POST- OPERATIVE

NURSING CARE PLAN # 1

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective cues: Acute pain related Short term: Independent: Independent: Short term:
“Sakit ang tahi naa to surgical 1. Assess pain 1. Assessment of the pain
sa mga 4 ang incision on right Within 8 hours of characteristics experience is the first Within 8 hours of
kasakit” as breast secondary nursing using:PQRST step in planning pain nursing
management strategies.
verbalized by the to Multiple interventions, the interventions, the
2. Assess patients Vital The patient is the most
patient Fibroadenomas patient will be able Signs such as BP, reliable source of patient will be able to
to report pain is RR, PR. information about his or report pain is
Objective cues: relieved or her pain. relieved or
 P- provoke controlled. controlled.
when 2. a normal response to
moving Long term: pain is an increase in “Dili na sakit maam”
3. Assess for signs and heart rate, breathing rate
arms as verbalized
symptoms associated and blood pressure.
 Q-cramping Within 2 days of with pain.
pain nursing 3. The patient in acute pain Goal met
 R- localized interventions, the may have an elevated BP
pain as patient will be able and HR. Patient may Long term:
claimed to appreciate have difficulty
concentrating.
 S-scale of 4 technique and 4. Assess the patient’s Within 2 days of
out of 10 methods to provide willingness or ability nursing
relief such as to explore a range of 4. Some patients may be interventions, the
 T- unaware of the
relaxation skills and techniques aimed at patient will be able to
continuous controlling pain effectiveness of
pain diversional nonpharmacological appreciate technique
claimed activities methods and may be and methods to
willing to try them,
 Facial either with or instead of provide relief such as
Grimaced traditional analgesic relaxation skills and
medications.
 Guarding diversional activities
behaviour 5. Get rid of additional
stressors or sources 5. Patients may experience
 Slow Partially met
of discomfort an exaggeration in pain
movement
whenever possible or a decreased ability to
 Has 3 op
6. Provide rest, tolerate painful stimuli if
site 2inch facilitate comfort, environmental,
depth and relaxation intrapersonal, or
intrapsychic factors are
further stressing them.
6. One’s experiences of
pain may become
exaggerated as a result of
exhaustion. Pain may
result in fatigue, which
may result in
exaggerated pain. A
peaceful and quiet
environment may
7. Use facilitate rest..
nonpharmacological
methods such as 7. Techniques are used to
breathing exercise bring about state of
and music therapy physical and mental
awareness and
tranquillity. The goal of
these techniques is to
reduce tension,
subsequently reducing
pain.
 8. Use diversional
activities such as 8. The aid of an imagined
such using guided event or a mental picture
imagery involves use of the five
senses to divert oneself
from painful stimuli.
Increasing one’s
9. Provide comfort concentration, these
measures such as techniques help an
repositioning individual decrease the
pain experience

9. Repositioning stimulates
10. Provide supportive
blood flow to the area
pillows to the
and thorough reduction
affected area and a
of pain reflexes.
firm mattress
Dependent:
11. Administer prescribe 10. These will provide
pain medications. comfort and ease the
patient’s pain.
Collaborative:
11. To effectively manage
0. Refer to physician for
pain.
guided pain
management.
0. For early detections of
any risk factors and
complications during
operation
 NURSING CARE PLAN #2

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objectives: Impaired Skin integrity Short term: Independent: Independent: Short term:
related to surgical Within 3 hours of 1. Assess incision 1. To provide After 3 hours of
 Presence of incision on right breast nursing interventions site taking note comparative nursing
surgical secondary to Multiple the patient will be able of size, color, baseline data interventions the
wound on location, 2. To assess early
Fibroadenomas. to verbalize feelings of patient was able to
right breast temperature, progression of
increased self-esteem texture, verbalize feelings of
where wound healing,
and ability to manage consistency of increased self-
incision development of
was made situation. wound/lesion if esteem and ability to
hemorrhage or
 Destruction possible manage situation
2. Assess for odors infection
on the skin Long term:
surface and drains 3. May indicate
Within 2 days of Long term:
 Irritable coming out particular
nursing interventions After 2 days of
 Capillary from the skin or vulnerability
the patient will be able area of injury nursing
refill on 4. To provide
to determine and apply 3. Assess skin interventions the
both arms comparative
some of therapeutic routinely, noting patient was able to
and legs <3 baseline and
seconds regimen. moisture, color, determine and apply
and elasticity on opportunity for
 Numbness some of therapeutic
areas timely intervention.
of regimen
4. Assess blood
surrounding
areas supply such as 5. It indicates poor
 Itchiness on capillary return circulation
right breast. 5. Monitor for 6. For any alteration
 Redness on diminish that indicates other
breast skin. peripheral areas. underlying problem
6. Monitor for occur.
vital signs
 7. Inspect skin on 7. To promote timely
a daily basis, intervention and
describing revision of plan of
lesions and care
changes
observed 8. To assist body’s
8. Keep the area natural process of
clean or dry, repair
carefully dress 9. For baseline data
wounds, support
incision, and 10. To avoid causing
prevent pain and to promote
infection good circulation
9. Review
11. To prevent friction
Medication
injury and
therapy regimen
protection from
Health Teachings:
10. Use proper exposure to
positioning infection.
when moving
12. To avoid shear
patient
injury
11. Provide
adequate
clothing or
covers and 13. Lessen constant
protect from pressure minimize
drafts risk associated with
immobility
 12. Keep bed linens 14. To maintain general
dry and free of good health and
wrinkles. promote fast wound
healing
13. Instructed SO to 15. To assist body
provide safety natural process of
measure during repair
ambulation.
14. Encourage to
have adequate 16. Provide dry and free
nutritional and from draft on wound
fluid intake area
15. Instuct Patient
0. To identify
to note sign of
appropriate
infection such nutritional needs or
as redness, faster wound
swelling, pain healing
and warm
Dependent:
16. Change dressing
per doctor’s
order

