- Acute Pain related to tumour advancement causing inflammation and compression on nerves and bones and chemotherapy as evidenced by verbalization of pain and agitation/restlessness
- Anxiety related to Crisis (breast cancer diagnosis) and threat of death as evidenced by verbalization of fear or worry and crying
- Impaired Skin Integrity related to effects of radiation and chemotherapy as evidenced by skin irritation, redness, skin peeling, swelling and damaged epidermal tissue
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbal reports from the patient Expressions of pain, such as crying Unpleasant feeling (such as a prick, burn, or ache) Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns -Guarding or protective behaviors | Acute Pain related to tumour advancement causing inflammation and compression on nerves and bones and chemotherapy as evidenced by verbalization of pain and agitation/restlessness | Patient will verbalize pain is reduced or controlled Patient will demonstrate the ability to perform ADLs due to improved comfort | 1. Administer pain medication as prescribed. Patients being treated for breast cancer often require a combination of opioids and NSAIDs along with antiemetics for nausea caused by chemotherapy to relieve pain and discomfort. 2. Evaluate the effectiveness of pain medication. After pain medications are administered, evaluate the effectiveness regularly. The dosage and type of medications may need to be adjusted by the physician if the patient’s pain is not controlled. 3. Provide nonpharmacological pain management. Participating in activities such as distraction, massage, hot/cold compresses, and acupuncture may provide the patient with pain relief and relaxation. 4. Educate patients about side effects and treatment. Inform the patient about what to expect regarding side effects of chemotherapy, radiation, and other treatments which are often uncomfortable. Educate and encourage patients to be honest about their pain and communicate regularly with their provider. | Patient verbalized pain is reduced or controlled Patient demonstrated the ability to perform ADLs due to improved comfort |
| Subjective data: Feeling nervous Verbalizing a sense of impending danger -Difficulty controlling one’s worrying Objective data: -Restlessness and tense appearance -Tachycardia -Tachypnoea -Hyperventilation -Diaphoresis -Trembling/tremors -Weakness or tiredness -Difficulty concentrating -Difficulty sleeping -GI distress | Anxiety related to Crisis (breast cancer diagnosis) and threat of death as evidenced by verbalization of fear or worry and crying | Patient will verbalize anxiety is decreased to a manageable level Patient will verbalize ways to cope with increasing anxiety/fear Patient will demonstrate ways to recognize symptoms of anxiety and fear at the onset to avoid reaching a panic state | 1. Provide a calm environment. A chaotic or stimulating environment can cause an increase in anxiety. Use a calm and supportive voice when talking with the patient. Patients can pick up on anxiety from the nurse and the surrounding environment. 2. Promote relaxation techniques. There are a variety of relaxation techniques that may work to help a patient’s anxiety and fear. These include meditation, yoga, deep breathing, guided imagery, and talk therapy. Encourage the patient to try multiple techniques to determine what works best for them. 3. Educate patients on their diagnosis. The fear of the unknown can come from a lack of information regarding their diagnosis. Evaluate the patient’s understanding of their diagnosis, treatment, and prognosis. Answering questions accurately and addressing misconceptions can ease fear and anxiety. 4. Evaluate support systems. Determine what kind of support system the patient has. Encourage family support along with support groups. Support groups can include other breast cancer patients, breast cancer survivors, and caregiver groups. Support helps reduce feelings of isolation, which can cause anxiety and fear. | Patient verbalized anxiety is decreased to a manageable level Patient verbalized ways to cope with increasing anxiety/fear Patient demonstrated ways to recognize symptoms of anxiety and fear at the onset to avoid reaching a panic state |
| Subjective data: -Pain -Itching -Numbness to affected and surrounding skin Objective data: -Changes to skin color -Warmth to skin -Swelling to tissues -Observed open areas or breakdown, excoriation | Impaired Skin Integrity related to effects of radiation and chemotherapy as evidenced by skin irritation, redness, skin peeling, swelling and damaged epidermal tissue | Patient will remain free of infection from impaired skin integrity Patient will alert provider of changes to the skin such as redness/swelling Patient will display optimal healing post-mastectomy or lumpectomy without signs of infection | 1. Ensure nutritional needs are met. Altered nutrition can cause skin breakdown and delayed wound healing. Collaborate with the dietician to ensure the patient is receiving adequate nutrition and is educated on the importance of adequate nutrition. 2. Education on radiation skin care protocol. If the patient is receiving radiation for their breast cancer treatment, educate them on how radiation can affect their skin integrity. Stress the importance of avoiding lotions, deodorants, and other potentially irritating products. 3. Adhere to limb restrictions. Lymphedema is a concern following the removal or radiation of axillary lymph nodes. The risk can be decreased by not taking a blood pressure or performing lab draws in the affected arm. 4. Encourage loose clothing. Encourage patients to wear soft and loose clothing during the months they are receiving chemotherapy and/or radiation therapy. Explain the importance of avoiding friction, tightness, or constriction from the clothing they wear. | Patient remained free of infection from impaired skin integrity Patient alerted provider of changes to the skin such as redness/swelling Patient displayed optimal healing post-mastectomy or lumpectomy without signs of infection |