In the following situation, identify 5 responses to actual or potential health

problems that are identified nursing diagnosis.

Situation A

Sia Tsu, 36-year-old woman is admitted to the hospital for a breast biopsy and possible
mastectomy. The patient tells the nurse she has known about the mass in her breast for
about 5 months but had not seen her doctor because she was afraid it might be
cancerous. She paces inside the room, telling the nurse she has a 4-year-old son and
she does not know what to expect if surgery is done.

The following morning, she undergoes a right modified radical mastectomy after a
frozen section reveals cancer.

Postoperatively, she experiences much incisional pain and swelling and limited
movement of her right arm. She glances at the surgical sight once when the dressings
are changed and verbalizes how awful she looks.

When the doctor informs her that four of the lymph nodes were positive for cancer and
she will undergo chemotherapy and radiation, she begins to cry. She says she is
worried that she would not be attractive to her husband.

Identify 5 human responses to actual or potential health problems:

1. Patient was afraid of uncertainty about the outcome and expectation

2. Patient was pacing around verbalizing she has a 4yr old son

3. Patient experiences much incisional pain and swelling on surgical sight

4. Patient experiences limited range of movement on her right arm

5. Patient begins to cry worried of the effect and outcome of chemotherapy and
radiation on her looks

Identify 3 priority nursing diagnoses:

1. Acute pain r/t surgical incision as evidenced by incisional pain and limited range of
motion on the right arm

2. Impaired tissue integrity r/t surgical incision and pain at site of tissue impairment as
evidenced by incisional pain and limited range of movement on the right arm

3. Anxiety r/t uncertainty about outcomes and expectations; concerns over relationship
and parenting roles as evidenced by distress behavior such as pacing and crying
Make a nursing care plan (NCP)and identify a priority problem that may serve as a
basis for your care of the patient in the scenario cited above.