NURSING PROCESS
A. LONG TERM OBJECTIVES
B. PRIORITIZED LIST OF NURSING PROBLEM
NURSING PROBLEM/S
Acute Pain related to
Wound at right breast secondary to Invasive
Ductal
Impaired Skin Integrity related to right breast
wound secondary to invasive ductal carcinoma.
Disturbed body image related to impending
surgical procedure on her right breast due to
invasive ductal carcinoma
Risk for infection related to break in skin
RANKING JUSTIFICATION
Unpleasant sensory and emotional experience arising
from actual or potential tissue damage can due to a
disease process..
A dimpling of the breast skin or nipple could be from the
loss of elasticity in the supporting ligaments as you age.
But dimpling may also be a sign that a tumor buried in
the tissues is pulling on the skin or nipples. In the case of
a tumor, dimpling might show up long before a lump
becomes large enough to feel.
Woman who undergo surgery for breast cancer
experience a sense of loss – changes in life routines,
social interactions, self-concept, and body image – and
fear of death. Recovery during the postoperative period
after mastectomy requires a great deal of energy. A
client’s usual coping strategies may not be effective. Not
every one perceives or handles stress in the same way.
Clients who have surgically lost a breast may adapt in the
same way as they would to any loss.
It is prioritized because based on the type of nursing
 integrity as evidenced by right breast wound
secondary to invasive ductal carcinoma
Ineffective Breathing Pattern related to disease
process secondary to invasive ductal carcinoma
Decisional conflict related to misconception of
the effects of the treatment
Anxiety related to threat to/or change in health
status
C. NURSING CARE PLAN
diagnosis the patient health is at “risk” and may likely
happen. A woman who has invasive ductal carcinoma
with draining wound is at risk for infection
This demands immediate treatment or care and
subsequent medical attention. This also needs attention as
based on the rule of ABC (Airway, Breathing and
Circulation). [Cancer of the lung and breast are the most
common cancers to cause breathlessness. The former
causes breathlessness by invading and obstructing
airways in the lung. Breast cancer on the other hand,
causes malignant pleural effusions rather than blocking
an area in the lungs
Socio-cultural and religious factors may influence how
people view and handle their problems. Some cultures
may prefer privacy and avoid sharing their fear in public,
even to health care providers. As resources become
limited and problems become more acute, this strategy
may prove ineffective. Vulnerable populations such as
patients, those in adverse socioeconomic situations, those
with complex medical problems such as those who find
themselves suddenly physically challenged may not have
the resources or skills to cope with their acute or chronic
stressors.
NURSING CARE PLAN 1

NURSING
ASSESSMENT PLANNING INTERVENTION/S RATIONALE/S EVALUTION/S
DIAGNOSIS
SUBJECTIVE: ACUTE PAIN Within 2-4 hours 1. Provide with calm 1. For adequate rest GOAL MET.
“May sugat related to of my care, patient and quiet and sleep.
ako sa aking Wound at right will be able to: environment. Patient was able to:
dib-dib” as breast secondary 2. To provide
verbalized by to Invasive -verbalized that 2. Provide comfort nonpharmacological -verbalized that pain
the patient. Ductal pain is relieved or measures. pain management. scale of 7 was decreased
controlled to 4 out of 10
OBJECTIVE: 3.Administer 3. To alleviate pain.
-painscale of 7 -verbalized that analgesics/ pain
out of 10 as 8- pain scale of 7 out reliever as indicated to 4. To prevent fatigue.
10 severe pain, of 10 will maximal dosage.
5-7 moderate decreased within 5. Reduces skeletal
pain, 0-4 mild 0-4 pain scale 4. Encourage adequate muscle tension which
pain rest periods. will reduce the
intensity of the pain.
-grimace face 5. Instruct/ encourage
noted use of relaxation 6.To redirect attention
exercises. and control the pain
-guarded felt.
behavior noted 6.Encourage
diversional activities. 7. Be able to know the
-uncomfortable degree of pain felt.
position 7. Encourage
verbalization of 8. To assist in muscle
-with dry and feelings about the and generalized
intact dressing pain. relaxation.
at right breast
8. Encourage deep
-VS breathing exercises.
BP=
140/90mmHg
RR= 30cpm
PR= 70 bpm
T= 37.1 C

