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NAME OF STUDENT (PRINT CLEARLY)

UNIT
CODE:

NNT2405

DETONI

INTRODUCTION TO MEDICAL SURGICAL

NURSING
TITLE:

STUDENT ID. NO.

ADRIANA

10319036

FAMILY NAME FIRST NAME

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DUE DATE
JANELLE

14/04/2014

Topic of assignment
NURSING CARE PLAN
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Campus
K45

JO

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Assignment title: Nursing Care Plan

Unit code and title: NNT2405 Introduction to Medical Surgical Nursing
Lecturer: Melanie Baker
Student name: Adriana Detoni
Student number: 10319036
Date of submission: 14th April 2014

Contents
Introduction:......................................................................................................................................4
Medical Diagnosis.............................................................................................................................4
Identified problems:...........................................................................................................................5
Prioritised Problem............................................................................................................................6
Conclusion.....................................................................................................................................7
Word Count...................................................................................................................................8
References.........................................................................................................................................9

Appendix A- Nursing Care Plan ...11

Introduction:
A nurse plays an imperative role in the education and post-operative treatment in a
patient following any surgery. It is the nurses objective to aid the patient into becoming as
independent as possible. Mrs Jasper is a 45 year old female who has been diagnosed with
breast cancer and has just undergone a right mastectomy and axially node clearance. She
currently has a pain score of six-out-of-ten on her right chest and as difficulty repositioning
herself in bed and refuses to sit out of bed. This paper will explore Mrs Jaspers current
medical condition and the nursing interventions that will be implemented in Mrs Jaspers life
so she is able to complete her activities of daily living to the highest extent of independence.
Six identified or plausible problems will also be discussed, one of which will be focusing on
the top prioritized nursing problem. An individualised nursing care plan will be tailored to
Mrs Jaspers problem which will compromise of aims, a plan, an evaluation and a rationale.
Medical Diagnosis
Breast cancer is a disease predominantly in females where malignant or cancerous
cells that originate in the breast form together to make a tumour. Cancer develops when the
abnormal cells grow and multiply and if left untreated can metastasize to other parts of the
body through blood vessels and lymph nodes (Ugiliweneza, 2008). Mrs Jasper has just
undergone a right mastectomy and axially node clearance. This is a surgical procedure to
remove the whole breast including the nipple. The main aim of a mastectomy is to remove
the entire breast tissue including the malignant tumour and the removal of excess skin
(Ugiliweneza, 2008).
Mrs Jasper has also undergone an axially node clearance, this procedure is done in
conjunction with a mastectomy. The axilla is a medical descriptive term for the armpit and
there are approximately 20 lymph nodes located there. It is very common for cancer to spread
from the breast and into the lymph nodes. The aim of an lymph node clearance is to remove

the lymph glands to ensure that no cancer has spread or is left behind (Dillon, Hayes, Quinn,
Advani, Masterson, Evoy, & McDermott, 2010).

Identified problems:
Mrs Jasper is faced with a range of identifiable nursing problems and these will be
discussed starting from the leading problem to less important problems. The initial and most
significant problem facing Mrs Jasper is her pain due to her altered comfort following her
right mastectomy. Pain is an imperative problem that needs to be identified and if left
untreated patients in most cases will not comply with activities of daily living. Mrs Jasper
states her pain is a 6/10 and this would be affecting her movement and mobility.
The second identified problem is altered skin integrity. Mrs Jasper has an increased
risk of pressure ulcers due to her lack of movement (Walton-Geer, 2009). She refuses to get
out of bed for meals and has difficulty repositioning herself in bed and declines to ambulate
outside of her bedroom. If Mrs Jasper does not move around enough she will get bed sores
which could potentially get infected and cause other major health problems.
The third identified health problem is Mrs Jasper is complaining about nausea and she
has a lack of appetite. This could lead to health problems such as malnutrition causing
additional muscle and bone weakness. Mrs Jasper is not receiving adequate nutrition and
hydration if she is refusing to eat and this could be detrimental in her post-operative healing
process.
The fourth identified health issue is Mrs Jaspers impaired gas exchange resulting in
the use her requiring a nasal cannula of 2L oxygen per minute.

