Name of Patient: J.L.

Age/Sex: 62/Female Room/Bed #: 309-3

Chief Complaint: Breast mass Physician: Dr. Alexander Uy Lim
Diagnosis: ____________________________________________

Date/ Cues Need Nursing Diagnosis Patient Outcome Planning of Interventions Imple Evaluation
Time ment
ation
F Objective: H Impaired skin That within 2 hours of  Monitor site of impaired February 01, 2020
E S/p Modified Radical E integrity r/t surgical nursing interventions, skin integrity at least @
B Mastectomy A incision AEB the patient will be able once daily for color 3:00 PM
R L disruption of skin in to develop and maintain changes, redness,
U Disruption of skin T the right breast optimal conditions for swelling, warmth, pain, GOAL PARTIALLY
A layers H wound healing by: or other signs of MET
R Rationale: a. maintaining normal infection. After 2 hours of
Y Vital signs: P A modified radical vital signs R: Systematic inspection nursing
Temp: 35.7˚C E mastectomy is a b. not showing any can identify impending interventions, the
0 PR: 67 cpm R procedure in which other problems early. following results
1 RR: 17 bpm C the entire breast is complications (e.g were observed:
CR: 67 cpm E removed, including infection, edema,  Monitor status of skin 1 a. post-surgery
2 BP: 140/70 mmHg P the skin, areola, redness, etc.) around wound. Monitor vital signs
0 T nipple, and most c. understanding the patient's skin care were
2 I axillary lymph importance of practices, noting the considered
0 O nodes, but the caring the incision type of soap or other normal; latest
N pectoralis major site cleansing agents used, VS are the ff:
@ muscle is spared. temperature of water, Temp: 35.5˚C
- Historically, a and frequency of skin PR: 67 cpm
1:00 modified radical cleansing. RR: 18 bpm
PM H mastectomy was R: Individualize plan is CR: 67 cpm
E the primary method necessary according to BP: 140/70
A of treatment of patient's skin condition, mmHg
L breast cancer. As needs, and preferences. b. other
T the treatment of complications
H breast cancer  Monitor for proper 2 or signs of
evolved, breast placement of tubes, infection were
M conservation has catheters, and other not monitored
A become more devices. Assess skin due to limited
N widely used. and tissue affected by time for
A However, the tape that secures intervention
G mastectomy still these devices. c. patient
E remains a viable R: Mechanical damage to understood
M option for women skin and tissues as a result the
E with breast cancer. of pressure, friction, or importance of
N shear is often associated caring the
T Reference: with external devices. incision site
Modified Radical by
Mastectomy. (2019,  Keep a sterile dressing verbalizing,
November 10). technique during wound "kada adlaw
Retrieved from care. mag ilis sang
https://emedicine.m R: This technique reduces amo ni
edscape.com/articl the risk of infection in (dressing)",
e/1830105- impaired skin integrity. "hadlok ko
overview tandogon kay
 Do not position the 3 daw sakit"
patient on site of
impaired skin integrity. If
ordered, turn and
position patient at least
every 2 hours, and
carefully transfer
patient.
R: This is to avoid adverse
effects of external
mechanical forces
(pressure, friction, and
shear).
  Administer antibiotics as
ordered.
R: Wound infections may
be managed well and more
efficiently with topical
agents, although
intravenous antibiotics may
be indicated.

 Tell patient to avoid 4

rubbing and scratching.
Provide gloves or clip
the nails if necessary.
R: Rubbing and scratching
can cause further injury
and delay healing.

 Provide optimum
nutrition including
vitamins, such as
Vitamins C and E.
R: To provide a positive
nitrogen balance to aid in
skin/tissue healing and
maintain general good
health.

 Check client's medical

record & laboratory
findings especially
platelet count, bleeding
time, clotting time.
R: Any deviation may
suggest blood
clotting/coagulation, thus
affecting healing.

 Instruct patient, S/Os 5

and family in the proper
care of the wound
including hand washing,
wound cleansing, and
dressing changes.
R: Accurate information
increases the patient's
ability to manage therapy
independently and reduce
the risk for infection.

References:
Wayne, G. (2019, March
20). Impaired Tissue (Skin)
Integrity – Nursing
Diagnosis & Care Plan.
Retrieved from
https://nurseslabs.com/imp
aired-tissue-integrity/

Impaired Skin Integrity.

(n.d.). Retrieved from
https://www.scribd.com/doc
/28789083/Impaired-Skin-
Integrity