Mastectomy nursing proces
•Transferir como DOCX, PDF•
10 gostaram•12,198 visualizações
Recomendados
Mais conteúdo relacionado
Mais procurados
Mais procurados (20)
Semelhante a Mastectomy nursing proces
Semelhante a Mastectomy nursing proces (20)
Mastectomy nursing proces
- 1. MASTECTOMY Definition Mastectomyisthe surgical removal of the breastwhichisusuallyasurgical managementforpatients withbreastcancer. Thisisdone to preventthe metastasize of the cancercells.Breastcanceris the mostcommon malignancyexperiencedbywomen.Breastcanceristhe uncontrolledgrowthof breastcells. NursingGoals The nursinggoal for a patientwhounderwentmastectomycanbe:painmanagement,counseling due to disturbedbodyimage,andpreventinginfectiondue tosurgical incision. Risk for Injury Areasinvolvingthe neckare consideredtobe the mostvascularizedpartsof a person’sbody.We all knowthat the mostcommon complicationof asurgeryisexcessivebleedingorhemorrhage,this was broughtaboutby excessive bloodlossintraorpostoperatively. NDx:Riskfor Injuryrelatedtochange incenterof gravitysecondarytoextensive removal of chest tissue Assessment Objectives Nursing Interventions Rationale DesiredOutcomes S: (none)O:The patientmay manifest: edema muscle weakness altered mobility sensoryand perceptual disturbances due to anesthesia Apprehension, restlessness thirst;cold, Short term:After 3-4 hoursof nurse-patient interaction,the patientwill verbalize understandingof individualfactors that contribute to possibilityof injuryandtake stepsto correct situations.Long Term:After3-4 daysof nurse- patient interaction,the patientwill demonstrate behaviors,lifestyle Establishpt. Rapport Monitorvital signs frequently. Accessmood, copingabilitiesand personality styles Identify interventionsand safetydevices Encourage participationin self-helpprograms, such as assertiveness training,positive self-image To gaintrust and cooperationof the pt. VScouldindicate possible bleeding That may resultin carelessnessand increasedrisk-taking without consequences. To promote safe physical environmentand individualsafety To enhance self- esteemandsense of self-worth Short term:The patientshall verbalize understandingof individualfactorsthat contribute topossibilityof injuryandtake stepsto correct situation.LongTerm:The patientshall demonstrate behaviors,lifestyle changesto reduce riskfactorsand protect self frominjury.
- 2. moist,pale skin increase in pulse rate, respirationrate drop in temperature decrease in urinaryoutput changesto reduce riskfactors and protectself from injury. Provide bibliotherapyand writtenresources Assistclientduring periodsof ambulation Walkclient’s unaffectedside Instructthe client to keepthe shoulderslevel and the muscle relaxed whenwalking For laterreview and self-pacedlearning The nurse supports the clientwhenorif clientloose balance The clientismore likelytodrifttoward the side of the body that isheavier Clientstendto accommodate for the change in the centerof gravityby leaningtothe side Acute Pain NDx:Acute painr/t postoperative incision. ASSESSMENT PLANNING NURSINGINTERVENTIONS RATIONALE EXPECTED OUTCOME S= Clientmay verbalize: Fear O= Clientmay manifest: Facial Grimaces Restlessness Guardedbehavior Irritability Sleepdisturbances Distraction behavior Autonomic alterationof muscle tone Short term:After3 hoursof nursing intervention, client’spainscale will be reduce.Long term:After1day of nursing intervention,client will be relieve from painand will appearmore relax. Establishrapport Monitorvital signs Assessverbal/non-verbal reportsof pain,noting location,intensity(0-10 scale),andduration Place inSemi-Fowler’s positionandsupport head/neckinneutral positionwithsandbagsor small pillowsasrequiredin immediate postoperative phase Instructclienttouse hands to supportneckduring movementandtoavoid hyperextensionof neck Keepcall lightand frequentlyneededitems To gain trustof the patient For baseline data Useful inevaluating pain,choice of interventions, effectivenessof therapy Prevents hyperextensionof the neckand protects integrityof the suture line Movementrestriction isimposedforonlya few hours postoperativelyto preventstressonthe suture line and Short term:After3 hrs of nursing intervention, client’spainscale shall have reduce.Long term:After1day of nursing intervention,client shall be relievedof painand shall appearmore relaxed.
