Nama : Kadek sane wijaya

Nim : 2027040
Kelas : 2B Kep.
Matkul : Bahasa Inggris

NURSING CARE IN NY. N WITH PRIORITY

BODY IMAGE DISORDERS

1. ASSESSMENT
a. Client Biodata
Identity
Name : Mrs. Ny
Gender : Female
Age : 25 years old
Religion : Islam
Status : Not married
Ethnicity: Java
Education : Junior High School
Occupation: IRT
Address : Muara Basung, Duri
Medical Diagnosis: Sinistra Mammary Carcinoma Stage III A
Entry Date : 29 maret 2021
Study Date : 17 maret 2021

b. Medical history

c. Main complaint
The client said that the pain in his left chest was due to a surgical wound, there
was an operating wound of ±15 cm horizontal and covered with gauze, there was
drainage.
p: Pain in the post-op mastectomy wound
Q: Pain is like being stabbed
R: Pain is felt in the left mammary part
S: Pain scale 6
Q: Pain comes and goes
The client looked weak and grimaced, the client said he had difficulty sleeping,
was not satisfied with sleeping, his sleep woke up because of the pain he was
experiencing.
 d. History of Present Disease
The client said that at first there was a lump in the left breast since 2 years ago.
At first a small lump appeared without causing pain but the patient did not
examine the lump. Then the lump got bigger and more painful, so in November
2020 the client decided to go to the Permata Hati Duri Hospital for a check-up.
Ultrasound examination revealed a breast tumor. The client did a follow-up
examination, namely PA examination with the results of mammary carcinoma,
and recommended to perform surgery but the client is not ready. On April 2,
2021, a client came to Permata Hati Duri Hospital with complaints of increasing
lumps, pain in the left breast accompanied by wounds. Then the client was
referred to the Arifin Achmad Pekanbaru Hospital, the client arrived at the ER on
April 3, 2021 at 11.00 WIB and then transferred to Dahlia's room to continue
treatment. The client is planned to undergo MRM (Modified Radical Mastectomy)
surgery on April 6, 2021.
e. Past medical history
The client said that he had previously been hospitalized for do a biopsy. The
client has no allergies to drugs, food, weather and has never had an accident. The
client said that he had never suffered from other diseases other than mammary
carcinoma.
f. Family Disease History
The client did not say that no family members had hereditary diseases (such as
cancer, hypertension, diabetes, and heart disease) and infectious diseases (such
as HIV, tuberculosis, and hepatitis).

2. Gordon's Functional Pattern

a. Health Perception Pattern
The client said that he had never taken care of his health status, if he was sick the
client had never received treatment. New clients realize that health is important.
b. Nutrition and Fluid Pattern
The client said there was no change in diet. The client says he eats 3 times a day
and finishes his food. No change in appetite. The types of food are rice,
vegetables, side dishes, and fruits. During the assessment, no nutritional
problems were found in the client. The client drank with a frequency of 5-7 times
a day, the types of drinks consumed before the illness were: mineral water, tea
and cold drinks. While at the hospital only drink mineral water
c. Elimination Pattern
BAK: When the client is at home, he urinates 4-5 times, it is clear yellow in color
and has a characteristic smell. After being hospitalized, the client BAK 3-4 times,
clear yellow color with a distinctive smell (ammonia)
 CHAPTER: At the client's home, CHAPTER 1X/day is brownish yellow with a soft
consistency and there are no complaints in defecation. After being hospitalized
the client has defecated 1 time.
d. Activity and Exercise Patterns
The client said the activity before the patient was sick could carry out his
activities independently. However, during the patient's illness, only light activities
and slightly disturbed so that the client just lies on the bed, in meeting the needs
of the patient is assisted by the family such as bathing, mobility in bed and
moving.
e. Sleep and Rest Pattern
At home, the client sleeps 7-8 hours per day and there is no difficulty sleeping.
While at the hospital the client sleeps 4-5 hours / day after surgery. At the time of
assessment, the client said that he had difficulty sleeping, was not satisfied with
his sleep, his sleep woke up especially at night because he felt pain in the left
chest area, which was a surgical scar and appeared when he moved.
f. Cognitive Perception Pattern
Concentration: Clients focus when spoken to
Memory: The client is able to remember the events and the course of the disease
several years ago. Knowledge of the disease: The client does not know the
causes, symptoms, and how to treat breast carcinoma and what foods can cure
breast carcinoma.
g. Perception Patterns and Self-Concept
The client said that he was sad and ashamed of his current condition, because his
left breast was no longer there and he felt that his body had changed shape. The
client seems to cry every time he tells about his illness and pasra but always prays
for a speedy recovery.
h. Reproductive Pattern…
The client said that his first menstruation was in 6th grade with a regular 28-day
cycle, 4-5 days of menstruation. Clients using Spiral KB since Last 4 Years
i. Mechanism and Coping Pattern
The client said he was worried if the cancer had spread to the right breast. Coping
used by clients when problems arise is to be silent, cry and pray.
j. Relationship Pattern
The client says the relationship between the family is good. Clients and families
seem harmonious and if they have problems, they are always discussed and
resolved together with family members.
k. Faith and Spiritual Pattern
The client said that during his illness the patient could not perform his prayers 5
times a day because the client was afraid to move due to the completion of the
operation but
 The client always pleads and prays for the healing of his illness.

