...the basic guide that we use to keep nurses focused on implementing, and even improving, nursing care is the nursing process. We are creatures of habit, relying on tried and true traditions, which allow us to maintain a routine. We may even think that the current method we are using is the best, and cannot be revised and improved, even by research. However, Tversky and Kahneman (1981) have demonstrated through studying the psychology of choice that we are all, especially expert professionals, in need of guidelines and algorithms to keep our judgment focused on the problem and to formulate a relevant solution(s) (Lewis, 2017). The use of evidence-based practice (EBP) is the response of healthcare professionals to this need to provide a continuous focus on the provision of quality care. In the profession of nursing, the basic guide that we use to keep nurses focused on implementing, and even improving, nursing care is the nursing process.

Those of us who use the nursing process recognize it as a problem-solving tool... The nursing process is comprised of six steps: assessment, diagnosis, outcomes evaluation (often called outcomes identification), planning, implementation, and evaluation. Originally published in 1973 (American Nurses Association, 2015), this process has not changed greatly because the initial process steps were already fairly comprehensive. Those of us who use the nursing process recognize it as a problem-solving tool that pushes the user from basic levels of thought into higher levels of thinking and expert practice (Walton, 2016). If we want to see nurses communicate effectively with other professionals and identify areas of improvement in nursing interventions, it is imperative that we use the nursing process. Yet within the nursing profession, there is a lack of value for the nursing process. Only 35% of nurses surveyed in one country use the nursing process (Baraki et al., 2017), and there is a deficit of outcomes research connected to the nursing process (Xiao, Widger, Tourangeau, & Berta, 2017).

Nurses and nursing students do not always express great enthusiasm for this important tool... Nurses and nursing students do not always express great enthusiasm for this important tool; hence the purpose of this article is to examine the nursing process through a case study to illustrate how it can improve nursing care. This case study will focus the steps of the nursing process applicable to one of the newer reconstructive treatments for women following a mastectomy, specifically, the Deep Inferior Epigastric Perforator, or DIEP (Klasson, Svensson, Wollmer, Velander, & Svensson, 2014). A DIEP follows either a single or double mastectomy, one that is either elective or required. In this procedure the plastic surgeon moves layers of the epidermis from the abdomen to rebuild the breast(s).

A focus on DIEP surgery and recovery through the lens of the nursing process, provides nurses an opportunity to consider the benefits of the nursing process for patients having this procedure. Some of the interventions identified here also apply to women undergoing alternative reconstructive procedures, and/or to those not having reconstruction, and/or to people experiencing different surgeries. In all of these cases, the registered nurse (RN) plays an essential role to help the patient a) prepare for surgery; b) respond during and after surgery; and c) recover from surgery.

It is critical to remind students and nurses alike of the importance of using the nursing process as an EBP tool... The nursing process provides a systematic method for the RN to identify and diagnose a problem experienced by a patient; select and implement interventions to facilitate the patient response; and evaluate that response. It is critical to remind students and nurses alike of the importance of using the nursing process as an EBP tool to identify and implement the most effective interventions to promote patient health. The more we use the nursing process, the more focused, effective, visible, and evidence-based nursing interventions will be (Rutherford, 2008).

Assessment

The nursing assessment of the patient with planned DIEP reconstruction should occur at least three times: a) before surgery, b) shortly after surgery, and c) about two weeks after surgery, so as to provide the best support for recovery. For the patient having a mastectomy, reconstruction by autologous tissue donation from the abdomen (DIEP) may be performed simultaneously or at a later date.

In performing the nursing assessment, the prioritization of problems or diagnoses occurs realistically... In performing the nursing assessment, the prioritization of problems or diagnoses occurs realistically (Kim & Kim, 2015; Wichitra, & Ratana, 2017); yet nurses need to ensure that all problems and diagnoses are eventually addressed. In promoting the health of a surgical patient, all aspects of a given assessment strategy should be addressed to collect a comprehensive baseline assessment. For the purposes of this article, all assessment areas of the categories from the diagnosis handbook by Doenges, Moorhouse, and Murr (2016), will be addressed. A nursing assessment should therefore address all of the following areas: activity/rest, circulation, ego integrity, elimination, food/fluid, hygiene, neurosensory status, pain/discomfort, respiration, safety, sexuality, social interactions, and teaching/learning needs (see Table 1), along with discharge considerations, as are presented below.

