Mastectomy nursing proces

1. MASTECTOMY
Definition
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, lifestyle
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.

2. moist, pale skin
increase in
pulse rate,
respiration rate
drop in
temperature
decrease in
urinary output
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 muscle
tone
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 of neck
Keep call light and
frequently needed items
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
prevent stress on the
suture line and
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.

3. Diaphoresis
Self-focusing
Impaired though
process
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
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:
SHORT
TERM:After 4
hours of
establish rapport
monitor and record vital
to gain the trust and
cooperation of the
SHORT TERM:The
patient shall participate
in prevention measures

4. 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
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.
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
instruct proper disposal of
soiled dressing
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
and treatment
programLONG TERM:
The patient shall be
able to display
progressive
improvement in wound
healing.

5. 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
Pallor
Cyanosis

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
perform
techniques to
enhance activity
tolerance.
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
management
8. Encourage
adequate rest
periods
9. Promote comfort
measures and
provide for relief
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
goals to be
establish to
perform wellness
7. Reduces stress
and excess
stimulation,
Short term:The
patient and the
significant others
shall have
identified negative
factors affecting
activity tolerance
and
eliminated/reduce
d their effects
when
possible.Long
term:The patient
shall have
improved his
activity and use
techniques to
enhance activity
tolerance.

6. 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/guid
ed imagery as
appropriate

promoting rest
8. Rest provides time
for energy
conservation and
recovery
9. To enhance ability
to participate in
activities
10. To reduce fatigue
11. 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
Assessment Objective Nursing Intervention Rationale Expected
Outcome
S: ӨO: Patient
may manifest:
Use of
Short
term:After 4
hours of
nursing
1. Establish patient’s
rapport
2. Monitor and record vital
signs
1. To gain trust and
cooperation of
the patient
2. To obtain
Short term:The
patient shall be
free from signs
and symptoms of

7. accessory
muscle to
breathe
Nasal flaring
Altered chest
excursion
Increase
anterior
posterior
diameter
Purse lip
breathing
Decrease
inspiration/
expiration






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
baseline data
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
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
S: ӨO:
Patient may
manifest:
Pallor
Short
term:After 4
hours of
nursing
interventions,
the patient will
1. Establish patient’s
rapport
2. Monitor and record
vital signs
3. Stress proper hand
washing technique
1. To gain trust and
cooperation of the
patient
2. To obtain baseline data
3. Patients with poor
nutritional status may
Short term:The
patient shall have
identified and
demonstrated
interventions to
prevent or reduce

8. Weakness
With dry
and intact
dressing on
the excised
area
Swelling
over the
incision
area

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.
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
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
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.
Assessment Objective Nursing Intervention Rationale Expected Outcome
S: noneO: The
patient may
manifest:
Short Term
GoalAfter 4 hours
of NPI, the will
1. Establish
patient rapport
2. Monitor and
1. to gain patient
trust and
cooperation
Short term:The shall
verbalize acceptance of
need and desire to change

9. unable to meet
the goals of a
treatment
knowledge
deficit of
prescribed
regimen
perceived
seriousness
difficulties with
prescribed
regimen
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
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
process
10. Assist client to
develop
strategies for
monitoring
therapeutic
regimen
11. Identify home-
and community-
based nursing
service
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
solution
8. to encourage
continuation of
desired
behaviors
9. enhances
commitment to
plan, optimizing
outcomes
10. promotes early
actions to achieve agreed-
on outcomesLong
term:The patient shall
participate in problem
solving of factors
interfering with
integration of therapeutic
regimen

10. 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
Assessment Objective Nursing Intervention Rationale Expected Outcome
S: noneO: The
patient may
manifest:
mild to
moderated
decrease in
mood
”acting out”
behavior
Guilt
Deviation from
unusual
behavior pattern
Withdrawal
from others and
normal activities
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
therapy to learn
new ways of
dealing with
anxiety and
feelings of
inadequacy
1. Establish patient rapport
2. Monitor and record vital
sign
3. 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
debilitating course
6. Meet with both members
of the couple
7. Encourage client and SO to
identify healthy coping
skills they have used in the
past
8. Refer to other sources as
needed, counselling,
psychotherapy,
1. The nurse
presence
provide
support.
Ensuring
privacy
demonstrate
for the
client’s
dignity
2. Numbing the
mind
interferes
with grieving
3. Sharing the
significant
loss
with person
who has
survived a
similar
experienced
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
feelings of
inadequacy

11. regression
Somatic
complaints
Avoidance of
affectively
change topics
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 data
16. 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
stages
18. 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
provides a
bond for
healing.

12. 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
sensations
= changes in
LOC
Short Term:After
3-4 hours of
nursing
interventions, the
patient will be
able to
demonstrate
relaxation
techniques.Long
Term:After 3-4
days of nursing
interventions, the
patient will be
able to
demonstrate an
improved
perfusion by
regaining
strength, strong
1. establish rapport
2. monitor and record
VS
3.assess signs of
decreased tse perfusion
4. identify changes
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
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
factors
5. to determine other
possible related factors.


6. to assess for
contributing factors
7. to note degree of
Short
Term:Patient
shall able to
demonstrate
relaxation
techniquesLong
Term:
Patient shall
able to
demonstrate
an improved
perfusion by
regaining
strength,
strong pulse
and maintain
alertness.

13. pulse and
maintain
alertness.
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
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
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
Assessment Objective Nursing Intervention Rationale Expected

14. Outcome
S: ӨO:
Patient may
manifest:
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..
1. Establish
patient’s
rapport
2. Monitor and
record vital
signs
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
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
1. To gain trust and
cooperation of the
patient
2. To obtain baseline
data
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
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
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..

15. 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
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

16. 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.