Scenario The RN is developing a plan of care for a 35yearold

Scenario: The RN is developing a plan of care for a 35-year-old female, newly diagnosed with breast cancer. Assessment findings include: the patient is teary and states, “I haven’t been sleeping since the diagnosis.” The patient doesn’t make eye contact, has difficulty sitting still and her voice is trembling. Her mucous membranes are dry and she says she has not had an appetite. She says, “I don’t know if I am going to need surgery to remove my breasts. I don’t know how it will make me feel or look”. Answer the following: •Develop a 3-part actual nursing diagnostic statement using the patient data in the scenario, including the problem, etiology and symptoms. •Provide rationale for your selection using clustered data •Explain why this diagnosis is a priority for this patient.

Solution

1). A 3-part actual nursing diagnostic statement: Dry mucous membranes related to the physiological consequences of advanced cancer (mostly during the metastasis stage) as evidenced by the loss of appetite.

2). The dry mucous membranes and loss of appetite occur as the cancer becomes more advanced or spreading to the other organs (metastasis).

3). This diagnosis indicates the necessity of planning a therapeutic intervention to fight aginst spread of cancer.