NURSING CARE PLAN NAME OF STUDENT: DATE OF ASSIGNMENT: NAME NAME OF PATI PATIEN ENT: T: CIVI CIVIL L STAT STATUS US:: Sing Single le WARD WARD:: I BED BED NO.: NO.: AGE: AGE: SEX: SEX: Male Male DIAGNOSIS OR CLINICAL IMPRESSION: Gastric cancer T3N3M0, s/p radical near total gastrectomy, roux-en-y gastrojejunostomy; currently on 3rd cycle of chemotherapy
CUES Subjective:
Does not currently wear protective mask when there are other people in the room Demonstrated improper handwashing technique Reduced dietary intake from 4 cups of rice per meal to 1 cup of rice due to altered taste upon initiation of chemotherapy Objective: BMI: 17.64 kg/m2 (underweight) Cachexic
Dry, rough skin Pale gums and oral mucosa Pale nail beds 2/15/11 CBC results: WBC and differential count normal except
NURSING DIAGNOSIS GOALS AND AND BACKGROUND OBJECTIVES KNOWLEDGE Ineffective protection Goal: The patient will r/t compromised have effective immune response protection. and clotting mechanisms Objectives: secondary to After the myelosuppresion nursing Ineffective protection is intervention, the state in which an the client will individual experiences a be able to: decrease in the ability NOC: Immune to guard against status, Blood internal or external coagulation, threats, such as illness Risk control of injury. It represents a broad diagnostic Manifest no category under which signs of Impaired Tissue/Skin infection and Integrity, Impaired Oral bleeding Mucous Membrane, and Risk for Bleeding, and Risk for Infection (Carpenito-Moyet, L. Handbook of Nursing Diagnosis, 12th ed. (2008). Lippincott Williams and Wilkins) Please refer to the last page for the pathophysiologic diagram of the patient’s condition.
NURS NURSIN ING G INT INTER ERVE VENT NTIO IONS NS AND AND RAT RATIO IONA NALE LE The student nurse will:
EVAL EVALUA UATI TION ON After the nursing intervention, the client will:
NIC: Bleeding precautions Infection Protection Risk identification identification
Monitor for signs of infection and bleeding and worsening anemia: a. Vita Vitall Sign Signs s Fever/tachycardia may suggest developing infection. Tachycardia and tachypnea may also be indicative of compensation for the anemia. b. Signs of infection infection at insertion insertion site of of IV line (warmth, redness, swelling, discharge, odor, pain or tenderness) The IV line is a possible site of entry of opportunistic pathogens. c. Breath sounds and sputum production Presence of adventitious breath sounds such as rales and sputum production suggest the presence presence of respiratory respiratory infection. d. White coating in tongue Fungal infections can occur. e. CBC CBC resu result lts s These laboratory tests help detect abnormalities that place the patient at risk
( ) Manifested normal vital signs ( )Manifested no signs of infection in IV insertion site ( ) Manifested clear breath sounds and absence of sputum production ( ) Manifested no white coating in the tongue ( ) CBC results
for elevated monocyte count Low Hgb, Hct, MCH, MCHC (anemia) On 3rd cycle of chemotherapy (epirubicin-cisplatinfluorouracil regimen)Day 2 as of 2/16/11 With ongoing 1 L PNSS + 750 mg 5 Fluorouracil received at ~350 cc level running at 11 gtts/min inserted on the dorsum of left hand; intact dressing; (-) inflammation; (-) tenderness
Most chemotherapeutic drugs cause bone marrow suppression which results to leucopenia, thrombocytopenia, and anemia. This therefore increases the risk of infection and bleeding tendencies. Moreover, the nutrional status of the patient has an effect on the resistance of the patient to fight off infections. Nutrition is also a key factor in the oxygen-carrying capacity of the blood in the patient. (Smeltzer, S. et. al. Textbook of Medical-Surgical Nursing. 11th ed. (2008). Lippincott Williams and Wilkins). Nutrition also has an impact on the patient’s immune function and outcome of cancer treatments (Tian, et.al. The Effects of Nutrition Status of Patients with Digestive System Cancers on Prognosis of the Disease. Cancer of Nursing. 2008) This is the priority problem because infections in the patient undergoing chemotherapy are
manifested: for bleeding and infection. Due to __No signs of myelosuppression caused by the infection chemotherapy, the number and type of __ No worsening of WBCs required to fight infection is decreased. decreased. Anemia is also common. Platelets the indicators of anemia are usually decreased, thus placing the __ Platelets within patient at high high risk for bleeding. bleeding. f. Fatigu Fatigue, e, weaknes weakness, s, short shortnes ness s of breath breath,, acceptable limits alteration in mental status ( ) Manifested These symptoms occur due to the body’s absence of altered tissue perfusion caused by anemia. g. Indicators Indicators of bleeding bleeding abnormalitie abnormalities s symptoms of (bruising, easy bleeding, petechiae, anemia bleeding gums, and nosebleed, occult bleeding) ( ) Manifested no These can be caused by low platelet signs of bleeding count as the bone marrow is further suppressed. Perform the necessary precautions needed to prevent infection.
