z

cues

Nursing diagnosis

Scientific rationale

Impaired skin
integrity secondary
to breast removal.

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
maybe 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

goal
Short term
planning: After 1
hour of nurse
patient interaction
within an 8hour
shift, patient will be
able to know,
verbalize and
demonstrate the
right measures on
taking care of her
postsurgical skin to
prevent infection.

Nursing
intervention
Provide and
explain
dressing and
drain care
(Jackson Pratt)
Administer
prophylactic
antibiotics as
prescribed.
Encourage and
Teach patient
on how to do
exercises such
as elbow
flexion/extensio
n & other
activities that
use the arm
with care; not
to raise it too
high or above
the shoulder

rationale
>this helps inpreventing
andpromoting anaseptic way
of wound healing.>Prophylaxis
isa prevention of spread
of infection thatmay
furtherpose a risk
onpatient.>thisfacilitateslymph
flow,prevent orreduceswelling
of affected part

Evaluation