Cues/ Evidences

Nursing
Diagnosis

Scientific Basis

Subjective Cues:
Medyo sakit jud
ang tinahian dai
pero maagwanta
ra man as
verbalized by the
patient.

Acute pain
related to
surgical
incision
secondary to
performed
surgery
(Modified
Radical
mastectomy)
as evidenced
by reported
pain scale of
6/10.

Pain is a highly
subjective state in
which a variety of
unpleasant
sensations and a
wide range of
distressing factors
may be experienced
by the sufferer.
Pain is a normal
body response when
a break in the skin or
any body parts
occurs. It is due to
the series of
reactions the body
produces. This
response includes
vasospasm which
causes
vasoconstriction.
The break in the skin
stimulates local pain
receptors so pain is
felt.
When a person

Pain Scale:
6/10 as 0 is the
lowest and 10 is
the highest with
the characteristic
of moderate pain.
Objective Cues:
With grimace
noted
especially
when exerting
movements.
Verbal report
of acute pain.

Goal and
Outcome
Criteria
After 8 hours of
nursing
intervention the
patient will be
able to manifest
a decrease in
the pain scale of

Nursing
Interventions
Independent:
Observe and
document
location
severity (0 to
10) scale, and
character of
pain.

6/10 to a
manageable
level of 2/10 or
lower.

Rationale

Assists in
differentiating
cause of pain and
provides
information about
disease progression
or resolution
development of
complications, and
effectiveness of
interventions.

Monitor vital
signs and pain
scale

Obtain baseline
vital signs, vital
signs changes
during onset of
pain, for future
comparison after
interventions.

Promote bed
rest, allowing
client to assume
position of
comfort

Bed rest in Low

Fowlers position
reduces intra
abdominal pressure,
however client will

Evaluation

After 30-45
minutes nursing
intervention, goal
was met as
evidenced by the
patients reports of
decrease in pain
scale from 6/10 to
2/10.

 Needs
assistance and
difficulty in
moving noted.
With the
following vital
signs:
BP = 120/80
RR = 22
PR = 84
TEMP. = 36.8 C

experiences pain, the

persons level of
comfort is altered.
Hence, the patient
may be irritable and
unconscious of what
is happening around.

Gulanick & Myers

(2007)
Nursing Care Plans
Nursing Diagnosis
& Interventions
6th edition
Singapore: Mosby
Inc.

naturally assume
least painful
position

Control
environmental
temperature
Encourage use
of relaxation
techniques such
as guided
imagery,
visualization
and deep
breathing
exercises.
Encourage
patients to
watch TV listen
to music. Read
newspaper and
magazines to
divert attention
from pain.
Dependent:

Cool surroundings
aid in minimizing
dermal discomfort
Promotes rest
redirects attention
and enhance
coping.

Helpful in
alleviating anxiety
and refocusing
attention which can
relieve pain.

 Administer pain
medications as
prescribed by
the physicians

Cues/ Evidences

Subjective Cues:

Nursing
Diagnosis

Scientific
Basis

Risk for

Goal and
Outcome
Criteria
Person at risk After 8 hours of

infection

For infection

related to

are those

post surgical whose

Objective Cues:

incisions

Weak in

secondary to defense

apperance
Clean and

performed

mechanisms

surgery

are

intact incision

( Modified

inadequate to

dressing/band

Radical

protect from

mastectomy)

the

aid was noted.

Afebrile with
the following

natural

inequitable
injuries and

Nursing
Interventions

Relieve the client of

pain using
pharmacologic
intervention.

Rationale

Independent:
Monitor the
Any suspicious
nursing
following for
drainage should
intervention, the
signs of infection
be cultured,
patient will be
such as redness,
antibiotics
swelling,
therapy is
able to be free
purulent
determined by
from any signs
drainage and
pathogens
and symptoms of
increase
identified at
temperature.
culture. Fever
infections as
Report
may indicate
manifested by
accordingly.
infection.
absence of fever.
Emphasize the
importance of
handwashing

It serves as a
first line of
defense against

Evaluation

After 8 hours of nursing

intervention, the patient will
be able to be free from any
signs and symptoms of
infections as manifested by
absence of fever,
temperature was 36.8 C at
the end of the shift.

vital signs:

exposures
that occur

BP = 120/80
RR = 22
PR = 84
TEMP. = 36.8 C

troughout the
course of
living.

technique.

infection.

