Nursing Care Plan for: Mastectomy

Scenario:
A 45 year old female is recovery on your unit from a bilateral mastectomy. The patient has difficulty
getting up from the bed to the chair without assistance. She is unable to push herself up in the bed as
well, making mobility difficult for her. After your morning assessment and helping the patient get from
the bed to the chair she confides in you she has been crying and is getting depressed about how her
husband (who she just newly married) will perceive her body. She says she hates the way her chest
looks and is embarrassed by it.

Nursing Diagnosis:

-Impaired Physical Mobility related to lymph-edema, nerve & muscle damage, and pain as evidence by
patient unable to get to bed from chair without assistance and unable to push herself up in bed.
Grieving related to loss of breasts and change to appearance as evidence by patient states she has
been crying and is depressed about her body appearance.

Subjective Data:

-After your morning assessment and helping the patient get from the bed to the chair she confides in
you she has been crying and is getting depressed about how her husband (who she just newly
married) will perceive her body. She says she hates the way her chest looks and is embarrassed by
it.

Objective Data:

-A 45 year old female is recovery on your unit from a bilateral mastectomy. The patient has difficulty
getting up from the bed to the chair without assistance. She is unable to push herself up in the bed as
well, making mobility difficult for her.

Nursing Outcomes:

-The patient will discuss her grief openly with her husband concerning her new physical appearance by
discharge.-The patient will express 2 positive changes in her new physical appearance by discharge.
-The patient will recognize at least 2 family members she can receive support from by discharge.
-The patient will report and exhibit an increase in strength in mobility by getting to and from bed to
chair with minimal assistance by post-opt day 3.
-The patient will verbalize 2 ways to prevent physical injury during ambulation by post-opt 2.
-The patient will perform exercise measures to increase mobility daily as tolerated.

Nursing Interventions:

-The nurse will assess daily the patient readiness to talk about new physical appearance.-The nurse will
encourage the patient to talk with husband about new physical appearance until patient feels
comfortable doing so.
-The nurse will assist and encourage the patient to focus on 2 positive changes in her appearance daily.
-The nurse will help the patient seek out two family members she has for support by discharge.
-The nurse will assess the patient strength in mobility daily.
-The nurse will demonstrate 2 ways to prevent physical injury during ambulation daily.
-The nurse will encourage and demonstrate exercises for the patient to complete daily to increase
mobility.

Constipation due to Hemorrhoids | Interventions & Goals

Scenario:
A 26 year old female is in day 3 of postpartum care from delivering a healthy baby girl via c-section.
She reports to you she is experiencing constipation and has been unable to have a bowel movement
for 5 days. She says she has been straining and she is having difficulty passing stool and when she
does it is a very hard small ball. In addition, she say she feels a lot of pressure in her rectum and
she is having pain from hemorrhoids she developed in the last trimester of her pregnancy. She says
she is afraid to have a bowel movement because of the pain caused by the hemorrhoids The patient
received many narcotics during and after the delivery.

Nursing Diagnosis:

-Constipation related to pain on defecation secondary to hemorrhoids as evidence by the patient

reporting she has not had a bowel movement for 5 days, hard stool, rectum pressure, and painful
hemorrhoids.

Subjective Data:

-The patient states she is experiencing constipation and has been unable to have a bowel movement
for 5 days. She says she has been straining and she is having difficulty passing stool and when she

does it is a very hard small ball. In addition, she say she feels a lot of pressure in her rectum and
she is having pain from hemorrhoids she developed in the last trimester of her pregnancy. She says
she is afraid to have a bowel movement because of the pain caused by the hemorrhoids.

Objective Data:

A 26 year old female is in day 3 of postpartum care from delivering a healthy baby girl via c-section.
The patient received many narcotics during and after the delivery.

Nursing Outcomes

-The patient will have a bowel movement before discharge.-The patient will report decreased pain in
rectum from hemorrhoids.
-The patient will verbalize 3 techniques on how to keep bowel movements regular.
-The patient will verbalize how to take prescribed medication regime to prevent constipation.

