Patient’s Profile

Name : Patient X

Age : 57 years old

Sex : Female

Birthday : December 28, 1966

Religion : Roman Catholic

Ethnic Background : Tagalog

Admitting : Invasive Breast Mass, Left

Diagnosis

Working Diagnosis : Invasive Ductal Carcinoma, Left Stage IV s/p 5 cycles

chemotherapy

Date and Time : September 01, 2024; 2:07am

Admitted

Chief Complaint

Breast Mass Pain on left

Nursing Care Plans

A. Prioritization of Problems
a.1. List of Problems
1. Acute pain related to breast inflammation as evidenced by patient reports of persistent pain
2. Imbalanced Nutrition
3. Impaired skin integrity related to growth of abnormal cells in the epidermis secondary to breast cancer
4. Disturbed Body Image related to changes in physical appearance from hair loss and surgical scars as evidenced by
patient’s reluctance to engage in social activities and verbalized feelings of self-consciousness
5. Risk for Bleeding as evidenced by low platelet counts associated with chemotherapy treatment.
a.2. Basis for Prioritization
NURSING DIAGNOSES JUSTIFICATION
Acute pain is prioritized first because unrelieved pain impacts both
physical and emotional well-being. From the perspective of Maslow’s
Hierarchy of Needs, pain management falls under the physiological
category, as it directly affects the patient’s ability to rest, recover,
1. Acute pain related to breast inflammation as and participate in care. Using Abdellah’s framework, alleviating
evidenced by patient reports of persistent pain discomfort is a key element in providing nursing care and fostering a
therapeutic environment. Additionally, untreated pain triggers a
stress response that can worsen inflammation and compromise
overall healing. Managing acute pain is foundational for addressing
the patient’s other needs effectively.
Imbalanced nutrition is ranked second because it has a broad
impact on the body’s ability to maintain energy levels, fight
2. Imbalanced Nutrition : Less than Body infections, and support recovery. Maslow’s hierarchy places nutrition
Requirements related to anorexia, nausea, within physiological needs, critical for survival and healing. Poor
vomiting, and altered liver function nutrition could delay recovery, exacerbate fatigue, and compromise
affecting metabolism the patient’s response to treatment. According to Abdellah’s
problem-solving approach, ensuring the patient’s body has
3. adequate resources to meet metabolic demands is essential for
maintaining health. Interventions targeting nutrition also address
long-term outcomes, supporting immune function and tissue repair.

Impaired skin integrity is prioritized next because it increases the

risk of infection, which can worsen the patient’s condition if left
unmanaged. While it is less immediately life-threatening than pain
4. Impaired skin integrity related to growth of
or nutrition, it remains a physiological need according to Maslow’s
abnormal cells in the epidermis secondary to
hierarchy. Additionally, Abdellah’s theory emphasizes the
breast cancer
importance of maintaining physical health and preventing
complications. Effective skin care interventions are critical for
supporting overall recovery and minimizing discomfort.

5. Disturbed Body Image related to changes in Disturbed body image is a psychosocial concern, falling under
physical appearance from hair loss and surgical Maslow’s esteem needs, which are addressed after physiological
scars as evidenced by patient’s reluctance to stability is achieved. While this diagnosis significantly impacts the
engage in social activities and verbalized patient’s emotional well-being, it does not pose an immediate
feelings of self-consciousness threat to survival or physical recovery. Abdellah’s nursing
problem related to mental hygiene highlights the need to address
emotional and social concerns, but only after basic physical
health issues are resolved. Addressing body image issues helps
 improve self-esteem and supports the patient’s long-term
psychological adjustment to their condition.

Risk for bleeding is ranked last in this case because it is a

potential problem rather than an active one. Based on the ABC
framework, there is no immediate airway, breathing, or circulation
6. Risk for Bleeding as evidenced by low platelet compromise. According to Abdellah’s focus on nursing problems,
counts associated with chemotherapy addressing active issues such as pain, nutrition, and skin integrity
treatment. takes precedence over preventive concerns. However, it remains
important to monitor closely for signs of bleeding, as this could
quickly become a priority if platelet counts drop further or
symptoms arise.

