Chapter 6: Cancer Care

*The following is a sample care plan meant for adaptation. Always revise to meet your facility’s protocols and the latest research and nursing diagnoses.

|PLAN OF NURSING CARE |
|The Patient With Cancer |
|nursing diagnosis: Risk for infection related to inadequate defenses related to myelosuppression secondary to radiation or antineoplastic |
|agents |
|goal: Prevention of infection |
|Nursing Interventions |Rationale |Expected Outcomes |
|1. Assess patient for evidence of infection: |1. Signs and symptoms of infection may be |● Demonstrates normal temperature and vital |
|a. Check vital signs every 4 hours. |diminished in the immunocompromised host. |signs. |
|b. Monitor white blood cell (WBC) count and |Prompt recognition of infection and subsequent |● Exhibits absence of signs of inflammation: |
|differential each day. |initiation of therapy will reduce morbidity and|local edema, erythema, pain, and warmth. |
|c. Inspect all sites that may serve as entry |mortality associated with infection. |● Exhibits normal breath sounds on |
|ports for pathogens (intravenous sites, wounds,| |auscultation. |
|skin folds, bony prominences, perineum, and | |● Takes deep breaths and coughs every 2 hours |
|oral cavity). | |to prevent respiratory dysfunction and |
| | |infection. |
|2. Report fever (≥38.3°C [101°F] or ≥38°C |2. Early detection of infection facilitates |● Exhibits absence of pathologic bacteria on |
|[100.4°F] for longer than 1 hour), chills, |early intervention. |cultures. |
|diaphoresis, swelling, heat, pain, erythema, | |● Avoids contact with others with infections. |
|exudate on any body surfaces. Also report | |● Avoids crowds. |
|change in respiratory or mental status, urinary| |● All personnel carry out hand hygiene after |
|frequency or burning, malaise, myalgias, | |each voiding and bowel movement. |
|arthralgias, rash, or diarrhea. | |● Excoriation and trauma of skin are avoided. |
|3. Obtain cultures and sensitivities as |3. Tests identify the organism and indicate the|● Trauma to mucous membranes is avoided |
|indicated before initiation of antimicrobial |most appropriate antimicrobial therapy. Use of |(avoidance of rectal thermometers, |
|treatment (wound exudate, sputum, urine, stool,|inappropriate antibiotics enhances |suppositories, vaginal tampons, perianal |
|blood). |proliferation of additional flora and |trauma). |
| |encourages growth of antibiotic-resistant | |
| |organisms. | |
|4. Initiate measures to minimize infection. |4. Exposure to infection is reduced. |● Uses recommended procedures and techniques if|
|a. Discuss with patient and family |a. Preventing contact with pathogens helps |participating in management of invasive lines |
|(1) Placing patient in private room if absolute|prevent infection. |or catheters. |
|WBC count <1000/mm3. | |● Uses electric razor. |
|(2) Importance of patient avoiding contact with| |● Is free of skin breakdown and stasis of |
|people who have known or recent infection or | |secretions. |
|recent vaccination. | |● Adheres to dietary and environmental |
| | |restrictions. |
| | |● Exhibits no signs of septicemia or septic |
| | |shock. |
|b. Instruct all personnel in careful hand |b. Hands are significant source of |● Exhibits normal vital signs, cardiac output, |
|hygiene before and after entering room. |contamination. |and arterial pressures when monitored. |
|c. Avoid rectal or vaginal procedures (rectal |c. Incidence of rectal and perianal abscesses |● Demonstrates ability to administer |
|temperatures, examinations, suppositories; |and subsequent systemic infection is high. |colony-stimulating factor. |
|vaginal tampons). |Manipulation may cause disruption of membrane | |
| |integrity and enhance progression of infection.| |
|d. Use stool softeners to prevent constipation |d. Minimizes trauma to tissues. | |
|and straining. | | |
|e. Assist patient in practice of meticulous |e. Prevents skin irritation. | |
|personal hygiene. | | |
|f. Instruct patient to use electric razor. |f. Minimizes skin trauma. | |
|g. Encourage patient to ambulate in room unless|g. Minimizes chance of skin breakdown and | |
|contraindicated. |stasis of pulmonary secretions. | |
|h. Avoid fresh fruits, raw meat, fish, and |h. Fresh fruits and vegetables harbor bacteria | |
|vegetables if absolute WBC count <1000/mm3; |not removed by ordinary washing. Flowers and | |
|remove fresh flowers and potted plants. |potted plants are sources of organisms. | |
|i. Each day: change water pitcher, denture |i. Stagnant water is a source of infection. | |
|cleaning fluids, and respiratory equipment | | |
|containing water. | | |
|5. Assess intravenous sites every day for |5. Nosocomial staphylococcal septicemia is | |
|evidence of infection: |closely associated with intravenous catheters. | |
|a. Change peripheral short-term intravenous |a. Incidence of infection is increased when | |
|sites every other day. |catheter is in place >72 hours. | |
|b. Cleanse skin with povidone-iodine before |b. Povidone-iodine is effective against many | |