- 3. Diaphoresis Self-focusing Impairedthough process withineasyreach Give cool liquidsorsoft foodssuchas ice creamor popsicles. Encourage clienttouse relaxationtechniquese.g., guidedimagery,softmusic, progressive relaxation Administeranalgesicsand throat sprays/lozengesas necessary Provide ice if indicated reduce muscle tension.Gentle flexingandstretching isthenpermitted accordingto pain tolerance tohelp preventneck soreness Limitsstretching, muscle strainsin operative area Softfoodsmay be toleratedbetterthan liquidsif clients experience sdifficulty of swallowing Helpsrefocus attentionandassist clienttomanage pain more effectively Reducespainand discomfort,enhances rest Reducestissues edemaand decreasedperception of pain Impaired Skin Integrity Mastectomy,like anyothersurgical procedures,includesinvasionof the insidebody,specificallythe skinand subcutaneousarea.Uponincision,therewillbe impairmentof the skinintegritycausing damage,impairmentof skincirculationandsensationandpaininthe incisionsite. The musclesare thenrepairedandthe skinincisionisclosedwithsuturesthatwill eitherabsorborbe removedsoon afterthe operation.The actual incisingof the skinisseenasan impairmentinthe skin’sintegrity. NDx:Impairedskinintegrity R/Tsurgery ASSESSMENT PLANNING INTERVENTIONS RATIONALE OUTCOMES S= ØO= the patient may manifest: SHORT TERM:After4 hoursof establishrapport monitorandrecord vital to gainthe trustand cooperationof the SHORT TERM:The patientshall participate inpreventionmeasures
- 4. Presence of surgical woundon the breastwhere incisionwasmade Pain Numbnessof surroundingareas Disruptionof skin surface Redness Itchiness Poorcapillaryrefill nursing interventions, the patient will participate in prevention measuresand treatment programLONG TERM:After1- 2 daysof nursing interventions, the patient will be able to display progressive improvement inwound healing. sign assessincisionsite taking note of size,color, location,temperature, texture,consistencyof wound/lesionif possible inspectsurroundingskin for erythema,induration, maceration assessforodors anddrains comingout fromthe skin/ area of injury inspectskinona daily basis,describinglesions and changesobserved keepthe areaclean/dry, carefullydresswounds, supportincision,and preventinfection use appropriate wound coverings encourage anincrease in proteinandcalorie intake encourage adequate rest and sleep encourage early ambulationand mobilization provide positionchanges practice aseptictechnique incleansing/dressingand medicatinglesions instructproperdisposal of soileddressing client to obtainbaseline data to provide comparative baseline data to assessextentof involvement to assessearly progressionof wound healing,developmentof hemorrhage or infection to promote timely intervention/revisionof planof care to assistbody’snatural processof repair protectthe wound and/orsurrounding tissue to aidin timelywound healingforthe patient to preventfatigue to promote circulation and reduce risks associatedwith immobility to preventbedulcers fromoccuring to reduce riskof cross- contamination to preventspreadof infectiousagent and treatment programLONGTERM: The patientshall be able to display progressive improvementinwound healing.