B. Nursing Care Plans

NCP 1: Acute pain related to breast inflammation as evidenced by patient reports of persistent pain
ASSESSMEN EXPLANATION OF THE NURSING
OBJECTIVE RATIONALE EVALUATION
T PROBLEM INTERVENTIONS

SUBJECTIVE STO: Dx: STO: Goal met

: Pain is a common
experience for patients After 8 hours of a. Assessed the After 8 hours of
a. To obtain
“Nahihirapan with cancer due to the nursing patient’s vital nursing
baseline
ako gumalaw invasive nature of the interventions, the signs. interventions, the
data.
kasi masakit” disease. Cancer cells patient will be patient was able
as verbalized can invade surrounding able to experience to experience
by the tissues and nerves, relief of pain from relief of pain from
patient 7/10 to 4/10 b. Assessed the 7/10 to 4/10 as
causing inflammation, b. Differenti
manifested by: degree of manifested by:
pressure, or injury, ation of
discomfort using
which triggers the  Absence of verbal  Absence of
verbal and
OBJECTIVE: body’s natural response facial and facial
nonverbal
to perceive it as painful. grimace nonverba grimace
 Facial indicators.
This pain can be related  No guarding l  No guarding
grimac indicator
to the cancer itself, behavior behavior
ing s may be
surgery, radiation  Can  Can
 Guardi therapy, chemotherapy, demonstrat a source demonstrat
ng or other treatments, e non of clues e non
behavi and can significantly pharmacolo to the pharmacolo
or impact a patient’s gical ways severity gical ways
quality of life. to relieve of the to relieve
 rednes pain, the
pain pain
s necessity
for, and
 dry
REFERENCE: LTO: the LTO: Goal
skin
effective unmet
 Swellin singh, S., Vera, M., After 72 hours of ness of
g Caitlin, Aishath, Treena, nursing interventi After 72 hours of
Jenny, Pangandaman, interventions, the ons. nursing
 7 out Q. H., Mohammed, patient will be interventions, the
of 10 Sandra, P., lomah, A. k., able to maintain a patient was not
pain Almana, A., Aslam, A., pain free able to maintain
scale Frank, Dorji, L., & BSN, condition. pain free
M. V. (2024b, October Tx: a. To assess condition.
27). 12 cancer nursing etiology
care plans. Nurseslabs. a. Performed pain and
NURSING assessment
https://nurseslabs.com/ contributi
DIAGNOSIS:
 ng
Acute pain cancer-nursing-care- factors
related to plans/#h-3-managing- b. Administered
breast acute-pain analgesics and anti-
inflammatio b. To
inflammatory
n as provide
medications as
evidenced pain
prescribed.
by patient relief to
b. Provided or
reports of the
promoted
persistent patient
nonpharmacological
pain pain management
such as: quiet
environment, calm c. To advise
activities, use of patients
relaxation with
exercises, and proper
diversional or skills and
distraction informati
activities. on on
how to
manage
pain
without
the use
of drugs.

a. To
Edx: prevent
a. Encouraged fatigue
adequate rest that can
periods. impair
ability to
manage
or cope
with
b. Instructed client to pain.
report any
improvement/exace
rbation in pain b. Unrelieve
experience. d pain
can
create
other
problems
such as
anger,
anxiety,
immobilit
y,
respirato
ry
problems
, and
delay in
healing.
NCP 2: Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to anorexia, nausea,
vomiting, and altered liver function affecting metabolism