Nursing Interventions:

-The nurse administer per MD orders Miralax and Colace as prescribed to help assist patient with bowel
movement.-The nurse assess and document when patient has had a bowel movement daily.
-The nurse will provide the patient with a sitz bath and hemorrhoid cream as prescribed to help with
hemorrhoid pain.
-The nurse will educate the patient on 3 techniques on how to keep bowl movements regular by
discharge.
-The nurse will educate the patient how to take prescribed medications to prevent constipation by
discharge.

Hepatitis | Fatigue & Imbalanced Nutrition

Scenario:

A 48 year old male is admitted to your floor with viral hepatitis. The patient reports feelings of stomach
pain, extreme tiredness, nausea/vomiting, muscle aches, and loss of appetite. You collect a 48 hour
food diary from the patient and note his caloric intake is 1000 calories less than his recommended
daily value. On assessment you note the right upper quadrant of the abdomen is very tender to the
touch.

Nursing Diagnosis:

-Imbalanced Nutrition: Less than body requirements related to epigastric pain and nausea/vomiting as
evidence by patient reports stomach pain, nausea/vomiting, and 48 hour food diary shows caloric
deficient.
-Fatigue related to reduced metabolism by liver as evidence by patient has diagnosis of hepatitis.
Subjective Data:
-The patient reports feelings of stomach pain, extreme tiredness, nausea/vomiting, muscle aches, and
loss of appetite. Patients gives a 48 hours recall of food.
Objective Data:
-A 48 year old male is admitted to your floor with viral hepatitis. Patients caloric intake is 1000 calories
less than his recommended daily value. On assessment you note the right upper quadrant of the
abdomen is very tender to the touch.
Nursing Outcomes:
-The patient will participant in activities that stimulate and balance physical and cognitive areas of the
body within 48 hours of hospitalization.-The patient will rate his energy level greater than 5 on 1-10
scale with 10 being very energetic before discharge.
-The patients caloric intake will equal his recommended daily caloric intake within 48 hours.
-The patient will experience a decrease in nausea/vomiting within 24 hours.
Nursing Interventions:
-The nurse will encourage and assist the patient to the bedside chair three times a day with each
meal.-The nurse will encourage and assist the patient with performing bedside exercises and provide
him with reading material to stimulate cognitive function daily.
-The nurse will assess the patients energy level before and after each nursing shift.
-The nurse will collaborate with the nutritionist about patients current caloric intake and recommended
daily caloric intake on day 1 of patients hospitalization.
-The nurse will follow out the nutritionists plan of care regarding patient caloric intake daily for each
meal and snacks.
-The nurse will administer Zofran 4mg IV every 8 hours for nausea and vomiting.
-The nurse will teach the patient 2 non-pharmacological ways to decrease nausea within 24 hours of
admission.

