About
Surgery to remove all breast tissue and possibly some lymph nodes in immediate area.
Assess
Incision, bleeding, bruising, circulation; Vital signs, pulse oximetry, pain level.
Complications
Ineffective coping; body image disturbance
Infection; post-operative complications ( pneumonia, DVT, constipation, paralytic ileus, pain, PE).
Diagnosis
- Acute pain related to surgical procedure
- Risk for infection related to surgical procedure
- Deficient knowledge related to post surgical treatment regimen
Goals
- The client will understand pre-, intra-, and post-operative instructions.
- The client will remain free from post-operative complications.
Interventions
- Teach client what to expect pre-, intra-, and post-operatively.
- Monitor vital signs every 15 minutes X 2, 30 minutes X2, one hour X2, than every 4 hours ( may have different guidelines for each clinical agency).
- Monitor incision for redness, edema, drainage, bruising.
- Apply elastic compression stockings and/or sequential compression device as ordered.
- Encourage coughing and deep breathing and early ambulation to facilitate movement of respiratory secretions.
- Administer pain medications prn as ordered.
- Teach client to maintain special Bra for 23 hours every day until follow-up appointment.
- Encourage client to discuss feeling associated with loss of body part.
- Provide support group information for client with additional resources for reconstruction options.
- Monitor for signs/ symptoms of complications.
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