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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. | |

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...Running head: STANDARDIZED TESTS ARE KILLING SOCIETY                  1                Standardized Tests Are Killing Society  Alyssa Masula  Jonathan Alder High School            STANDARDIZED TESTS ARE KILLING SOCIETY                                                            2      ABSTRACT    STANDARDIZED TESTS ARE KILLING SOCIETY     Alyssa Masula          This essay provides an exploration of the harm done to individuals and societies by standardized  testing.  In her studies, the author discovered mixed results, containing both support and rejection  for her original hypothesis. She includes evidence to prove her point true. She provides  information gathered from various sources including published works and studies by Peter  Sacks, Nicholas Lemann, and Jacques Steinberg. As well as these, she has added the support of a  political cartoon and an article from the distinguished newspaper “The Columbus Dispatch”.          STANDARDIZED TESTS ARE KILLING SOCIETY                                                            3  Standardized Tests Are Killing Society  A student sits down at a desk and is given a #2 pencil, a test, and a time limit. Upon him  rests the expectation that his future will will depend on the result of said test.  Overwhelmed by  the idea of failure and a consequential meaningless life, he cannot concentrate and has a panic  attack.  Too much pressure is placed on young people to succeed on tests that are supposed to be  objective, yet in re...

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