|arterial puncture or venipuncture. |gram-positive and gram-negative pathogens. | |
|c. Change central venous catheter dressings |c. Allows observation of site and removes | |
|every 48 hours. |source of contamination. | |
|d. Change all solutions and infusion sets every|d. Once introduced into the system, | |
|72–96 hours. |microorganisms are capable of growing in | |
| |infusion sets despite replacement of container | |
| |and high flow rates. | |
|e. Follow Infusion Nursing Society guidelines |e. Infusion nursing society collaborates with | |
|for care of peripheral and central venous |other nursing subspecialties in determining | |
|access devices. |guidelines for intravenous access care. | |
|6. Avoid intramuscular injections. |6. Reduces risk for skin abscesses. | |
|7. Avoid insertion of urinary catheters; if |7. Rates of infection greatly increase after | |
|catheters are necessary, use strict aseptic |urinary catheterization. | |
|technique. | | |
|8. Teach patient or family member to administer|8. Granulocyte colony-stimulating factor | |
|granulocyte (or granulocyte-macrophage) |decreases the duration of neutropenia and the | |
|colony-stimulating factor when prescribed. |potential for infection. | |
|9. Advise patient to avoid exposure to animal |9. Minimizes exposure to potential sources of | |
|excreta; discuss dental procedures with health |infection and disruption of skin integrity. | |
|care provider ; avoid vaginal douche; and avoid| | |
|vaginal or rectal manipulation during sexual | | |
|contact during period of neutropenia (Marrs, | | |
|2006; Zitella, et al., 2006). | | |
|nursing diagnosis: Impaired skin integrity: erythematous and wet desquamation reactions to radiation therapy |
|Nursing Interventions |Rationale |Expected Outcomes |
|1. In erythematous areas: |1. Care to the affected areas must focus on |● Avoids use of soaps, powders, and other |
| |preventing further skin irritation, drying, and|cosmetics on site of radiation therapy. |
| |damage. | |
|a. Avoid the use of soaps, cosmetics, perfumes,|a. These substances may cause pain and |● States rationale for special care of skin. |
|powders, lotions and ointments, deodorants. |additional skin irritation and damage. |● Exhibits minimal change in skin. |
|b. Use only lukewarm water to bathe the area. |b. Avoiding water of extreme temperatures |● Avoids trauma to affected skin region (avoids|
| |minimizes additional skin damage, irritation |shaving, constricting and irritating clothing, |
| |and pain. |extremes of temperature, and use of adhesive |
| | |tape). |
|c. Avoid rubbing or scratching the area. |c. Rubbing and or scratching will lead to |● Reports change in skin promptly. |
| |additional skin irritation, damage and |● Demonstrates proper care of blistered or open|
| |increased risk of infection. |areas. |
|d. Avoid shaving the area with a straight-edged|d. Use of razors may lead to additional |● Exhibits absence of infection of blistered |
|razor. |irritation and disruption of skin integrity and|and opened areas. |
| |increased risk of infection. |● Wound is free from development of eschar. |
|e. Avoid applying hot-water bottles, heating |e. Avoiding extreme temperatures minimizes | |
|pads, ice, and adhesive tape to the area. |additional skin damage, irritation, burns and | |
| |pain. | |
|f. Avoid exposing the area to sunlight or cold |f. Sun exposure or extreme cold weather may | |
|weather. |lead to additional skin damage and pain. | |
|g. Avoid tight clothing in the area. Use cotton|g. Allows air circulation to affected area. | |
|clothing. | | |
|h. Apply vitamin A and D ointment to the area. |h. Aids healing. | |
|2. If wet desquamation occurs: |2. Open weeping areas are susceptible to | |
| |bacterial infection. Care must be taken to | |
| |prevent introduction of pathogens. | |
|a. Do not disrupt any blisters that have |a. Disruption of skin blisters disrupts skin | |
|formed. |integrity and may lead to increased risk of | |
| |infection. | |
|b. Avoid frequent washing of the area. |b. Frequent washing may lead to increased | |
| |irritation and skin damage, with increased risk| |
| |for infection. | |
|c. Report any blistering. |c. Blistering of skin represents progression of| |
| |skin damage. | |
|d. Use prescribed creams or ointments. |d. Decreases irritation and inflammation of the| |
| |area. | |
|e. If area weeps, apply a nonadhesive absorbent|e. Enhances drying. | |
|dressing. | | |
|f. If the area is without drainage, use |f. Promotes healing. | |
|moisture and vapor-permeable dressings such as | | |
|hydrocolloids and hydrogels on noninfected | | |
|areas (Swearingen, 2008). | | |
|g. Consult with enterostomal therapist (ET) and|g. Eschar must be removed to promote healing | |
|health care provider if eschar forms. |and prevent infection. ET nurses have expertise| |
| |in the care of wounds. | |
|nursing diagnosis: Impaired oral mucous membrane: stomatitis |
|goal: Maintenance of intact oral mucous membranes |
|Nursing Interventions |Rationale |Expected Outcomes |
|1. Assess oral cavity daily. |1. Provides baseline for later evaluation. |● States rationale for frequent oral assessment|