Perform aseptic technique in all procedures. This reduces the possibility of introduction of pathogens pathogens to the patient. patient. Proper hand hand hygiene is one of the best ways to stop transmission of infection. Perform IV site care. This is done prevent accumulation of bacteria and thus prevent infection. Facilitate wearing surgical mask of patient when he is not alone in his room. This protects the patient from sources of infection.
Demonstrate
Advise patient to avoid fresh, unpeeled fruits and vegetables; uncooked meat; unprocessed/uncooked animal products; and yogurt and other fluid with lactobacilli such as Yakult. (Neutropenic diet). Eating a neutropenic diet is recommended in order to limit exposure to pathogens in fresh fruits and vegetables and uncooked meat.
( ) Dry, intact dressing of IV site, (-) inflammation/pain/te nderss ( ) Wore mask when he is not alone in the room ( ) Verbalized that she will consume a neutropenic diet
harder to evaluate because the body cannot mount adequate immune response to the infection. Thus, the infections usually worsen and become fatal to the immunocompromised patient.
proper hand washing technique Perform ways to enhance resistance to infection Perform the necessary precautions needed to prevent and monitor for bleeding
Identify early signs of developing infection, worsening anemia, and presence of clotting abnormalities he has to report to the nurse or physician
Discuss and demonstrate proper hand washing technique to the patient and watcher. This is done to reduce the entry of organisms into the patient. Facilitate adequate rest and hydration (daily fluid intake of at least 1 1/2 L). These are important in infection prevention and control. Assist in meticulous oral care. Gums and oral mucosa may bleed easily because of altered clotting. Moreover, chemotherapeutic drugs can cause dryness of the oral mucosa, thus making it more prone to injury. injury.
( ) Return demonstrated proper handwashing technique ( ) Achieved adequate rest ( ) Able to drink at least 1 ½ L of water per day ( )Demonstrated proper meticulous oral care
Encourage soft diet and advise him to avoid hot foods/liquids. This will help prevent trauma to oral cavity. Hot foods cause vasodilation, thereby increasing bleeding tendencies. Moreover, the patient has missing teeth and ill fitting dentures which makes it harder to chew
( ) Adhered to avoiding hot foods and eating soft diet
Advise client to refrain from eating dark food such as chocolates. This is to facilitate monitoring monitoring of occult bleeding.