NURSING
ASSESSMEN EXPLANATION OF THE
OBJECTIVE INTERVENTION RATIONALE EVALUATION
T PROBLEM
S

SUBJECTIV Nutritional and fluid volume STO: After 8 hours of Dx: STO: Goal met
E: status can be significantly nursing interventions,
affected in patients with the patient will: a. Complete After 8 hours of
a. This will
“Minsan cancer. Many individuals da nursing
allow the
kinakain ko experience changes in  demonstrate thorough interventions,
nurse to
lahat pero appetite, taste alterations, increased nutrition the patient was
understand
kadalasan and difficulty swallowing, energy levels as screening able to:
where the
may leading to poor intake and evidenced by .
patient’s
natitira” malnutrition. Cancer increased  demonstra
present
treatments such as activity ted
nutritional
chemotherapy and radiation tolerance and increased
OBJECTIVE: status is
can cause nausea, vomiting, participation in energy
and assess
 Poor and diarrhea, further activities of levels as
needs.
woun impacting nutritional status. daily living evidenced
d  identify b. Obtained by
healin appropriate the increased
Reference:
g nutritional patient’s b. These activity
Singh, S., Vera, M., Caitlin,
 Nause needs/requirem height measurem tolerance
Aishath, Treena, Jenny,
a and ents. and ents are and
Pangandaman, Q. H.,
vomiti weight. required to participati
Mohammed, Sandra, P.,
ng lomah, A. k., Almana, A., determine on in
 Anore Aslam, A., Frank, Dorji, L., & nutritional activities
xia BSN, M. V. (2024b, October needs. of daily
 BMI of 27). 12 cancer nursing care Daily living
LTO: After 72 hours of
23.8 plans. Nurseslabs. weights  Identified
nursing interventions,
https://nurseslabs.com/imbala provide appropriat
the patient will:
nced-nutrition-less-body- feedback e
NURSING requirements/  consume about nutritional
DIAGNOSIS adequate whether needs and
: nutrition; the requireme
treatment nts to
Nursing  steadily gain plan needs support
Diagnosis: weight toward adjustment her overall
Imbalanced ideal weight for s. health and
Nutrition: height and age. recovery.
Less than
Body
Requireme Tx: LTO: Goals
nts related a. Small, unmet
to a. Provide frequent
anorexia, small portions After 72 hours of
nausea, frequent might be nursing
vomiting, meals more interventions,
and altered instead of tolerable the patient:
liver three full and
meals.  barely
function increase
ingested
affecting overall
enough
metabolis calorie
nourishme
m. intake.
nt;
 did not
b. Ensure a gain
pleasant b. Patients weight
environm are more addressing
ent, likely to the target
facilitate eat in a weight for
proper setting height and
positionin without age
g, and unpleasant
provide odors and
good oral noisy
hygiene. distraction
s. Oral
hygiene
before
meals has
a positive
effect on
appetite
and the
taste of
food.
 Elevating
the head of
the bed at
least 30
degrees to
aid in
swallowing
and
reduces
the risk of
Edx: aspiration
while
a. Encourag eating.
ed
nutritiona
l
suppleme
nts and a. Drinks,
healthy fruits and
snacks in veggies
between have
meals. plenty of
b. Involved nutrients
client’s (vitamins,
significan minerals,
t others and
in care, protein).
assisting b. Enhances
them to commitme
learn nt to plan,
ways of optimizing
managing outcomes.
problems
of
nutrition
NCP 3:Impaired skin integrity related to growth of abnormal cells in the epidermis secondary to breast cancer
EXPLANATION
NURSING
ASSESSMENT OF THE OBJECTIVE RATIONALE EVALUATION
INTERVENTIONS
PROBLEM