Cellulitis Ineffective Tissue Perfusion

Scenario:
A 70 year old male presents to you floor. He was admitted to you from the ER. The patient is alert and
oriented times four. He lives alone at home and has a home health nurse that visits him 2 times a
week. The patient states he noticed that his right and left legs have started to become extremely red,
warm to the touch, and tender when he touches them. He also states that they have started to swell.
He reports having pain while walking. On assessment you note that the right and left lower areas of his
legs are swollen with 2+ pitting edema and that on palpation the areas feel very warm. The patient
winces in pain as your palpate the area. You note as well that the patients feet are cool to the touch
and you are unable to palpate a pulse. You use a Doppler to find the dorsalis pedis and post tibial
pulses which you document as faint in both the right and left feet. The patient history includes:
diabetes, congestive heart failure, peripheral vascular disease, CABG 5 years ago, mitral valve
replacement 2 years ago, and hypertension. An ultrasound was performed on the lower extremities to
rule out a deep vein thrombosis in the right and left legs. This test came back as negative. Pt VS
include: HR 75, BP 140/92, Temperature 99.4, oxygen saturation 96% on room air, pain 4 on 1-10 scale
in legs, and RR 15. WBCs 15.3, Blood sugar 257. Blood cultures are pending at this time. The patient is
started on IV antibiotics. The patients medical diagnosis is Cellulitis.
Nursing Diagnosis:
Ineffective peripheral tissue perfusion related inflammatory response secondary to cellulitis as
evidence by faint doppler pulses in the lower extremities and patients complaint of pain when walking.
Subjective Data:
The patient states he noticed that his right and left legs have started to become extremely red, warm
to the touch, and tender when he touches them. He also states that they have started to swell. He
reports having pain while walking.
Objective Data:
A 70 year old male presents to you floor. He was admitted to you from the ER. The patient is alert and
oriented times four. He lives alone at home and has a home health nurse that visits him 2 times a
week. On assessment you note that the right and left lower areas of his legs are swollen with 2+
pitting edema and that on palpation the areas feel very warm. The patient winces in pain as your
palpate the area. You note as well that the patients feet are cool to the touch and you are unable to
palpate a pulse. You use a Doppler to find the dorsalis pedis and post tibial pulses which you document
as faint in both the right and left feet. The patient history includes: diabetes, congestive heart failure,
peripheral vascular disease, CABG 5 years ago, mitral valve replacement 2 years ago, and
hypertension. An ultrasound was performed on the lower extremities to rule out a deep vein
thrombosis in the right and left legs. This test came back as negative. Pt VS include: HR 75, BP 140/92,
Temperature 99.4, oxygen saturation 96% on room air, pain 4 on 1-10 scale in legs, and RR 15. WBCs
15.3, Blood sugar 257. Blood cultures are pending at this time. The patient is started on IV antibiotics.
The patients medical diagnosis is Cellulitis.
Nursing Outcomes:
-Pt will have dopplerable pulses in lower extremities during hospitalization.-Pt right and left leg will
show signs of healing within 48 hours (decrease appearance of redness, swelling, and pain in the
affected areas).Pt will demonstarte how to check his feet and legs for infection and verbalize the
importance of doing this often due to his diabetes by discharge.
Nursing Interventions:
-The nurses will assess the patients doralis pedis and post tibial pulses with the doppler every 4 hours
for 24 hours.-The nurse will elevate the patients lower extremities on pillows above the heart level to
decrease swelling.-The nurse will administered IV antibiotics according to md order.-The nurse will
assess the patients lower extremities for signs of healing every shift.
-The nurse will demonstrated and have the patient demonstrate how to check his feet and legs for
infection daily by discharge.

Maternity Diagnosis, Interventions for Premature Rupture

of Membranes, PROM, or ROM
Scenario:
A 24 year old pregnant female presents to the L&D triage area complaining of gush of water and
constantly feeling wet. She denies having any labor contractions. She states the she is 37 weeks along
and is nervous about the gush of water she experienced so she decided to come to the L&D triage

area. According to the patients last menstrual period she is indeed 37 weeks along. A fern test is
ordered and comes back as positive. VS HR 85, BP 130/82, Temp. 98.7, O2 Sat 98% on RA, RR 18. All
reflexes are checked and are intact. No edema is present and UA comes back as negative. Pt denies
any uterus tenderness. Fetal Heart Rate is present with a rate 130 bpm and the patient states she felt
the babys last movement about an hour ago. The patient is to be kept overnight for monitoring and
complete bed rest.
Nursing Diagnosis:
Risk for infection related to loss of protective barrier as evidence by positive ferns test.
Subjective Data:
A 24 year old pregnant female presents to the L&D triage area complaining of gush of water and
constantly feeling wet. She denies having any labor contractions. She states the she is 37 weeks along
and is nervous about the gush of water she experienced so she decided to come to the L&D triage
area. Pt denies any uterus tenderness and the patient states she felt the babys last movement about
an hour ago.
Objective Data:
According to the patients last menstrual period she is indeed 37 weeks along. A fern test is ordered
and comes back as positive. VS HR 85, BP 130/82, Temp. 98.7, O2 Sat 98% on RA, RR 18. All reflexes
are checked and are intact. No edema is present and UA comes back as negative. Pt denies any uterus
tenderness. Fetal Heart Rate is present with a rate 130 bpm. The patient is to be kept overnight for
monitoring and complete bed rest.
Nursing Outcomes:
-Pt will be free from any signs and symptoms of infection such as foul smelling/looking vaginal
drainage, elevated temperature, uterus tenderness or rigidness, diminished fetal movement,
tachycardia, and hypo-tension throughout rest of pregnancy.-The patient will verbalized 6 signs and
symptoms of infection to the nurse.
-The patient will verbalized the importance of refraining from sexual intercourse of any type or usage
of tampons until after pregnancy.
Nursing Interventions:
-The nurse will assess the patient from any signs and symptoms of infection every 4 hours while
hospitalized.-The nurse will follow sterile procedure during any vaginal exams.
-The nurse will educate the patient on 6 signs and symptoms of infection the patient should watch out
for.
-The nurse will verbalize and demonstrate proper hand hygiene techniques to the patient.
-The nurse will educate the patient on the importance of refraining from any type of sexual intercourse
and tampons usage until after pregnancy.