The fifth identified issue is Mrs Jaspers impaired communication due to the loss of
self-dignity following the mastectomy. It appears that her self-confidence has decreased as
she does not look at the operation site and presents to be teary.
The sixth identified problem is that Mrs Jasper is unable to move adequately resulting
in and out of bed. This could manifest to her being unable to ambulate and eliminate waste.
Prioritised Problem
Effective post-operative pain control is a crucial constituent in the care of a patient
who has just undergone surgery (Chrisp, 2009). Inadequate pain management can result a
patient in a delayed healing process, morbidity and even mortality (Sinatra, 2009). Mrs
Jasper has undergone a right mastectomy two days ago and states her pain score a 6/10. If
pain becomes an issue with any patient the nurse needs to have this problem addressed and it
should then be a top priority. Patients who are suffering any type of pain will be less
compliant with any of their activities of daily living and may refrain from completing them
(Chrisp, 2013).
An individuals pain perception can often vary depending on a number of factors. It is
important for a nurse to realise that pain is subjective data that cannot be measured and must
always be taken into consideration whilst caring for a patient (Chrisp, 2013). In the case
study for Mrs Jasper it is a nurses role to aid in relieving the feelings of pain and preventing
any other problems that could arise worsening the pain. A patients pain can be assessed by a
nurse using a proper approach such as a pain assessment tool. A 10 point scale ranging from 1
where there is no pain to 10 where the patient is in the worst pain of their life (Kaasalainen,,
Martin-Misener, Carter, Dicenso, Donald, & Baxter, 2010). The rating also depends on the
observer and when told by the patient is classified as subjective data.

Joint interventions are the use of a multi-disciplinary team to treat a problem that a nurse
cannot alone (Chrisp, Taylor, Douglas, Rebeiro, 2013). An example of this is that a nurse is
unable to prescribe any pain medication for Mrs Jasper, nor is she allowed to increase
dosages. A nurse is also unable to carry out appropriate physiotherapy for a patient. This
therefore then requires the need of an external team of healthcare professionals to provide
holistic care.
Conclusion

Mrs Jackson has just recently undergone a right mastectomy and axially node
clearance. Six identified nursing diagnoses have been prioritised with the most important
being Mrs Jaspers pain management. She has had an individual nursing care plan written up
for her. If Mrs Jaspers pain can be successfully managed it can be seen that the other five of
her nursing problems will be less severe or even eliminated.

8
Word Count

1020

References
Adam, K., Gibson, E., Lyle, A., & Strong, J. (2010). Development of roles for occupational
therapists and physiotherapists in work related practice. an australian perspective,
36(3), 263-272.

Breivik, H., Borchgrevink, P. C., Allen, S. M., Rosseland, L. A., Romundstad, L., Breivik
Hals, E. K., Kvarstein, G., & Stubhaug, A. (2008). Assessment of pain. Oxford
Journals, 101(1), 17-24.
Chrisp , J., Taylor, C., Douglas , C., & Rebeiro, G. (2013). Potter and Perry's fundamentals
of nursing (4th ed.). Chatswood, New South Wales: Elsevier.
Dillon, M. F., Hayes, B. D., Quinn, C. M., Advani, V., Masterson, C., Evoy, D., &
McDermott, E. W. (2010). The extent of axillary lymph node clearance required
following detection of sentinel node micrometastases. The Breast Journal, 16(5),
533-536. doi:10.1111/j.1524-4741.2010.00959.x
Kaasalainen, S., Martin-Misener, R., Carter, N., Dicenso, A., Donald, F., & Baxter, P. (2010).
The nurse practitioner role in pain management in long-term care. Journal of
Advanced Nursing, 66(3), 542-551. doi:10.1111/j.1365-2648.2009.05206.x
Sinatra, R. S., & Ebooks Corporation. (2009). Acute pain management. Cambridge:
Cambridge University Press
Ugiliweneza, B. (2008). Analysis of mastectomy in breast cancer treatment. Value in
Health, 11(3), A56-A56. doi:10.1016/S1098-3015(10)70187-X

10

Villarreal-Colin, P., Robles-Vidal, C., & Drucker-Zertuche, M. (2007). Skin-sparing

mastectomy in breast cancer. BMC Cancer, 7(Suppl 1), A48-A48. doi:10.1186/14712407-7-S1-A48

Walton-Geer, P. S. (2009). Prevention of pressure ulcers in the surgical patient. AORN

Journal, 89(3), 538-548.

Workman, S. R. (2013). The importance of establishing a rapport with patients. BMJ

(Clinical Research Ed.), 347, f5745

Zeller, J. L., Burke, A. E., & Glass, R. M. (2008). Acute pain treatment. Journal of the
American Medical Association, 299(1), 128.