- 5. Activity Intolerance Activityintolerance referstothe insufficientphysiological orpsychological energytocomplete desireddailyactivities.Mostactivityintolerance isrelatedtogeneralizedweaknessanddebilitation secondarytoacute or chronicillnessanddisease.Thisisespeciallyapparentinelderlypatientswith a historyof orthopedic,cardiopulmonary,diabeticorpulmonary –relatedproblems.Itisalso commonin personswhoundergone surgeriesanditisexperiencedpostoperatively. The personis sufferingfroma physical andpsychological inabilitytocomplete dailyactivitiescaused by generalizedweaknessdue topost-surgical procedure.Post-operativepatientusuallyisunderbed restfor a fewdaysthat may hinderthemtotheirusual activity.Painthatmayaccompany post-op alsoinhibitthe clienttopossible rangesof motion. NDx:Activityintolerance relatedtogeneralizedweakness Assessment Objective NursingIntervention Rationale Expected Outcome S: ӨO: Patient may manifest: Weakness Limitedrange of motion Fatigue Dyspnea Decreased hemoglobinand hematocritlevel Immobility Exertional discomfort Abnormal heart rate andblood pressure Pallor Cyanosis Short term:After 4 hoursof nursing interventions, the patientand the significant, otherswill be able to identify negative factors affectingactivity tolerance and eliminate/reduce theireffects when possible.Long term:After3 daysof nursing interventions, the patientwill be able to improve his activityand perform techniquesto enhance activity tolerance. 1. Establish patient’srapport 2. Monitorand record vital signs 3. Assesspatient’s condition 4. Assesspatient’s level of mobility 5. Assessnutritional status 6. Ascertainability to standand move aboutand degree of assistance necessary/use of equipment 7. Provide aquite environmentand encourage use of stress management 8. Encourage adequate rest periods 9. Promote comfort measuresand provide forrelief 1. To gain trustand cooperationof the patient 2. To obtainbaseline data 3. To obtainbaseline data to be use in evaluating patient’s condition 4. Thisaidsin definingwhat patientiscapable of,whichis necessarybefore settingrealistic goals 5. Adequate energy reservesare requiredfor activity 6. To know what goalsto be establishto performwellness 7. Reducesstress and excess stimulation, Short term:The patientandthe significantothers shall have identifiednegative factors affecting activitytolerance and eliminated/reduce d theireffects when possible.Long term:The patient shall have improvedhis activityanduse techniquesto enhance activity tolerance.
- 6. of pain 10. Plancare with restperiods between activities 11. InstructSO in monitoring response to activityandin recognizingsigns and symptoms 12. Assistclientin learningand demonstrating appropriate safetymeasures 13. Encourage client to maintain positive attitudes; suggestuse of relaxation techniques,such as visualization/guid edimageryas appropriate promotingrest 8. Restprovidestime for energy conservationand recovery 9. To enhance ability to participate in activities 10. To reduce fatigue 11. To indicate need to otheractivity level 12. To prevent injuries 13. To enhance sense of well-being Risk for Ineffective Breathing Pattern Anesthesiaisanartificiallyinducedstate of partial ortotal lossof sensationwithorwithoutlossof consciousness.Anesthesia agentscanproduce muscle relaxation,blocktransmissionof painnerve impulsesandsuppressreflexes.The depthandeffectsof anesthesiaare monitoredbyobserving changesinrespirationandoxygensaturationandendtidal carbondioxidelevels,heartrate,urine outputand bloodpressure. NDx:Riskfor ineffectivebreathingpatternrelatedtochemicallyinduce muscularrelaxation Assessment Objective NursingIntervention Rationale Expected Outcome S: ӨO: Patient may manifest: Use of Short term:After4 hoursof nursing 1. Establishpatient’s rapport 2. Monitorand record vital signs 1. To gain trustand cooperationof the patient 2. To obtain Short term:The patientshall be free fromsigns and symptomsof