| | |and hygiene. |
|2. Instruct patient to report oral burning, |2. Identification of initial stages of |● Identifies signs and symptoms of stomatitis |
|pain, areas of redness, open lesions on the |stomatitis will facilitate prompt |to report to nurse or health care provider . |
|lips, pain associated with swallowing, or |interventions, including modification of |● Participates in recommended oral hygiene |
|decreased tolerance to temperature extremes of |treatment as prescribed by health care provider|regimen. |
|food. |. | |
|3. Encourage and assist in oral hygiene. |3. Patients who are having discomfort or pain, |● Avoids mouthwashes with alcohol. |
| |or other symptoms related to the disease and |● Brushes teeth and mouth with soft toothbrush.|
| |treatment may require encouragement and |● Uses lubricant to keep lips soft and |
| |assistance in performing oral hygiene. |nonirritated. |
| | |● Avoids hard-to-chew, spicy, and hot foods. |
|Preventive | | |
|a. Advise patient to avoid irritants such as |a. Alcohol content of mouthwashes will dry oral|● Exhibits clean, intact oral mucosa. |
|commercial mouthwashes, alcoholic beverages, |tissues and potentiate breakdown. |● Exhibits no ulcerations or infections of oral|
|and tobacco. | |cavity. |
| | |● Exhibits no evidence of bleeding. |
|b. Brush with soft toothbrush; use nonabrasive |b. Limits trauma and removes debris. |● Reports absent or decreased oral pain. |
|toothpaste after meals and bedtime; floss every| |● Reports no difficulty swallowing. |
|24 hours unless painful or platelet count falls| |● Exhibits healing (reepithelialization) of |
|below 40,000 cu/mm. | |oral mucosa within 5 to 7 days (mild |
| | |stomatitis). |
|Mild stomatitis (generalized erythema, limited | |● Exhibits healing of oral tissues within 10 to|
|ulcerations, small white patches: Candida) | |14 days (severe stomatitis). |
|c. Use normal saline mouth rinses every 2 hours|c. Assists in removing debris, thick |● Exhibits no bleeding or oral ulceration. |
|while awake; every 6 hours at night. |secretions, and bacteria. |● Consumes adequate fluid and food. |
|d. Use soft toothbrush or toothette. |d. Minimizes trauma. |● Exhibits absence of dehydration and weight |
| | |loss. |
|e. Remove dentures except for meals; be certain|e. Minimizes friction and discomfort. | |
|dentures fit well. | | |
|f. Apply water soluble lip lubricant. |f. Promotes comfort. | |
|g. Avoid foods that are spicy or hard to chew |g. Prevents local trauma. | |
|and those with extremes of temperature. | | |
|Severe stomatitis (confluent ulcerations with | | |
|bleeding and white patches covering more than | | |
|25% of oral mucosa) | | |
|h. Obtain tissue samples for culture and |h. Assists in identifying need for | |
|sensitivity tests of areas of infection. |antimicrobial therapy. | |
|i. Assess ability to chew and swallow; assess |i. Patient may be in danger of aspiration. | |
|gag reflex. | | |
|j. Use oral rinses (may combine in solution |j. Facilitates cleansing, provides for safety | |
|saline, anti-Candida agent, such as Mycostatin,|and comfort. | |
|and topical anesthetic agent as described | | |
|below) as prescribed or place patient on side | | |
|and irrigate mouth; have suction available. | | |
|k. Remove dentures. |k. Prevents trauma from ill-fitting dentures. | |
|l. Use toothette or gauze soaked with solution |l. Limits trauma, promotes comfort. | |
|for cleansing. | | |
|m. Use water soluble lip lubricant. |m. Promotes comfort. | |
|n. Provide liquid or pureed diet. |n. Ensures intake of easily digestible foods. | |
|o. Monitor for dehydration. |o. Decreased oral intake and ulcerations | |
| |potentiate fluid deficits. | |
|4. Minimize discomfort. | | |
|a. Consult health care provider for use of |a. Alleviates pain and increases sense of | |
|topical anesthetic, such as dyclonine and |well-being; promotes participation in oral | |
|diphenhydramine, or viscous lidocaine. |hygiene and nutritional intake. | |
|b. Administer systemic analgesics as |b. Adequate management of pain related to | |
|prescribed. |severe stomatitis can facilitate improved | |
| |quality of life, participation in other aspects| |
| |of activities of daily living, oral intake and | |
| |verbal communication. | |
|c. Perform mouth care as described. |c. Promotes removal of debris, healing, and | |
| |comfort. | |
|nursing diagnosis: Impaired tissue integrity: alopecia |
|goal: Maintenance of tissue integrity; coping with hair loss |
|Nursing Interventions |Rationale |Expected Outcomes |
|1. Discuss potential hair loss and regrowth |1. Provides information so patient and family |● Identifies alopecia as potential side effect |
|with patient and family; advise that hair loss |can begin to prepare cognitively and |of treatment. |
|may occur on body parts other than the head. |emotionally for loss. | |
|2. Explore potential impact of hair loss on |2. Facilitates coping. |● Identifies positive and negative feelings and|
|self-image, interpersonal relationships, and | |threats to self-image. |