SUBJECTIVE: STO: Dx: STO: Goal met

The skin, our
“Minsan body's largest After 8 hours of a. Assessed After 8 hours of
a. To evaluate
nararamdaman ko organ, serves nursing dressings/woun nursing
if the patient
na lang may as a vital interventions, the ds for interventions, the
is
lumalabas na defensive patient will be able characteristics patient was able to
undergoing
nana” as shield, to demonstrate of drainage. demonstrate
active
verbalized by the protecting us behavior to prevent Monitor behavior to prevent
bleeding; to
patient from harmful the occurrence of redness, the occurrence of
recognize
elements like complication as swelling and complication as
early signs of
sunlight, evidence by; pain. evidence by:
wound
OBJECTIVE: injury, and  Participate in healing.  The patient
infection. Skin the b. Early actively
 presence of
health is prevention of recognition participated in
wound and b. Monitored
intrinsically complication of preventive
pus temperature.
linked to its (e.g. developing measures and
 redness integrity. infection, infection exhibited no
When skin delayed enables signs of
 dry skin integrity is rapid
wound complications.
compromised, healing institution of
 swelling Tx:
it means the active treatment.
 V/S as skin is
 follows: bleeding) a. Assisted with LTO: Goal unmet
impaired, wound care.
 BP- injured, or LTO: b. Administered After 72 hours of
120/70mmH unable to heal antibiotics as nursing
g After 72 hours of interventions, the
and recover nursing prescribed.
 T- 36.5 normally. In a. To evaluate patient was not free
 PR- 80bpm interventions, the of impairment in skin
the context of the integrity
 RR- 23cpm patient will be free integrity as
breast cancer, of the
 SPO2- 99% of impairment in evidenced by
the growth of wound.
skin integrity as redness, and skin
abnormal cells b. Antibiotics
NURSING evidenced by breakdown.
in the are
DIAGNOSIS: healing skin c. Demonstrated
epidermis can prevention of
Impaired skin without redness, good skin
lead to various spread of
integrity related infection, or skin hygiene, e.g.,
skin changes infection that
to growth of breakdown. wash
that may further
abnormal cells in thoroughly and
compromise pose a risk
the epidermis pat dry
its integrity. As on patients.
secondary to carefully.
the tumor c. Maintaining
breast cancer
grows, it clean, dry
exerts skin provides
pressure on Edx: a barrier to
surrounding infection.
a. Encouraged Patting skin
tissues,
wearing of dry instead
including the
loose of rubbing
skin.
fitting/nonconst reduces risk
ructive of dermal
dressing. trauma to
REFERENCE:
medical- fragile skin.
surgical
nursing; b. Encouraged to
clinical eat foods high
management in vitamin A, D,
for positive a. Reduces
E, K,C. pressure on
outcome; 8 th

edition; compromise
chapter 16; d tissues,
pg.253 which may
c. Advised patient improve
or relative to circulation/h
report any ealing.
 untoward signs b. To facilitate
and symptoms faster wound
such as fever healing and
or redness on boost the
the affected immune
part. system.

c. Fever and
redness are
the usual
signs of
having an
infection and
early
detection of
wounds limit
its spread.

NCP 4:Disturbed body image related to changes in physical appearance as evidenced by patient’s reluctance to engage
in social activities and verbalized feelings of self-consciousness

NURSING
ASSESSM EXPLANATION OF EVALUATIO
OBJECTIVE INTERVENTI RATIONALE
ENT THE PROBLEM N
ONS
SUBJECTIV Body image is STO: After 8 Dx: STO: Goal
E: recognized as a critical hours of met