- 7. accessory muscle to breathe Nasal flaring Alteredchest excursion Increase anterior posterior diameter Purse lip breathing Decrease inspiration/ expiration interventions, the patientwill be free from signsand symptomsof ineffective breathing pattern.Long term:After2 daysof nursing interventions, the patientwill maintaina normal and effective breathing pattern. 3. Use pulse oximetryto monitoroxygen saturationandpulse rate 4. Monitorvital capacityin patientswith neuromuscular weaknessandobserve trends 5. Instructclienttodeep breathe duringwalking hoursor use an incentive spirometer 6. Splintincisiontoreduce discomfort 7. Administeroxygenas prescribed 8. Instructclienttoself- administeranalgesia before deepbreathing and coughingif a patient-controlled analgesiapumpis available baseline data 3. To detect changesin oxygenation 4. Monitoring detectschanges early 5. Deepbreathing distendsalveoli and promotes increasedgas diffusion 6. Painor fearof paininterferes withdeep breathing 7. Supplemental oxygenprovides a higher concentration than foundin room air 8. Painismore adequately controlledwhen an analgesicis givenbefore severe pain develops ineffective breathing pattern.Long term:The patient shall have maintaineda normal and effective breathing pattern. Risk for Infection Skinisconsideredasa firstline of defenseagainstanyforeignorganism.Because of the surgical procedure the skinisimpairedcausingapossible entryforthe organismshencemaycause infection. NDx:Riskfor infectionrelatedtosurgical wound AssessmentObjective NursingIntervention Rationale Expected Outcome S: ӨO: Patientmay manifest: Pallor Short term:After4 hoursof nursing interventions, the patientwill 1. Establishpatient’s rapport 2. Monitorand record vital signs 3. Stressproperhand washingtechnique 1. To gain trustand cooperationof the patient 2. To obtainbaseline data 3. Patientswithpoor nutritional statusmay Short term:The patientshall have identifiedand demonstrated interventionsto preventorreduce
- 8. Weakness Withdry and intact dressingon the excised area Swelling overthe incision area be able to identifyand demonstrate interventions to preventor reduce riskof infection.Long term: After2 days of nursing interventions, the patientwill achieve timely woundhealing and be free fromsignsand symptomsof infection. 4. Provide regular cathetercare 5. Instructon proper woundcare 6. Encourage to eat vitaminCrich foods 7. Emphasized necessityof taking antibioticsas directed 8. Closelyobserveand instructto report signsand symptoms of infectionsuchas fever,sore throat, swelling,painand drainage 9. Inspectthe wound for swelling,unusual drainage,odor redness,or separationof the suture lines 10. Emptyand re- establishnegative pressure inclose wounddrainsat leastonce pershift be anergicor unable to mustera cellular immune response to pathogensandare therefore more susceptibletoinfection 4. For firstline defense againstnosocomial infectionsorcross contamination 5. To maintainoptimal nutritional status 6. To promote wound healing 7. To boostthe immune system 8. To preventanddetect as earlyas possible the presence of any progressinginfection 9. Woundinfectionare accompaniedbysigns of inflammationanda delayinhealing 10. Negative pressurepulls fluidfromthe incisional area,which facilitateshealing riskof infection. Long term: The patientshall have achieved timelywound healingandfree fromsignsand symptomsof infection. Ineffective Therapeutic Management Withan ongoingchanges inhealthcare,patientsare beingexpectedtobe co-managersof their care. Theyare beingdischargedfromhospitalsearlier,andare face withincreasingcomplex therapeuticregimenstobe handledinthe home environment.Likewise,patientswithchronic illness oftenhave limitedaccesstohealthcare providersandare expectedassumeresponsibilityfor managingthe nuancesof theirdisease.Patient’swithsensoryperceptiondeficits,alteredcognition, financial limitations,andthose lackingsupportsystemmayfindthemselvesoverwhelmedandunable to followthe treatmentplan.Elderlypatients,whooftenexperience mostof the above problems, are speciallyathighriskforineffectivemanagementof the therapeuticplan. Assessment Objective NursingIntervention Rationale ExpectedOutcome S: noneO:The patientmay manifest: Short Term GoalAfter4 hours of NPI, the will 1. Establish patientrapport 2. Monitorand 1. to gainpatient trust and cooperation Short term:The shall verbalize acceptance of needanddesire tochange
