Medical Surgical Nursing

(Tina Sui) #1
Reducing Fear and Anxiety and Improving Coping Ability

Promoting Decision-Making Ability

Breast Cancer/ Postoperative Nursing Diagnosis


Pain and discomfort related to surgical procedure

Disturbed sensory perception related to nerve irritation in affected arm, breast, or
chest wall

Disturbed body image related to loss or alteration of breast

Risk for impaired adjustment related to the diagnosis of cancer and surgical
treatment

Self-care deficit related to partial immobility of arm

Risk for sexual dysfunction related to loss of body part, change in self-image, and
fear of partner's responses

Deficient knowledge: drain management after breast surgery

Deficient knowledge: arm exercises to regain mobility of affected extremity

Deficient knowledge: hand and arm care after an axillary lymph node dissection
(ALND)

Postoperative Nursing Interventions


Relieving Pain and Discomfort

Managing Postoperative Sensations

Promoting Positive Body Image

Promoting Positive Adjustment and Coping

Monitoring and Managing Potential Complications

Lymphedema


Occurs in about 10% to 30% of patients who undergo ALND and in about 0% to
7% of patients who have SLNB

lymphatic channels become inadequate to ensure a return flow of lymph fluid to the
general circulation.

Risk factors: age, obesity, extensive axillary disease, radiation treatment, and injury
or infection to the extremity

Edema resolved after development of collateral circulation.
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