A mastectomy is a surgical procedure involving the removal of breast tissue to treat or prevent breast cancer. This nursing diagnosis focuses on identifying patient needs, managing post-operative complications, and supporting physical and emotional recovery.
Causes (Related to)
Mastectomy procedures are performed for several reasons:
- Diagnosed breast cancer
- Preventive surgery due to high genetic risk
- Recurrent breast cancer
- Ductal carcinoma in situ (DCIS)
- BRCA1 or BRCA2 gene mutations
- Strong family history of breast cancer
Signs and Symptoms (As evidenced by)
Subjective: (Patient reports)
- Post-operative pain
- Altered body image concerns
- Anxiety about recovery
- Decreased range of motion
- Numbness or tingling in chest wall/arm
- Emotional distress
- Concerns about sexuality
- Fear of cancer recurrence
Objective: (Nurse assesses)
- Surgical incision site
- Drain output and characteristics
- Arm mobility limitations
- Signs of infection
- Lymphedema
- Vital sign changes
- Wound healing progress
- Psychological status
Expected Outcomes
- The patient will demonstrate proper wound care techniques
- The patient will report adequate pain control
- The patient will show an improved range of motion
- The patient will verbalize acceptance of body image changes
- The patient will maintain proper drain care
- The patient will avoid post-operative complications
- The patient will demonstrate independence in self-care activities
Nursing Assessment
Monitor Post-operative Status
- Assess vital signs
- Check incision site
- Monitor drain output
- Evaluate pain levels
- Assess for complications
Evaluate Physical Function
- Range of motion
- Upper extremity strength
- Activity tolerance
- Self-care abilities
- Lymphedema signs
Assess Psychological Status
- Body image concerns
- Emotional adjustment
- Support system
- Coping mechanisms
- Depression/anxiety signs
Monitor Recovery Progress
- Wound healing
- Pain management effectiveness
- Rehabilitation participation
- Complication prevention
- Return to daily activities
Nursing Care Plans
Nursing Care Plan 1: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to surgical trauma as evidenced by verbal reports of pain, guarding behavior, and altered vital signs.
Related Factors:
- Surgical incision
- Tissue trauma
- Drain placement
- Muscle tension
- Anxiety
Nursing Interventions and Rationales:
- Administer prescribed pain medications
Rationale: Promotes comfort and facilitates recovery - Teach proper positioning techniques
Rationale: Reduces tension on the surgical site - Monitor pain levels regularly
Rationale: Ensures effective pain management
Desired Outcomes:
- The patient will report pain at an acceptable level
- The patient will demonstrate proper positioning
- The patient will use pain management strategies effectively
Nursing Care Plan 2: Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection related to surgical procedure and presence of surgical drains as evidenced by compromised skin integrity.
Related Factors:
- Surgical incision
- Presence of drains
- Decreased mobility
- Compromised immune system
- Chemotherapy effects
Nursing Interventions and Rationales:
- Perform sterile dressing changes
Rationale: Prevents wound contamination - Monitor drain output
Rationale: Detects early signs of infection - Teach infection prevention measures
Rationale: Empowers patient in self-care
Desired Outcomes:
- The patient will remain free from infection
- The patient will demonstrate proper wound care
- The patient will identify infection signs/symptoms
Nursing Care Plan 3: Disturbed Body Image
Nursing Diagnosis Statement:
Disturbed Body Image related to surgical alterations as evidenced by verbalized concerns about appearance and self-perception.
Related Factors:
- Loss of breast tissue
- Surgical scars
- Changed appearance
- Altered self-perception
- Social concerns
Nursing Interventions and Rationales:
- Provide emotional support
Rationale: Promotes psychological adjustment - Discuss reconstruction options
Rationale: Offers hope and choices - Connect with support groups
Rationale: Facilitates peer support
Desired Outcomes:
- The patient will express acceptance of body changes
- The patient will utilize coping strategies
- The patient will maintain self-esteem
Nursing Care Plan 4: Impaired Physical Mobility
Nursing Diagnosis Statement:
Impaired Physical Mobility related to post-operative pain and surgical precautions as evidenced by decreased range of motion.
Related Factors:
- Surgical site pain
- Movement restrictions
- Fear of injury
- Muscle weakness
- Drain presence
Nursing Interventions and Rationales:
- Teach ROM exercises
Rationale: Prevents frozen shoulder - Assist with early mobilization
Rationale: Promotes recovery - Monitor exercise tolerance
Rationale: Prevents overexertion
Desired Outcomes:
- The patient will demonstrate improved ROM
- The patient will perform exercises independently
- The patient will maintain proper posture
Nursing Care Plan 5: Risk for Lymphedema
Nursing Diagnosis Statement:
Risk for Lymphedema related to lymph node removal as evidenced by potential for upper extremity swelling.
Related Factors:
- Lymph node dissection
- Decreased lymph drainage
- Activity limitations
- Wound healing
- Radiation effects
Nursing Interventions and Rationales:
- Teach lymphedema prevention
Rationale: Reduces risk of complications - Monitor arm circumference
Rationale: Detects early lymphedema - Demonstrate compression techniques
Rationale: Supports lymph circulation
Desired Outcomes:
- The patient will remain free from lymphedema
- The patient will practice prevention measures
- The patient will recognize early symptoms
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- He X, Wang X, Fu X. The effects of the quality nursing mode intervention on the psychological moods, postoperative complications, and nursing satisfaction of breast cancer surgery patients. Am J Transl Res. 2021 Oct 15;13(10):11540-11547. PMID: 34786080; PMCID: PMC8581850.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Li Y, Zhang X, Zhang L, Wang W. Effects of evidence-based nursing on psychological well-being, postoperative complications and quality of life after breast cancer surgery. Am J Transl Res. 2021 May 15;13(5):5165-5173. PMID: 34150105; PMCID: PMC8205832.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
- Weingarden H, Laky ZE, Ladis I, Austen WG Jr, Wilhelm S. Body Image After Mastectomy Scale: A New Measure of Body Image Behaviors and Beliefs in Women Following Mastectomy. J Womens Health (Larchmt). 2022 Jan;31(1):47-54. doi: 10.1089/jwh.2021.0131. Epub 2021 Aug 26. PMID: 34449252; PMCID: PMC8785764.