Collaborative:
0. Refer to dietitian as
appropriate
 Nursing Care Plan #3

Cues Nursing Diagnosis Objectives Nursing Interventions Rationale Evaluation

Risk for Infection Short Term: Independent: Short term Goal:
Objectives Cues: related to tissue 1. Observe and 1. Changes in color Goal Met. After 2 hours
 Presence of destruction secondary After 2 hours of nursing report signs of and presence of of nursing interventions
surgical wound to surgical incision on interventions the patient infection such as moisture the patient was able to
on right breast right breast will be able to redness, warmth, indicates growth enumerate techniques
where incision enumerate techniques discharges, and of to prevent risk of
was made to prevent risk of increased body microorganism infection.
infection. temperature.
“Kabalo nako unsaon
2. Observed for 2. To evaluate the pama agi para
Long term: localized sign of presence or malikayan ang infection
infection sites of character of sa akong samad” as
Within 2 days of surgical infection. verbalized
nursing interventions incisions or
the patient will be able wounds. Goal met
to remain free of 3. Handwashing
infection as evidenced 3. Emphasize the remains the most Long Term:
by incision is clean and importance of effective method
dry. handwashing
 technique before of infection After 2 days of nursing
and after control. interventions the patient
cleaning the was able to remain free
surgical incision. of infection evidenced
by incisions is clean
4. Maintain aseptic 4. Aseptic and dry.
technique when technique for
changing dressing changes Goal met
dressing or and wound care
caring the limits the
wound. introduction of
pathogens.

5. Wet area can be

5. Emphazise the lodge area of
patient to keep bacteria.
around wound
clean and dry.
6. Patients need to
6. Teach the patient be able to
and family of recognize
infection and important signs
when to report and changes in
these to the their condition so
physician or early treatment
nurse can be initiated.

7. Foods rich in
protein can
 7. Encourage promote faster
intake of protein wound healing.
rich foods such
as milk, egg and
chicken. 8. Phytochemical
screening of the
8. Emphasize the guava leaves
use of boiled extracts revealed
guava leaves the presence of
when changing some bioactive
the wound compounds that
dressing. have been
9 Emphasize associated with
necessity of antimicrobial
taking antibiotics activities. (El-
as prescribed Mahmood
Collaborative: Muhammad
0. Refer to Abubakar, 2009)
physician for
guided infection
9. Used to treat
control
management. patient having
infections caused
by
microorganism

0. For early
detections of any
risk factors and
complications
during operation
 NURSING CARE PLAN # 4

Cues Nursing Objectives Nursing Intervention Rationale Evaluation

Diagnosis
Subjective Cues: Disturbed Short Term: Independent: Short Term Goal:
Body image Within 4 hours 1. Assess meaning of 1. The extent of response is more Goal Met. After 4
Objective Cues: of nursing loss or change to related to the value or importance hours of
•Presence of interventions the patient and SO, the patient places in the part or nursing
surgical wound on patient will be including future function than the actual value or interventions
right breast where able to expectations and importance. This necessitates the patient was
incision was made incorporate impact of cultural support to work through to optimal able to
changes into or religious resolution. incorporate
self-concept beliefs.. changes into
without negating 2. Alteration in body image can have self-concept
self-esteem. an effect on the patient’s ability to without
carry out daily roles and negating self-
2. Assess the responsibilities. Reflecting bowel esteem.
perceived impact activity
Long Term: of change in ADLs,
Within 2 days of social participation,
nursing personal Long Term Goal:
intervention the relationships, and 3. Adolescents and young adults may After 3 days of nursing
patient will be occupational be individually affected by changes intervention
able to verbalize activities. in the structure or function of their the patient was
acceptance of bodies at a time when able to
self in situation. 3. Assess the result of developmental changes are verbalize
body image normally rapid and at a time when acceptance of
disturbance in developing social and intimate self in
relation to the situation.
 patient’s relationships is particularly As evidenced by
developmental important. “Nadawat na
stage. nako na
4. There is a broad range of behaviors natangalan og
associated with body image bukol sa totoy”
4. Evaluate the disturbance, ranging from totally
patient’s behavior ignoring the altered structure or
regarding the function to preoccupation with it..
actual or perceived
changed body part 5. Negative statements about the
or function. affected body part may indicate
5. Evaluate the limited ability to integrate the
patient’s verbal change into the patient’s self-
remarks about the concept.
actual or perceived
change in body 6. Acceptance of these feelings as a
part or function. normal response to what has
6. Acknowledge and occurred facilitates resolution. It is
accept expression not helpful or possible to push
of feelings of patient before ready to deal with
frustration, situation.
dependency, anger, 7. Experiencing stages of grief over
grief, and hostility. loss of a body part or function is
normal and typically involves a
period of denial, the length of which
varies among individuals.
8. A good conversation provides
7. Recognize the ongoing support for patient and
normalcy of family.
 response to the
actual or perceived 9. The more noticeable the change in
change in body body structure or function, the more
structure or anxious the patient may have about
function.. the response of others to the change.

8. Encourage family
interaction with
each other

9. Assist the patient

in incorporating
actual changes into
ADLs, social life,
interpersonal
relationships, and
occupational
activities.

Collaborative:
10. Refer to physical 10. These are helpful in identifying
and occupational ways/devices to regain and maintain
therapy, vocational independence. Patient may need
counselor, further assistance to resolve
psychiatric persistent emotional problems.
counseling, clinical
specialist
psychiatric nurse,
social services, and
psychologist, as
needed.