Your patient has just returned to the unit from the PACU after breast surgery for removal of a malignancy. You are planning this patient's care. What would be an appropriate major nursing diagnosis for you to include in this patient's plan of care?
A) Disturbed sensory perception related to nerve irritation in breast
B) Self-care related to fear of moving affected arm
C) Deficient knowledge: care of unaffected breast
D) Undisturbed body image related to loss of the breast
Ans: A
Feedback: Based on the health history and other assessment data, major postoperative nursing diagnoses may include the following: Pain and discomfort related to surgical procedure; Disturbed sensory perception related to nerve irritation in affected arm, breast, or chest wall; Disturbed body image related to loss or alteration of the breast; Risk for impaired adjustment related to the diagnosis of cancer and surgical treatment; Self-care deficit related to partial immobility of upper extremity on operative side; Risk for sexual dysfunction related to loss of body part, change in self-image, and fear of partner's responses; Deficient knowledge: drain management after breast surgery; Deficient knowledge: arm exercises to regain mobility of affected extremity; Deficient knowledge: hand and arm care after an axillary lymph node dissection (ALND). This makes options B, C, and D incorrect.
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