Nursing DiagnosisCuesAnalysisGoalObjectivesNursing InterventionRationaleEvaluation

Anxiety related to what will happen after the chemotherapy

Subjective Cues:

Objective Cues:

- The client was observed to be anxious and always ask questions regarding her chemotherapy

Vague uneasy feeling of discomfort or dread accompanied by an autonomic response; a feeling of apprehension caused by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures to deal with threat.Goal: After 8 hours of nursing intervention, the client will be able to appear relaxed and report anxiety is reduced to a manageable level.

Objectives:After the nursing intervention, the client's level of anxiety is assessed.

After the nursing intervention, the client will be able to identify feelings and begin to deal with problems.

Identify clients perception of the threat represented by the situation.

Monitor vital signs.

Observe behaviours.

Establish a therapeutic relationship, conveying empathy and unconditional positive regard.

Provide accurate information about the situation.

Provide comfort measures. Modify procedure as much as possible.

Accept client as is.

Assist client to use anxiety for coping with the situation, if helpful.

These factors can cause/exacerbate anxiety.

To identify physical responses associated with both medical and emotional conditions.

To identify clients level of anxiety.

To avoid the contagious effect/transmission of anxiety.

Helps client to identify what is reality based.

To limit degree of stress and avoid overwhelming anxious adult.

The client may need to be where he or she is at point in time, such as in denial after receiving the diagnosis of a terminal illness.

Moderate anxiety heightens awareness and permits the client to focus on dealing with problems. After 8 hours of nursing intervention, the client appeared to be relaxed and report anxiety is reduced to a manageable level, the goal was met.

After the nursing intervention. The clients level of anxiety was assessed, the objective was met.

After the nursing intervention, the client were able to identify feelings and begin to deal with problems, the objective was met.

Nursing DiagnosisCuesAnalysisGoalObjectivesNursing InterventionRationaleEvaluation

Fear related to what will be the results after the 2d echo

Subjective Cues:

- The client reported that she is afraid of what will be the results of her 2d echo.

Objective Cues:Response to perceived threat [real or imagined] that is consciously recognized as a danger.Goal:After 8 hours of nursing intervention, the client will be able to acknowledge and discuss fears, recognizing healthy versus unhealthy fears.

Objectives:After the nursing intervention, the clients degree of fear and reality of threat perceived by the client is assessed.

After the nursing intervention, the client will be assisted in dealing with fear/situation.

Ascertain clients perception of what is occurring and how this affects life.

Compare verbal/nonverbal responses.

Stay with the client or make arrangements to have someone else is there.

Discuss clients perceptions/fearful feelings. Listen/active-listen to clients concerns.

Provide information in verbal and written form. Speak in simple sentences and concrete terms.

Acknowledge normalcy of fear, pain, despair, and give permission to express feelings appropriately/freely.

Manage environmental factors such as loud noises, harsh lighting, and changing persons location without knowledge of family.

Fear is a defensive mechanism in protecting oneself but, if left unchecked, can become disabling to the clients life.

To note congruencies or misperceptions of situation.

Providing client with unusual/desired support persons can diminish feelings of fear.

Promotes atmosphere of caring and permits explanation/correction of misperceptions.

Facilitates understanding and retention of information.

Promotes attitude of caring, opens door for discussion about feelings and/or addressing reality of situation.

These factors can cause/exacerbate stress, especially to very young or to older individuals.After 8 hours of nursing intervention, the client were able to acknowledge and discuss fears, recognized healthy versus unhealthy fears, the goal was met.

After the nursing intervention, the clients degree of fear and reality of threat perceived by the client was assessed, the objective was met.

After the nursing intervention, the client was able to be assisted in dealing with fear/situation, the objective was met.

Nursing DiagnosisCuesAnalysisGoalObjectivesNursing InterventionRationaleEvaluation

Disturbed body image related to loss or alteration of breast

Subjective Cues:

Objective Cues:

- The client has undergone removal of her left breast tissue.

Confusion [and/or dissatisfaction] in mental picture of ones physical self.Goal: After 8 hours of nursing intervention, the client will be able to recognize and incorporate body image change into self-concept in accurate manner without negating self-esteem.

Objectives:After the nursing intervention, the client will be able to verbalize understanding of body changes.

After the nursing intervention, the clients coping abilities and skills is determined.

After the nursing intervention, the client is assisted in dealing/accepting issues of self-concept related to body image.

