Acute Pain

Impaired Skin Integrity

Disturbed Body Image

Risk for Infection

Readiness for enhanced fluid intake

Nursing diagnosis: impaired Skin/Tissue Integrity related to surgical removal of skin and tissue; altered circulation, presence of edema, drainage; changes in skin elasticity, sensation; tissuedestruction (radiation)

Possibly evidenced byDisruption of skin surface, destruction of skin layers and subcutaneous tissues

Desired Outcomes/Evaluation Criteria—Client WillWound Healing: Primary IntentionAchieve timely wound healing free of purulent drainage or erythema.Knowledge: Treatment ProceduresVerbalize understanding of treatment plan to promote wound healing.Demonstrate wound care techniques that facilitate increased tissue granulation at incision site.Demonstrate behaviors that prevent complications.

Nursing intervention with rationale:1. Assess dressings and wound for amount and characteristics of drainage.Rationale: Use of dressings depends on the extent of surgery and the type of wound closure. Pressure dressings are usually applied initially and are reinforced, not changed. Drainage occurs because of the trauma of the procedure and manipulation of the numerous blood vessels and lymphatics in the area.

2. Provide drain care, instructing client/family in the process, as indicated.Rationale: The Jackson-Pratt drain is most commonly used for mastectomies to maintain negative pressure in the wound and is easily managed. Simple mastectomies use one drain, whereas more complex procedures, such as those involving removal of lymph nodes, may require several drains. Drains are usually removed around the third day or when drainage ceases, possibly after client is discharged. Teaching facilitates self-care, reducing a major concern of client.

3. Monitor temperature.Rationale: Early recognition of developing infection enables rapid institution of treatment.

4. Place in semi-Fowler’s position on back or unaffected side; avoid letting the affected arm dangle.Rationale: Assists with drainage of fluid through use of gravity.

5. Prevent or minimize edema of involved arm.Rationale: Reduces the discomfort and associated complications.

6. Elevate hand and arm with shoulder positioned at appropriate angles at no more than 65 degrees of flexion, 45–65 degrees of abduction, 45–60 degrees of internal rotation, and forearm resting on wedge or pillow, as indicated.Rationale: Elevation of affected arm facilitates drainage and resolution of edema. Lymphedema is present in approximately 24% to 49% postmastectomy depending on surgical procedure performed (Warren et al, 2007). This may develop immediately after surgery or years later.

7. Avoid measuring blood pressure (BP), injecting medications, or inserting intravenous (IV) lines in affected arm.Rationale: Increases potential of constriction, infection, and lymphedema on affected side.

8. Inspect donor and graft site, if done, for color and blister formation; note drainage from donor site.

Rationale: Assesses circulation of affected area. Blister formation identifies bacterial growth and infection.

9. Encourage wearing of loose-fitting, nonconstrictive clothing. Inform the client not to wear wristwatch or other jewelry on affected arm.Rationale: Reduces pressure on compromised tissues, which may improve circulation and healing, and minimize lymphedema.

10. Administer antibiotics, as indicated.Rationale: Provides prophylaxis to treat specific infection and enhance healing.

Nursing diagnosis: marred Skin/Tissue Integrity compared to surgical dismissal of skin as well as tissue; altered circulation, participation of edema, drainage; changes in skin elasticity, sensation; tissuedestruction (radiation)

Possibly evidenced byDisruption of skin surface, drop of skin layers as well as subcutaneous tissues

Desired Outcomes/Evaluation Criteria—Client WillWound Healing: Primary IntentionAchieve timely wound recovering giveaway of purulent drainage or erythema.Knowledge: Treatment ProceduresVerbalize bargain of diagnosis devise to foster wound healing.Demonstrate wound caring techniques that promote increasing hankie granulation during rent site.Demonstrate behaviors that forestall complications.

Nursing involvement with rationale:1. Assess dressings as well as wound for volume as well as characteristics of drainage.Rationale: Use of dressings depends upon a border of operation as well as a sort of wound closure. Pressure dressings have been customarily practical primarily as well as have been reinforced, not changed. Drainage occurs since of a mishap of a procession as well as strategy of a countless red red blood vessels as well as lymphatics in a area.

2. Provide empty care, instructing client/family in a process, as indicated.Rationale: The Jackson-Pratt empty is many ordinarily used for mastectomies to say disastrous vigour in a wound as well as is simply managed. Simple mastectomies operate a single drain, since some-more formidable procedures, such as those involving dismissal of lymph nodes, might need multiform drains. Drains have been customarily private around a third day or when drainage ceases, presumably after customer is discharged. Teaching facilitates self-care, shortening a vital regard of client.

3. Monitor temperature.Rationale: Early approval of building infection enables fast establishment of treatment.

4. Place in semi-Fowler’s upon all sides upon behind or unblushing side; equivocate vouchsafing a influenced arm dangle.Rationale: Assists with drainage of liquid by operate of gravity.

5. Prevent or minimize edema of concerned arm.Rationale: Reduces a annoy as well as compared complications.

6. Elevate palm as well as arm with shoulder positioned during suitable angles during no some-more than 65 degrees of flexion, 45–65 degrees of abduction, 45–60 degrees of inner rotation, as well as forearm lazy upon crowd or pillow, as indicated.Rationale: Elevation of influenced arm facilitates drainage as well as fortitude of edema. Lymphedema is benefaction in we estimate 24% to 49% postmastectomy depending upon surgical procession achieved (Warren et al, 2007). This might rise rught away after operation or years later.

7. Avoid measuring red red blood vigour (BP), injecting medications, or inserting intravenous (IV) lines in influenced arm.Rationale: Increases intensity of constriction, infection, as well as lymphedema upon influenced side.

8. Inspect donor as well as swindle site, if done, for tone as well as scald formation; note drainage from donor site.Rationale: Assesses dissemination of influenced area. Blister arrangement identifies bacterial expansion as well as infection.

9. Encourage wearing of loose-fitting, nonconstrictive clothing. Inform a customer not to wear wristwatch or alternative valuables upon influenced arm.Rationale: Reduces vigour upon compromised tissues, that might urge dissemination as well as healing, as well as minimize lymphedema.

10. Administer antibiotics, as indicated.Rationale: Provides treatment to provide specific infection as well as raise healing.