NURSING CARE PLAN

NAME OF STUDENT:
NAME OF CLIENT:
DIAGNOSIS OR CLINICAL IMPRESSION: Laryngeal Cancer

CUES
S: NURSING HEALTH HISTORY
- 58 years old male
- With family history of
hypertension and stroke
- Lifestyle: 69 pack years,
chronic alcoholic, past illegal
drug user
- Had history of fever after
radiation therapy but was
resolved with medications
- Increase in intake of food and
vegetables was initiated
- Doctor prescribed 1.5L of fluid
intake
- Radiation therapy finished 1 0
days PTA, 3rd cycle of
chemotherapy
- Post-surgical client,
immunosuppressed, chronically
ill
O: PHYSICAL EXAMINATION
- Vital signs:

RR 20 breaths/min

BP 120/70mmHg, L
arm

PR- 67/min, L arm,

radial

T-35.9^C
- Skin graft over mouth
extending to neck
- Mark from tracheostomy,
midline, neck, 0.5 cm diameter
- Lateral mouth erosions
- Decreased intake of food,
difficulty swallowing

NURSING
DIAGNOSI
S
Risk for
Infection
r/t
compromi
sed
immune
defenses
secondary
to cancer

BACKGROUND
KNOWLEDGE

DATE OF ASSIGNMENT:
CIVIL STATUS: AGE: SEX:
WARD: CI
BED:

GOALS AND OBJECTIVES

RISK FOR
INFECTION is
defined as at
increased risk for
being invaded by
pathogenic
organisms.
(Doenges, 2004)

GOAL:
By the end of the duty, Mr. C
will demonstrate no signs of
infection.

Presence of a
healing wound
may still be
subjected to
different scenarios
wherein certain
pathogens, both
virulent and
opportunistic, may
get involved.
Proper hygiene and
environmental
sanitation may be
practiced to
decrease the
chances of getting
infection. Such
activities like
proper
handwashing and
using disinfectants
are some.
(Microbiology for
the Health
Sciences, Burton &
Engelkirk, 1996)

1. Not develop further breaks

from primary defenses

NURSING INTERVENTIONS
AND RATIONALE

EVALUATION

During nursing intervention,

the student nurse will:

By the end of the shift,

the client will be able
to:

1. Maintain strict asepsis

when performing
procedures to client. R:
Asepsis will prevent client
from entry o organisms
thus, protecting her from
infection.

1. Not acquire any

infective organism.

OBJECTIVES:
By the end of the nursing
intervention, the client will:

2. Exercise meticulous
handwashing before and
after handling patient. R:
Frequent, meticulous
handwashing greatly
decreases the chanced of
spreaing infection.
3. Check presence of
invasive devices and
monitor their present
condition. R: Checking of
condition of lines or devices,
their duration of attachment
will help the nurse identify
possible sources of
infection, which she then
can remove.

(blenderized feeding)
LABORATORY RESULTS
(02/14/11) Hgb: 84 g/L LOW
RBC: 2.80 10^12/L LOW
HCT: 0.249% LOW
WBC: 6.88 10^9/L NORMAL
Neutrophil 0.745 HIGH
Lymphocyte = 0.112 LOW
Mono = 0.103 NORMAL
Eoso = 0.300 NORMAL
Baso = 0.001 NORMAL

Increased risk of
infection in clients
with chemotherapy
treatments due to
destruction of
rapidly dividing
hematopoietic
cells, resulting in
immunosuppressio
n. (Gale, 1994)

4. Monitor vital signs

especially temperature
every 4 hours. R: Fever or
hypothermia may indicate
presence of infection.
2. Achieve timely wound
healing with no infection.

5. Check incisions/ wounds

for signs of infection. R: Skin
and mucosa provide first
line defense against
microorganisms.

2. Cleanliness and
hygiene are
maintained at wound
sites and bed sides.

6. Cleanse mouth erosions,

if not contraindicated. R:
Ensures that wound is free
from infection- causing
organisms and is kept clean
to prevent infections.

