NURSING CARE PLAN(sample)

Medical Diagnosis: Breast mass bilateral to consider fibroadenoma.Nursing Diagnosis: Deficient fluid volume related to vomiting.Short term goal: After 8hours of nursing intervention, patient will replace the loss body fluid.Long term goal: After hospitalization days, patient will be able to maintain adequate fluid volume as evidence by moist lips and.good skin color.

Assessment Nursing Problem Scientific Reason Intervention Rationale Evaluation

Subjective Cues:“Nang hihina ako

kakasuka” as verbalized by the

patient.

Objective cues:- Chapped lips- (+) Vomit 4x

after surgery- Dryness of

buccal mucosa

- Weight from 57kg – 55kg

Dehydration or electrolyte imbalance

Postoperative nausea and vomiting is the most frequent side effect after anesthesia. Postoperative nausea and vomiting is always self-limiting and non-fatal, it can cause significant morbidity, including dehydration and electrolyte imbalance.

- Increase fluid intake

- Continue giving IV as ordered by the doctor

- Monitor patient’s weight

- Monitor vital signs every 2hours

- Elevate bed up to neck with low pillow as doctor’s ordered

- Monitor intake and output

- To prevent dehydration

- To replace fluid loss

- Indicator of overall fluid and nutritional status

- To know the patient’s condition

- For the client to decreased dizziness and feel comfortable

- Provides information about overall fluid balance

After hospitalization, the patient maintained adequate fluid volume as evidence by moist lips and good skin color.

NURSING CARE PLAN

(sample)

Medical Diagnosis: Breast mass bilateral to consider fibroadenoma.Nursing Diagnosis: Disturbed sleeping pattern related to shortness of breath.Short term goal: After 8hours of shift, patient will report at least 4 hours of sleep.Long term goal: After hospitalization, the patient will have complete sleep and rest periods.

Assessment Nursing Problem Scientific Reason Intervention Rationale Evaluation

Subjective Cues:“Paputol putol ang

tulog ko” as verbalized by the

patient.

Objective cues:- Restlessness- Inability to

concentrate

Disturbed sleeping pattern

Decreased REM that can cause impaired processing information in the brain that lead to disturbed sleeping pattern

- Monitor vital signs

- Assess the cause of sleep deprivation

- Encourage patient to diversional activities

- Provide quite environment

-Explore other sleep aids such as warm bath or milk

- To know the patient’s condition

- To know underlying condition

- To divert patient’s attention from the surgical pain

- This provide conducive environment for the patient

- To promote wellness

After hospitalization, the patient has complete sleep and rest periods.

NURSING CARE PLAN(sample)

Medical Diagnosis: Breast mass bilateral to consider fibroadenoma.Nursing Diagnosis: Acute pain related to post surgical incision or inflammation of breast.Short term goal: After 8hours of nursing intervention, patient will report relieve pain from 8/10-6/10.Long term goal: After hospitalization days, the patient will report relief pain.

Assessment Nursing Problem Scientific Reason Intervention Rationale Evaluation

Subjective Cues:“Masakit pa ang

opera ko” as verbalized by the

patient.

- Pain Scale 8/10

Objective cues:- (+) Facial

grimace- Narrowed

focus- Observed

evidence of pain

- Expressive behavior

Post operative pain Because of the tissue trauma, the inflammatory process of body is being activated by relasing histamine, substance P, bradikinin, prostaglandin, endokokinins which are highly acidic. Increasedacidity on the trauma site or the injuired site heighten in pain fibers which stimulates the sensation of pain and makes pain more intensed.

- Assess for referred pain

- Note client’s attitude toward pain

- Encourage patient to diversional activities

- Allow the client to verbalized expression about pain

- Give medicine for pain

- To help determine of underlying condition or organ dysfunction requiring treatment

- To help the client to verbalized the intensity of pain

- To divert patient’s attention from the pain

- Verbalization allows outlet for emotions and may enhance coping mechanism

- To lessen the pain of the patient

After hospitalization days, the patient will report relieved pain.

NURSING CARE PLAN(sample)

Medical Diagnosis: Breast mass bilateral to consider fibroadenoma.Nursing Diagnosis: Deficient knowledge related to unfamiliarity about disease processShort term goal: After 8hours of nursing intervention, Long term goal: At the end of hospitalization days, the patient has evidence of learning plan and actions performed.

Assessment Nursing Problem Scientific Reason Intervention Rationale Evaluation

Subjective Cues:“Nung nag

pacheckup ako, tska ko na lang nalaman” as verbalized by the

patient.

Objective cues:- With worried

gaze- Frequently

asking questions about his condition and treatment

Deficient knowledge regarding the disease process

There is this presence of knowledge deficit due to some unfamiliar information that causes some confusion to the client that needs to be discussed.

- Encourage client to do breast self examination

- Provide explanations of reasons for test procedures and preparation needed

- Review disease process/prognosis. Discuss hospitalization and prospective treatment as indicated. Encourage questions, expression of concern.

- Identify individual restriction such as lifting heavy objects

- For the client to monitor her condition regarding with her own breast

- Information can decrease anxiety and for the patient to know the procedures to be done

- Provides knowledge base from which patient can make informed choices. Effective communication and support at this time can diminish anxiety and promote healing.

- Activities that may increase pressure that can strains surgical repairs and may delay healing.

- At the end of hospitalization days, the patient has evidence of learning plan and actions performed.

NURSING CARE PLAN(sample)

Medical Diagnosis: Breast mass bilateral to consider fibroadenoma.

Nursing Diagnosis: Anxiety related to post operative breast mass removalShort term goal: After 8hours of nursing intervention, the patient will be able to verbalize absence of or decrease in subjective distress.Long term goal: After hospitalization days, the patient will be able to demonstrate improve concentration and accuracy of thoughts.

Assessment Nursing Problem Scientific Reason Intervention Rationale Evaluation

Subjective Cues:“Baka tubuan pa ako

ng bukol sa ibang parte ng dibdib ko”

as verbalized by the patient.

Objective cues:- Restless - Fatigue- narrowed

focus- Irritability

Anxiety Anxiety is a psychological and physiological state characterized by cognitive, somatic, emotional, and behavioral componentsAnd it generalized mood condition that occurs without an identifiable triggering stimulus.

- Assesses client’s level of anxiety.

- Encouraged patient to share thoughts & verbalize feelings.

- Encourage patient to have divertional activities.

- To help the patient to cope up with being anxious - Provides opportunity to examine realistic fears & misconceptions about the illness.

- To lessen anxiety

At the end of hospitalization, the patient will be able to demonstrate improve concentration and accuracy of thoughts.