Nursing Diagnosis

NURSING DIAGNOSIS: RISK FOR INJURY RELATED TO SIDE EFFECTS SECONDARY TO CHEMOTHERAPY
CUES/EVIDENCES SUBJECTIVE: y Was not able to gather data. Patient and significant others were sleeping. OBJECTIVE: y Undergone chemotherapy: March 20, 2011 y History: Breast CA 2004 Colon CA 2010 y Poor appetite y (+) HPN x 10 years y DM x 5 years on short acting Insulin y Gen. survey: Physical Assessment by ER nurse Skin: Generalized jaundice HEENT: Icteric sclerae, pale palpebral conjunctiva, dry lips y CBC (March 22, 14:30) CBC: Normal Hgb: 10.2g/dL13-16 g/dL Hct: 30.2 % 42-50 % WBC: 2,940/cumm510 T/cumm Differential Count: Neutrophil: 78% 55-60% Lymphocytes: 18% 20-35% Monocyte: 1% 1-6% OBJECTIVES Within our 2-day care, the client will understand treatment plan, identify emergent problems and be able to tolerate expected effects of treatment as evidenced by: 1. Client will be able to tolerate expected side effects of treatment and understand their presence. 2. Side effects will be treated as indicated and potential serious effects will be identified early, with immediate treatment initiated. 3. Will rebound quickly from side effects of chemotherapy and resume prechemo activities. 4. Modify environment as indicated to enhance safety. INTERVENTIONS INDEPENDENT: y Monitor client for side effects of chemotherapy and reinforce client s education y Monitor client for side effects of chemotherapy after administration, such as diarrhea, constipation, hair loss, nausea and vomiting y Provide individualized education related to chemotherapy regimen, expected side effects, knowledge of each drug used and possible treatments to minimize side effects y Evaluate individual s emotional and behavioral response to environmental surroundings and condition. EVALUATION At the end of our 2-day care, the client and significant others discussed treatment plan, identify emergent problems, but unable to tolerate expected effects of treatment as evidenced by: 1. Client able to identify expected side effects but unable to tolerate such as poor appetite. She had a little amount of food per meal. Breakfast: banana & bread Lunch: 4 tbslugaw, half fish, 1 pc fruit 2. Patient s condition was already appraised to her family. Family prompted not to buy the medicine (Neocytes) for it is expensive and AP advised them that liver has already metastasized. 3. Condition of patient becomes severe. 4. Significant others knew when and how to use the side rails. Observed to lift the side rails when patient and SO are sleeping; turned off
y Discuss importance of self-monitoring of conditions/emotions. COLLABORATIVE y Administer medications as ordered: Ranitidine 50mg q 8hrs slow IV push
Eosinophil: 3% 1-4% Basophil: 0% 0-0.5% Platelet: 116 T/cumm150-400 T/cumm RBC: 3.4M/cumm4.66.2M/cumm Mean Corpuscles Vol: 89.6 80 96 Mean Corpuscles Hgb 30.3 27-31 Mean Corpuscles Hgb Conc. 33.8 33-36 y Chemistry (March 28, 2011) Urea Nitrogen 80 mg/dl (8-23) ALT (SGPT) 59.9 (9-52) U/L AST (SGOT) 159 U/L (5-34) Alk. Phosphate 540 U/L (38-126) K+ 4.75 mEq/L (3.6-5.0) Na+ 116 mEq/L (135-145) y Activated PTT 57.5 secs (25 -45) y PT 18.9 secs(10 13) y Ultrasound (Abdomen) March 28,2011 Echogenic liver w/ echogenic masses of variable sizes The spleen is normal Pancreas cannot properly outlined The gallbladder is normal in size, thickess and echofree. No biliary duct dilatation Impressions: Liver
y Refer for laboratory exams as ordered: CBC, Pro time, BUN, K+
the lights when the patient was sleeping and turning it on when needed. 5. Place pillows to her sides for her comfort. 6. Complained when the water for bedbath was cold or hot, ensuring her comfort. 7. Assisted when patient went to comfort room.
8. Lab result not in normal range: CBC: Normal Hgb: 8.8 g/dL13-16 g/dL Hct: 24.9 % 42-50 % WBC: 780 /cumm510 T/cumm Differential Count: Neutrophil: 45% 5560% Lymphocytes: 49% 2035% Monocyte: 3% 1-6% Eosinophil: 3% 1-4% Basophil: 0% 0-0.5% Platelet: 69 T/cumm150-400 T/cumm RBC: 2.8M/cumm4.66.2M/cumm Mean Corpuscles
metastasis
Vol: 89.2 80 96 Mean Corpuscles Hgb31.5 27-31 Mean Corpuscles Hgb Conc. 35.3 33-36

Nursing Diagnosis

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NURSING DIAGNOSIS: RISK FOR INJURY RELATED TO SIDE EFFECTS SECONDARY TO CHEMOTHERAPY

y Refer for laboratory exams as ordered: CBC, Pro time, BUN, K+

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