|sexuality. | | |
|3. Prevent or minimize hair loss through the |3. Retains hair as long as possible. |● Verbalizes meaning that hair and possible |
|following: | |hair loss have for him or her. |
|a. Use scalp hypothermia and scalp tourniquets,|a. Decreases hair follicle uptake of |● States rationale for modifications in hair |
|if appropriate. |chemotherapy (not used for patients with |care and treatment. |
| |leukemia or lymphoma because tumor cells may be| |
| |present in blood vessels or scalp tissue). | |
|b. Cut long hair before treatment. |b–e. Minimizes hair loss due to the weight and |● Uses mild shampoo and conditioner and |
| |manipulation of hair. |shampoos hair only when necessary. |
|c. Use mild shampoo and conditioner, gently pat| |● Avoids hair dryer, curlers, sprays, and other|
|dry, and avoid excessive shampooing. | |stresses on hair and scalp. |
|d. Avoid electric curlers, curling irons, | |● Wears hat or scarf over hair when exposed to |
|dryers, clips, barrettes, hair sprays, hair | |sun. |
|dyes, and permanent waves. | | |
|e. Avoid excessive combing or brushing; use | |● Takes steps to deal with possible hair loss |
|wide-toothed comb. | |before it occurs; purchases wig or hairpiece. |
|4. Prevent trauma to scalp. |4. Preserves tissue integrity. |● Maintains hygiene and grooming. |
|a. Lubricate scalp with vitamin A and D |a. Assists in maintaining skin integrity. |● Interacts and socializes with others. |
|ointment to decrease itching. | | |
|b. Have patient use sunscreen or wear hat when |b. Prevents ultraviolet light exposure. |● States that hair loss and necessity of wig |
|in the sun. | |are temporary. |
|5. Suggest ways to assist in coping with hair |5. Minimizes change in appearance. | |
|loss: | | |
|a. Purchase wig or hairpiece before hair loss. |a. Wig that closely resembles hair color and | |
| |style is more easily selected if hair loss has | |
| |not begun. | |
|b. If hair loss has occurred, take photograph |b. Facilitates adjustment. | |
|to wig shop to assist in selection. | | |
|c. Begin to wear wig before hair loss. |c. Enables patient to be prepared for loss and | |
| |facilitates adjustment. | |
|d. Contact the American Cancer Society for |d. Provides options to patient. | |
|donated wigs, or a store that specializes in | | |
|this product. | | |
|e. Wear hat, scarf, or turban. |e. Conceals loss. | |
|6. Encourage patient to wear own clothes and |6. Assists in maintaining personal identity. | |
|retain social contacts. | | |
|7. Explain that hair growth usually begins |7. Reassures patient that hair loss is usually | |
|again once therapy is completed. |temporary. | |
|nursing diagnosis: Imbalanced nutrition, less than body requirements, related to nausea and vomiting |
|goal: Patient experiences less nausea and vomiting associated with chemotherapy; weight loss is minimized |
|Nursing Interventions |Rationale |Expected Outcomes |
|1. Assess the patient’s previous experiences |1. Identifies patient concerns, misinformation,|● Identifies previous triggers of nausea and |
|and expectations of nausea and vomiting, |potential strategies for intervention. Also |vomiting. |
|including causes and interventions used. |gives patient sense of empowerment and control.|● Exhibits decreased apprehension and anxiety. |
|2. Adjust diet before and after drug |2. Each patient responds differently to food |● Identifies previously used successful |
|administration according to patient preference |after chemotherapy. A diet containing foods |interventions for nausea and vomiting. |
|and tolerance. |that relieve the patient’s nausea or vomiting |● Reports decrease in nausea. |
| |is most helpful. |● Reports decrease in incidence of vomiting. |
|3. Prevent unpleasant sights, odors, and sounds|3. Unpleasant sensations can stimulate the |● Consumes adequate fluid and food when nausea |
|in the environment. |nausea and vomiting center. |subsides. |
|4. Use distraction, music therapy, biofeedback,|4. Decreases anxiety, which can contribute to |● Demonstrates use of distraction, relaxation, |
|self-hypnosis, relaxation techniques, and |nausea and vomiting. Psychological conditioning|and imagery when indicated. |
|guided imagery before, during, and after |may also be decreased. | |
|chemotherapy. | | |
|5. Administer prescribed antiemetics, |5. Administration of antiemetic regimen before |● Exhibits normal skin turgor and moist mucous |
|sedatives, and corticosteroids before |onset of nausea and vomiting limits the adverse|membranes. |
|chemotherapy and afterward as needed. |experience and facilitates control. Combination| |
| |drug therapy reduces nausea and vomiting | |
| |through various triggering mechanisms. | |
|6. Ensure adequate fluid hydration before, |6. Adequate fluid volume dilutes drug levels, |● Reports no additional weight loss. |
|during, and after drug administration; assess |decreasing stimulation of vomiting receptors. | |
|intake and output. | | |
|7. Encourage frequent oral hygiene. |7. Reduces unpleasant taste sensations. | |