- 9. unable tomeet the goalsof a treatment knowledge deficitof prescribed regimen perceived seriousness difficultieswith prescribed regimen verbalize acceptance of need and desire to change actionsto achieve agreed-on outcomesLong Term GoalAfter2 daysof NPIthe patientwill participate in problemsolvingof factors interfering withintegrationof therapeutic regimen record vital sign 3. Assessfor relatedfactors that may negatively affectsuccess withfollowing regimen 4. Assesspatients confidence or herabilityto performdesired behavior 5. Assesspatient’s abilitytolearn or remember the desired healthrelated activity 6. Assesspatients abilityto performthe desiredactivity 7. Use therapeutic communication skills 8. Provide positive reinforcement for efforts 9. Promote client and SO participationin planningand evaluatingthe process 10. Assistclientto develop strategiesfor monitoring therapeutic regimen 11. Identifyhome- and community- basednursing service 2. to obtain baseline data 3. patient’s received seriousnessand threatof disease affecthisor her compliance with the program 4. positive convictionthat one can be advised successfully executivea behavioris correlatedwith performance and successful outcomes 5. cognitive impairments needtobe alternative plan can be advised 6. patient’swith limitedfinancial may unable to purchase special foods 7. to assistclientto problem-solve solution 8. to encourage continuationof desired behaviors 9. enhances commitmentto plan,optimizing outcomes 10. promotesearly actionsto achieve agreed- on outcomesLong term:The patientshall participate inproblem solvingof factors interferingwith integrationof therapeutic regimen
- 10. recognitionof changes, allowing proactive response 11. for assessment, follow-upcare, and educationin clientshome Risk for Dysfunctional Grieving Extended,unsuccessful use of intellectual andemotional responsesbywhichindividuals,families, communitiesattempttoworkthroughthe processof modifyingself-conceptbasedonthe perceptionof loss.Dysfunctionalgrievingisastate inwhichan individual isunableorunwillingto acknowledge ormournanactual or perceivedloss.Thismaysubsequentlyimpairfurthergrowth, development,orfunctioning.Dysfunctionalgrief maybe markedbya broadrange of behaviorsthat may include pervasive denial, ora refusal topartake inself-care measuresorthe activitiesof daily living. NDx:Riskfor dysfunctionalgrievingr/tlossof breast Assessment Objective NursingIntervention Rationale ExpectedOutcome S: noneO:The patientmay manifest: mildto moderated decrease in mood ”acting out” behavior Guilt Deviationfrom unusual behaviorpattern Withdrawal fromothersand normal activities Behavior Short Term GoalAfter4 hours of NPIthe patient will verbalize a sense of beginning to deal withgrief occurringfrom the lossof breastLong Term GoalAfter2 daysof NPIthe patientwill participate in therapyto learn newwaysof dealingwith anxietyand feelingsof inadequacy 1. Establish patientrapport 2. Monitorand record vital sign 3. Assessclientsabilityto manage activitiesof daily livingandperiodof time since losshasoccurred 4. Note stage of grief is experiencing 5. Acknowledgeclient’ssense of relief whendeath followsalongand debilitatingcourse 6. Meetwithboth members of the couple 7. Encourage clientandSO to identifyhealthycoping skillstheyhave usedinthe past 8. Refertoother sourcesas needed,counselling, psychotherapy, 1. The nurse presence provide support. Ensuring privacy demonstrate for the client’s dignity 2. Numbingthe mind interferes withgrieving 3. Sharingthe significant loss withperson whohas surviveda similar experienced Short term:The patientshall verbalize asense of beginningtodeal withgrief occurring fromthe lossof breastLong term:The patient shall participate in therapyto learn new waysof dealing withanxietyand feelingsof inadequacy
- 11. regression Somatic complaints Avoidance of affectively change topics significance of loss religiousreferences,grief supportgroup 9. Avoidtryingtodiminish the 10. Acknowledgeclient’sgrief and reinforce thatfeeling angry or sad isnormal and expected 11. Stay withclientandensure privacyduringemotional periods 12. Avoidadministering prescribedsedativesor tranquilizersasa substitute forspending time withthe client 13. Encourage sharingwith those whocan be empathic,suchas another breastcancer survivor 14. to gainpatienttrustand cooperation 15. to obtainbaseline data 16. Theypersistandinterfere withnormal activities, clientmayneedadditional assistance. 17. stagesof grief may progressina predictable manneror may be experiencedindifferent stages 18. sadnessandlossare still there,butthe deathmay be release andthe grieving processmay be soother 19. to determine how theyare dealingwiththe loss 20. these can be usedin currentsituationto facilitate dealingwithgrief providesa bondfor healing.