Diagnosis

In the Nurse’s Pocket Guide, Doenges and colleagues (2016) provide the reader with “tools for choosing nursing diagnoses” (Appendix 1). These tools divide an assessment into the categories listed in Table 1, followed by examples of nursing diagnoses organized according to those divisions. In the following review of the nursing diagnoses organized according to the assessment, I consider one diagnosis for each assessment category that is relevant to the care of a patient planning for undergoing a DIEP (Table 1).

Table 1. DIEP-Relevant Nursing Diagnoses According to Nursing Focus Areas

By systematically reviewing the areas of nursing focus for the person planning a DIEP, problems can be addressed early or even avoided. Although one might feel it is impossible to address every diagnosis for each patient, ethically, we owe it to patients to address each nursing focus area, most of which are applicable to a patient undergoing surgery. The alternative is to ignore some aspect that could end up being more critical to a patient's health than we initially realized. By systematically reviewing the areas of nursing focus for the person planning a DIEP, problems can be addressed early or even avoided. For example, the risk for dry eye is due to the length of the surgical procedure which can be more than eight hours. This is a nursing diagnosis that takes little time, and which, when addressed with a prophylactic lubricant, can prevent a corneal tear. Nursing interventions that can be implemented to address a DIEP patient's diagnoses are considered below

Outcome Identification, Planning and Implementation

The nurse plans for a patient undergoing a DIEP, identifies relevant care needs and strategies, and takes steps to implement relevant interventions. Because there are no obvious symptoms prior to surgery for the patient planning reconstructive surgery, nurses work with patients pre-operatively to anticipate possible needs. These needs may include education for the patient and the use of handouts and/or electronic resources.

It is critical for nurses to play an active role in health promotion for people planning reconstructive surgery with DIEP. If we work with patients to provide a comprehensive plan of care, they will experience better physical and psychosocial outcomes, and we will have done our job as we share all that we know with them. At baseline, as well as post-operatively, the RN should assess a patient for the desired outcomes (Table 2) and provide interventions as needed.

Table 2. Nursing Diagnoses, Interventions, and Outcomes Assessed at Baseline and Post-operatively

Before Surgery
Nursing focus areas to address before surgery include teaching/learning, activity/rest, food/fluid, and ego integrity. These areas are discussed below.

Teaching/learning: Readiness for enhanced knowledge. Some questions to consider when discussing DIEP with the patient include: a) What experience has the patient already had with surgery? (so as to help the patient to connect with prior surgical experiences and build confidence in success with this treatment); b) What is the DIEP?; c) What are the side effects?; and d) Why should the patient select this procedure?

The nurse can explain to the patient that the DIEP procedure involves donation of fatty tissue from the abdomen to the breast(s). The DIEP does not involve transfer of muscles as do some other procedures. One result of the mastectomy is that the breast(s) will be numb. The numbness will not be painful, and will become less noticeable over time. Donating tissue from the abdomen also causes the abdomen to become numb. The numbness will feel new and strange, but will generally not be noticeable after several weeks.

The initial tissue donation from the abdomen will not be the final procedure. Most people undergoing the DIEP will have three surgeries with about three months between procedures: a) DIEP with abdominal tissue donation, b) breast augmentation - liposuction from the thighs to fill in the breast skin to the desired size and look, and c) re-building or tattooing the nipples and areola. The first procedure may occur simultaneously with a mastectomy, and requires a 2-3 month recovery with actual time off from work. The next procedure takes about 10 days for initial recovery with an additional two to four weeks for bruising and stitches to fade. Recovery from the third procedure varies, depending on the procedure selected.

Activity/rest: Risk for activity intolerance. Before surgery, encourage patients to do as many of their favorite exercises as possible to a) improve strength for surgery, and b) enhance circulation for new tissue. Patients should do push-ups from their knees, toes, or from the wall while standing to improve upper body strength and circulation. They should work to complete sets of 5-10 push-ups, 3-5 times per day. The arms may become sore, which is normal. Push-ups will also improve strength and circulation to the upper body after surgery, so as to promote healing.