|8. Provide pain relief measures, if necessary. |8. Increased comfort increases physical | |
| |tolerance of symptoms. | |
|9. Consult with dietician as needed. |9. Interdisciplinary collaboration essential in| |
| |addressing complex patient needs. | |
|10. Assess and address other contributing |10. Multiple factors may contribute nausea and | |
|factors to nausea and vomiting, such as other |vomiting. | |
|symptoms, constipation, gastrointestinal | | |
|irritation, electrolyte imbalance, radiation | | |
|therapy, medications, and central nervous | | |
|system metastasis. | | |
|nursing diagnosis: Imbalanced nutrition: less than body requirements, related to anorexia, cachexia, or malabsorption |
|goal: Maintenance of nutritional status and of weight within 10% of pretreatment weight |
|Nursing Interventions |Rationale |Expected Outcomes |
|1. Teach patient to avoid unpleasant sights, |1. Anorexia can be stimulated or increased with|● Patient and family identify minimal |
|odors, sounds in the environment during |noxious stimuli. |nutritional requirements. |
|mealtime. | |● Exhibits weight loss no greater than 10% of |
| | |pretreatment weight. |
|2. Suggest foods that are preferred and well |2. Foods preferred, well tolerated, and high in|● Reports decreasing anorexia and increased |
|tolerated by the patient, preferably |calories and protein maintain nutritional |interest in eating. |
|high-calorie and high-protein foods. Respect |status during periods of increased metabolic |● Demonstrates normal skin turgor. |
|ethnic and cultural food preferences. |demand. | |
|3. Encourage adequate fluid intake, but limit |3. Fluids are necessary to eliminate wastes and|● Identifies rationale for dietary |
|fluids at mealtime. |prevent dehydration. Increased fluids with |modifications. Patient and family verbalize |
| |meals can lead to early satiety. |strategies to address minimize nutritional |
| | |deficits. |
| | |● Participates in calorie counts and diet |
| | |histories. |
|4. Suggest smaller, more frequent meals. |4. Smaller, more frequent meals are better |● Uses appropriate relaxation and imagery |
| |tolerated because early satiety does not occur.|before meals. |
|5. Promote relaxed, quiet environment during |5. A quiet environment promotes relaxation. |● Exhibits laboratory and clinical findings |
|mealtime with increased social interaction as |Social interaction at mealtime increases |indicative of adequate nutritional intake: |
|desired. |appetite. |normal serum protein and transferrin levels; |
| | |normal serum iron levels; normal hemoglobin, |
| | |hematocrit, and lymphocyte levels; normal |
| | |urinary creatinine levels. |
|6. If patient desires, serve wine at mealtime |6. Wine often may stimulate appetite and add | |
|with foods. |calories. | |
|7. Consider cold foods, if desired. |7. Cold, high-protein foods are often more |● Consumes diet high in required nutrients. |
| |tolerable and less odorous than hot foods. |● Carries out oral hygiene before meals. |
|8. Encourage nutritional supplements and |8. Supplements and snacks add protein and |● Reports that pain does not interfere with |
|high-protein foods between meals. |calories to meet nutritional requirements. |meals. |
|9. Encourage frequent oral hygiene. |9. Oral hygiene stimulates appetite and |● Reports decreasing episodes of nausea and |
| |increases saliva production. |vomiting |
|10. Provide pain relief measures. |10. Pain impairs appetite. |● Participates in increasing levels of |
| | |activity. |
|11. Provide control of nausea and vomiting. |11. Nausea and vomiting increase anorexia. |● States rationale for use of tube feedings or |
| | |parenteral nutrition. |
|12. Increase activity level as tolerated. |12. Increased activity promotes appetite. | |
|13. Decrease anxiety by encouraging |13. Relief of anxiety may increase appetite. |● Participates in management of tube feedings |
|verbalization of fears, concerns; use of | |or parenteral nutrition, if prescribed. |
|relaxation techniques; imagery at mealtime. | | |
|14. Position patient properly at mealtime. |14. Proper body position and alignment are | |
| |necessary to aid chewing and swallowing. | |
|15. For collaborative management, provide |15. Tube feedings may be necessary in the | |
|enteral tube feedings of commercial liquid |severely debilitated patient who has a | |
|diets, elemental diets, or blenderized foods as|functioning gastrointestinal system. | |
|prescribed. | | |
|16. Provide parenteral nutrition with lipid |16. Parenteral nutrition with supplemental fats| |
|supplements as prescribed. |supplies needed calories and proteins to meet | |
| |nutritional demands, especially in the | |
| |nonfunctional gastrointestinal system. | |
|17. Administer appetite stimulants as |17. Although the mechanism is unclear, | |
|prescribed by health care provider . |medications such as megestrol acetate (Megace) | |
| |have been noted to improve appetite in patients| |
| |with cancer and human immunodeficiency virus | |
| |(HIV) infection. | |
|18. Encourage family and friends not to nag or |18. Pressuring patient to eat may cause | |