3. Physical Examination
1. General Inspection
BP : 130/80 mm/Hg
N : 88 x/minute
RR : 20 x/minute.
Temperature : 37.1˚C
Weight : 65kg
Physical Complaints: None
2. Special Inspection
a. Head: Round head shape, shoulder length hair, easy hair loss, black color, no
dandruff, when palpated there are no lumps.
b. Face : symmetrical
c. Eyes: The eyes are symmetrical on the right and left, there is no edema of the
eyelids and there are dark circles in the eyes, the cornea is clear, the conjunctiva
is not anemic, the pupil is isocortic and the sclera is not icteric.
d. Nose: No nostril breathing, clean nasal cavity, normal smell.
e. Mouth: Symmetrical mouth shape, no dental caries. The state of the mouth is
clean, does not smell, the tongue is clean and does not have difficulty
swallowing.
f. Neck: There is no enlargement of the thyroid gland, there is no enlargement of
the lymph nodes and there is no dam in the jugular vein.
g. Thoracic Examination
a. Chest: Normochest, there is a post-mastectomy wound on the left breast
covered with a bandage measuring ± 15 cm. The gauze looks clean, no liquid
seeps, drainage is installed.
b. Lungs:
Inspection: Symmetrical, intercostal reactions are not visible,
Palpation: Vocal fremitus between right and left is equally developed
Percussion: Resonance throughout the lung fields,
Auscultation: No additional breath sounds (vesicular)
c. Heart
Inspection: Ictus cordis not visible
Palpation: regular heart rate
Percussion :Deafness
Auscultation: Regular rhythm, no additional heart sounds
h. Abdominal Examination
Inspection: Flat shape, no bumps, symmetrical
Percussion : Tympani
 Palpation: No tenderness, Auscultation: Intestinal peristalsis 30x/minute
i. Integumentary Check
Dark brown skin color Looks like a surgical wound on the left breast, texture
rough skin, elastic turgor, wrinkles, tenderness in the left breast.
j. Genital Examination
Brownish yellow urine, No catheter, client said no complaints
k. Musculoskeletal Examination

4. Focus Data
1. Subjective Data:
a. The client says pain in his left breast
P: The client says pain in the post-op mastectomy wound
Q: The client says the pain is like being stabbed
R: The client says the pain is felt in the left breast
S: Pain scale 6
Q: The client says the pain is often felt suddenly and arises when moving
b. The client says he has difficulty sleeping, is not satisfied with sleeping, his sleep
wakes up because of the pain he is experiencing
c. The client says that the wound feels hot around the wound
d. The client said that he was sad and ashamed of his current condition, because
his left breast was no longer there and he felt that his body had changed shape.
e. The client said he was worried if the cancer had spread to the right breast.
2. Objective Data:
a. The client looks weak and grimaces
b. Pain scale 6
c. Vital sign:
TD 130/80 mm/Hg
Pulse 88 x/minute
Temperature 37.1˚C
RR 20x/minute.
d. The post-mastectomy wound on the left mammary is ±15 cm horizontal and
covered with a bandage
e. The wound looks red
f. Installed drainage amounting to 200 ml
g. The client looks resigned and often cries

