About
Reconstructive procedure for mastectomy clients involving transplant of abdominal muscles, blood vessels, and tissue to the breast area.
Assess
Bleeding, incision, vital signs, lung sounds, bowel sounds, knowledge related to procedure and post-operative care
Complications
Post-operative complications including atelectasis, pneumonia, DVT, PE, infection, hemorrhage, paralytic ileus, bowel obstruction.
Tissue necrosis and loss of Flap
Diagnosis
- Knowledge deficit related to possible surgical intervention
- Acute pain related to surgical procedure
- Constipation related to anesthesia, pain medications
- Ineffective health maintenance related to care after surgery
- Sexual dysfunction related to perceived body changes
- Risk for impaired tissue perfusion
- Risk for infection
- Sexual dysfunction related to perceived body changes
Goals
- The client will understand pre-, intra-, and post-operative instructions.
- The client will be free from infection.
- The client will be able to normally eliminate urine and have positive bowel sounds.
- The client will demonstrate effective coughing and deep breathing and incentive spirometry post-operatively.
- The client will have positive sensation, capillary refill to transplanted tissue site.
- The client will ambulate at least three times daily after post-op day 1.
- The client will identify signs and symptoms that require follow-up or indicate infection.
- The client will have a pain of less than 4 on a VAS 0-10 pain scale.
- The client will verbalize concerns and fears related to change in body image and sexual functioning.
Interventions
- Teach client what to expect prior to, during, and after procedures.
- Teach client coughing and deep breathing exercises to minimize risk of pneumonia.
- Post-operatively, monitor VS every 15 minutes X 2, every 30 Minutes X 2, every 1 hour X 2, than every 4 hours ( may have different guidelines for each clinical agency).
- Monitor voiding amount, color and clarity.
- Monitor sensation and capillary refill to transplanted tissue every two hours.
- Notify physician if unable to void greater than 6 hours after removing indwelling catheter.
- Provide proper catheter care; monitor for s/s of infection.
- Initiate early ambulation to minimize risks of complications.
- Administer medicines ( analgesics, stool softeners, hormone replacement, etc.) as ordered.
- Perform assessments every 4-8 hours to monitor for complications ( circulation, oxygenation, auscultation, etc).
- Monitor for signs/ symptoms of complications.
- Encourage client to discuss feelings associated with changes in body image.
- Encourage client to splint abdomen and walk with a slightly stooped posture to prevent strain on incision.
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