11

Appendix A- Nursing Care Plan

NURSING DIAGNOSIS : Mastectomy and axially node clearance resulting in alteration of
comfort due to pain
Aims/Goals
For the purpose of
this assignment 3
or more goals for
your one (1) top
prioritized Nursing
Diagnoses
1. Acute pain
related to right
mastectomy
secondary to
surgical incision to
be reduced from 6
out of ten to a two to
three out of ten in
the next twenty four
hours

Plan &
Implementation
(generally are the
same thing)
Interventions will be
planned for each goal.

Expected Outcome/
Evaluation

Referenced evidence
based rationales
For the purpose of your
assignment provide
these for individual or
groups of interventions

1. Establish rapport
with patient
2. Evaluate verbal and
non-verbal pain
characteristics
identified by patient
such as duration,
frequency and location
3. Assess and monitor
on an hourly basis the
decline in pain score
with the use of effective
analgesia in a
therapeutic range
4. Ensure patient is
positioned properly and
not putting pressure on
surgical wound site
5. Monitor vital signs to
detect any
abnormalities
6. Place patient in the
semi-fowlers position
with the right arm
elevated and ensure
head and neck is
supported in a neutral
position

The expected outcome

for the patient would be
to successfully decrease
or eradicate the pain.
The patient would have
a noticeably decreased
pain score when being
evaluated and will be
more compliant with
completing other
activities of daily living
such as eating,
repositioning
themselves and
communicating.

Rapport is crucial in
gaining the patients trust
and ensuring the patient
does not feel ashamed or
embarrassed whilst
communicating with a
health professional
(Workman, 2013).
Pain scales are an
effective method of
comparing baseline
evaluations to a patients
response to analgesia
(Chrisp, 2013).
Patients personal report
of pain is the most
consistent indication for
its intensity and
existence (Chrisp, 2013).
Semi-fowler position
prevents hyperextension
of the neck and protects
integrity of the suture
line (UCSF, N.D).
Vital signs such as heart
rate, blood pressure and
respirations can rise
when patients are

12
suffering acute pain . By
monitoring these, nurses
are able to compare and
notice any changes in
baseline observations
(Chrisp, 2013).

2. The ability for the

patient to reposition
themselves without
pain

1. Educate patient on
correct positioning and
movement
2. Ensure patient is not
placing pressure on
suture sight
3. Involve external
teams such as a
physiotherapist
4. Promote rest and
relaxation
5.Implement the use of
analgesia whilst the
wound is healing
6.Monitor vital signs
after repositioning to
detect any abnormal
peaks in respirations,
blood pressure and
heart rate

The expected outcome

for the patient will be
to move and reposition
themselves
independently without
pain using an
appropriate technique.
This can be evaluated
by the patient reporting
any pain, assessing the
patients facial
expressions and also by
monitoring their vital
signs to check if these
is a spike in blood
pressure, respirations
and heart rate.

A physiotherapist can
demonstrate and educate
the patient about
exercises and
movements that can be
performed to decrease
long term pain and
increase the patients
healing process, this can
be a task done
independently without
the assistance of a nurse
(Adam, Gibson, Lyle,
Strong, 2010)
Patients are more pron
and succeptible to
pressure ulcers when
there is a decrease in
movement and they
remain in a constant
position over extended
periods of time (Walton-

Geer, 2009).

13
3. The patient will
be at an adequate
pain level before
being discharged

1.Involve and educate

the patient about pain
management techniques
2. Integrate other forms
of pain relief such as
non-pharmacological
techniques to assist
pharmacological
treatments
3. Allow the patient to
express the usefulness
of pharmacological and
non-pharmacological
pain relief
4. Provide an
environment that is
warm and quiet for
optimal patient
recovery
5. Take a pain score on
every set of
observations to ensure
there is little/no pain
6. Ensure the patient
does not make any
facial grimces when
attempting to move or
reposition themselves
without the nurses
assistance.

The patient will be able

to successfully manage
their pain levels before
discharge and the use
of other treatment
methods to complement
pharmacological
treatments are effective.

The use of blanket or hot

pack after surgery can
provide comfort to the
patient particularly postsurgery (Chrisp, 2013).
It is optimal to a patients
wellbeing after any
procedure or surgery
they are in a comfortable
state (Tollefson, 2012).
Treatments such as
applying a heat pack or a
cold pack can reduce
pain and inflammation
(Body, Bergmann,
Boonen, Boutsen,
Bruyere, Devogelaer,
Goemaere, Hollevoet,
Kaufman, Milsen,
Rozenberg, Reginster,
2011).