- 12. 21. dependinguponmeaning of the loss,individual may require on-goingsupport to workthroughgrief 22. grief worksinvolve dealing withthe realityof a significantloss 23. validatingclient’sfeelings give permissionforhimor herto experiencetrue emotions Ineffective Peripheral Tissue Perfusion The importance of lymphaticsysteminmaintainingfluidbalance inthe body.The plasmafiltersinto the interstitial spacesfrombloodflowingthroughthe capillaries.Muchof thisinterstitial fluidis absorbedbytissue cellsorreabsorbedbythe bloodbefore itflowsoutof the tissue.A small amount of interstitial fluidisleftbehind.If thiswouldcontinue overevenabrief period,the increased interstitialfluidwouldcause massive edema.Thisedemawouldcausestissue destructionordeath. Thisproblemcan be avoidedbythe presence of lymphaticvesselsthatactas “drains” to collectthe excessfluidandreturnittothe venousbloodjustbefore itreachesthe heart. NDx:Ineffective tissue perfusion(lymphedema) r/tcompromisedflow of lymphaticfluid Assessment DesiredGoal NursingInterventions Rationale Expected outcome SOOThe patient may manifest:=weak pulses=edema= drowsiness = altered sensations = changesin LOC Short Term:After 3-4 hoursof nursing interventions,the patientwill be able to demonstrate relaxation techniques.Long Term:After3-4 daysof nursing interventions,the patientwill be able to demonstrate an improved perfusionby regaining strength,strong 1. establishrapport 2. monitorand record VS 3.assesssignsof decreasedtse perfusion 4. identifychanges relatedtosystemicor peripheral alterationsin circulation. 5. evaluate signsof infectionwhenimmune systemiscompromised 6. observe forsignsof pulmonaryemboli. 7. assesslower extremities,notingskin 1. to gain pt’strust 2. to have a baseline data 3. to plan foreffective treatmentandgive promptcare. 4. to assespredisposing factors 5. to determine other possible relatedfactors. 6. to assessfor contributingfactors 7. to note degree of Short Term:Patient shall able to demonstrate relaxation techniquesLong Term: Patientshall able to demonstrate an improved perfusionby regaining strength, strongpulse and maintain alertness.
- 13. pulse and maintain alertness. texture,presence of edema,ulcerations 8. encourage early ambulationif possible 9. elevate HOB 10. Provide quiet, relaxingenvironment 11. cautionpt to avoid activitiesthatcould increase cardiac workload. 12. teachrelaxation techniqueslike deep breathing 13. encourage pt.to rest 14. positionpt.ona semi-fowler’sposition 15. keepenvironment allergenfree forthe pt. 16. educate onproper handwashing 17. encourage pt.to eat nutritiousfoods impairmentinvolved 8. to enhance venous return 9. to increase gravitational bloodflow 10. To preventadditional stressto pt. 11. to maximize tse perfusion 12. to facilitate restand recuperationandproper oxygenation 13. to enable the bodyto recuperate andrepair 14. to facilitate proper chestexpansion 15. to preventpresence whichmay cause increasedmucussecretion 16. to preventinfection 17. to meetdailycaloric requirementandfacilitate repairwithbodytissue Fear Fear isa strong andunpleasantemotioncausedbythe awarenessoranticipationof painordanger. Thisemotionisprimarilyexternallymotivatedandsource-specific,thatisthe individual experiencing the fearcan identifythe person,place orthingprecipitatingthisfeeling.The factorsthatprecipitate fearare, to some extent,universal,fearof death,pairandbodilyinjuryordefectare commonto mostpeople. NDx:Fear r/t diagnosisof canceras manifestedbyinsomniaand crying AssessmentObjective NursingIntervention Rationale Expected
