VIII.

NCP Proper Explanation of the Problem S: The usual type of breast Masakit operation here pa din in the yung operasyo Philippines is Modified n ko, Radical medyo kumikirot Mastectomy. The exact Rated cause of this is pain as unknown. 8/10, characteri Modified radical zed as sharp and mastectomy is a surgical non procedure to radiating treat breast O: Calm and cancer. In order for this coherent Grimacing procedure to be an noted operable With intact and option, a definitive dry diagnosis of dreesing breast cancer With must be medial established. and lateral JP The first clinical sign for drain, approximately drainage cahracteri 80% of women with breast zed as bright red cancer is a mass (lump) fluid With Vital located in the breast. A lump signs of can be BP: 110/70 LA discovered by sitting, T: monthly selfexamination or 36.4 via axilla, PR: by a health 74 regular professional who can find at radial pulse,+2, 1025% of breast cancers RR: 18 symmetric that are al on both missed by yearly chest mammograms area (a low Problem PAIN Objectives Interventions Rationale Evaluation

LTO: Tx: After 3 days of nursing Assess interventions the patient reports of condition will improved pain, noting as manifest by: location, a. Verbalization of duration, and no pain intensity (0-10 b. Appear relaxed, scale). Note able to verbal and sleep/rest non verbal appropriately cues. STO: After 8 hours of nursing interventions the patient condition will improved as manifest by: a. Express reduction in pain from 8 to 3 as the rating.

Aids in identifying degree of discomfort and need for/ effectiveness of analgesia. The amount of tissue, muscle, and lymphatic system removed can affect the amount of pain experienced. Note: Pain in chest wall can occur from muscle tension, be affected by extremes in heat and cold, and continue for several months. Early recognition of developing infection can enable rapid institution of treatment.

Monitor Vital sign especially Temperature.

Dx: Discuss normality of phantom breast sensation.

Provides reassurance that sensations are not imaginary and that relief can be obtained.

Nursing diagnosis: Acute pain related to tissue trauma secondary to s/p right modified radical mastectomy

radiation x ray of the breasts). A biopsy can be performed to examine the cells from a lump that is suspicious for cancer. The diagnosis of the extent of cancer and spread to regional lymph nodes determines the treatment course (i.e., whether surgery, chemotherapy, or radiation therapy, either singly or in combinations). Staging the cancer can estimate the amount of tumor, which is important not only for diagnosis but for prognosis (statistical outcome of the disease process). Patients with a type of breast cancer called ductal carcinoma in situ (DCIS), which is a stage 0 cancer, have the best outcome ) (nearly all these patients are cured of breast cancer). Persons who

Assist patient to find position of comfort.

Elevation of arm, size of dressings, and presence of drains affects patients ability to relax and rest/sleep effectively. Promotes relaxation, helps to focus attention, and may enhance coping abilities.

/ Provide basic comfort measures (e.g repositioning on back or unaffected side, backrub) and diversional activities. Splint/ support chest during coughing and deep breathing exercises. Give appropriate pain medication on a regular schedule before pain is severe and before activities are scheduled.

Facilitates participation in activity without undue discomfort.

Maintains comfort level and permits patient to exercise arm and to ambulate without pain hindering efforts.

Educ: Encourage patient to express feelings.

Loss of body parts, disfigurem ent and perceived

have cancerous spread to other distant places within the body (metastases) have stage IV cancer and the worst prognosis (potential for survival). Persons affected with stage IV breast cancer have essentially no chance for cure.

loss of sexual desirability engender grieving process that needs to be dealt with so that patient can make plan for the future. Encourage diversional activities.

Promotes relaxation, helps to refocus attention and may enhance coping abilities.

Townsend, Courtney. Sabiston Textbook of Surgery, 16th edition. St. Louis: W. B. Saunders Company, 2009.

Nursing Care Plan Proper Problem SEIZURE Explanation of the Problem Objectives Interventions Rationale Evaluatio n

S:

O:

Seizures are disturbance in the normal brain function resulting from abnormal electrical discharges in the brain, which can cause loss of With Vital signs of T= level of 36.4 taken consciousnes s, via axilla; uncontrolled PR= 120 body taken at movements, brachial changes in pulse, behavior and regular sensations RR= 35 symmetric and changes in autonomic al on both chest area. system. Majority of Asleep most of the seizures happen in the time. first years of No life. episodes of seizure Hindi naman na sya nagseizure as verbalized by the father.

LTO: Tx: After 3 days on nursing interventions the patient condition will improve as manifest by: a. control seizure activities b. no signs of complicat ion or injury

Explore with patient the various stimuli that may precipitate seizure activity.

Loss of sleep, flashing lights and other stimuli may increase brain activity, thereby increasing the potential for seizure activity. Understanding importance of providing own safety needs.

Maintain strict bed rest. Explain necessity for this action Perform neurologic/ vital sign check after seizure, e.g LOC, pulse, respiration rate) Document type of seizure activity

STO: After 8 hours of nursing interventions the patient will be able to: a. at least only have 2 episodes of seizure in a day.

Documents postictal state and time/ completeness of recovery to normal state.

Helps to localize the cerebral area of involvement.

Nursing Diagnosis: Risk for fall related to possible seizure episodes.

Dx: Cradle head, place on soft area.

Gentle guiding of extremities reduces of physical injury when patient lacks voluntary muscle control. Minimizes injury should occur while patient is in bed.

Keep padded side rails up with bed in lowest position or placed bed up against wall and pad floor if rails

not available. Use metal or tympanic thermometer when necessary to take temperature. Administered medications as indicated: Phenobarbital .

Reduces risk of biting and breaking glass thermometer or suffering injury if sudden seizure activity occurs. Potentiates/ Enhances effects of AEDs and allows for lower dosage to reduce side effect. Promotes patient safety.

Stay with patient during/ after seizure.

Educ: Discuss seizure warning signs and usual seizure pattern.

Enables patient to protect from surgery and recognizes changes that require notification of physician/ further interventions.

http://www.scribd.com/doc/12307434/Nursingcribcom-NURSING-CARE-PLAN-Seizure

Problem SEIZURE

Explanation of the problem

Objectives

Interventions

Rationale

Evaluation

S:

O:

Seizures are disturbance in the normal Hindi brain function naman na resulting from sya nagseizure as abnormal electrical verbalized discharges in by the the brain, father. which can cause loss of level of With Vital signs of T= consciousness, uncontrolled 36.4 taken body via axilla; movements, PR= 120 changes in taken at behavior and brachial sensations and pulse, changes in regular autonomic RR= 35 symmetrical system. Majority of on both chest area. seizures happen in the Asleep most of the first years of life. time. No episodes of seizure

LTO: Tx: After 3 days of Perform Documents nursing neurologic/ postictal intervention the vital sign state and patient condition check after time/ will improve as seizure, e.g completenes manifest by: LOC, pulse, s of recovery a. Maintain respiration to normal effective rate state. respiratory pattern with Dx: airway Loosen the Facilitates patent. patients breathing clothing and chest STO: from neck/ expansion. After 8 hours of chest and nursing abdominal intervention the areas. patient condition Placed in Promotes will improve as lying drainage of manifest by: position, flat secretions; surface; prevents turn head to tongue from side during obstructing seizure airways. activity. Suction as Reduces needed risk of aspiration/ asphyxiation Educ: Educate SO how to recognize warning signs and how to care for patient during and after seizure.

Nursing Diagnosis: Risk for ineffective airway clearance related to Seizure episodes

Knowing what to do when seizure occurs can prevent injury/ complicatio ns and decrease SOs feelings of helplessnes s.