|cajole patient about eating. |conflict and unnecessary stress. | |
|19. Assess and address other contributing |19. Multiple factors contribute to anorexia and| |
|factors to nausea, vomiting, and anorexia such |nausea. | |
|as other symptoms, constipation, GI irritation,| | |
|electrolyte imbalance, radiation therapy, | | |
|medications, and central nervous system | | |
|metastasis. | | |
|nursing diagnosis: Fatigue |
|goal: Increased activity tolerance and decreased fatigue level |
|Nursing Interventions |Rationale |Expected Outcomes |
|1. Encourage rest periods during the day, |1. During rest, energy is conserved and levels |● Reports decreasing levels of fatigue. |
|especially before and after physical exertion. |are replenished. Several shorter rest periods |● Increases participation in activities |
| |may be more beneficial than one longer rest |gradually. |
| |period. |● Rests when fatigued. |
| | |● Reports restful sleep. |
|2. At minimum, promote patient’s normal sleep |2. Sleep helps to restore energy levels. |● Requests assistance with activities |
|habits. |Prolonged napping during day may interfere with|appropriately. |
| |sleep habits. | |
|3. Rearrange daily schedule and organize |3. Reorganization of activities can reduce |● Reports adequate energy to participate in |
|activities to conserve energy expenditure. |energy losses and stressors. |activities important to him or her (eg, |
| | |visiting with family, hobbies). |
|4. Encourage patient to ask for others’ |4. Conserves energy. |● Consumes diet with recommended protein and |
|assistance with necessary chores, such as | |caloric intake. |
|housework, child care, shopping, cooking. | |● Uses relaxation exercises and imagery to |
| | |decrease anxiety and promote rest. |
|5. Encourage reduced job workload, if necessary|5. Reducing workload decreases physical and |● Participates in planned exercise program |
|and possible, by reducing number of hours |psychological stress and increases periods of |gradually. |
|worked per week. |rest and relaxation. |● Reports no breathlessness during activities. |
|6. Encourage adequate protein and calorie |6. Protein and calorie depletion decreases |● Exhibits acceptable hemoglobin and hematocrit|
|intake. |activity tolerance. |levels. |
|7. Encourage use of relaxation techniques, |7. Promotion of relaxation and psychological |● Exhibits normal fluid and electrolyte |
|mental imagery. |rest decreases physical fatigue. |balance. |
| | |● Reports decreased discomfort. |
|8. Encourage participation in planned exercise |8. Proper exercise programs increase endurance |● Exhibits improved mobility. |
|programs. |and stamina and lower fatigue. | |
|9. For collaborative management, administer |9. Lowered hemoglobin and hematocrit predispose| |
|blood products as prescribed. |patient to fatigue due to decreased oxygen | |
| |availability. | |
|10. Assess for fluid and electrolyte |10. May contribute to altered nerve | |
|disturbances. |transmission and muscle function. | |
|11. Assess for sources of discomfort. |11. Coping with discomfort requires energy | |
| |expenditure. | |
|12. Provide strategies to facilitate mobility. |12. Impaired mobility requires increased energy| |
| |expenditure. | |
|nursing diagnosis: Chronic pain |
|goal: Relief of pain and discomfort |
|Nursing Interventions |Rationale |Expected Outcomes |
|1. Use pain scale to assess pain and discomfort|1. Provides baseline for assessing changes in |● Reports decreased level of pain and |
|characteristics: location, quality, frequency, |pain level and evaluation of interventions. |discomfort on pain scale. |
|duration, etc. | | |
|2. Assure patient that you know that pain is |2. Fear that pain will not be considered real |● Reports less disruption from pain and |
|real and will assist him or her in reducing it.|increases anxiety and reduces pain tolerance. |discomfort. |
|3. Assess other factors contributing to |3. Provides data about factors that decrease |● Explains how fatigue, fear, anger, etc., |
|patient’s pain: fear, fatigue, anger, etc. |patient’s ability to tolerate pain and increase|contribute to severity of pain and discomfort. |
| |pain level. | |
|4. Administer analgesics to promote optimum |4. Analgesics tend to be more effective when |● Accepts analgesia as prescribed. |
|pain relief within limits of health care |administered early in pain cycle. | |
|provider ’s prescription. | | |
|5. Assess patient’s behavioral responses to |5. Provides additional information about |● Exhibits decreased physical and behavioral |
|pain and pain experience. |patient’s pain. |signs of pain and discomfort in acute pain (no |
| | |grimacing, crying, moaning; displays interest |
| | |in surroundings and activities around him). |
|6. Collaborate with patient, health care |6. New methods of administering analgesia must |● Takes an active role in administration of |
|provider , and other health care team members |be acceptable to patient, health care provider |analgesia. |
