Breast Mass Bilateral To Consider Fibroadenoma

NURSING CARE PLAN (sample)

Medical Diagnosis: Breast mass bilateral to consider fibroadenoma. Nursing Diagnosis: Deficient fluid volume related to vomiting. Short term goal: After 8hours of nursing intervention, patient will replace the loss body fluid. Long term goal: After hospitalization days, patient will be able to maintain adequate fluid volume as evidence by moist lips and.good skin color. Assessment Subjective Cues: “Nang hihina ako kakasuka” as verbalized by the patient. Objective cues: - Chapped lips - (+) Vomit 4x after surgery - Dryness of buccal mucosa - Weight from 57kg – 55kg

Nursing Problem Dehydration or electrolyte imbalance

Scientific Reason Postoperative nausea and vomiting is the most frequent side effect after anesthesia. Postoperative nausea and vomiting is always self-limiting and non-fatal, it can cause significant morbidity, including dehydration and electrolyte imbalance.

Intervention

Rationale

- Increase fluid intake

- To prevent dehydration

- Continue giving IV as ordered by the doctor

- To replace fluid loss

- Monitor patient’s weight

- Indicator of overall fluid and nutritional status

- Monitor vital signs every 2hours

- To know the patient’s condition

- Elevate bed up to neck with low pillow as doctor’s ordered

- For the client to decreased dizziness and feel comfortable

- Monitor intake and output

- Provides information about overall fluid balance

Evaluation After hospitalization, the patient maintained adequate fluid volume as evidence by moist lips and good skin color.

NURSING CARE PLAN (sample)

Medical Diagnosis: Breast mass bilateral to consider fibroadenoma. Nursing Diagnosis: Disturbed sleeping pattern related to shortness of breath. Short term goal: After 8hours of shift, patient will report at least 4 hours of sleep. Long term goal: After hospitalization, the patient will have complete sleep and rest periods. Assessment Subjective Cues: “Paputol putol ang tulog ko” as verbalized by the patient. Objective cues: - Restlessness - Inability to concentrate

Nursing Problem

Scientific Reason

Disturbed sleeping pattern

Decreased REM that can cause impaired processing information in the brain that lead to disturbed sleeping pattern

Intervention

Rationale

- Monitor vital signs

- To know the patient’s condition

- Assess the cause of sleep deprivation

- To know underlying condition

- Encourage patient to diversional activities

- To divert patient’s attention from the surgical pain

- Provide quite environment

- This provide conducive environment for the patient

-Explore other sleep aids such as warm bath or milk

- To promote wellness

Evaluation After hospitalization, the patient has complete sleep and rest periods.

NURSING CARE PLAN (sample)

Medical Diagnosis: Breast mass bilateral to consider fibroadenoma. Nursing Diagnosis: Acute pain related to post surgical incision or inflammation of breast. Short term goal: After 8hours of nursing intervention, patient will report relieve pain from 8/10-6/10. Long term goal: After hospitalization days, the patient will report relief pain. Assessment

Nursing Problem

Scientific Reason

Subjective Cues: “Masakit pa ang opera ko” as verbalized by the patient.

Post operative pain

Because of the tissue trauma, the inflammatory process of body is being activated by relasing histamine, substance P, bradikinin, prostaglandin, endokokinins which are highly acidic. Increased acidity on the trauma site or the injuired site heighten in pain fibers which stimulates the sensation of pain and makes pain more intensed.

- Pain Scale 8/10 Objective cues: - (+) Facial grimace - Narrowed focus - Observed evidence of pain - Expressive behavior

Intervention

Rationale

- Assess for referred - To help determine pain of underlying condition or organ dysfunction requiring treatment - Note client’s attitude toward pain

- To help the client to verbalized the intensity of pain

- Encourage patient to diversional activities

- To divert patient’s attention from the pain

- Allow the client to verbalized expression about pain

- Verbalization allows outlet for emotions and may enhance coping mechanism

- Give medicine for pain

- To lessen the pain of the patient

Evaluation After hospitalization days, the patient will report relieved pain.

NURSING CARE PLAN (sample)

Medical Diagnosis: Breast mass bilateral to consider fibroadenoma. Nursing Diagnosis: Deficient knowledge related to unfamiliarity about disease process Short term goal: After 8hours of nursing intervention, Long term goal: At the end of hospitalization days, the patient has evidence of learning plan and actions performed. Assessment

Nursing Problem

Scientific Reason

Subjective Cues: “Nung nag pacheckup ako, tska ko na lang nalaman” as verbalized by the patient.

Deficient knowledge regarding the disease process

There is this presence of knowledge deficit due to some unfamiliar information that causes some confusion to the client that needs to be discussed.

Objective cues: With worried gaze - Frequently asking questions about his condition and treatment

Intervention

Rationale

Evaluation

- Encourage client to do breast self examination

- For the client to monitor her condition regarding with her own breast

- Provide explanations of reasons for test procedures and preparation needed

- Information can decrease anxiety and for the patient to know the procedures to be done

- At the end of hospitalization days, the patient has evidence of learning plan and actions performed.

- Review disease process/prognosis. Discuss hospitalization and prospective treatment as indicated. Encourage questions, expression of concern. - Identify individual restriction such as lifting heavy objects

- Provides knowledge base from which patient can make informed choices. Effective communication and support at this time can diminish anxiety and promote healing. - Activities that may increase pressure that can strains surgical repairs and may delay healing.

NURSING CARE PLAN (sample)

Medical Diagnosis: Breast mass bilateral to consider fibroadenoma. Nursing Diagnosis: Anxiety related to post operative breast mass removal Short term goal: After 8hours of nursing intervention, the patient will be able to verbalize absence of or decrease in subjective distress. Long term goal: After hospitalization days, the patient will be able to demonstrate improve concentration and accuracy of thoughts. Assessment Subjective Cues: “Baka tubuan pa ako ng bukol sa ibang parte ng dibdib ko” as verbalized by the patient. Objective cues: - Restless - Fatigue - narrowed focus - Irritability

Nursing Problem Anxiety

Scientific Reason Anxiety is a psychological and physiological state characterized by cognitive, somatic, emotional, and behavioral components And it generalized mood condition that occurs without an identifiable triggering stimulus.

Intervention

Rationale

- Assesses client’s level of anxiety.

Evaluation

- To help the patient At the end of to cope up with hospitalization, the being anxious patient will be able to demonstrate - Encouraged - Provides improve patient to share opportunity to concentration and thoughts & verbalize examine realistic accuracy of feelings. fears & thoughts. misconceptions about the illness. - Encourage patient to have divertional activities.

- To lessen anxiety