ASSESSMENT

Subjective: N/a Objective: >Chart dx: s/p left breast mastectomy s/t malignant neoplasm >post surgical suture on affected part >presence of Jackson Pratt

BACKGROUN D KNOWLEDGE
Breast Cancer is the most common malignancy in women and is second only to lung Cancer as a cause of Cancer death. Decrease in mortality may be ascribed to the combined benefits of early detection and better treatment. One of its treatment modalities is an invasive procedure causing a breakage in the continuity of the skin as removal of the affected part is done---leaving the skin impaired for a moment until healing of

NURSING DIAGNOSIS
Impaired skin integrity related to surgery secondary to breast removal.

PLANNING
Short term planning: After 1 hour of nurse patient interaction within an 8 hour shift, patient will be able to know, verbalize and demonstrate the right measures on taking care of her post surgical skin to prevent infection. Long Term planning: After 3 weeks of continuous nursing intervention, patient will remain free of impairment in skin integrity, as evidenced by healing skin without

INTERVENTIO N
>Provide and explain dressing and drain care (Jackson Pratt) >Administer prophylactic antibiotics as prescribed.

RATIONALE
>this helps in preventing and promoting an aseptic way of wound healing.

EVALUATION

>Encourage and Teach patient on how to do exercises such as elbow flexion/extensi on & other activities that use the arm with care; not to raise it too high or above the shoulder. >Advise patient or relative to report any untoward s/sx

Short term: After 1 hour of nurse patient interaction within an 8 hour shift, >Prophylaxis is patient was a prevention of able to spread of verbalize and infection that demonstrate may further the right pose a risk on measures in patient. taking of her post surgical >this skin. facilitates lymph flow, Long Term: After 3 weeks prevent or of continuous reduce nursing swelling of intervention, affected part. patients surgical site was able to gradually heal without untoward symptoms and with stability .
>Fever &

redness are the usual signs of having an

GOAL MET.

tissue takes place which happens depending on the bodys ability to heal.

redness, infection, hematoma formation or breakdown.

such as fever or redness on affected part.

infection & early detection would limit its spread.