( ) Refrained from eating dark foods
Report the following to the nurse/doctor. -Cough/colds -Pus in urine - Development of white coating in the oral cavity especially the tongue -Pain/tenderness in IV site - Bruising, easy bleeding, petechiae, bleeding gums, and nosebleed, occult bleeding - Weakness - Shortness of breath, alteration in mental
( )Stated all early signs of developing infection, worsening anemia, and presence of clotting abnormalities he has to report to the nurse or physician
status Early detection of these signs and symptoms are needed in order to immediately address the problem. Subjective: Unintended weight loss of 70 kg to 51.5 kg in a span of 13 months
Reported decrease in food intake during the first 2 cycles of chemotherapy because of decreased appetite secondary to altered taste Difficulty chewing because of missing teeth and ill-fitting dentures Eats with small feedings 3x a day. ‘.” Does not usually like the food served as ration so watcher buys food in Bayanihan for him Because of altered taste and impaired chewing, he just adds water to his rice and eats it, sometimes even without viand Usual dietary intake before gastrectomy: 4 cups of rice and 1
Imbalanced nutrition: Goal: The patient will The student nurse will: less than body requirements related take in nutritional to decreased intake requirements in secondary to altered accordance taste with his activity Imbalanced Nutrition: level and Less than Body metabolic Requirements is the needs. state in which an individual, who is not Objectives: NPO, experiences or is At the end of at risk for inadequate the nursing NIC: Nutritional monitoring intake or metabolism of interventions, Nutritional management nutrients for metabolic the client will needs with or without be able to: Provide health teaching about proper weight loss. nutrition and its importance in client’s NOC: (Carpenito-Moyet, L. recuperation. Nutritional Handbook of Nursing status: food Adequate Adequate nutrition nutrition can minimize the the adverse Diagnosis, 12th ed. and fluid intake effects of treatment and decrease (2008). Lippincott State the need treatment-related symptoms Williams and Wilkins) for proper Nutrition has an impact nutrition in his Assist patient in determining the quantity on the patient’s immune condition. and quality of foods that he is not eating that function and outcome of he should be taking in. cancer treatments. This will make client aware of the foods he Adequate nutrition can Pinpoint the should be taking in. The amount is important minimize the adverse deficiencies in because the goal for the patient is weight effects of treatments, his daily intake. gain. The quality is also important because decrease treatmentnutrients are needed in order to enhance related symptoms, and resistance to infection. improve quality of life. Chemotherapy-induced Diet modifications to reduce risk of toxicity may also have State the diet recurrence of neoplastic growth and to more severe effects on modifications improve nutrition during chemotherapy patients with prehe has to make -Increase intake of cooked vegetables and existing malnutrition. to achieve peeled/canned fruits. This is done to reduce
After the nursing intervention, the client will:
( ) Stated that proper nutrition is needed to enhance resistance to infection and enhance treatment results ( ) Stated the diet modifications correctly
( ) Selected quantity and quality of foods that he would eat from the food choices in the neutropenic diet
serving of viand for each of the 3 meals Usual dietary intake at home after the gastrectomy: Breakfast: 1 cup rice, 1 serving viand Lunch: 1 cup rice, 1 serving viand Dinner: ½ cup rice, ½ serving viand Usual dietary intake upon initiation of chemotherapy: Breakfast: ½ serving of pansit or ½ cup rice with ½ serving of viand Lunch: ½ cup rice with ½ serving of viand Dinner: ½ cup rice with ½ serving of viand Objective: Height: 171 cm Weight: 51.5 kg BMI: 17.64 kg/m2 (underweight) DBW: 54 kgs
Ectomorph, cachexic Sunken periorbital region (+) Dental caries, (+) missing teeth (+) ill-fitting dentures (+) muscle wasting in
(Tian, et.al. The Effects of Nutrition Status of Patients with Digestive System Cancers on Prognosis of the Disease. Cancer of Nursing. 2008)
optimal nutrition
Perform ways to enhance appetite
risk of exposure to pathogens. - Reduce intake of fatty foods and smoked foods. This is done in order to reduce carcinogenic substance -Small frequent feedings of neutropenic diet (every 2 hours) to facilitate absorption. The patient should should increase increase the frequency frequency of meal intake in order to balance it with the amount of food eaten. - Limit spicy, fatty and excessively salty or sweet foods, foods with strong odours and foods not well tolerated. These are usually unpleasant to the patient’s taste.
Weigh patient daily with same set of clothes at the same time of the day. This is done to assess improvements improvements in weight. Assist patient to a sitting position before eating or feeding. This will keep the patient’s appetite while anticipating for food. Provide oral care before eating. This can minimize the altered taste and enhance appetite. Advise the patient to add spices in his food in order to mask the altered taste (e.g. add calamansi when eating pansit or add t he sauce of preferred viand). This is done to mask the altered taste.