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Have client describe self, noting what is positive and what is negative.

Discuss meaning of loss/change to client.

Observe interaction of client with significant others.

Listen to clients comments and responses to the situation.

Note withdrawn behaviour and the use of denial.

Visit client frequently and acknowledge the individual as someone who is worthwhile.

Assist in correcting underlying problems.

Provide information at clients level of acceptance and in small pieces.

To know how client believes others see self.

A small loss may have big impact.

Distortions in body image may be unconsciously reinforced by family members and/or secondary gain issues may interfere with progress.

Different situations are upsetting to different people, depending on individual coping skills and past experiences.

May be normal response to situation or may be indicative of mental illness.

Provides opportunities for listening to concerns and questions.

To promote optimal healing/adaptation.

To allow easier assimilation.After8 hours of nursing intervention, the client were able to recognize and incorporate body image change into self-concept in accurate manner without negating self-esteem, the goal was met.

After the nursing intervention, the client was able to verbalize understanding of body changes, the objective was met.

After the nursing intervention, the client coping abilities and skills were determines, the objective was met.

After the nursing intervention, the client was assisted in dealing/accepting issues of self-concept related to body image, the objective was met.

Nursing DiagnosisCuesAnalysisGoalObjectivesNursing InterventionRationaleEvaluation

Decisional conflict related to treatment options.

Subjective Cues:

Objective Cues:

- The client reported that she is confused regarding her treatment options.

Uncertainty about course of action to be taken when choice among competing actions involves risk, loss, or challenge to values and beliefs.Goal:After 8 hours of nursing intervention, the client will be able to verbalize awareness of positive and negative aspects of choices/alternative actions.

Objectives:After the nursing intervention, the client will be assisted in knowing the causative/contributing factors.

After the nursing intervention, the client will be assisted to develop/effectively use problem-solving skills.

Active-listen/identify reason for indecisiveness.

Review information client has about the healthcare decision.

Clarify and prioritize individual goals, noting where the subject of the conflict falls on this scale.

Identify positive aspects of this experience and assist client to view it as a learning opportunity.

Correct misperceptions client may have and provide factual information.

Helps client to clarify problem and work toward a solution.

Accurate and clearly understood information about situation will help the client make the best decision for self.

Choices may have risky, uncertain outcomes; may reflect a need to make value judgments or may generate anticipated regret over having to reject positive choice and accept negative consequences.

To develop new and creative solutions.

Provides for better decision making.After 8 hours of nursing intervention, the client were able to verbalize awareness of positive and negative aspects of choices/alternative actions, the goal was met.

After the nursing intervention, the client was assisted in knowing the causative/contributing factors, the objective was met.

After the nursing intervention, the client was assisted in developing/effectively using problem-solving skills, the objective was met.

Nursing DiagnosisCuesAnalysisGoalObjectivesNursing InterventionRationaleEvaluation

Impaired Skin Integrity related to left breast wound secondary to breast cancer.

Subjective Cues:

Objective Cues:

- During the physical examination, the client has a scar on her left breast due to her surgery.

Altered epidermis and/ or dermis.Goal:After 8 hours of nursing intervention, the client will be able to show no signs of infection of her left breast.

Objectives:After the nursing intervention, the clients causative/contributing factors will be assessed.

After the nursing intervention, the client will be able to participate in prevention measures and treatment program.

Assess skin, note for color, turgor, and sensation.

Demonstrate good skin hygiene.

Instruct family to maintain clean clothes preferably cotton fabric.

Emphasize the importance of proper nutrition and fluid intake.

Provide and apply wound dressing.

Encourage early ambulation.

Assist client in understanding and following medical regimen.

Encourage to verbalize feelings.

Establishes comparative baseline providing opportunity for timing intervention.

Maintaining clean dry skin provide barrier to infection.

Stiff or rough clothes causes skin friction and increases risk of infection.

Improve nutrition and hydration will improve skin condition.

Wound dressing serves as barrier to surrounding tissue.

Promotes circulation.

Enhances commitment to plans, optimizing outcomes.

To promote proper intervention to the problem.After 8 hours of nursing intervention. The client was able to show no sign of infection on her left breast, the goal was met.

After the nursing intervention, the clients causative/contributing factors was assessed, the objective was met.

After the nursing intervention, the client was able to participate in the prevention and treatment program, the objective was met.