“Nakakahiy psychosocial issue for nursing a. Assess a. Provides After 8 hours
a kapag cancer patients. interventions, ed the of nursing
pinag Cancer and its the patient patient' a interventions,
titinginan treatment can will be able to: s baseline the patient
ako ng mga profoundly affect one’s  Verbali current and is was able to:
tao” body image and create ze view of able to
major challenges. Body underst one's gauge if  Verball
OBJECTIVE image is a complex anding body. the y
: construct that extends of body patient' articula
 Focu well beyond how one change s te
sing views his or her s; current underst
beha physical appearance. It  Seek b. Assess anding
self-
vior has most consistently informa ed the of the
image is
on been defined as a tion physica
patient' realistic.
chan multifaceted construct and l
s basic b. This can
ged that involves actively change
sense help
body perceptions, thoughts, pursue s she is
feelings, and behaviors growth. of self- identify experie
part
related to the entire worth. the ncing.
 Inten
tiona body and its LTO: After 72 underlyi  Demon
l functioning. hours of ng strated
hidin nursing emotion an
g of interventions, al and interest
body REFERENCE: the patient social in
part will be able to: factors seeking
 Poor Fingeret, M. C., Teo, I.,  Verbali contribu additio
eye & Epner, D. E. (2014). ze ting to nal
cont Managing body image accepta the informa
difficulties of adult c. Assess
act nce of ed the patient' tion
cancer patients: self in a and
patient' s
lessons from available situatio resourc
NURSING s disturbe
research. Cancer, n; es to
DIAGNOSI current d body
120(5), 633–641.  Look support
S: coping image.
https://doi.org/10.1002 at, her
Disturbed pattern
/cncr.28469 touch, person
body s.
image talk al
related to about, growth.
c. This will
changes and allow
in physical care for the
appearanc actual
nurse to
e as or LTO: Goal
individu
evidenced perceiv met
alize the
by ed After 72 hours
altered
patient'
patient’s of nursing
body s plan of interventions,
reluctance
to engage parts or d. Assess care the patient
in social functio ed the and was able to:
activities ns. patient’ ensure
and s proper  Verball
verbalized current coping y
feelings of Support patterns express
self- system. are accepta
conscious being nce of
ness utilized their
current
to
situatio
improve
Tx: n,
the includin
patient' g any
a. Provide s image
da physica
of self. l
support
ive and change
s.
non- d. Having  Demon
judgme a strated
ntal network behavio
environ and rs
ment. support indicati
system ng
Will accepta
greatly nce of
help in their
the body
patient’ image,
s such as
recover looking
b. Monitor y at,
ed the process. touchin
patient’ g,
a. Creating talking
s
a safe about,
progres
and and
s and caring
adjuste acceptin
g for
d their
interve environ
ment body or
ntions specific
as can help
body
the
 needed patient parts.
. feel
comfort
able
expressi
ng their
concern
s and
fears
about
their
body
image.
c. Reassu
red the
patient
that
b. Regularl
the
y
emotio
evaluati
nal
ng the
respons
effectiv
e to the
eness of
change
the
in body
interven
appear
tions
ance is
and
normal.
making
necessa
ry
modifica
d. Demon
tions
strated
can
a
ensure
positive
that the
, caring
patient’
attitude
s needs
In
are
routine
address
activiti
ed and
es
that the
interven
 tions
remain
relevant
and
e. Used benefici
touch al.
during
c. Grief
interact
over the
ions
loss or
and
change
maintai
of a
n eye
body
contact
part is
.
normal
and
typically
involves
a period
of
denial.