NURSING CARE PLAN 2

NURSING
ASSESSMENT PLANNING INTERVENTION/S RATIONALE/S EVALUTION/S
DIAGNOSIS
SUBJECTIVE: Impaired Skin Within my 3 days 1. Assess skin, note 1. establishes GOAL MET.
“Pepeklat Integrity related span of care for color, turgor and comparative baseline
siguro ‘tong to right breast patient will sensation. providing opportunity At the end of my 3 days
sugat ko, wound maintain her for timing nursing intervention the
minsan may secondary to normal vital signs 2. Demonstrate good intervention. client maintained her
amoy siya”, as invasive ductal and well being and skin hygiene 2. Maintaining clean normal vital signs and
verbalized by carcinoma. no further signs of dry skin provides there was no further signs
the patient. infection will be 3. Instruct family to barrier to infection. of infection on her breast
seen or observed maintain clean dry 3. stiff or rough wound.
OBJECTIVE: on her. clothes preferably clothes causes skin Vital Signs:
-disruption of cotton fabric. friction and increases BP= 120/70mmHg
skin surface risk of infection.
-with dry, clean 4. Emphasize the
and intact importance of proper 4. improve nutrition RR= 24cpm
dressing at right nutrition and fluid and hydration will PR= 84 bpm
breast. intake. improve skin T= 37.3
- foul odor was 5. provide and apply condition.
noted coming wound dressing
from her right 5. wound dressing
breast 6. encourage early serves as barrier to
ambulation surrounding tissue.
-VS 6. promotes
BP= 7: assist client in circulation
140/90mmHg understanding and
RR= 30cpm following medical
PR= 70 bpm regimen 7. enhances
T= 37.1 C commitment to plans,
8: encourage client to optimizing outcomes
verbalize feelings

8.to promote proper

intervention to the
problem

NURSING CARE PLAN 3

NURSING
ASSESSMENT PLANNING INTERVENTION/S RATIONALE/S EVALUTION/S
DIAGNOSIS
Subjective: Disturbed body At the end of my 1. Establish trusting 1.To gain trust. GOAL MET:
“Ano kaya ang image related to shift, the client relationship or rapport
itsura ko impending will begin to to the patient. After my shift the
pagkatapos ng surgical exhibit her client began to exhibit
operasyon?” as procedure on perception on her 2. Ascertain whether 2.This provides her perception on her
verbalized by her right breast baseline body support and information about baseline body image after
the patient due to invasive image after counseling were patient’s level of surgery , as evidenced by
ductal surgery , as initiated when the knowledge and verbalization of positive
Objective: carcinoma evidenced by possibility of and/or anxiety about adaptation to her
- Patient is verbalization of necessity of individual situation. impending surgery.
scheduled for positive adaptation mastectomy was first
Mastectomy to her impending discussed.
tomorrow surgery, 3.It helps patient
3. Encourage patient realize that feelings
to verbalize feelings are not unusual and
regarding the that guilty about them
procedure done. is not necessary or
Acknowledge helpful. Patient needs
normality of feelings to recognize feelings
of anger, depression, before they can be
and grief over loss. dealt with effectively.
Discuss daily “ups
and downs” that can 4. This suggests of
occur. problems in
adjustment that may
4. Note behaviors of require further
withdrawal, increased evaluation and more
dependency, extensive therapy.
manipulation, or
noninvolvement in 5.Independence in
care. self-care helps
improve self-
5. Provide opportunity confidence and
for patient to deal with acceptance of
mastectomy through situation.
participation in self-
care. 6.Loss of breast
causes many
6. Encourage reactions, including
questions about feeling disfigured,
current situation and fear of viewing scar,
future expectations. and fear of partner’s
Provide emotional reaction to change in
support when surgical body.
dressings are
removed. 7. Promotes sense of
control and give
7 Plan or schedule message that patient
care activities with can handle situation,
patient. enhancing self-
8. Maintain positive concept.
approach during care
activities, avoiding 8. Assists patient to
expressions of disdain accept body changes
or revulsion. Do not and feel all right
take angry expressions about self. Anger is
of patient personally. most often directed at
the situation and lack
9. Identify role of control individual
concerns as woman, has over what has
wife, mother, career happened
woman, and so forth. (powerlessness), not
with the individual
 caregiver.