3. Identify techniques to
prevent skin infection

7. Provide meticulous skin

care (cleansing bath) R: To
prevent skin breakdown
which is a possible way of
infection.
8. Assist with oral care
(Orahex) if needed. R:
Provides care if client is
unable.
9. Promote frequent and
adequate fluid intake. R: To
liquefy secretions and
facilitate expectorations to
prevent stasis of body fluids
and promotes moist mucus
membranes.
10. Encourage to apply
lubricant (petroleum jelly) to
lips and skin graft. R: Keeps
areas moist.
11. Encourage frequent

3. Developed
resistance to infection
through techniques

position
changes/ambulation,
coughing, and deep
breathing exercises. R: To
promote ventilation in all
lung segments and aids in
mobilizing secretions to
prevent pneumonia.
12. Provide health teaching
on:
- possible individual causes
of infection to establish an
information background for
the patient.
- techniques to prevent or
reduce risk of infection to
initialize learning of patient.
- proper handwashing
technique to client because
it is the most basic
technique to prevent
infection.
- thorough handwashing
technique to other patients
and caregivers to
encourage client to practice
learned skill.
- avoidance of people with
respiratory infections and
respiratory diseases
- effect of chemotherapy
and radiation therapy on
body
S: NURSING HEALTH HISTORY
- 58 years old male
- With family history of
hypertension and stroke
- Lifestyle: 69 pack years,
chronic alcoholic, past illegal
drug user
- Reports difficulty swallowing
- SO verbalized that client only
eats a few spoons during lunch

Imbalance
d
Nutrition:
Less than
Body
Requirem
ents
related to
decreased
intake and

IMBALANCED
NUTRITION: LESS
THAN BODY
REQUIREMENTS is
defined as Intake
of nutrients
insufficient to meet
metabolic needs
(Doenges, 2004).

GOAL: By the end of the duty,

the client will maintain
nutritional status, minimize
weight loss and experience
less nausea and vomiting.
OBJECTIVES:
By the end of the nursing
intervention, the client will:

During the nursing

intervention, the student
nurse will:

After the nursing

intervention, the client
will:

and dinner, but occasionally

looks for food in between meal
times
- Chemotherapeutic drug: Cis5FU
O: PHYSICAL EXAMINATION
- Vital signs:

RR 20 breaths/min

BP 120/70mmHg, L
arm

PR- 67/min, L arm,

radial
- Upper and lower extremities:
nail beds pale, 1 sec capillary
refill
- Peripheral pulses: regular
- Difficulty in swallowing
- Height: 160 cm
Weight: 46.5 kg
Cachexic with distinct bony
prominences
(+) skin pallor
-Smooth, warm, dry skin with
fair turgor
(+) muscle wasting
Pale conjuctiva, mucosa and
nailbeds
(+) thinning of hair
LABORATORY RESULTS
(02/14/11) Hgb: 84 g/L LOW
RBC: 2.80 10^12/L LOW
HCT: 0.249% LOW
Ca: 2.17 mmol/L
Na: 140 mmol/L
K: 3.5 mmol/L (Borderline)
Mg: 0.8 mmol/L

early
satiety
secondary
to nausea
and
vomiting
and
difficulty
swallowin
g

Medicine looks on
nausea and
vomiting as
pathophysiological
responses
accompanying
certain tumors and
tumor locations
and as
unavoidable sideeffects in some
forms of therapy.
Medical treatment
involves
prescribing
antiemetics and
sedation to reduce
symptom
occurrence or
emotional distress,
and managing any
associated
nutriotional deficits
or F&E imbalances.
Nausea is a vague
but distinctly
disagreeably
queasy feeling in
the stomach and a
tightening
sensation in the
throat
accompanied by a
strong revulsion
toward food and
eating. It is usually
preceded by
anorexia. Vomiting
is a sudden,
powerful oral
expulsion of
stomach contents.
This two often
follows the

1. Identify predisposing
factors that lead to
undernourishment of patient

2. Follow the dietary plan for

patient

1.
Teach
mother
the
possible
predisposing
factors
that
lead
to
undernourishment
of
patient.
R:
To
initiate
learning.
2.
Provide
information
regarding the dietary plan
for the client. R: To provide
ongoing
support
and
increase
likelihood
of
accomplishing dietary goals.
3. Instruct patient to avoid
unpleasant sights, odor,
sounds in the environment
during
mealtime.
R:
Decrease in appetite can be
stimulated
with
noxious
stimuli.
4. Suggest foods that are
preferred and well tolerated
by the patient, preferably
high-calorie
and
highprotein foods. R: Foods
preferred, well tolerated,
and high in calories and
protein maintain nutritional
status during periods of
increased
metabolic
demand.
5. Encourage adequate fluid
intake, but limit fluids at
mealtime. R: Fluids are
necessary
to
eliminate
wastes
and
prevent
dehydration.
Increased
fluids with meals can lead
to early satiety.
6. Suggest smaller, more