Maintain aseptic
technique when
changing
dressing/caring
wound.

Regular wound
dressing
promotes fast
healing and
drying of
wounds.

Keep area
around wound
clean and dry.

Wet are can

belodge area of
bacteria

Maintain clean
environment

Bust and dirt

particles carry
microorganisms

Encourage
patient to eat
protein and
calorie rich
foods .

This helps
stabilize weight
improves muscle
tone and mass,
and aids wound
healing.

Limit visitors

This reduces the

number of
microorganisms
in patients
environment and
restricts

Dependent:

visitation by
individuals with
any type of
infection.

Emphasize
necessity of
Premature
taking antibiotics
discontinuation
as ordered
of treatment
when client
begins to feel
well may result
in return of
infection
Cues/
Evidences
Subjective
Cues:
katol man
ang tahi dai
as verbalized
by the patient.

Nursing
Diagnosis

Scientific Basis
Mastectomy,

Impaired
Skin
Integrity
related
to
presence of
wound
secondary to

Goal and Outcome

Criteria
SHORT TERM:

establish rapport

like any other

surgical

After 4 hours of

procedures,

nursing

includes

interventions,

invasion of the patient

inside

Nursing
Interventions

body, participate

(
Modified
specifically the prevention
Radical
and measures
mastectomy) skin

the
will assess incision
in
site taking note
and

of size, color,
location,

Rationale

Evaluation

SHORT TERM:
to gain the
trust and
The patient shall
cooperation of participate in prevention
the client
measures and treatment
program
to provide
comparative
baseline data

subcutaneous

Objective
Cues:
Presence
of
surgical
wound on
the breast
where
incision
was made
Pain

Post
Operative
Procedure

area.

Upon

incision,

there LONG TERM:

will

be

impairment

of After 1-2 days of

the

Disruptio
n of skin
surface
Redness
Itchiness
Poor
capillary
refill

LONG TERM:
temperature,
texture,
consistency of
wound/ lesion if
possible

integrity

interventions,

the

assess for odors

and drains
damage,
to
display
coming out from
impairment of progressive
the skin/ area of
skin circulation improvement
in
injury
causing

patient will be able

sensation wound healing

and pain in the

incision
An

The patient shall be able

to display progressive
improvement in wound
healing.

skin nursing

and

Numbnes
s of
surroundi
ng areas

treatment program

site.

incision

made

in

breast.

is
the
The

underlying
muscles

are

opened

to

expose

the

tumor beneath
the breast. The
surgeon

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

then

inspect skin on a
daily basis,
describing
lesions and
changes
observed
keep the area
clean/dry,
carefully dress
wounds, support

to promote
timely
intervention/r
evision of
plan of care
to assist
bodys natural
process of
repair

removes
or

all

part
of

the

breast

while

taking

great

care

not

to

injured

nearby

blood

vessels

or nerves. The
muscles
then
and

are

repaired
the

skin

incision

is

closed

with

sutures

that

will

either

absorb

or

removed

be
soon

after

the

operation.

The

actual

incision, and
prevent infection
use appropriate
wound coverings

encourage an
increase in
protein and
calorie intake

to prevent
fatigue

incising
as

an

impairment
the

to aid in
timely wound
healing for the
patient

encourage
adequate rest and
sleep
to promote
circulation
and reduce
encourage early
risks
ambulation and
associated
mobilization
with
immobility

of the skin is
seen

protect the
wound and/or
surrounding
tissue

in

skins

provide position

to prevent bed
ulcers from
occurring

integrity.

changes

to reduce risk
of crosscontamination

practice aseptic
technique in
cleansing/dressin to prevent
g and medicating
spread of
lesions
infectious
agent
instruct proper
disposal of
soiled dressing