ASSESSMENT

Explanation
of the
problem

SUBJECTIVE:
May nakakapa akong
bukol sa dibdib ko, anong
dapat kong gawin? (I
have a lump in my breast
what should I do?) as
verbalized by the patient
OBJECTIVE:
Verbalization of the
problem
Statement of
misconception
V/S taken as follows
T: 37.1 C
P: 92
R: 19
BP: 120/ 80

Deficient knowledge
regarding illness,
prognosis, treatment, selfcare, and discharge needs.

Breast
Cancer Is the
leading type
of cancer in
women. Most
breast cancer
begins in the
lining of the
milk ducts,
sometimes
the lobule.
The cancer
grows
through the
wall of the
duct and into
the fatty
tissue. Breast
cancer
metastasizes
most
commonly to
auxiliary
nodes, lung,
bone, liver,
and the
brain.

PLANNING

INTERVENTION

After 8 hours INDEPENDENT

of nursing
Review with
intervention
patient
the patient
understanding of
will
specific diagnosis,
verbalize
treatment
accurate
alternatives, and
information
future
about
expectations.
diagnosis,
prognosis,
and potential
complication
s at own
level of
Provide clear,
readiness.
accurate
information in a
factual but
sensitive manner.
Answer
specifically, but do
not provide
unessential details.

Provide
anticipatory
guidance with
patient regarding
treatment protocol,
length of therapy,
expected results,
possible side
effects. Be honest
with the patient.

RATIONALE

Validates
current level of
understanding,
identifies
learning needs,
and provides
knowledge base
from which
patient can
make informed
decisions.

Helps with
adjustment to
the diagnosis of
cancer by
providing
needed
information
along with time
to absorb it.

Patient has the

right to know
(be informed)
and participate
in decision
making.
Accurate and
concise
information
helps dispel
fears and
anxiety, helps
clarify expected
routine, and
enables patient
to maintain

EVALUATION

Fully met since the

patient was able to
verbalize accurate
information about
diagnosis, prognosis, and
potential complications at
own level of readiness.

Problem
PAIN
S:
Masakit pa
din yung
operasyon ko,
medyo
kumikirot
Rated pain as
8/10,
characterized
as sharp and
non radiating
O:
Calm and
coherent
Grimacing
noted
With intact
and dry
dreesing
With medial
and lateral JP
drain,
drainage
cahracterized
as bright red
fluid
With Vital
signs of BP:
110/70 LA

Explanation of
the Problem
The usual type of
breast operation
here in the
Philippines is
Modified Radical
Mastectomy. The
exact cause of this
is unknown.
Modified radical
mastectomy is a
surgical procedure
to treat breast
cancer. In order for
this procedure to
be an operable
option, a definitive
diagnosis of breast
cancer must be
established. The
first clinical sign for
approximately 80%
of women with
breast cancer is a
mass (lump)
located in the
breast. A lump can
be discovered by
monthly selfexamination or by
a health

Objectives

Interventions

LTO:
Tx:
After 3 days of
Assess reports
nursing
of pain, noting
interventions the
location,
patient condition
duration, and
will improved as
intensity (0-10
manifest by:
scale). Note
a. Verbalizatio
verbal and non
n of no pain
verbal cues.
b. Appear
relaxed,
able to
sleep/rest
appropriatel
y
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.

Monitor Vital

Rationale

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.

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

Elevation of arm, size of

Evaluation
Fully met since the
patient condition was
improved as manifest
by:
Express reduction in
pain from 8 to 3 as
the rating.

sitting, T: 36.4
via axilla, PR:
74 regular at
radial pulse,
+2, RR: 18
symmetrical
on both chest
area

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

professional who
can find 1025% of
breast cancers that
are missed by
yearly
mammograms (a
low 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

sign especially
Temperature.

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.

Facilitates participation
in activity without undue
discomfort.

Dx:
Discuss
normality of
phantom breast
sensation.

Assist patient
to find position
of comfort.

Provide basic
comfort
measures (e.g
repositioning

Maintains comfort level

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

Loss of body parts,

disfigurement and
perceived loss of sexual
desirability engender
grieving process that
needs to be dealt with
so that patient can

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 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.

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.

Educ:
Encourage
patient to
express
feelings.

make plan for the

future.

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

Encourage
diversional
activities.

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

ASSESSMENT
S> Nakakahiya
makakalbo ako
O>
Coherent and
Conversant
Submits self
to Nursing
Procedure
and Care
done
A> DDisturbed
Body Image
realted to
illness
treatment.

EXPLANATIO
N OF THE
PROBLEM
The length of
Chemotherapy
treatment
depends on
whether the
cancer shrinks,
how much it
shrinks, and
how a woman
tolerates
length of
treatment.
Some of the
most common
possible side
effect is hair
loss.

OBJECTIVES
STO> After 8 hours of
Nursing Intervention the
patient will be able to
verbalize understanding
of body changes
LTO> After 1 day of
Nursing Intervention, the
patient will be able to
verbalize acceptance of
self in situation in the
effects of therapeutic
regimen.

IMPLEMENATION
DX> Monitor vital signs
and record
Ddetermine
patients
perception of
cancer and cancer
treatments.
TX> Ask for patient for
verbal feedback, and
correct misconception
about individuals type
of cancer and treatment.
Pprovide
anticipatory
guidance with
patient regarding
treatment
Protocol, length of
therapy and
possible side
effects
EDX> Refer to
community resources as
indicated.
Rreview specific
medication
regimen and use
of OTC drugs.

RATIONALE
Ffor baseline data
Aaids in
identification of
ideas, attitudes
and fears,
misconception
Mmisconceptions
about cancer may
be more
disturbing than
facts and can
interfere with
treatments/ delay
healing.
Aaccurate and
concise
information helps
dispel fears and
anxiety, helps
clarify the
expected routine.
Ppromotes
competent selfcare and optimal
independence.
Eenhances ability
to manage selfcare and avoid
potential
complications,
drug reactions.

EVALUATION
STO> Goal is met
if patient was
able to verbalize
understanding of
body changes.
LTO> Goal is met
if patient was
able to verbalize
acceptance of
self in situation
in the effects of
therapeutic
regimen.