Pt. W.P.G
Dx: Excision Biopsy, Frozen section modified Radical Mastectomy right
Cues
Nursing
Nursing Objective
Nursing Intervention
Diagnosis
S:
Acute Pain
Within 8 hours of
-Monitor vital signs
Scientific explanation
-Elevated vital signs can be a sign of pain.
- To assess etiology and contributing factors.
- Timely intervention is more likely to be
successful in alleviating pain.
- To provide non-pharmacological pain
management.
ordered.
irritability
Cues
Pt. W.P.G
Dx: Excision Biopsy, Frozen section modified Radical Mastectomy right
Nursing Diagnosis
Nursing Objective
Nursing Intervention
O:
Vs:
BP- 140/90
T: 36
- post surgical suture
on the right breast
- presence of Jackson
Pratt
Impaired skin
integrity related to
surgical incision
secondary to breast
removal
>elevation of temp.
may be assign of
infection for early
detection
>this helps in
preventing and
promoting an aseptic
way of wound healing.
Short term:
After 1-2 hours of nursing
intervention, patient was
able to verbalize and
demonstrate the right
measures in taking of her
post surgical skin.
hematoma formation or
breakdown.
>Administer prophylactic
antibiotics as prescribed.
>Prophylaxis is a
prevention of spread
of infection that may
further pose a risk on
patient.
Scientific explanation
Evaluation
Short term:
risk of infection.
Long term:
After 2-3 weeks of
nursing
intervention, the
achieve timely
healing
- Negative pressure pulls fluid
from the incisional area, which
facilitates healing
-to prevent infection
patient achieved
timely wound
healing and has
been free from
signs and
symptoms of
infection.