9.This may reveal

how patient’s self-
view has been altered.

NURSING CARE PLAN 4

NURSING
ASSESSMENT PLANNING INTERVENTION/S RATIONALE/S EVALUTION/S
DIAGNOSIS
Objective: Risk for Within 8 hrs span 1. Monitor vital signs. 1.an increase in Goal Met:
-wound at right infection related of nursing care, 2. Administer temperature is the first
breast to break in skin patient will be able prophylactic sign of infection. Patient did not show
-foul smell integrity as to maintain an antibiotics as ordered. signs and symptoms of
coming from evidenced by optimum level of 2. to reduce and infection;
the wound right breast wellness and no prevent bacterial a.) Patient was afecrile :
-clean and intact wound progress of infection T= 37.1c
dressing at right secondary to infection or spread 3. Orient client for
breast invasive ductal of wound. signs and symptoms 3.Health teachings are b.) there was no spread or
- foul smell carcinoma of sepsis (systemic essential for the even signs of further
coming from infection); fever, complete recovery of infection on the patient’s
her wound was chills, diaphoresis, a client breast wound.
noted. altered level of
consciousness, 4.kills or prevent the
- Vital Signs: positive blood spread of
BP= cultures. microorganisms.
130/90mmHg
RR= 24cpm 5. to prevent growth
PR= 84 bpm 4.Stress proper hand of bacteria and
T= 37.3 C washing techniques infection
between nurse and
patient 6.to improve immune
5. Change dressing as system
needed or as
indicated. 7.to promote wellness
6.Eat nutritious food
and encourage to take
vitamins
7.Promote good
hygiene

NURSING CARE PLAN 5

NURSING
ASSESSMENT PLANNING INTERVENTION/S RATIONALE/S EVALUTION/S
DIAGNOSIS
S/O: Ineffective After 8hours of 1.Assessed respiratory 1.Provides a basis for GOAL MET
-RR=34cpm Breathing care, patient will rate. evaluating adequacy At the end of the shift,
-shortness of Pattern related be able to establish of ventilation the client was able to
breath to disease normal and 2.Noted chest establish normal and
-dyspneic process effective breathing movement; use of 2.Use of accessory effective breathing
- use of secondary to pattern as accessory muscles muscles of respiration pattern as evidenced by:
accessory invasive ductal evidenced by: during respiration. may occur in response
muscles while carcinoma -RR of 16-20cpm to ineffective Client’s respiratory rate
breathing -be free from 3.Maintained patient ventilation. is within normal range:
cyanosis or other on moderate to high RR-20 cpm.
symptoms of back rest. 3.Positioning helps
 hypoxia maximize lung Client was free from
4.Encourage patient to expansion. cyanosis or other
have adequate rest signs/symptoms of
periods between 4.To prevent fatigue hypoxia.
activity
5.To maintain
5.Checked for adequate airway
obstructions: patency
accumulation of
secretions.

NURSING CARE PLAN 6

NURSING
ASSESSMENT PLANNING INTERVENTION/S RATIONALE/S EVALUTION/S
DIAGNOSIS
Decisional After 8 hours of 1.Provide 1.Lack of knowledge Patient will be able to
 Subjective: conflict related nursing explanations about about the procedures make a decision and
-She is to intervention client the procedure desired may contribute to the express satisfaction with
concerned about misconception will be able to by the client, pre- client’s/family’s choices.
the outcome of of the effects of make a decision procedural and post- inability to cope
the surgery and the treatment and express procedural tests, positively with this Patient will be able to
prospect of satisfaction with examinations, and event, which may be acknowledge feelings of
undergoing choices follow-up. behaviorally anxiety and distress
chemotherapy manifested by the associated with choice to
or radiation. After 20 minutes client canceling making difficult decision.
-she has not of nursing appointments or
made up her diagnosis patient verbalizing
mind about will be able to ambivalence. Patient will be able to
 2.To assist patient to
2.Promote safe and develop problem-
hopeful environment solving skills
acknowledge such as: accepting
feelings of anxiety verbal expressions of 3.Helps client to
and distress anger/ guilt reinforce reasons for
associated with decision and to be
undergoing
choice to making 3.Assist client to look comfortable that this
chemotherapy
difficult decision. at alternatives and is the course she
use problem-solving wants to pursue.
- Vital Signs: evaluate the treatment
process to validate
BP= options in relation to
After 30 minutes decision. Involve
130/90mmHg personal values and
of nursing significant others as 4.Conflict can arise
RR= 24cpm decide on a course of
intervention appropriate. within the client
PR= 84 bpm action.
patient will be able herself as well as
T= 37.3 C
to evaluate the 4.Evaluate the within the family.
treatment options influence of family Allows the nurse to
in relation to and significant encourage positive
personal values other(s) on the client. forces or provide
and decide on a support where it is
course of action. lacking.

