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    NCP N.D.

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    Liza Marie Cayetano Adarne
    The client underwent a surgical excision of a breast mass followed by a modified radical mastectomy (MRM). The nursing diagnosis was acute pain related to the surgical procedures. Short term objectives were for the client to accurately report her pain level and for her pain to decrease with monitoring and pain management. Long term objectives were for the client's pain to be relieved within 2-5 days and for her to learn pain management techniques. Nursing interventions included pain assessment, non-pharmacological pain management, splinting the surgical site, administering prescribed analgesics, and educating the client and her family. The evaluation was that the client's objectives were met with no reported pain and compliance with health teachings.

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    NCP N.D.

    Uploaded by

    Liza Marie Cayetano Adarne
    292 views3 pages
    The client underwent a surgical excision of a breast mass followed by a modified radical mastectomy (MRM). The nursing diagnosis was acute pain related to the surgical procedures. Short term objectives were for the client to accurately report her pain level and for her pain to decrease with monitoring and pain management. Long term objectives were for the client's pain to be relieved within 2-5 days and for her to learn pain management techniques. Nursing interventions included pain assessment, non-pharmacological pain management, splinting the surgical site, administering prescribed analgesics, and educating the client and her family. The evaluation was that the client's objectives were met with no reported pain and compliance with health teachings.

    Original Description:

    Nursing Care Plan

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    The client underwent a surgical excision of a breast mass followed by a modified radical mastectomy (MRM). The nursing diagnosis was acute pain related to the surgical procedures. Short term objectives were for the client to accurately report her pain level and for her pain to decrease with monitoring and pain management. Long term objectives were for the client's pain to be relieved within 2-5 days and for her to learn pain management techniques. Nursing interventions included pain assessment, non-pharmacological pain management, splinting the surgical site, administering prescribed analgesics, and educating the client and her family. The evaluation was that the client's objectives were met with no reported pain and compliance with health teachings.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    292 views3 pages

    NCP N.D.

    Uploaded by

    Liza Marie Cayetano Adarne
    The client underwent a surgical excision of a breast mass followed by a modified radical mastectomy (MRM). The nursing diagnosis was acute pain related to the surgical procedures. Short term objectives were for the client to accurately report her pain level and for her pain to decrease with monitoring and pain management. Long term objectives were for the client's pain to be relieved within 2-5 days and for her to learn pain management techniques. Nursing interventions included pain assessment, non-pharmacological pain management, splinting the surgical site, administering prescribed analgesics, and educating the client and her family. The evaluation was that the client's objectives were met with no reported pain and compliance with health teachings.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    The client underwent excision of breast mass followed by modified radical mastectomy and is experiencing acute pain. The nurses' goals are to manage the client's pain and ensure she follows health teachings.

    The client underwent excision of breast mass followed by a modified radical mastectomy (MRM).

    Some of the short term objectives for the client are to accurately report her pain level, have her pain maintained or decreased, and learn non-pharmacological pain management techniques.

    ASSESSMENT

    NURSING
    DIAGNOSIS
    OBJECTIVES: Acute pain
    Clients
    related to
    underwent
    surgical
    excision of
    procedure
    breast mass
    (excision of
    which followed breast mass
    by MRM.
    followed by
    MRM)

    RATIONALE
    A surgical
    incision
    (excision of
    breast mass
    followed by
    MRM) results
    to an
    unpleasant
    sensory and
    emotional
    experience due
    to tissue
    damage.
    Breast lump
    removal is a
    surgery to
    remove a
    breast cancer
    along with
    some
    surrounding
    tissue from the
    breast.
    Modified
    Radical
    Mastectomy is
    the removal of
    the breast

    OBJECTIVES

    NURSING
    RATIONALE
    INTERVENTIONS
    SHORTINDEPENDENT
    TERM:
    1.) Introduce
    1.) This will
    Within the shift yourself to the client establish rapport
    the client:
    and her relatives.
    with the patient
    1.) will be able
    and her relatives
    to accurately
    and through this
    report her pain
    patient will feel
    when asked by
    comfortable in
    the nurses.
    giving
    2.) her pain felt
    information to
    will either be
    the nurses.
    maintained or
    2.) Assess clients
    decreased by
    pain using pain
    2.) Pain is a
    consistently
    scale.
    subjective data
    monitoring and
    and only the
    assessing her
    client can
    and attending
    express pain
    her needs.
    that shes
    3. client and her
    experiencing.
    relatives will be 3.) Observe for
    able to learn and clients body
    3.) This can also
    apply nongestures such as
    indicate that the
    pharmacological facial grimace,
    client is
    (deep breathing guarding the postexperiencing
    exercises,
    operative site.
    pain.
    therapeutic
    touch and
    4.) Assess the postdiversional
    operative site for
    techniques) in
    signs of necrosis etc. 4.) Consistently

    EVALUATION
    Objectives are
    met.
    Client did not
    complain of any
    pain within the
    shift or
    demonstrated
    signs of pain.
    Client and her
    relatives
    complied to the
    health teachings
    that were
    provided to
    them by the
    nurses.

    (including the
    skin, breast
    tissue, areola,
    and nipple and
    most of the
    lymph nodes
    under the arm.

    managing pain.
    LONG-TERM:
    After 2-5 days
    the client
    1.) will report
    pain is relieved
    or controlled
    2.) the client
    and her relatives
    complied with
    the health
    teachings done
    by the nurses.

    5.) Apply
    blinder/splint at the
    post-operative site.

    6.) Provide nonpharmacological


    techniques (relaxing
    techniques and
    diversional activities
    preferred by the
    client)
    DEPENDENT
    1.) Administer
    analgesics as
    prescribed or usage
    of PCA (patient
    controlled analgesia)

    assessing the
    post-operative
    site will prevent
    complications
    thus preventing
    the pain that the
    client may
    experience.

    5.) This will


    reduce the pain
    when the client
    moves or
    coughs.

    6.) Nonpharmacological
    techniques can
    provide relief of
    pain
    emotionally and
    psychologically.

    1.) This
    medications
    reduces pain

    while PCA
    administer
    analgesia when
    the client feels
    pain.

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