings responses directed dressing.
and concerns of at patient may -If you have gauze
partner regarding actually reflect and paper tape, you
sexual aspects, and partner’s concern may remove it two
provide information about hurting days after surgery
and support. patient, fear of and shower after
cancer or death, that. Use a towel to
difficulty in dealing dry your incision
with personality and thoroughly after
behavior changes in showering. Be
patient, or inability careful not to touch
to look at the or remove the steri-
operative area. strips or sutures.
-Bruising and some
swellings are
Dependent - If feasible, common in women
- Review reconstruction after surgery.
possibilities for provides less -A low-grade fever
reconstructive disfiguring or “near- that is under 100
surgery or normal” cosmetic degrees Fahrenheit
prosthetic result. Variations in is normal the day
augmentation. skin flap may be after surgery.
done for facilitation - Avoid strenuous
of reconstructive activity, heavy lifting
procedure, which is and vigorous
often performed at exercise until the
the same time as stitches are
 the mastectomy. removed.
The associated - Walking is a
emotional boost normal activity that
may help patient can be restarted
get through the right away.
more complex - Following a lymph
surgical recovery node dissection,
process and don't avoid using
adjunctive your arm, but don't
therapies. Note: On exercise it until your
occasion, first post-operative
reconstruction may visit.
not be done for 3–6 - You will be given
mo. A prolonged exercises to regain
delay may result in movement and
increased tension in flexibility. You may
relationships and be referred to
impair patient’s physical therapy for
incorporation of additional
changes into self- rehabilitation if it is
concept. needed.
Out-patient
-Instruct patient to
Collaborative - Provides a place to return to the
- Discuss and refer exchange concerns healthcare provider
to support groups, and feelings with for the follow
including Men in others who have up check-up.
Our Lives for SO, as had a similar -Instruct patient and
appropriate. experience, and family to call
identifies ways SO the provider if the
can facilitate patient feels no
patient’s recovery. improvement of
health status.
-Instruct patient to
inform physician
immediately if
symptoms may
reoccur.
-Report if side
effects of
 medication have
severely occurred.
Diet
- You may resume
your regular diet as
soon as you can
take fluids after
recovering from
anesthesia.
- Encourage patient
to drink 8 to 10
glasses of water and
non-caffeinated
beverages per day,
plenty of fruits and
vegetables as well
as lower fat foods.
Support System
Encourage to
socialize and
verbalize feelings to
family and
significant others.
Spiritual
Spiritual -Encourage
patient and family
to pray and
meditate on the
word of God to
promote emotional
health and reducing
negative emotions,
stress and anxiety of
current disease. This
also provide peace
of mind to both the
patient and family.

Reference:
Vera, M. B. (2019, June 1). 15+ Mastectomy Nursing Care Plans. Nurseslabs. https://nurseslabs.com/mastectomy-nursing-care-plans/4/

UCSF Health. (2020, October 6). Mastectomy: Instructions After Surgery. Ucsfhealth.Org. https://www.ucsfhealth.org/education/mastectomy-instructions-after-
surgery