Nursing Care Plan

Patient had undergone exploratory laparotomy and radiation

therapy. When there is an incision to the skin the body has a
higher risk for infection because first line of defense is already
destroyed. During her radiation therapy patient had first-degree
burns and was prescribed with an ointment to relieve it.
Assessment Nursing
Diagnosis
Planning Interventions Rationale Evaluation
>destructi
on of
skin
layers
>skin
discolora
tion
>dry scaly
skin
>first
degree
burn on
the site
of
radiation
Impaired kin
Integrity r!t
radiation
therapy.
"t the end
of # week
the patient
will be
able to
maintain
skin
integrity$
with no
signs of
complicatio
ns$ as
manifested
by healed
skin
>%bserve skin
for changes$
abrasions$
rashes$ scaling$
wounds$ bleeding
and redness
>&urn patient at
least every '
hours.
>(lean the area
with mild soap
>)acilitates
identification of
potential
complications
>Prevents
pressure and
compromise of
skin and tissues$
which may result
in in*ury
>&o remove or
prevent
accumulation of
therapy layers$
color of
skin same
as the
other parts
of the
body$ and
skin is
smooth to
touch.
>+eep the area
dry by removing
wet linens and
carefully
dressing the
wound
>timulate
circulation to
surrounding
areas.
>"pply
medication
,ointment- as
ordered
bacteria in the
site of lesion
and to prevent
further dryness
of skin.
>&o prevent skin
breakdown because
moisture
potentiate skin
breakdown.
>&o assist body.s
natural process
of repair.
>&o facilitate
faster healing of
lesion.
Nursing Care Plan
/efore she was diagnosed of cancer patient had recurrent 001
pain. "t present patient experiences low back pains.
Assessment Nursing
Diagnosis
Planning Interventions Rationale Evaluation
>grimacing
>guarding
the
painful
area
>restlessn
ess
>changes
in pulse
and blood
pressure
> pain
rate of
2!#3
"lteration in
comfort4
"cute Pain
related to
tumor
invasion
secondary to
disease
process.
"t the end
of the
shift$ the
patient
will be
able to
demonstrate
relief of
pain as
manifested
by not
grimacing$
appears
rested$
pulse and
/P on
normal
range and
>Position the
patient
comfortably.
>5onitor vital
signs and recorded
>Identify ways of
avoiding or
minimi6ing pain
such as splinting
when coughing$ firm
mattress$ using
proper supporting
shoes for low back
pain and
>&o somehow
alleviate pain
>&o assess any
deviations
from normal
range because
pain could
effect all of
these
>&o help
patient avoid
occurrence of
pain and to
decrease
intensity
during pain
episodes.
level of
pain
decreased
from 2!#3-
'!#3.
maintaining good
body mechanics.
>Provide 7uiet
environment
>Provide comfort
measures ,/ack
rubbing-
>8ncourage patient
to do relaxation
exercises$ such as
deep breathing
>8ncourage ade7uate
rest periods
>"dminister pain
reliever as ordered
>&o somehow
make the
client feel
relax and not
tense
>&o provide
nonpharmacolog
ical pain
management
>&o divert the
attention of
the client
>&o prevent
fatigue
>&o maintain
9acceptable
level of pain
Nursing Care Plan
"s side effects of treatment modalities of cancer such as
chemotherapy and radiation therapy$ patient experienced severe
nausea and vomiting despite the medications given to relieve it.
he also had diarrhea from the :
th
day of her radiation therapy up
to a week after finishing the whole course of the therapy. he also
had weight loss from #:; lbs to #<3 lbs.
Assessment Nursing
Diagnosis
Planning Interventions Rationale Evaluation
>severe
vomiting
>diarrhea
>weight
loss,from
#:;lbs to
#<3 lbs-
>satiety
immediately
after
ingesting
food
>abdominal
pain or
discomfort
Imbalanced
=utrition4
0ess than
body
re7uirement
r!t
inability to
take in
enough food
and side
effects of
chemotherapy
and
radiation
therapy.
"t the end
of one week
patient
will be
able to
manifest
signs of
weight gain
such as
good
appetite$
less number
of
vomiting$
normal
bowel
>"ssess patient.s
dietary status$
ability to eat$
presence of nausea
and vomiting and
diarrhea.
>Weigh patient
everyday$ on same
scale$ at same
>Provides
information
regarding
identification
of specific
problem of
lack of
sufficient
nutrition$ and
helps
establish plan
of care for
meeting needs.
>Provides
accurate
measurement of
elimination
and body
weight
gradually
returning
to normal
range.
time.
>Identify food
preferences and
encourage family to
bring foods from
home.