5. Data Analysis
No. CLIENT DATA ETIOLOGY PROBLEM
NURSING
1. Subjective data: Physical injury Acute Pain
 - The client says pain in the left agent
breast (Operating
- P: The client says pain in the Procedure)
surgical wound area
- Q: The client says pain
- like being stabbed
- R: The client says it hurts
felt in the left breast
- S: Pain scale 6
- Q: The client says the pain is
often felt suddenly and arises
when moving
Objective Data:
- Post-mastectomy wound on
left mammary ±15 cm
horizontal and covered with
bandage
- The client looks weak and
grimaces
- Pain scale 6
- Vital sign:
- TD 130/80 mm/Hg
- Pulse 88 x/minute
- Temperature 37.1˚C
- RR 20 x/minute.
2. Subjective data : Surgical incision Disturbance
- The client said there was a wound Network Integrity
surgical scar on his left breast Skin
- The client says that the wound
feels hot around the wound.
Objective Data:
- Performed mastectomy surgery
on April 9, 2021
- Looks like surgery scars
mammae sinistra of ±15 cm
horizontally and covered with
bandage
- The wound looks red
3. Subjective data : Lack of sleep Sleep pattern
- The client says he has difficulty control disorder
 sleeping, is not satisfied with
sleep, his sleep wakes up
because of the pain he is
experiencing
Objective Data:
- Looks dark circles on the eyes
- Clients seem to yawn
frequently
- The client looks weak
4. Subjective data : Losing body parts Image Disturbance
- The client said he was sad and Body
embarrassed by his current
condition, because his left
breast was no longer there and
felt his body changed shape.
Objective Data:
- The client looks resigned and
often cries
5. Subjective data : Invasive Procedure Infection Risk
- The client says that sometimes
the wound feels hot around the
wound.
Objective Data:
- Looks like surgery scars
mammae sinistra of ±15 cm
horizontally and covered with
bandage
- Installed drainage amounting to
200 ml
- Leukocytes: 15.18 x 103 l
- Vital sign:
 TD 130/80 mm/Hg
 Pulse 88 x/minute
 Temperature 37.1˚C
 RR 20x/minute.
6. Subjective data : Less Exposure to Anxiety
- The client said he was worried Information
if the cancer spread to the right
breast.
Objective Data
 - The client looks restless
- The client looks tense
- Vital sign:
 TD 130/80 mm/Hg
 Pulse 88 x/minute
 Temperature 37.1˚C
 RR 20 x/minute

6. Nursing Diagnosis
Nursing diagnoses for Mrs. N with breast carcinoma post mastectomy on the third day
are:
1) Acute pain related to physical injury agent
2) Impaired skin tissue integrity related to therapeutic effects mastectomy
3) Impaired sleep patterns related to lack of sleep control
4) Impaired body image related to loss of body part
5) Risk of infection
6) Anxiety related to lack of exposure to information

7. Nursing Intervention
Nursing interventions carried out to Mrs. N in Dahlia Room with a diagnosis of
Carcinoma Mammae Post Mastectomy on the third day can be seen in the following
table :

No Nursing diagnosis outside Nursing intervention

1. Acute pain After care nursing 3x24 hours,
Get in touch with then
agents Expected pain level decreased
physical injury with the result criteria:
• Complaints of pain
decreased
• Grimace down
• Decreased sleep difficulties
• Decreased fear of repeated
injury
• Blood pressure improves
• Improved sleep patterns
Observation
• Identify the location,
characteristics, duration,
frequency, quality,pain
intensity
• Identify pain scale
• Identify non-verbal pain
responses
• Identify the factors that
exacerbate and relieve pain
Therapeutic
• Provide non-pharmacological
techniques to reduce pain
(deep breathing technique)
• Environmental control that
exacerbate the pain