Acute Pain
Scenario
A 68 year old male is admitted for hypertension. The patient blood pressure is now under control but
now the patient has developed pain in his left big toe. The patient toe is red and warm to the touch.
When the toe is touched the patient winces in pain. The patient states it hurts to move his toe
and that it is painful for a blanket or sheet to touch it. He states it hurt more at night and describes the
pain as throbbing and crushing. The doctors diagnosis is gout. The patient states his mother had gout
attacks but this is the first time he has had one and finds it very painful. The patient rates his pain 8 on
1-10 scale.
Nursing Diagnosis
Acute pain related to tissue trauma and reflex muscle spasms secondary to gout as evidence by
patient rates pain 8 on 1-10 scale and winces in pain.
Subjective Data
The patient states it hurts to move his toe and that it is painful for a blanket or sheet to touch it. He
states it hurt more at night and describes the pain as throbbing and crushing. The patient states his
mother had gout attacks but this is the first time he has had one and finds it very painful. The patient
rates his pain 8 on 1-10 scale.
Objective Data
A 68 year old male is admitted for hypertension. The patient blood pressure is now under control but
now the patient has developed pain in his left big toe. The patient toe is red and warm to the touch.
When the toe is touched the patient winces in pain.
Nursing Outcomes

-The patient will verbalize decrease in pain by rating pain less than 4 on 1-10 scale within 24 hours of
receiving pain medication.
-The patient will be able to move his left big toe without pain in 48 hours after starting Colichine.
-The patient will verbalize 5 signs on how to recognize early signs and symptoms of a pending gout
attack.
-The patient will verbalize 6 foods to avoid to help prevent future gout attacks.
-The patient will verbalize how to correctly take Colichine before discharge.
-The patient will demonstrate 4 non-pharmacological techniques to help decrease pain during gout
attacks.
Nursing Interventions
-The nurse will assess the patients pain level every 2 hours while patient is awake until patients pain
rating is less than 4 on 1-10 scale.
-The nurse will administered Colichine 0.5mg BID per md instructions to the patient to help with gout
pain and swelling.
-The nurse will assess the patients ability to mobilize his left big toe within 48 hours of starting
Colichine.
-The nurse will educate the patient on 5 signs on how to recognize early signs and symptoms of a
pending gout attack.
-The nurse will educate the patient on 6 foods to avoid to help prevent future gout attacks.
-The nurse will educate the patient on how to correcly take Colichine for gout before discharge.
-The nurse will educate the patient and have him demonstrate 4 non-pharmacological techniques to
help decrease pain during gout attacks.