>"dminister
antiemetics as
ordered.
>Provide small$
fre7uent meals with
dense caloric
intake.
>8ncourage patient
efficacy of
dietary
regimen.
>)amiliar
foods may
entice the
patient to
eat.
>&o prevent
nausea and
vomiting which
will
eventually
enhance
appetite.
>>elps to
encourage
patient to eat
and desired
caloric intake
will be met.
>>elps in
to take some
dietary
supplements.
meeting
re7uired
dietary
intake.
Nursing Care Plan
&he first symptom she had encountered is a change with his
bowel elimination. he had diarrhea and constipation alternately.
&hese symptoms progressed to passage of goat-like stools with a
feeling of incomplete fecal evacuation. "fter her radiation therapy
she again had severe diarrhea.
Assessment Nursing
Diagnosis
Planning Interventions Rationale Evaluation
>fre7uent
passage of
watery
stools
>abdominal
pain
>cramping
>increased
bowel
sounds
>malaise
>fecal
urgency
Diarrhea r!t
inflammation
of the bowel
mucosa
secondary to
procto-
sigmoid colon
cancer.
"t the end
of ' days$
patient
will be
able to
achieve
normal
bowel
elimination
pattern as
manifested
by passage
of formed
stools and
patient
will not
manifest
any fluid
>5onitor patient
for presence and
fre7uency of
diarrhea and
characteristic of
stool.
>5onitor I and % if
diarrhea is severe.
>"dminister
antidiarrheals as
ordered.
>Identifies
problem and
severity$ and
facilitates
establishment
of plan of
care.
>Diarrhea can
deplete fluids
and
electrolytes
resulting in
weakness over
an extended
episode.
>Decreases
gastric
motility and
and
electrolyte
imbalances.
>5aintain patient
in close proximity
to commode or
bathroom.
>Instruct patient
to comply with
fluid and dietary
intake as
appropriate.
>Instruct patient
to avoid caffeine
drinks$ spicy
foods$ raw foods$
and gas producing
foods such as
controls
number of
bowel
elimination.
>Prevents
embarrassment
for patient if
she has an
accidental
incontinent
episode.
>Provides bulk
to stool and
provides for
fluid
replacement.
>Dietary
substances may
act as
diuretics and
increase fluid
in colon$ or
cabbage$ beans$ or
onions.
>Instruct patient
regarding cleaning
the perianal area.
>Instruct patient
to perform
relaxation
techni7ues.
may be
irritating to
bowel and
actually
increase
motility and
diarrhea.
>>elps to
provide
comfort and
maintain skin
integrity.
>>elps to
reduce stress
and
temporarily
alleviates
emotional
distress$
which can
worsen
diarrhea.
Nursing Care Plan
&hough she recovered well from her illness she still feels
anxious that the disease may reoccur.
Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis
>fear of
unspecific
conse7uenc
es
>anxious
>worried
"nxiety r!t
threat to or
change in
health
status.
Patient
will be
able to
reduce and
maintain
anxiety
level at
acceptable
level.
>8stablish a
therapeutic
relationship$
conveying empathy
and unconditional
positive regard.
>Provide comfort
measures
>Provide accurate
information about
the situation.
Don.t give false
reassurances.
>5anage
environmental
factors$ such
noise.
>"dminister anti
anxiety drugs as
ordered with
>?educes
anxiety and
promotes
rapport$
caring$ and
trust.
>&o help
lessen anxiety
by means of
relaxation.
>>elps patient
to identify
what is
reality based.
>Prevents
additional
stimuli.
>Promotes
relaxation and
reduces
caution. anxiety.
Nursing Care Plan
During early occurrence of disease patient complains of easy
fatigability accompanied with fever. he usually considers it as
flu and all she needs is to have some rest.
Assessment Nursing
Diagnosis
Planning Interventions Rationale Evaluation
>inability
to
maintain
usual
routine
activities
>irritabil
ity
>restlessn
ess
>dyspnea
>pain
)atigue r!t
decreased
metabolic
energy
production
secondary to
procto-
sigmoid
cancer.
"t the end
of # day$
patient
will be
able to
increased
energy and
be able to
perform
usual
activities.
>Provide periods of
rest or sleep
alternating with
periods of activity
as patient can
tolerate.
>"void scheduling
patient for two or
more energy-
draining procedures
on same day$ if
possible.
>chedule patient.s
daily routine based
on specific needs
and desires.
>8ncourage food
high in iron and
>Prevents
excessive
fatigue and
increases
stamina.
>(onserving
energy helps
to avoid
overexertion
and potential
for
exhaustion.