To assist patient to
develop problem-
solving skills

NURSING CARE PLAN 7

 NURSING
ASSESSMENT PLANNING INTERVENTION/S RATIONALE/S EVALUTION/S
DIAGNOSIS
SUBJECTIVE: Anxiety related Within 8hours of 1.Monitor Vital signs 1. to identify After 8 hours of nursng
“hindi ko alam to threat to/or nursing physical response interventions the patient
kung change in interventionsthe 2. Use presence, touch associated with both appeared relaxed and
makakpagtrabah health status patient will appear verbalization or medical and the level of anxiety will
o na ako kaagad relaxed and the demeanour to remind emotional conditions. reduced to manageable
pagka-galing ko” level of anxiety client and to level.
as verbalized by will reduced to encourage expression 2. Being supportive
the patient manageable level. or clarification of and approachable
needs, concerns, encourages
OBJECTIVE: unknown and communication
-restlessness questions
-difficulty in 3. It defines are not
sleeping 3.Accept clients threatened, the client
-fatigue defences, do not may feel safe enough
confront and argue to look at the
- Vital Signs: and debate behavior
BP= 130/90mmHg
RR= 24cpm 4.Allow and reinforce 4.Talking or
PR= 84 bpm clients personal otherwise expressing
T= 37.3 C reaction towards the feeling reduces
threatens to wellbeing anxiety

5.Explain everything 5. To educate the

necessary regarding patient regarding the
the disease. disease to reduce
anxiety.
DISCHARGE PLAN: METHOD

MEDICATIO  Inform the patient of the importance of compliance of medication especially maintenance of medicines.
N  Inform the patient that she must take her medications at the right time prescribed by her doctor.
 Since the patient is taking several medications, advise her to organize medications in a container so that it
would be easier to access the medications on time.
 Inform the patient not to skip medication, and if skipped, do not double the next dose.
 Encourage the patient to avoid taking OTC drugs unless consult has been done by the physician.

EXERCISE  Inform the patient that she can be ambulatory but avoid strenuous activities. Avoid lifting heavy things.
 Encourage the patient to do stretching in the morning and at night as this would help in the circulation of
the blood in the body.
 If patient feels dizzy or weak, encourage to do range of motion exercise.
 Encourage patient to do deep breathing exercise.

TREATMENT  Inform the patient to take prescribed medications on time and with the right dosage.
 If any signs and symptoms of recurrence of illness, immediately report to the doctor so that it can be
intervened on.
 Do not use any herbal medications to cure any sickness, immediately seek medical advice.
 Avoid becoming too fatigue. Always make sure that she will be having adequate rest.
 Avoid stressful environment.
 If dizzy, advise to sit or lie down immediately to avoid casualties.
HEATLTH  Encourage the patient to have adequate rest and sleep.
TEACHING  Advise the patient to have proper hygiene.
 Encourage the patient to contact health care provider once symptoms are felt.
 Relaxation technique can be done to help reduce blood pressure.
 Lifestyle modification should be done because they are effective in preventing further illnesses.

OUT-  Encourage the patient to have regular check-ups to monitor her health status.
PATIENT  Inform the patient not to self diagnose if there are cases where signs and symptoms are felt.
DIET Inform client to promote proper nutrition by:

 Increasing the consumption of protein rich foods.

 Minimizing total fat intake.
 Minimizing salt intake.
 Increasing the intake of nutritious food.
Minimize intake of foods rich in carbohydrates and sugar.