1. Identified all
predisposing factors
that lead to
undernourishment of
patient

2. Followed the dietary

plan for patient as
evidenced by the
following:
reported
decreasing
anorexia and
increased interest
in eating
demonstrated
normal skin turgor
used appropriate
imagery and
relaxation before
meals
consumed diet
high in required
nutrients
carried out oral
hygiene before
meals
reported
decreasing
episodes of nausea
and vomiting
participated in
increasing levels of
activity

negative effect on
eating, sleeping
and controlling
activities. ( The
Cancer Experience,
Carnevali, 1990)

frequent meals. R: Smaller,

more frequent meals are
better tolerated because
early satiety does not occur.
7. Promote relaxed, quiet
environment
during
mealtime with increased
social interaction as desired.
R: A quiet environment
promotes relaxation. Social
interaction
at
mealtime
increases appetite.

3. Verbalize understanding of
causative factors and
necessary interventions

8. Consider cold foods, if

desired.
R:
Cold,
high
protein foods are often
more tolerable and less
odorous than hot foods.
9. Advocate high-protein
foods in between meals.
Snacks add protein and
calories to meet nutritional
requirements.
10. Encourage frequent oral
hygiene. R: Oral hygiene
stimulates
appetite
and
increases saliva production.

4. Demonstrate progressive
weight gain toward goal

3.Verbalized
understanding of the
need for lifestyle
modifications of
patient

11.
Use
distraction
or
conversation before and
during chemotherapy. R:
Decreases anxiety which
can contribute to nausea
and vomiting.
12. Position patient properly
at mealtime. R: Proper body
position and alignment are
necessary to aid chewing
and swallowing.
15.Encourage to verbalize

4.Demonstrated
progressive weight
gain toward goal.

understanding of the
treatment plan for client R:
to enable the independency
in implementation of it.

S: NURSING HEALTH HISTORY

- 58 years old male
- With family history of
hypertension and stroke
- Lifestyle: 69 pack years,
chronic alcoholic, past illegal
drug user
- Reported occasional episodes
of chest pain/heaviness,
dyspnea
- Radiation therapy finished 1 0
days PTA
- Reports decreased level of
activity compared to condition
prior to illness
- Has no DOB
- Reports dizziness when
suddenly sits up
O: PHYSICAL EXAMINATION
- Vital signs:

RR 20 breaths/min

BP 120/70mmHg, L
arm

PR- 67/min, L arm,

radial
- Upper and lower extremities:
nail beds pale, 1 sec capillary
refill
- Peripheral pulses: regular
- Difficulty in swallowing
- (+) pallor: conjunctiva

Ineffective
Peripheral
Tissue
Perfusion
related to
Decrease
d oxygen
carrying
capacity
of the
blood and
increased
oxygen
demand
secondary
to chronic
illness

INEFFECTIVE
PERIPHERAL
TISSUE PERFUSION
is defined as
decrease in oxygen
resulting in the
failure to nourish
tissues at the
capillary level
(Doenges, 2004).

GOAL:
By the end of the shift, Mr. C
will maintain optimal tissue
perfusion to vital organs
OBJECTIVES:
NOC: Circulatory Monitoring
1. Display hemodynamic
stability.

Chemotherapy
causes
myelosuppresion
which results to
anemia. Anemia
presents with a
decreased level of
Hemoglobin
concentration.
(Gale, 1994)
Weakness,
immobility, fatigue
and inactivity
typically increase
with advanced
cancer as a result
of the disease,
treatment,
inadequate
nutritional intake
or dyspnea.

16. Instruct to monitor

weight of patient every
week and record it on a
weekly log. R: To have a
baseline for either
development or deviation
from goal
During nursing intervention,
the student nurse will:

NIC: Circulatory Care

1. Monitor hemodynamic
stability indicators (vital
signs, peripheral pulses,
capillary refill time, pallor,
skin temperature, vital
signs) and compare with
baseline. Rationale: They
are the baseline to indicate
the status of cardiac output.