>8ncourages
compliance
with treatment
regimen and
reduces
fatigue.
>>elps to
avoid anemia
minerals$ unless
disease process
contraindicates.
>Provide small$
easily digested
foods.
>Instruct patient
regarding effects
of fatigue on daily
activity and
personal lifestyle.
and
deminerali6ati
on that can
affect
fatigue.
>)re7uent$
small meals
conserve
energy and
encourage
increased
intake of
nutritive
sustenance.
>>elps to
increase
patient.s
compliance and
allows for
planning
schedule for
activity and
rest.
Nursing Care Plan
he was advised to avoid having in contact with people having infectious or
communicable diseases. "fter her radiotherapy she had vaginal discharge.
Assessment Nursing
Diagnosis
Planning Interventions Rationale Evaluation
>deficient
immunity
Ineffective
protection
"t the end
of # week
>tress proper hand
washing techni7ues
>" first-line
defense
>weakness
>low blood
counts
r!t effects
of
chemotherapy
and radiation
therapy.
patient
will be
free from
infection.
by all caregivers
between
therapies!clients.
>5aintain sterile
techni7ue for
invasive
procedures.
>5aintain ade7uate
nutritional intake$
rest$ and have
appropriate
exercise program.
>Instruct patient
and family in
techni7ue to
protect the
integrity of the
skin.
>"ssess vaginal
discharge.
against
nosocomial
infections!cro
ss-
contamination.
> &o avoid
exposure to
infectious
agents.
>&o maintain
health and
decrease
susceptibility
to infection.
>&o have
ade7uate
protection
against
infection.
>&o easily
detect
>Instruct to
cleanse perineum
fre7uently4 wash
genitalia from
front to back.
>Inform patient to
avoid using
douches$ sprays$ or
irritating soaps.
potential
problems that
may arise.
>Promotes
comfort and
prevents
introduction
of
microorganisms
>Prevents
alteration of
p> of vagina
and irritation
of genitalia.
Nursing Care Plan
he had #
st
degree burns when she.s undergoing with her radiation therapy and
for the time that her skin is burned she never looked at the mirror. he doesn.t want to
have hair loss so she chose the therapy that wouldn.t result to alopecia even though it.s
very expensive.
Assessment Nursing
Diagnosis
Planning Interventions Rationale Evaluation
>discolora /ody Image "t the end >8valuate level of >5ay identify
tion of
skin
> darkened
tips of
fingernail
s
>refusal
to look at
self
Disturbance
r!t changes
in physical
appearance as
side effect
of therapies.
of # week
patient
will be
able to
recogni6e
physical
change in
body image
and deal
appropriate
ly with
situation.
patient.s knowledge
about disease
process$ treatment
and anxiety level.
>0isten to
patient.s comments
and responses to
the situation.
>@isit patient
fre7uently and
acknowledge the
individual as
someone who is
worthwhile.
>"llow patient to
use denial by not
participating in
care.
>Provide positive
reinforcement
during care.
extent of
problem and
interventions
that will be
re7uired.
>&o determine
patient.s
coping skills.
>Provides
opportunities
for listening
to concerns
and 7uestions.
>Provides time
for individual
to adapt with
situation.
>Promotes
trust and
establishes
>Provide
opportunity for
patient to
participate in
self-care.
>Identify support
groups for patient!
family to contact.
rapport with
patient.
>Promotes
self-esteem
and
facilitates
feeling of
control of
body and
health.
>Provides
ongoing
support for
patient and
family and
allows for
ventilation of
feelings.
Nursing Care Plan
"s a part of the grieving process$ she had gone through the denial stage. he had
asked Aod why she has the disease where in fact there are those who are more sinful than
she is.
Assessment Nursing
Diagnosis
Planning Interventions Rationale Evaluat
ion
>7uestions
why cancer
affected
piritual
Distress r!t
diagnosis of
"t the end
of ; days$
patient
>"ssess patient.s
desire to discuss
religious concerns$
>"llows patient
to have
unconditional
her cancer. will be
able to
express her
feelings
about her
current
religious
beliefs and
will
grieving
process and
be able to
utili6e
coping
mechanisms
successfull
y.
and if patient
wants to talk about
this$ be accepting
and non-*udgmental
>"llow sufficient
time for patient to
continue with
religious
practices.
>Provide
opportunity and
assist with
devotional
readings$ prayers$
religious rituals$
meditation$ guided
imagery$ music and
or biofeedback.
regard$ which
fosters self-
esteem and
feelings of
worth.
>>elp to support
patient by
accepting beliefs
and religious
practices.
>"llows patient
to reconcile with
others and
improve coping
skills.