|when changes in pain management are necessary. |, and health care team to be effective; |● Identifies additional effective pain relief |
| |patient’s participation decreases the sense of |strategies. |
| |powerlessness. | |
|7. Encourage strategies of pain relief that |7. Encourages success of pain relief strategies|● Uses alternative pain relief strategies |
|patient has used successfully in previous pain |accepted by patient and family. |appropriately. |
|experience. | | |
|8. Teach patient new strategies to relieve pain|8. Increases number of options and strategies |● Reports effective use of new pain relief |
|and discomfort: distraction, imagery, |available to patient. |strategies and decrease in pain intensity. |
|relaxation, cutaneous stimulation, etc. | |● Reports that decreased level of pain permits |
| | |participation in other activities and events. |
|nursing diagnosis: Anticipatory grieving related to loss; altered role functioning |
|goal: Appropriate progression through grieving process |
|Nursing Interventions |Rationale |Expected Outcomes |
|1. Encourage verbalization of fears, concerns, |1. An increased and accurate knowledge base |● The patient and family progress through the |
|and questions regarding disease, treatment, and|decreases anxiety and dispels misconceptions. |phases of grief as evidenced by increased |
|future implications. | |verbalization and expression of grief. |
|2. Explore previous successful coping |2. Provides frame of reference and examples of |● The patient and family identify resources |
|strategies. |coping. |available to aid coping strategies during |
| | |grieving. |
|3. Encourage active participation of patient or|3. Active participation maintains patient |● The patient and family use resources and |
|family in care and treatment decisions. |independence and control. |supports appropriately. |
|4. Visit family frequently to establish and |4. Frequent contacts promote trust and security|● The patient and family discuss the future |
|maintain relationships and physical closeness. |and reduce feelings of fear and isolation. |openly with each other. |
|5. Encourage ventilation of negative feelings, |5. This allows for emotional expression without|● The patient and family discuss concerns and |
|including projected anger and hostility, within|loss of self-esteem. |feelings openly with each other. |
|acceptable limits. | | |
|6. Allow for periods of crying and expression |6. These feelings are necessary for separation |● The patient and family use nonverbal |
|of sadness. |and detachment to occur. |expressions of concern for each other. |
|7. Involve spiritual advisor as desired by the |7. This facilitates the grief process and | |
|patient and family. |spiritual care. | |
|8. Advise professional counseling as indicated |8. This facilitates the grief process. | |
|for patient or family to alleviate pathologic | | |
|grieving. | | |
|9. Allow for progression through the grieving |9. Grief work is variable. Not every person | |
|process at the individual pace of the patient |uses every phase of the grief process, and the | |
|and family. |time spent in dealing with each phase varies | |
| |with every person. To complete grief work, this| |
| |variability must be allowed. | |
|nursing diagnosis: Disturbed body image and situational low self-esteem related to changes in appearance, function, and roles |
|goal: Improved body image and self-esteem |
|Nursing Interventions |Rationale |Expected Outcomes |
|1. Assess patient’s feelings about body image |1. Provides baseline assessment for evaluating |● Identifies concerns of importance. |
|and level of self-esteem. |changes and assessing effectiveness of |● Takes active role in activities. |
| |interventions. |● Maintains previous role in decision making. |
|2. Identify potential threats to patient’s |2. Anticipates changes and permits patient to |● Verbalizes feelings and reactions to losses |
|self-esteem (eg, altered appearance, decreased |identify importance of these areas to him or |or threatened losses. |
|sexual function, hair loss, decreased energy, |her. |● Participates in self-care activities. |
|role changes). Validate concerns with patient. | |● Permits others to assist in care when he or |
| | |she is unable to be independent. |
|3. Encourage continued participation in |3. Encourages and permits continued control of |● Exhibits interest in appearance and uses aids|
|activities and decision making. |events and self. |(cosmetics, scarves, etc.) appropriately. |
|4. Encourage patient to verbalize concerns. |4. Identifying concerns is an important step in|● Participates with others in conversations and|
| |coping with them. |social events and activities. |
|5. Individualize care for the patient. |5. Prevents or reduces depersonalization and |● Verbalizes concern about sexual partner |
| |emphasizes patient’s self-worth. |and/or significant others. |
|6. Assist patient in self-care when fatigue, |6. Physical well-being improves self-esteem. |● Explores alternative ways of expressing |
|lethargy, nausea, vomiting, and other symptoms | |concern and affection. |
|prevent independence. | | |