2. Display absent episodes of

pallor and coldness on
extremities.
2. Provide skin and foot
care. R: Prevents skin
integrity problems and
decreases chances of
hypothermia.
3. Reduce workload of the

By the end of the shift,

Mr. C will be able to:

3. Keep extremities warm

1. Display
hemodynamic stability
by having the
following within normal
parameters:
blood pressure
heart rate
respiratory rate
temperature
peripheral pulses
capillary refill
time
nail beds, color
2. Display absent
episodes of:
pallor
coldness on
extremities

LABORATORY RESULTS
(02/14/11) Hgb: 84 g/L LOW
RBC: 2.80 10^12/L LOW
HCT: 0.249% LOW
MCV: 88.9 fL
MCH: 30 pg

heart.
Bone marrow
depression after
certain types of
chemotherapy and
radiation theraoy
often results to
decreased
production of RBC
and
thrombocytopenia.
Because of
decreased RBC,
and hemoglobin
concentration, the
carrier of oxygen
to the different
parts of the body
and the periphery
is less. Because of
these, ineffective
tissue perfusion
ensues. (Porth,
2007)

through warm sponge bath.

R: This prevents
hypothermia.

4. Place Mr. C in semiFowlers position or his

preferred position of
comfort. If not preferred,
recommend orthopneic
position. Rationale: This
position decreases workload
of breathing, and venous
return and preload to the
heart.
Arterial
Interference: Head
and chest elevated,
and extremities in
dependent position
Do not use pillows
under knees.
5. Elevate head of bed to 30
degrees or as tolerated or
preferred. R: This promotes
venous drainage from the
head.
6. Advise to change position
at least every 2 hours
during waking time. R:
Prevents pooling of blood.
7. Promote a calm and
restful environment using
script for Noninvasive
Measure combining
relaxation, rhythmic

3. Participate in
activities that reduce
the workload of the
heart.

breathing, and imagery.

Rationale: Reduction in
myocardial oxygen demand
can be achieved by allowing
for rest and relaxation
periods.
4. Maintain normal level of
fluid balance.

NOC: Neurocognitive
5. Display normal neurologic
status.

8. Stress importance of
avoiding straining/ bearing
down, especially during
defecation. R: Valsalva
maneuver causes vagal
stimulation, reducing heart
rate (bradycardia), which
may be followed by rebound
tachycardia, both of which
impairs cardiac output.
9. Instruct on increasing
fiber-rich foods and increase
in liquid diet to avoid
Valsalva maneuver on
defecation. R: Fiber and
water soften wastes
excreted and avoids
constipation.

NIC: Activity Tolerance [0005]

6. Demonstrate adequate
response to activities.

10. Measure intake and

output every shift. R:
Monitoring for increased
fluid in the body is vital in
knowing fluid imbalances.
NIC: Neurologic
Management [4150]
11. Monitor neurologic
status: Glasgow Coma

4. Normal level of
I&O

5. Demonstrate within
normal parameters:
papillary size and
response
Glasgow coma scale
6. Demonstrate
decreased episodes of:
increase in ICP
increase in blood
pressure

7. Report absent:
difficulty of
breathing at rest
difficulty of
breathing in mild
exertion.

7. Demonstrate increased selfmanagement of ADL's.

Scale, papillary size and

response, cardiovascular
and respiratory status in
accordance with schedule.
R: Routine
neuroassessment can cause
slight increases in
intracranial pressure.
13. Provide comfort
measures. Gently touch face
or hand. Talk quietly with
patient. R: This relaxes and
calms patient.
NIC: Energy Management
[0180]

8. Perform relaxation
strategies.

9. State other possible

nonpharmacological
strategies.

9. Display:
Light range-ofmotion (ROM)
exercises in bed,
progressing to sitting
10. Display absent:
Chest discomfort
Hypotension
Tachycardia or
arrhythmia
Cool, moist,
cyanotic extremities

14. Observe patient's

schedule. Allow rest periods
between all activities. R:
Rest between activities
provides time for energy
conservation and recovery.
Heart rate recovery
following activity is greatest
at the beginning of a rest
period.

11. Accurately
perform a chosen
relaxation strategy.

15. Perform light range of

motion exercises but in
between rest periods
allowed . R: Light exercise
will promote normal
sleep/rest pattern.

12. State other

possible
nonpharmacological
strategies.

16. Discourage client from

wearing constricting
clothes. R: Decreases
circulation of blood.

10. Verbalize understanding of

health teaching.