2. Disruption of After care nursing 3x24 hours,
integrity skin tissue then
related to effect expected skin integrity and
mastectomy network increases with
therapy result criteria:
• Decreased network damage • Apply a dressing according to
• Decreased skin layer damage
• Pain decreases
• Redness decreases
• Improved skin temperature
• Sensation improves
 Texture improved
3. Pattern disorder After care nursing 3x24 hours,
sleep related then
with a lack of expected complaints of difficulty
• Facilitate rest and sleep
Education
• Describe the causes, periods,
and triggers of pain
• Describe pain relief strategies
• Encourage self-monitoring of
pain
Collaboration
 Collaborative administration
of analgesics, if necessary
Observation
• Monitor wound
characteristics
• Monitor for signs of infection
Therapeutic
the type of wound
• Maintain sterile technique
when performing wound care
• Change dressing according to
the amount of exudate and
drainage schedule change
position every 2 hours or
according to the patient's
condition
Education
• Describe the signs and
symptoms of infection
• Recommend consuming
foods high in calories and
protein
• Teach wound care
procedures to clients and
families
Collaboration
 Collaborative administration
of antibiotics, if necessary
Observation
• Identify sleep activity
patterns
 sleep control sleeping decreased with the
result criteria:
• Complaints of being
dissatisfied with decreased • Identify foods or drinks that
sleep
• Complaints of decreased
sleep patterns
• Complaints of insufficient
rest decreased
 • Increased activity ability
4. Image disturbance After care nursing 3x24 hours,
body relate with then
loss parts of body expected body image level
increases with the result
criteria:
• Negative feelings about body
changes decreased
• Decreased concern about
rejection/reaction of others
• Hiding excessive body parts
decreases
• Shows excessive body parts
decreased
 • Focus on lower body parts
• Identification of sleep-
disturbing factors
(physical/psychological)
interfere with sleep
Therapeutic
• Environmental modification
(lighting, noise)
• Facilitate stress relief before
bed
Education
• Explain the importance of
getting enough sleep during
illness
 Teach autogenic muscle
relaxation or other non-
pharmacological methods
Observation
• Monitor the frequency of
self-critical statements
• Monitor whether the patient
can see the changed body
parts
 Therapeutic
• Discuss changes in the body
and its functions
• Discuss differences in physical
appearance on self-esteem
• Discuss stressful conditions
that affect body image (eg,
injury, illness, surgery)
• Discuss how to develop
realistic body image
expectations
• Discuss patient and family
perceptions of changes in
body image
Education
• Explain to family about body
image change treatment

5. Risk of infection After care nursing 3x24 hours,
Relate with then
procedure invasive expected infection rate
decreased result criteria:
• Fever decreases
• Redness decreases
• Purulent drainage decrease
• Periods of malaise decrease
• White blood cell levels
getting better
• Culture of the wound area
getting better
• White blood cell levels
getting better
6. Related anxiety After care nursing 3x24 hours,
with less then
expected level of anxiety
decreased outcome criteria:
• Worried that the conditions
faced are declining
• Decreased restless behavior
• Decreased tense behavior
 • Improved sleep patterns
• Encourage self-disclosure of
body image
 Practice the body's functions.
Observation
• Monitor for signs and
symptoms of local and
systemic infection
Therapeutic
• Limit the number of visitors
• Give skin care to the wound
area
• Wash hands before and after
contact with patients and the
patient's environment
• Maintain aseptic technique in
high risk patients
Education
• Describe the signs and
symptoms of infection
• Teach how to check the
condition of the wound or
surgical wound
Collaboration
 Collaborative administration
of antibiotics, if necessary
Observation
• Monitor for signs of anxiety
• Identify when anxiety levels
change when exposed to
information
Therapeutic
• Create a therapeutic
atmosphere to foster trust
• Motivation to identify
situations that trigger anxiety
Education
• Inform factually about the
diagnosis, treatment, and
prognosis
• Describe the procedure,
 including the sensations you
may experience
 Practice relaxation
techniques