|7. Assist patient in selecting and using |7. Promotes positive body image. | |
|cosmetics, scarves, hair pieces, and clothing | | |
|that increase his or her sense of | | |
|attractiveness. | | |
|8. Encourage patient and partner to share |8. Provides opportunity for expressing concern,| |
|concerns about altered sexuality and sexual |affection, and acceptance. | |
|function and to explore alternatives to their | | |
|usual sexual expression. | | |
|9. Refer to collaborating specialists as |9. Interdisciplinary collaboration essential in| |
|needed. |meeting patient needs. | |
|collaborative problem: Potential complication: risk for bleeding problems |
|goal: Prevention of bleeding |
|Nursing Interventions |Rationale |Expected Outcomes |
|1. Assess for potential for bleeding: monitor |1. Mild risk: 50,000–100,000/mm3 (0.05–0.1 × |● Signs and symptoms of bleeding are |
|platelet count. |1012/L) Moderate risk: 20,000–50,000/mm3 |identified. |
| |(0.02–0.05 × 1012/L) Severe risk: less than |● Exhibits no blood in feces, urine, or emesis.|
| |20,000/mm3 (0.02 × 1012/L) |● Exhibits no bleeding of gums or of injection |
| | |or venipuncture sites. |
|2. Assess for bleeding: |2. Early detection promotes early intervention.|● Exhibits no ecchymosis (bruising). |
|a. Petechiae or ecchymosis |a. Indicates injury to microcirculation and |● Patient and family identify ways to prevent |
| |larger vessels. |bleeding. |
|b. Decrease in hemoglobin or hematocrit |b–e. Indicates blood loss. |● Uses recommended measures to reduce risk of |
|c. Prolonged bleeding from invasive procedures,| |bleeding (uses soft toothbrush, shaves with |
|venipunctures, minor cuts or scratches | |electric razor only). |
|d. Frank or occult blood in any body excretion,| |● Exhibits normal vital signs. |
|emesis, sputum | |● Reports that environmental hazards have been |
|e. Bleeding from any body orifice | |reduced or removed. |
| | |● Consumes adequate fluid. |
| | |● Reports absence of constipation. |
|f. Altered mental status |f. Indicates neurologic involvement. |● Avoids substances interfering with clotting. |
|3. Instruct patient and family about ways to |3. Patient can participate in self-protection. |● Absence of tissue destruction. |
|minimize bleeding: | | |
|a. Use soft toothbrush or toothette for mouth |a. Prevents trauma to oral tissues. |● Exhibits normal mental status and absence of |
|care. | |signs of intracranial bleeding. |
|b. Avoid commercial mouthwashes. |b. Contain high alcohol content that will dry |● Avoids medications that interfere with |
| |oral tissues. |clotting (eg, aspirin). |
|c. Use electric razor for shaving. |c. Prevents trauma to skin. |● Absence of epistaxis and cerebral bleeding. |
|d. Use emery board for nail care. |d. Reduces risk of trauma to nailbeds. | |
|e. Avoid foods that are difficult to chew. |e. Prevents oral tissue trauma. | |
|4. Initiate measures to minimize bleeding. |4. Preserves circulating blood volume. | |
|a. Draw all blood for lab work with one daily |a. Minimizes trauma and blood loss. | |
|venipuncture. | | |
|b. Avoid taking temperature rectally or |b. Prevents trauma to rectal mucosa. | |
|administering suppositories and enemas. | | |
|c. Avoid intramuscular injections; use smallest|c. Prevents intramuscular bleeding. | |
|needle possible. | | |
|d. Apply direct pressure to injection and |d. Minimizes blood loss. | |
|venipuncture sites for at least 5 minutes. | | |
|e. Lubricate lips with petrolatum. |e. Prevents skin from drying. | |
|f. Avoid bladder catheterizations; use smallest|f. Prevents trauma to urethra. | |
|catheter if catheterization is necessary. | | |
|g. Maintain fluid intake of at least 3 L per 24|g. Hydration helps to prevent skin drying. | |
|hours unless contraindicated. | | |
|h. Use stool softeners or increase bulk in |h. Prevents constipation and straining that may| |
|diet. |injure rectal tissue. | |
|i. Avoid medications that will interfere with |i. Minimizes risk of bleeding. | |
|clotting (eg, aspirin). | | |
|j. Recommend use of water-based lubricant |j. Prevents friction and tissue trauma. | |
|before sexual intercourse. | | |
|5. When platelet count is less than 20,000/mm3,|5. Platelet count of less than 20,000/mm3 (0.02| |
|institute the following: |× 1012/L) is associated with increased risk of | |
| |spontaneous bleeding. | |
|a. Bed rest with padded side rails. |a. Reduces risk of injury. | |
|b. Avoidance of strenuous activity. |b. Increases intracranial pressure and risk of | |
| |cerebral hemorrhage. | |
|c. Platelet transfusions as prescribed; |c. Allergic reactions to blood products are | |
|administer prescribed diphenhydramine |associated with antigen–antibody reaction that | |
|hydrochloride (Benadryl) or hydrocortisone |causes platelet destruction. | |
|sodium succinate (Solu-Cortef) to prevent | | |
|reaction to platelet transfusion. | | |
|d. Supervise activity when out of bed. |d. Reduces risk of falls. | |
|e. Caution against forceful nose blowing. |e. Prevents trauma to nasal mucosa and | |
| |increased intracranial pressure. | |