Activity Intolerance, Anemia, Low Hemoglobin, Sickle Cell

Anemia, Iron Deficiency, Pernicious, Aplastic Anemia, Folic
Acid Deficiency, and Thalassemia
Scenario:
A 45 year old female presents to the ER. Patient states she has been so weak and just plain tried for
the past week. She states she cant even climb the stairs to her bedroom and has been sleeping
downstairs because she is so weak. Her mother has been having to do everything for her lately. She
also complains of cold/numb feet and hands constantly, intermittent chest pain/shortness of breath on
exertion, and dizziness. During your history assessment, the patient states she had this same thing 1
years ago and the doctor told her she was anemic. On assessment, you note that the patients skin is
pale and cool to the touch. Vital signs: HR 116 (normal sinus rhythm), BP 92/58, O2 Sat 94% on RA,
and Temperature 98.0F. Medications include: Multivitamin 1 TAB PO daily, Lortab 5-325mg PO prn for
back pain. Labs values: Hgb 7.5, Hct 22.9, Troponins 0.01, ABGs normal.
Nursing Diagnosis:
Activity Intolerance related to verbal report of fatigue or weakness as evidence by imbalance between
oxygen supply and demand.
Subjective Data:
Patient states she has been so weak and just plain tried for the past week. She states she cant even
climb the stairs to her bedroom and has been sleeping downstairs because she is so weak. Her mother
has been having to do everything for her lately. She also complains of cold/numb feet and hands
constantly, intermittent chest pain/shortness of breath on exertion, and dizziness. During your history
assessment, the patient states she had this same thing 1 years ago and the doctor told her she was
anemic.
Objective Data:
On assessment, you note that the patients skin is pale and cool to the touch. Vital signs: HR 116
regular, BP 92/58, O2 Sat 94% on RA, and Temperature 98.0F. Medications include: Multivitamin 1 TAB
PO daily, Lortab 5-325mg PO prn for back pain. Labs values: Hgb 7.5, Hct 22.9, Troponins 0.01, ABGs
normal
Nursing Outcomes:
-Pt will be able to walk approximately 300 feet without verbalizing complaints of fatigue or exhibiting
signs of fatigue by discharge. -Patients hgb will be greater than 10 within 24 hours.
-Patient will verbalize two signs and symptoms of anemia by discharge.
-Pt will verbalize 2 energy conserving techniques within 12 hours.
Nursing Interventions:

-The nurse will ambulate with the patient in the hallway approximately 300 feet and assess for any
signs of fatigue during ambulation before discharge.-The nurse will administer 2 units of PRBCs and
recheck a HGB within 10 hours per md order.
-The nurse will verbalize and provide printed education material on 4 signs and symptoms of anemia
by discharge.
-The nurse will demonstrate and verbalized 4 energy conserving techniques within 12 hours.

Impaired Skin Integrity | Diagnosis & Risk for Pressure

Ulcers, Risk for Skin Breakdown, Altered Skin Integrity
Scenario:
An 93 year old female presents to the ER with her family. The patient looks very thin and
malnourished. Pts weight is 95 lb and height is 5 6. Pt has advance stage of Alzheimers and is
aphasic. Pt is also a type 1 Diabetic. Contractures are noted in both upper extremities. The family
states the patient has been unable to walk for the past year which has lead to her being bed ridden
and has not be able to eat for the past week. On assessment, you note that the patient has a stage 3
pressure ulcer on her right heel and sacral area. The wound on the heel is draining purulent yellow
drainage and is 3 inches wide and 1 1/2 inches deep. The sacral wound is 5 inches wide and 2 inches
deep with no drainage noted. Pt VS: HR 80, BP 120/80, O2 Sat 98% on RA, and RR 15. Pt takes the
following medications: Lisinopril 12.5 mg PO Daily, ASA 81mg PO Daily, Regular Insulin per sliding
scale with meals, Lantus 30 units Subq at night. Lab and Diagnostic work shows: WBC 22, Blood Sugar
126.
Nursing Diagnosis:
Impaired Skin Integrity related to malnutrition and pressure ulcers as evidence by disruption of
epidermal and dermal tissues.
Subjective Data:
Unable to walk for the past year and has not be able to eat for the past week.
Objective Data:
Pts weight is 95 lb and height is 5 6. Pt has advance stage of Alzheimers and is aphasic. Pt is also a
type 1 Diabetic. Contractures are note in both upper extremities. stage 3 pressure ulcer on her right
heel and sacral area. The wound on the heel is draining purulent yellow drainage and is 3 inches wide
and 1 1/2 inches deep. The sacral wound is 5 inches wide and 2 inches deep with no drainage noted. Pt
VS: HR 80, BP 120/80, O2 Sat 98% on RA, and RR 15. Pt takes the following medications: Lisinopril
12.5 mg PO Daily, ASA 81mg PO Daily, Regular Insulin per sliding scale with meals, Lantus 30 units
Subq at night. Lab and Diagnostic work shows: WBC 22, Blood Sugar 126.
Nursing Outcomes:
-Pt will not have any further skin breakdown during the hospitalization.-Pts wounds will be kept clean
and free from any further infection.
-Pt will gain at least 3 lbs by discharge.
-Pt family will verbalize 2 ways on how to prevent pressure ulcers.
Nursing Interventions:
-Pt will be turned every two hours as evidence by nursing documentation.-Pts wounds will be changed
daily per wound care orders and proper hand hygiene will be performed before and after dressing
changes.
-Pt will be started on TPN per MD order and will be weighed every day.
-The nurse will verbalize and demonstrate to the pts family 4 ways on how to prevent pressure ulcers.