By exercising preoperatively, the mind is prepared for physical pain as a result of some suffering during the preoperative period. Lifting weights and swimming are also excellent activities to build upper body strength and circulation in preparation for the DIEP procedure. Sleeping 6-8 hours per night before surgery as often as possible is imperative so that the cells are rested. The nurse can also discuss with a patient how to promote adequate, quality sleep.

Research is needed to explore the impact of taking vitamins... before surgery. Food/fluid: Readiness for enhanced nutrition. Encourage patients to eat a balanced diet with some carbohydrates, protein, fruits, and vegetables, and to reduce sweets every day for several weeks before surgery to put the body in the best condition for post-operative healing. Research is needed to explore the impact of taking vitamins (e.g., vitamin C, vitamin D, and fish oil) before surgery. For example, fish oil has been used to treat inflammation (Organic Facts, 2018) which would clearly benefit patients having surgery, though it should be stopped a few days prior to surgery due to the effect of increased bleeding time (Hazard Vallerand, Sanoski, HopferDeglin, & Mansell, 2017). Adequate hydration before surgery also puts the body in a better position to heal.

Ego integrity: Disturbed body image. Having breast reconstruction for any reason puts the patient in a position of a body image change. The RN does not have to engage the patient in counseling, but could ask whether the patient is accessing counseling to address body image, sexuality, and family processes. For the patient diagnosed with breast cancer, there may be free counseling services available. The nurse could prepare a handout of resources for these patients.

Preparing patients for surgery provides them with a sense of engagement, control, and connectedness to the body, as well as physical confidence. Pre-operative nurses have an opportunity to review these interventions and others (Table 2) to better prepare patients for surgery.

Immediately after Surgery
The DIEP procedure is an involved, complex procedure transferring a thin layer of tissue and skin from the abdomen to the breasts. It requires a long abdominal incision stretching from hip to hip. The blood vessels are microscopic and require rest and time to heal. After a DIEP procedure, there are several areas of concern that require nursing attention, such as safety, activity, and pain.

Safety: Impaired tissue integrity. After a long surgery, the body may be so dehydrated that the eyes are not lubricated enough to open. Nurses should be prepared for this problem, in case prevention measures were not used, and interventions need to be developed. Possible interventions include warm compresses to the eye, a saline rinse, and an eye patch to the affected eye. Encourage patients to keep their eyes closed if there is any problem. Reassure them that you will work to moisten the eyes so that they open as soon as possible. Collaboration with an ophthalmologist may be necessary for the best outcome.

Chest. The surgeons have worked very hard to build new breasts, attaching tiny blood vessels to provide circulation to the chest. What the chest needs is rest. Instruct the patient to allow the chest to heal by using the arms minimally at first and reclining at about a 45-degree angle to facilitate drainage of fluid away from the chest. The skin removal and incision across the abdomen will cause tightness, and prevent reclining flat for several weeks.

Abdomen. The doctors have removed tissue from the abdomen so the patient has a long incision across the lower abdomen. This area of the body needs rest and ice. Ice packs are a primary source of treatment for inflammation (Venes, 2017). Prepare to provide the patient with an ice pack as soon as she gets to an inpatient room. The nurse can place the ice pack on areas of the abdomen or lay the ice pack on the bed next to the abdomen. Instruct the patient to use the ice pack as much as possible on the abdomen for two to four weeks after surgery. However, do not place an ice pack on the chest/breasts. Ice to the chest will constrict the blood vessels, possibly killing the new tissue the doctors connected there. This is a critically important point! Some plastic surgeons avoid this problem by advising patients not to use ice at all; however avoiding ice eliminates a natural method to reduce inflammation and pain for the patient. Nurses have an active role to play in educating patients on how to use ice safely after abdominal surgery.