- 14. Outcome S: ӨO: Patientmay manifest: tachypnea tachycardia denial fright fatigue dry mouth Narrowed focus insomnia crying Short term:After4 hoursof nursing interventions,the patientwill demonstrate understanding throughthe use of effectivecoping behaviorsand resourcesLong term: After2 days of nursing interventions,the patientwill display appropriate range of feelingsand lessened fear.. 1. Establish patient’s rapport 2. Monitorand record vital signs 3. Determine whatthe patientis fearful of by careful and thoughtful questioning 4. compare verbal and nonverbal responses 5. Assessthe degree of fear and the measures patientusesto cope withthat fear 6. Document behavioral and verbal expressionsof fear 7. Determine to whatdegree the patients fearsmay be affecting his/herability to performADL 8. Maintaina calm and tolerant mannerwhile interactingwith patient 9. Establisha working 1. To gain trustand cooperationof the patient 2. To obtainbaseline data 3. patientwhofindit unacceptable to expressfearmayfind it helpful toknow that someone is willingtolistenif theydecide toshare theirfeelingsat sometimesinthe future 4. to note congruencies or misperceptionsof situation 5. Thishelpsdetermine the effectivenessof copingstrategies usedbythe pt. 6. Physiologic symptomsand complaintswill intensifyasthe level of fearincreases 7. Persistent, immobilizingfears may requires treatmentwith anti- anxietymedications 8. The patient’sfeeling of stabilityincreases ina calmand nonthreatening atmosphere and ongoingrelationship establishestrustand a basisfor communicating fearful feelings 9. If home environment Short term:The patientshall demonstrate understanding throughthe use of effective coping behaviorsand resourcesLong term: The patient shall display appropriate range of feelingsand lessenedfear..
- 15. relationship through continuityof care 10. Provide safety measure within the home when indicated 11. As patientfear subsides, encourage him/herto explore specific events precedingthe onsetof fear 12. Encourage rest periods 13. Exercisesin relaxation, meditation,or guidedimagery isunsafe,patient’s fearsare notresolved and fearmay becomingdisabling 10. Recognitionand explanationof factors leadingtofearare significantin developing alternative responses 11. Restimprovesability to cop 12. Exercise reducesthe physiological response tofear OtherNursingCare Plans SleepPatternDisturbance Painisa discomfortthatis causedby the stimulationof the nerve endings.Since painisexperience by the patientthere are timesthathe can’t control it that makeshimunable tosleepandsudden wake up due to paincause interruptiontosleepcausingsleepdisturbance. Hyperthermia Bodytemperature elevatedusuallyoccursinresponse toaninfectionorinflammationtemperature usuallycontrolledbythe Hypothalamusthe thermostatforthe body.Entryof microorganismcan cause an alterationinthe hypothalamicsetpoint.Bodytemperature elevationoccurswhenthe body’simmune response istriggeredbypyrogens(fever- producingsubstances)andinterleukin1,a part of the innate immune system,andproductbythe phagocyticcells.These chemicalsstimulate the cellsof the hypothalamustoproduce prostaglandinE,thusincreasingthe temperature setpoint. Turningup the heatis the body’swayof fightingthe microorganismandmakingthe bodyless comfortable place forthem.Whenthisconditionoccurs,manyphysiological stressestake place. Some of these include increasedcell metabolism,increasedheartrate,increasedcardiacoutput. Thisprocessprevailsuntil the bodytemperature matchesthe thermal point ImpairedPhysical Mobility
- 16. Mastectomyincludesincisionof vital partssuchas skin,subcutaneousfats,andsome muscles,that causesdamage to these partswhichleadstoimpairmentof neuromuscularresponsesof the body, that eventuallycausesthe bodytoimpairit’smobility. DisturbedBodyImage Mastectomyas a surgical procedure involvesthe removal of one orbothof the client’sbreasts. Upon removal,there isapotential of developingalow self-esteemandsocial stigmadue tothe surgical removal of the breastcreatinga disturbedbodyimage because the breastparticularlyfor womenisa signof femininity.