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ASSESSMENT NURSING

DIAGNOSIS

RATI ONAL E O BJEC TI VE S NUR SING

INTERVENTIONS

RATIONALE EVALUATION

OBJECTIVES:

Clients

underwentexcision of

breast mass

which followed

by MRM.

Acute pain

related to

surgicalprocedure

(excision of

breast mass

followed by

MRM)

A surgical

incision

(excision ofbreast mass

followed by

MRM) results

to an

unpleasant

sensory and

emotional

experience due

to tissuedamage.

Breast lump

remoal is a

surgery to

remoe a

breast cancer

along with

some

surrounding

tissue from the

breast.

Modified

Radical

Mastectomy is

the remoal of

the breast

SHORT-

TERM:

!ithin the shiftthe client"

#.) will be able

to accurately

report her pain

when as$ed by

the nurses.

%.) her pain felt

will either be

maintained ordecreased by

consistently

monitoring and

assessing her

and attending

her needs.

&. client and her

relaties will be

able to learn and

apply non'

pharmacological

(deep breathing

exercises

therapeutic

touch and

diersional

techniues) in

INDEPENDENT

#.) *ntroduce

yourself to the clientand her relaties.

%.) Assess clientspain using pain

scale.

&.) +bsere for

clients body

gestures such as

facial grimace

guarding the post'

operatie site.

,.) Assess the post'

operatie site for

signs of necrosis etc.

#.) -his will

establish rapportwith the patient

and her relaties

and through this

patient will feel

comfortable in

giing

information to

the nurses.

%.) ain is a

sub/ectie data

and only the

client can

express pain

that shes

experiencing.

&.) -his can also

indicate that the

client is

experiencing

pain.

,.) Consistently

+b/ecties are

met.

Client did not

complain of any

pain within the

shift or

demonstrated

signs of pain.

Client and her

relatiescomplied to the

health teachings

that were

proided to

them by the

nurses.

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(including the

s$in breast

tissue areola

and nipple and

most of thelymph nodes

under the arm.

managing pain.

LONG-TERM:

After %'0 days

the client#.) will report

pain is relieed

or controlled

%.) the client

and her relaties

complied with

the health

teachings done

by the nurses.

0.) Apply

blinder1splint at the

post'operatie site.

2.) roide non'

pharmacological

techniues (relaxingtechniues and

diersional actiities

preferred by the

client)

DEPENDENT

#.) Administer

analgesics as

prescribed or usage

of CA (patient

controlled analgesia)

assessing the

post'operatie

site will preent

complications

thus preentingthe pain that the

client may

experience.

0.) -his will

reduce the pain

when the client

moes orcoughs.

2.) 3on'

pharmacological

techniues can

proide relief of

pain

emotionally and

psychologically.

#.) -his

medications

reduces pain

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while CA

administer

analgesia when

the client feels

pain.