Activity/rest: Risk for activity intolerance. After surgery, the patient should exercise the legs by walking to the restroom as soon as possible and walking out in the hallway as tolerated. Movement will keep the body more flexible so that stiffness and constipation do not become part of the pain problem. It will be difficult, or even impossible, to stand straight after a mastectomy followed by DIEP. Depending on body type and size, abdominal tissue has been removed which may shorten the skin between the shoulders and pelvis. New tissue will eventually grow and the reduction of inflammation, through interventions described above, will facilitate stretching of abdominal tissue to make it easier to stand upright more quickly. Standing upright will occur naturally as the patient makes efforts to reduce the strain on the back.

There will be a belt around the patient's waist for the 4-6 Jackson-Pratt (JP) drains, some from the chest, and others from the abdomen. As the drains fill with fluid, they become heavy. Because of the strain on the back due to limited range-of-motion from the surgery, hanging the JP drains on the waist may add to the back pain. Consider putting the drains on a lanyard(s), attaching them with ribbons and a safety pin, or placing the drains in a 'purse' so the patient can hang them around the neck, lay them on the bed, hang them on shoulders, or hand them to someone else to carry while walking. Moving the drains off the waist may help alleviate strain to the back and allow the patient to stand a little straighter.

Pain/discomfort: Acute pain. Post-operatively, patients will be administered a narcotic, possibly continuously through the intravenous line. Instruct the patient not to use additional pain medicine unless she is having pain, due to the risk of constipation from narcotics and limited mobility. Help the patient prevent pain through interventions already mentioned: changing position, walking, applying ice, and rest.

Ibuprofen is being investigated for its pain-reduction and anti-inflammatory effects before and following plastic surgery (Kelley, Bennett, Chung, &Kozlow, 2016). Although inflammation is a necessary step in the healing process, inflammation also causes pain (Nordqvist, 2015). Anti-inflammatory properties are achieved at doses of 400-800 mg of ibuprofen 3-4 times per day up to 3200 mg per day for 10-14 days (Hazard Vallerand et al., 2017).

Administration of ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), reduces inflammation, and therefore pain and patient dependence on narcotics. If ibuprofen is not ordered, the RN can advocate for the patient by requesting an order from the physician. Patients who have experienced DIEP following mastectomy have shared that ibuprofen can reduce inflammation, and therefore pain, so dramatically that narcotics may be needed for a few days only (rather than weeks) to control the pain.

For surgeons uncertain about the risk of bleeding, ibuprofen can be started 1-4 days after surgery. Because NSAIDS can cause gastrointestinal irritation (Hazard Vallerand et al., 2017), ibuprofen should be given with food; dosing can be adjusted to fall within snacking hours (e.g. 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m). Provide the patient with clear instructions about taking this medication when they return home, and verify their understanding.

Respiration: Ineffective airway clearance. Provide patients with an incentive spirometer and show them how to use it. Encourage them to continue using it several times daily for about a month to facilitate deep breathing despite the discomfort, especially on those days when they do not get out for a walk. Explain to them that the incentive spirometer can prevent them from getting a lung infection, such as pneumonia.

Elimination: Risk for constipation. Talk to patients about bowel movements and passing gas. For example, ensure that the patient reduces pain medication sufficiently to promote normal elimination. Review high fiber foods, including fruits and vegetables, and provide medication for motility as needed. Educate the patient about when to use medication to promote motility.

Nurses play a critical role in preparing patients for surgery, and guiding them with the best post-operative interventions available. There are many nursing interventions that can be used and taught to patients in the immediate post-operative period. Nurses play a critical role in preparing patients for surgery, and guiding them with the best post-operative interventions available. We must place our patients in the best position to heal and to experience comfort while promoting EBP by initiating all relevant nursing interventions for each patient and evaluating the effectiveness of these interventions.

Post-Operatively (5-14 Days after Surgery)

A few days after surgery, the patient will go home. Following are some post-operative ideas, related to the nursing diagnoses and listed above on Tables 1 and 2, to review with patients before discharge. These post-operative suggestions pertain to: activity and rest, safety, and pain and discomfort, along with food and fluids.