( ) Manifested weight increase of at least 1 pound
( ) Verbalized improvement of appetite
lower extremities, midthigh circumference 15 inches Pale nail beds, gums, and oral mucosa 2/5/11 CBC results: Low Hgb, Hct, MCH, MCHC (anemia) Subjective: Adheres with chemotherapy; currently on 3rd cycle of chemotherapy
Readiness for Effective Therapeutic Regimen Management
Readiness for Effective Follows medical advice Therapeutic Regimen Management is a Exercises when at pattern in which the home individual integrates into daily living a Walks around the program for treatment room when in the hospital of illness and its sequelae that is Has adequate satisfactory for meeting diversional activities health goals. Carpenito(reading newspaper, Moyet, L. Handbook of talking to brother) Nursing Diagnosis, 12th ed. (2008). Lippincott He said, “Wala naman akong problema sa Williams and Wilkins pagpapaospital. Kaya nga ako The patient has nagpapaospital para verbalized intent to magamot.” improve on his therapeutic regimen Does not have management. fear/anxiety towards the treatment and his condition
At the end of The student nurse will: the nursing interventions, the patient will be able to maintain an effective therapeutic regimen for the management of cancer. At the end of the nursing interventions, the client will be able to: NOC: Compliance behavior, Knowledge: Disease Process and Management
After the nursing intervention, the client will:
NIC: Teaching (Disease process and management) Decision making suppor
Explore with the patient and the caregiver the benefits and barriers in performing therapeutic regimen management for cancer. The health belief model states that one’s perception perception of barriers barriers and benefits benefits of disease affect health seeking behaviors. State perceived Describe the nature (risk factors and benefits and manifestations) of cancer. barriers to This would be a brief review so that the performing patient fully fully understands understands his disease disease therapeutic condition. This enhances adherence to regimen regimen.
( ) Stated perceived benefits and barriers to performing therapeutic regimen ( ) Identified his risk factors and manifestations of cancer ( ) Stated the name
Stated that his family is very supportive in his treatment Verbalized that he wants to improve on his treatment regimen so that the tumor growth will not recur
Identifiy the risk factors and manifestations of cancer State the name use of his drugs
Discuss the name and general use of his drugs. This is done in order to increase her level of compliance with his chemotherapy drugs as well as pre-chemo drugs (metoclopramide and diphenhyrdramine). Discuss the importance of ambulation and range of motion exercise (with demonstration)
Demonstrate proper exercise Demonstrate stress and pain management
Discuss and demonstrate stress and pain management strategies. Deep breathing exercise Self-Hypnosis Imagery
State ways to enhance sleep and rest
Discuss the strategies that help tom enhance sleep. Rest and sleep are important in increasing resistance to infections during chemotherapy. chemotherapy. It also reduces stress.
Verbalize commitment to adhere to prescribed therapeutic regimen for cancer
Explore feelings about current therapeutic regimen management.
and use of each drugs
( ) Performed ambulation and range of motion exercises ( ) Demonstrated stress and pain management strategies
( ) Stated strategies to enhance sleep ( )Verbalized enhanced sleep and rest ( ) Verbalized commitment to adhere to prescribed therapeutic regimen for cancer
Other identified nursing problems: Ineffective peripheral tissue perfusion related to impaired oxygen carrying capacity secondary to anemia PC: Antineoplastic drug reactions References: Carpenito-Moyet, L. Handbook of Nursing Diagnosis, 12th ed. (2008). Lippincott Williams and Wilkins Ridgers, S. Medical-Surgical Nursing Care Plans. (20 07). Thomson Learning Asia Smeltzer, S. et. al. Textbook of Medical-Surgical Nursing. 11th ed. (2008). Lippincott Williams and Wilkins Tian, et.al. The Effects of Nutrition Status of Patients with Digestive System Cancers on Prognosis of the Disease. Cancer of Nursing. 2008
