ASSESSMENT

NURSING
DIAGNOSIS
OBJECTIVES: Acute pain
Clients
related to
underwent
surgical
excision of
procedure
breast mass
(excision of
which followed breast mass
by MRM.
followed by
MRM)

RATIONALE
A surgical
incision
(excision of
breast mass
followed by
MRM) results
to an
unpleasant
sensory and
emotional
experience due
to tissue
damage.
Breast lump
removal is a
surgery to
remove a
breast cancer
along with
some
surrounding
tissue from the
breast.
Modified
Radical
Mastectomy is
the removal of
the breast

OBJECTIVES

NURSING
RATIONALE
INTERVENTIONS
SHORTINDEPENDENT
TERM:
1.) Introduce
1.) This will
Within the shift yourself to the client establish rapport
the client:
and her relatives.
with the patient
1.) will be able
and her relatives
to accurately
and through this
report her pain
patient will feel
when asked by
comfortable in
the nurses.
giving
2.) her pain felt
information to
will either be
the nurses.
maintained or
2.) Assess clients
decreased by
pain using pain
2.) Pain is a
consistently
scale.
subjective data
monitoring and
and only the
assessing her
client can
and attending
express pain
her needs.
that shes
3. client and her
experiencing.
relatives will be 3.) Observe for
able to learn and clients body
3.) This can also
apply nongestures such as
indicate that the
pharmacological facial grimace,
client is
(deep breathing guarding the postexperiencing
exercises,
operative site.
pain.
therapeutic
touch and
4.) Assess the postdiversional
operative site for
techniques) in
signs of necrosis etc. 4.) Consistently

EVALUATION
Objectives are
met.
Client did not
complain of any
pain within the
shift or
demonstrated
signs of pain.
Client and her
relatives
complied to the
health teachings
that were
provided to
them by the
nurses.

(including the
skin, breast
tissue, areola,
and nipple and
most of the
lymph nodes
under the arm.

managing pain.
LONG-TERM:
After 2-5 days
the client
1.) will report
pain is relieved
or controlled
2.) the client
and her relatives
complied with
the health
teachings done
by the nurses.

5.) Apply
blinder/splint at the
post-operative site.

6.) Provide nonpharmacological

techniques (relaxing
techniques and
diversional activities
preferred by the
client)
DEPENDENT
1.) Administer
analgesics as
prescribed or usage
of PCA (patient
controlled analgesia)

assessing the
post-operative
site will prevent
complications
thus preventing
the pain that the
client may
experience.

5.) This will

reduce the pain
when the client
moves or
coughs.

6.) Nonpharmacological
techniques can
provide relief of
pain
emotionally and
psychologically.

1.) This
medications
reduces pain

while PCA
administer
analgesia when
the client feels
pain.