Nursing diagnoses for modified radical mastectomy

myviefolle07 · Sep 12, 2009

Hi everyone,
I have a case study that I have to "discuss two actual and one potential nursing problems and their evidence-based interventions in the first 48 hours after surgery".
The patient it's based on is a 40 year old Mum who was found to have invasive ductal carcinoma who underwent a modified radical mastectomy with lymph node dissection. Post op, she has an IV infusion and a demand-only morphine PCA running. She also has a Jackson-Pratt drain coming out of the breast wound.
I'm a bit lost and unfortunately don't really have anyone at uni I can ask. I presume they are asking for nursing diagnoses (would you agree?) but am not really sure what ones to use. I had thought of "Acute Pain" but is it right of me to assume she'd be in acute pain, or is that a 'potential' problem rather than an actual one?
I'm also not sure what to use to cover the risk of haemorrhage, perhaps "Deficient fluid volume", or "Infection" - but that would be my 'potential' problem again.
Essentially, I guess what I'm asking, is what are her 'actual' problems? Would it be immobility related issues?

potential problem: disturbed body image

actual: fluid deficient rt loss of body fluids

risk for infection rt incision/surgery wound

:nurse:

myviefolle07 · Sep 12, 2009

also since she might have problems expanding chest & breathing 2 days post op.. there is a risk for infection in lungs (pneumonia) and ineffective breathing pattern

olther than that yes u can address immobility but do remember maslow's hierchy

MattiesMama · Sep 13, 2009

It's not presumptive to assume that she would be in physical pain after a serious operation, it's a given. In this case pain control is a priority because pain can impair her ability to rest after the surgery, which can impair the bodies ability to repair itself. So acute pain is definately one NANDA I would use.

The most common post-op complication is infection...even though it is a potential problem, it's a very serious one. If you want to stay away from a "risk for" diagnosis, you could always do Impaired tissue integrity r/t surgical dissection, and have the goal be timely healing of surgical wounds with no sign of localized or systemic infection.

JomoNurse · Sep 13, 2009

pain is definitely a biggie if the patient is post op!!

Smurfie · Sep 13, 2009

Thank you all so much for your help. I think I'll stick with acute pain, and then maybe impaired tissue integrity. For a potential problem, I think I'll head down the psychosocial nursing path and maybe do disturbed body image or the like. Thanks again!

Daytonite, BSN, RN · Sep 13, 2009

the information that you are to use in formulating your actual and potential nursing problems has been provided for you. you just have to pick apart the clues:

it is 48 hours after surgery of a 40 year female with invasive ductal carcinoma who underwent a modified radical mastectomy with lymph node dissection - this is one of the nastiest and most aggressive cancers
has a demand-only morphine pca running - this is normal medical treatment for this surgery and we have no idea how many times she has pressed the button for a dose
has a jackson-pratt drain coming out of the breast wound - this is normal medical treatment for this surgery

read about her medical diagnosis so you understand her disease: http://www.cancer.gov/cancertopics/wyntk/breast - what you need to know about breast cancer. read about the procedure she had so you understand what was done: http://www.surgeryencyclopedia.com/la-pa/modified-radical-mastectomy.html - modified radical mastectomy.

this is a post op patient that underwent general anesthesia. there are some things we know we must monitor in post op patients who have undergone general anesthesia for major surgery:

breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
hypotension (shock, hemorrhage)
thrombophlebitis in the lower extremity
elevated or depressed temperature
any number of problems with the incision/wound (dehiscence, evisceration, infection)
fluid and electrolyte imbalances
urinary retention
constipation
surgical pain
nausea/vomiting (paralytic ileus)

many of these can be transitioned into actual or potential nursing problems and a name (nursing diagnosis) attached to them based on the patient's surgery and need. this patient will have shoulder and arm soreness. with lymph node removal there will be issues involving the potential swelling of the tissues in the involved arm later on. no blood pressures or fingersticks should be done in that arm because the lymph nodes are no longer there and its immunity compromised. she will need physical therapy of that arm post surgically. surgery is only the first step in the treatment of the cancer. she will probably need chemotherapy and possibly radiation therapy. breast reconstruction may also be an option that the surgeon provided for her. she needs to be educated about these things and that falls within our nursing role.

acute pain
impaired physical mobility (of the arm on the involved side)
deficient knowledge, treatment and breast reconstruction
risk for ineffective airway clearance