Activity/rest: Risk for activity intolerance. Advise patients to sleep in a recliner, if available, for a few days so the abdomen is not stretched out too quickly. After several days, they can sleep on their side on a couch, in a position that allows the back to rest against the couch and the knees to be bent. Patients may need to move the head to the other end of the couch in the middle of the night to shift to the other side. After the drains come out, patients can move to sleeping on the bed, while continuing to sleep on their side. Once in the bed, it might help to hug a pillow while sleeping andr tuck a pillow between the knees and/or behind the back.

Patients will need a daily nap for about the first two weeks to provide the energy necessary for healing. Naps will help reduce swelling to the abdomen, and allow the arms to rest. Advise patients to start taking walks outside a day or two after returning home. Initially, they should limit the distance they walk, then gradually work to walk several blocks by about Day 7, and about six blocks by Day 14. Patients should walk slowly and plan to walk more than once per day. The sooner they move, the quicker swelling is reduced and pain is alleviated.

Patients should continue to protect their breasts for a few more weeks. Although they can move their arms, they should not lift more than five pounds of weight or exert force with the arms, because doing so will affect the chest. Patients may begin to drive about 10-14 days after surgery per surgeon recommendation. However, they will notice the pressure this puts on the chest, so driving should be limited. Remind patients to rest the arms as much as they can. They can move their arms to avoid stiffness, but should not work them too hard. Around 10-14 days after surgery, they can begin the following, gentle, range-of-motion exercises:

a. Lift one arm straight up (as straight as possible), move the arm in a circles 5-10 times; reverse direction of the circles; switch arms.

b. With arms loosely hanging at sides, roll shoulders up, back, and around repeating 10 times.

c. Do other gentle rolls with arms and shoulders.

Safety: Impaired tissue integrity. Ice packs wrapped in a cloth will continue to be helpful for several weeks. Patients should use ice as much as they can tolerate, but only on the abdomen, for approximately 60-90 minutes each time with a break of about 30 minutes. Remember to advise patients not to use ice packs on the chest/breasts as ice will constrict the blood vessels, impairing circulation to this area (P. Tiwari, personal communication, November 4, 2016). Ice will provide tremendous relief to the abdomen as the cold temperature reduces inflammation, decreasing the need for narcotics.

Pain/discomfort: Acute pain. Patients should take pain medication as needed. If they continue high doses of ibuprofen with food three to four times daily and use an ice pack to the abdomen, they may be able to stop taking narcotics within just a few days.

Food/fluid: Readiness for enhanced nutrition. Patients will be dehydrated after surgery. For at least the first two weeks, instruct patients to drink eight to twelve 8-ounce glasses of water daily. Remind them that walking to the kitchen to get water and to the bathroom is good activity.

Post-operatively: 15-30 Days after Surgery

About 2-4 weeks after surgery, patients should increase activity by walking outside, resting as needed, and icing the abdomen as needed. Within this time frame, patients should be standing essentially upright. They should not force this position, yet remain hopeful that this upright position will soon be a natural position once again. If sleeping at night is a problem, the nurse can advise an increase in daily activity and to reduce daytime rest periods. After the drains are removed, patients should purchase compression underwear (e.g., Spanx). The thicker kind of fabric, which may also be cheaper, will not roll down as much on the abdomen.

By day 15, patients should discontinue ibuprofen as the anti-inflammatory effect should have been attained at this point. However, if patients are having too much pain or discomfort, they can take ibuprofen as needed, continuing to add rest, ice, and compression. Patients should not lift more than five pounds until they are 4-6 weeks post-operative, or when the surgeon has specified that increased lifting is permissible. If they feel overextended, they should use ice and rest to promote healing.

Evaluation

Implementing the interventions described above (Table 2) is expected to provide several health benefits. Goals to consider as a result of these interventions include reduced inflammation in a shorter timeframe; a shorter duration of drainage; reduced pain and related use of narcotics; a quicker return to normal musculoskeletal function; normal bowel movements with less use of aids; a sense of control over their outcomes; and a quicker overall recovery.