COPD
Scenario:
A 70 year old female presents from the ER to your PCU unit. The patient is excessively sleepy and falls
asleep easily even with stimuli. Pt is oriented times 4 though. Patient exhibited dyspnea on ambulation
from stretcher to bed. Pt family member tells you that the patient has been sleeping constantly for 2
weeks. The patient is on 3L nasal cannula with oxygen saturation of 88%. You note when the patient is
asleep she has apneic episodes where her oxygen saturation will decrease to 82%. The patient has a
history of obstruction sleep apnea and states (when awake) she does not wear her CPAP machine at
night because it is too loud. The patient is a current smoker and has been since she was 19 years
old. VS: HR 85, BP 130/82, Temp 98.6, RR irregular 19. ABGs were collected and the patients pCO2 74,

pH 7.24, P02 55, HCO3 33.2. Bipap ordered with the following settings Ipap 20, Epap 8, Oxygen
Percentage 30%, Rate 12.
Nursing Diagnosis:
Impaired Gas Exchange related to decreased lung compliance and altered level of consciousness as
evidence by dyspnea on exertion, decreased oxygen content, decreased oxygen saturation, and
increased PCO2.
Subjective Data:
Pt family member tells you that the patient has been sleeping constantly for 2 weeks. States she does
not wear her CPAP machine at night because it is too loud.
Objective Data:
A 70 year old female presents from the ER to your PCU unit. The patient is excessively sleepy and falls
asleep easily even with stimuli. Pt is oriented times 4 though. Patient exhibited dyspnea on ambulation
from stretcher to bed. The patient is on 3L nasal cannula with oxygen saturation of 88%. You note
when the patient is asleep she has apneic episodes where her oxygen saturation will decrease to 82%.
The patient has a history of obstruction sleep apnea. The patient is a current smoker and has been
since she was 19 years old. VS: HR 85, BP 130/82, Temp 98.6, RR irregular 19. ABGs were collected and
the patients pCO2 74, pH 7.24, P02 55, HCO3 33.2. Bipap ordered with the following settings Ipap 20,
Epap 8, Oxygen Percentage 30%, Rate 12.
Nursing Outcomes:
-Pts ABGs will be within normal limits with 24 hours of hospital stay.-Pt will be verbalize the
understanding of smoking cessation and how it relates to COPD.
-Pt will list 3 signs and symptoms of high PCO2 level and when to notify her doctor.
-Pt will tolerate the bipap machine.
-Pt will be free from any facial and mouth breakdown from bipap machine.
-Pt will verbalize 4 benefits of wearing a CPAP machine at home when she sleeps.
-Pt will be provided with a CPAP machine to take home that meets her expectations.
Nursing Interventions:
-The nurse will notify respiratory therapy to obtain ABG at 1500 and report results to the pulmonary
md.-The nurse will monitor patients vital signs every hours while on the bipap machine.
-The nurse will offer mouth care and fluids every 2 hours while the patient is on bipap.
-The nurse will teach the patient 3 signs and symptoms that indicate PCO2 level may be high and when
to contact her md.
-The nurse will provide the patient with smoking cessation materials and how it relates to COPD
educational material.
-The nurse will administer Ativan 0.5 mg PO every 6 hours to the patient as needed for anxiety when
on the bipap machine.
-The nurse will teach the patient 4 benefits of wearing a CPAP machine at home when she sleeps.
-The nurse will consult with discharge planning to help patient obtain a CPAP machine that meets her
expectations to wear at home.