8. Display adequate
management of
activities and rest.

17. Assist patient in

prioritizing tasks in life and
seeking assistance from

family/friends in those tasks

patient is unable to perform.
R: Conserves energy.
18. Instruct on possible
relaxation strategies. R:
Relaxation strategies help
conserve energy and
decrease stress.
19. Inform on other possible
and nonpharmacologic
management of cancer
related fatigue [journal]. R:
Research on these
interventions has yielded
positive outcomes in cancer
survivors with different
diagnoses undergoing a
variety of cancer treatments
(Mustian, et. al., 2007).
- Exercise: Resistance and
Walking
- Psychosocial:
Individual/Group
- Yoga, Mindfulness-Based
Stress Reduction, Sleep
Therapy, Nutrition Therapy,
Polarity Therapy
20. Provide health teaching
on:
- importance of prioritization
of activities
- recognition of signs of
fatigue (Talk Test)
- asking for family/friends
for help
- effect of Hgb on
chemotherapy
- expectation of fatigue as
side effect of chemotherapy

13. Verbalize
understanding of
health teaching on:
importance of
prioritization of
activities
recognition of
signs of fatigue (Talk
Test)
asking for
family/friends for help
effect of Hgb on
chemotherapy
expectation of
fatigue as side effect
of chemotherapy
Importance of
protein in diet

- Importance of protein and

iron in diet
S: NURSING HEALTH HISTORY
- 58 years old male
- With family history of
hypertension and stroke
- Lifestyle: 69 pack years,
chronic alcoholic, past illegal
drug user
- Tracheostomy tube removed
- Radiation therapy finished 1 0
days PTA, 3rd cycle of
chemotheraoy
- Post-surgical client
(glossectomy),
immunosuppressed, chronically
ill
- Reports dysphagia
O: PHYSICAL EXAMINATION
- Vital signs:

RR 20 breaths/min

BP 120/70mmHg, L
arm

PR- 67/min, L arm,

radial

T-35.9^C
- Skin graft over mouth
extending to neck
- Mark from tracheostomy,
midline, neck, 0.5 cm diameter
- Lateral mouth erosions
- Hoarse/slurred speech
- Coherent, oriented to time
person and place

Readiness
for
Enhanced
Coping

Readiness for
Enhanced Coping
is defines as A
pattern of
cognitive and
behavioral efforts
to manage
demands that is
sufficient for wellbeing and can be
strengthened.
(Doenges, 2004).

GOAL: After nursing

intervention, the client will
express feelings of optimism
about the present.
OBJECTIVES:
NOC: Coping
1. Reports decrease in stress.

During nursing intervention,

the student nurse will:

After nursing
intervention, the client
will be able to:

NIC: Coping Enhancement

1. Review extent of feelings
of anxiety. R: There is a
need to know the extent of
disequilibrium and need for
intervention to prevent or
resolve the crisis.
2. Discuss indication and
method of treatment. R:
Promotes active
participation of client in
therapeutic regimen.

1. Consistently
report a decrease in
stress

2. Verbalize in own
words the relevant
information about
treatment

3. Note expressions of
indecision, dependence on
others, and inability to
manage own ADL's. R: May
indicate need to lean on
others for a time.
2. Uses behaviors to reduce
stress.

4. Assess presence of
positive coping skillls/inner
strengths e.g (use of
relaxation techniques,
willingness to express
feelings, use of support
systems). R: Past coping
skills may be reused to
relieve tension and preserve
individual's sense of control.
5. Encourage patient to talk
about what is happening at
this time and what has
occurred to precipitate

3. Demonstrate at 3
least behaviors to
reduce stress
use of relaxation
techniques,
willingness to
express feelings,
use of support
systems

feelings of anxiety. R:
Provides clues to asses
patient to develop coping
and regain equilibrium.
6. Evaluate ability to
understand events and
correct misconceptions by
providing factual
information. R: Assists in
the identification and
correction of perception of
reality.
References:

Carpenito-Moyet, L. J. (2008) Handbook of Nursing Diagnosis (12th ed.). Philadelphia: Lippincott Williams & Wilkins

Doenges, M., Moorhouse, M. F. & Murr, A. (2006). Nurses pocket guide: Diagnoses, prioritized interventions and rationales. Philadelphia: F.A. Davis

Gale, S. (1994). Oncology Nursing. Texas: Skidmore-Roth Co.

Mustian, K.,Morrow, G., Carroll, J., et. al., (2007). Integrative Nonpharmacologic Behavioral Interventions for the Management of Cancer-Related
Fatigue. Oncologist 2007;12;52-67. Retrieved from http://www.TheOncologist.com/cgi/content/full/12/suppl_1/52