Discussion

If nurses are to provide comprehensive, systematic nursing care, they must use the nursing process (Silveira Cardoso, Fonseca Martins, Silveira da Rosa, Costa Passos, & Cezar-Vaz, 2016). Many interventions described in this article are based on the knowledge we have that inflammation causes pain. It is in reducing inflammation through the use of rest, ice, compression, and elevation (RICE), along with ibuprofen, movement, and vitamins that nurses can lead patients to a potential quicker recovery. The importance of reducing inflammation in post-operative patients having the DIEP procedure, or other conditions involving inflammation, has led this author to wonder whether we might need a nursing diagnosis of “Inflammation” so that we can begin to address the problem of inflammation directly and help patients to address it.

...it is important to continue monitoring the effectiveness of previously recommended interventions. The number of interventions reviewed here for use with the patient undergoing the DIEP procedure is extensive. However, many can be used with other surgeries, especially abdominal surgeries. Additionally, it is important to continue monitoring the effectiveness of previously recommended interventions. For example, nurses need to monitor the effectiveness of taking vitamin D before and after surgery. If no benefits from taking Vitamin D are found, nurses must question medical orders related to the prescribing of this vitamin. Let us not sit by while our patients suffer – whether from direct, acute pain, or the consequences of taking too many narcotics coupled with immobility, or a lengthy post-operative recovery period.

When we fail to identify relevant nursing diagnoses for our patients, we leave them with fewer resources to address the problems they confront...When we fail to identify relevant nursing diagnoses for our patients, we leave them with fewer resources to address the problems they confront after a complex surgery. We owe it to patients to be comprehensive in our diagnoses, review all potential interventions, and read current research to identify newer interventions. Nurses should not refrain from identifying every relevant nursing diagnosis, for if we leave the diagnosis unuttered, then how do we arrive at the interventions? Nursing diagnoses provide us a handle on which to “hang our interventions.” If physicians or other healthcare providers do not understand our language, then we need to be more explicit or slow down and explain it to them. Patients who feel the effects of our interventions to promote healing will thank us.

Nursing interventions make a difference. Nursing interventions make a difference. It is up to us to work through the nursing process so as to give patients the diagnoses they deserve, to search for effective interventions, and to evaluate them properly so that changes can be made. Patients today are having complex surgeries and experiencing complex treatments. They are in need of nurses who offer them all of the available EBP knowledge. Make the time to give patients all the interventions they deserve.

Conclusion

People undergoing surgery require nursing interventions before, during, and after the procedure. As surgeries change or are added, it is important to identify and share effective interventions to strengthen the use of the nursing process and associated EBPs. Some plastic surgeons now provide breast reconstruction through autologous abdominal tissue donation using DIEP. The DIEP is a relatively new procedure and nurses may be unfamiliar with the applicable interventions. This article has highlighted care for the patient who chooses a DIEP technique by using our nursing standards of practice, including assessing, developing a nursing diagnosis, identifying desired outcomes, planning, implementing, and evaluating (American Nurses Association, 2015; Rutherford, 2008). Some interventions can be used for patients with other types of surgeries, and still others have been recommended for research.

It is the responsibility of each nurse to properly diagnose each patient with all of the relevant nursing diagnoses and remain informed of recent evidence... It is the responsibility of each nurse to properly diagnose each patient with all of the relevant nursing diagnoses and remain informed of recent evidence so that comprehensive care at all stages of a patient’s journey is planned, implemented, and evaluated. A comprehensive use of the nursing process will promote both a quicker recovery and a reduced use of narcotics, goals shared by patients, and all members of the healthcare team.

Author

Jamie L. Leslie, PhD, MA, BSN, RN
Email: jamie.leslie@uc.edu

Jamie L. Leslie is an Assistant Professor Educator at the University of Cincinnati in Cincinnati, OH. She has worked as a registered nurse in the areas of medical-surgical care, intensive care, and home healthcare. Dr. Leslie has found the use of the nursing process to be most helpful in identifying relevant interventions for her patients. At the age of 43, she was diagnosed with extensive areas of stage 0 breast cancer, also known as ductal carcinoma in situ (DCIS). Treatment included a double mastectomy with simultaneous reconstruction using the Deep Inferior Epigastric Perforator (DIEP) procedure. Experiencing this treatment, both as a patient and as a nurse, has given her valuable insights into nursing interventions for this patient population.