d. Positive
and
caring
comme
Edx:
nts help
a. Instruct the
ed the patient
patient respond
on more
techniq positivel
ues to y to
manag changes
e in
negativ appeara
e self- nce.
talk
e. Affirmati
and
on of
promot
individu
ea
ality
 positive and
image. accepta
nce is
importa
nt in
reducin
g the
patient’
b. Encour s
aged feelings
family of
and insecurit
friends y and
to offer self-
support doubt.
.

a. Provides
them
with
practical
tools to
actively
challeng
e and
c. Encour replace
aged the
the negativ
patient e
to look thought
at/touc patterns
h the and
affecte empowe
d limb. ring
them to
maintai
na
healthy
self-
percepti
 on.

b. Knowing
that
there
are
constan
t people
who
accept
body
changes
and
provide
support
is
helpful
to
encoura
ge
social
engage
ment
and fast
adaptati
on to
the
situatio
n.

c. Accepta
nce may
begin
by
looking
at or
touchin
g the
affected
 limb
and
may
help to
incorpor
ate
changes
into
body
image.

NCP 5: Risk for Bleeding as evidenced by low platelet counts associated with chemotherapy treatment.

NURSING
ASSESSM EXPLANATION OF EVALUATIO
OBJECTIVE INTERVENTI RATIONALE
ENT THE PROBLEM N
ONS

SUBJECTI Breast cancer STO: After 8 Dx: STO: After 8

VE: patients can be at hours of hours of
risk for bleeding due nursing a. Deter nursing
a. Early
to several factors. interventions mine interventions
identifi
OBJECTIV The invasive nature , the patient the , the patient
cation
E: of the cancer itself will: client’s will:
of
health
 pres can damage blood  demon history
possibl
 demon
enc vessels. Treatments strate for
e risks
strate
e of like chemotherapy measu signs
for
measu
wou can suppress bone res to that
bleedi
res to
nd marrow function, ng
preve can be preve
and reducing platelet nt associa
provid
nt
pus production bleedi ted
es a
bleedi
necessary for founda
 red clotting. ng; with a ng;
tion
nes Anticoagulant  recogn risk for  recogn
for
s therapy, often used ize bleedin ize
imple
to prevent blood signs g such signs
mentin
 dry
 skin clots, can also of as liver g of
increase bleeding bleedi diseas approp bleedi
 swel risk. Additionally, ng e. riate ng
ling surgical procedures that preven that
can damage blood need tive need
NURSING vessels. Underlying to be
b. Assess
measu to be
DIAGNOS medical conditions report
skin
res. report
IS: like coagulation ed ed
disorders or age- immed and immed
Risk for related changes can iately mucou b. Patient iately
Bleeding further contribute to to a s s with to a
as bleeding tendencies. health membr reduce health
evidence care anes d care
d by low REFERENCE: profes for platele profes
platelet Konishi, T., Fujiogi, sional. signs t sional.
counts M., Shigemi, D., of counts
associate Matsui, H., Fushimi, LTO: After petechi or LTO: After
d with 72 hours of ae, impair 72 hours of
K., Tanabe, M., Seto,
chemoth nursing bruisin ed nursing
Y., & Yasunaga, H.
erapy interventions g, clottin interventions
(2022). Risk Factors
treatmen for Postoperative , the patient hemat g , the patient
t. will: oma factor will:
Bleeding Following
Breast Cancer formati activit
 not y may  not
Surgery: A on, or
experi experi experi
Nationwide Database oozing
ence ence ence
Study of 477,108 of
bleedi bleedi bleedi
Cases in Japan. blood.
ng as ng into ng as
World journal of eviden eviden
surgery, 46(12), tissues
ced by that ced by
3062–3071. norma norma
https://doi.org/10.10 are
l blood out of l blood
07/s00268-022- pressu pressu
06746-z propor
re, tion to re,
stable the stable
hemat injury. hemat
ocrit, ocrit,
hemog hemog
lobin c. Evalua lobin
levels, te the c. Drugs levels,
and client’s that and
desire use of desire
d any compr d
ranges medica omise ranges
for tions the for
coagul that body’s coagul
ation can ability ation
profile affect to clot profile
s. hemos increa s.
tasis. se a
patient
’s risk
Tx: for
a. Monito bleedi
r the ng.
client’s
vital
signs, a. Hypot
especi ension
ally and
blood tachyc
pressu ardia
re (BP) are
and initial
heart compe
rate nsator
(HR). y
Look mecha
for nisms
signs usually
of noted
orthost with
atic bleedi
hypote ng.
nsion.

b. Ensure
b. Excess
that
ive
the
moistu
skin,
re
especi
 ally weake
skin ns the
folds, skin
is barrier
approp ,
riately makin
dried g it
especi more
ally suscep
after a tible to
bath. damag
e.

a. Expos
Edx: ed
skin
a. Encour and
age lesions
the use should
of mild be
skin cleane
cleans d
ers. gently
with
hypoal
lergeni
c, non-
irritati
ng
b. Instruc produc
t the ts.
client
to
avoid
using
rough b. Rough
or non- or
 abrasiv abrasi
e ve
materi materi
als als can
(towels cause
, friction
sheets, and
etc.). traum
a to
the
skin
c. Educat
e the
client
and
family c. Client
memb and
ers family
about educat
signs ion
of about
bleedin early
g that recogn
need ition of
to be hemor
reporte rhage
d to a signs
healthc and
are sympt
provid oms is
er. import
ant for
institut
ing or
increa
sing
the
intensi
ty of
replac
ement
 therap
y.

C. Discharge Plan
HEALTH TEACHING
Diet/ 1. Encouraged a balanced diet rich in fruits, vegetables, lean proteins, and whole grains.
Nutrition
2. Emphasized the importance of staying hydrated by drinking plenty of water.
3. Advised the patient to limit intake of processed foods, sugary drinks, and excessive amounts of fatty foods.
Activity 1. Encouraged the patient to gradually increase physical activity as tolerated, starting with light activities like
walking. It is important to avoid strenuous activities, reminding the patient to take frequent rest periods to
prevent fatigue.
Medication 1. Emphasized the importance of medication adherence.
2. Educated the client about the importance of taking her prescription schedule.
3. Instructed significant others on proper medication intake.
4. Instructed significant others on how the drug works to be aid of.
Environme 1. Advised the patient to avoid stressful situations or environments that may exacerbate conditions.
nt
Treatment Advised the patient to go to scheduled regular follow-up appointments to assess treatment response, monitor for
any side effects, and make necessary adjustments to the treatment plan.