Cues nurslng ulagnosls SclenLlflc Analysls lannlng nurslng lnLervenLlons 8aLlonale

Sub[ecLlve Cues
nlboLo akong
LoLoy sa Luo nga
bahln maong naa
me dlrl sa hosplLal
karon" as
verballzed by Lhe
paLlenL


Cb[ecLlve Cues
O ulsrupLlon
of skln
surface
(epldermls)
and
desLrucLlon
of skln
layers
(dermls) aL
Lhe rlghL
breasL
lmpalred skln
lnLegrlLy relaLed Lo
rupLured of
epldermls/dermls
skln layers
secondary Lo breasL
cancer
Cancer are conslsL of
abnormal cells wlLh a
damage unA caused by
carclnogens LhaL Lends
Lo muLaLe l noL
repalred leadlng Lo
carclnogenesls
(formaLlon of cancer
cells) lL undergone a
neoplasLlc growLh
resulLlng Lo a Llssue
mass LhaL lncreases lLs
slze over Llme leadlng
Lo Llssue pressure and
mechanlcal expanslon
and may rupLures over
Llme or durlng
appllcaLlon of a sLrong
force lnLernally Lo
forcefully expel
someLhlng (eg durlng
valsalva maneuver)

(medlcalsurglcal
nurslng cllnlcal
managemenL for
poslLlve ouLcome 8
Lh

edlLlon chapLer 16
pg233)
ShorL Lerm
AfLer 1 hour of nurslng
lnLeracLlon Lhe paLlenL
wlll be able Lo
demonsLraLe behavlor
Lo prevenL Lhe
occurrence of
compllcaLlon as
evldence by
a arLlclpaLe ln
Lhe prevenLlon
of
compllcaLlon
( eg lnfecLlon
delayed
wound heallng
and acLlve
bleedlng)

Long Lerm
AfLer 2 days of nurslng
lnLeracLlon Lhe paLlenL
wlll be able Lo
a ulsplay early
slgns of wound
heallng such
as
CloL formaLlon
Scab ls presenL
and
eplLhellum
(new
epldermls) ls
lndependenL
a 1o assessed
paLlenL's condlLlon
1 Assessed
dresslngs/wound
for characLerlsLlcs
of dralnage
MonlLor redness
swelllng and paln

2 MonlLor
LemperaLure




b 1o asslsL cllenL ln
promoLlng opLlmal
heallng
1 laced cllenL ln a
moderaLe hlgh
back resL








2 Assessed ln wound
dresslng




1 1o evaluaLe lf
Lhe paLlenL
undergone
acLlve bleedlng
Lo recognlze
early slgns of
wound heallng
2 Larly
recognlLlon of
developlng
lnfecLlon enable
rapld lnsLlLuLlon
of LreaLmenL



1 laclllLaLes
dralnage from
Lhe wound
Lhrough Lhe
gravlLaLlonal
force and
promoLes lung
expanslon Lhus
prevenLlng
pneumonla and
asplraLlon
2 1o evaluaLe Lhe
lnLegrlLy of Lhe
wound
growlng lnLo
Lhe wound
LplLhellum
grown
compleLely
lnLo Lhe
wound
granulaLlon
Llssue formed
Jound ls
compleLely
closed scab
has been
sloughed
granulaLlon
Llssue replace
wlLh new one

















3 Lncouraged
wearlng of loose
flLLlng/nonconsLrlc
Llve dresslng



CollaboraLlve
1 CollaboraLe wlLh
Lhe dleLlclan
regardlng foods
hlgh ln vlLamln A
u L k C
3 8educes
pressure on
compromlsed
Llssues whlch
may lmprove
clrculaLlon/heall
ng

1 1o faclllLaLes
fasLer wound
heallng and
boasL lmmune
sysLem