Republic of the Philippines

Mindanao State University

College of Health Sciences
Marawi City

NSG 124.6 RLE

Oncology Duty

Day 3 Activity: Nursing Care Plan

Sittie Jaleah C. Unda

Section C

Prof. Ulysses T. Abellana, MAN, RN

Instructor

February 2021
 NURSING CARE PLAN

NURSING
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

1. Monitor the client’s vital signs. 1. Monitor any change in patient’s vital
Chart Dx: 2. Explain the rationale for bed signs.
Ewing Sarcoma exercise & early ambulation. 2. Aggressive pursuit of ROM exercises
& early ambulation can decrease deep
vein thrombosis & muscle wasting &
Subjective: increase in strength.
“I always needed 3. To encourage movement in order to At the end of the intervention,
assistance upon After 8 hours of 3. Perform exercises that is
nursing interventions, appropriate for the patient. maintain muscle flexibility. the
moving.” as Impaired physical
the patient will objective was met as evidenced
verbalized by the mobility related to
patient. maintain position of by;
decreased muscle function & skin 4. Encourage use of trapeze 4. Shoulder and arm muscles need • Patient response to
strength secondary to the integrity as evidence assistive device. strengthening to use assistive device.
interventions as evidenced
Objective: pathological disease. by absence by using safety measures
contractures foot 5. Demonstrate the use of trapeze, 5. For the patient to know the proper use
and roller pads. of assistive device. such as (side rails, overhead
• Weak in drop, and so forth.
rails, overhead trapeze)
appearance
• Seen patient participating in
6. Plan diversional activities for 6. Diversional activity can help client to self-care routine
• With limited stress management. refocus on matters other than his
range of motion associated fears.
• Irritable at times 7. Observe client movement when 7. To rate any in congruencies with
client is un aware of observation. reports of abilities.
• With pain scale
of 7/10 8. Support affected body parts 8. To maintain position of function &
using pillows reduce risk of pressure ulcers.
• Difficulty in
turning 9. Encourage participation in self- 9. Enhances self-concept & sense of
care independence

10. Instruct the use of side rails 10. To reduce the risk of incidental injury
overhead.
11. Administer medication as 11. To alleviate patient’s illness with
prescribed by the physician or pharmacological method.
doctor.
 NURSING
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

• Monitor daily food • Identifies nutritional strengths

Chart Dx: intake; have patient keep and deficiencies.
Lung Cancer food diary as indicated.
• To have baseline data. If these
Subjective: Imbalanced Nutrition: After 8 hours of • Measure height, weight measurements fall below After 8 hours of nursing
Less than Body nursing interventions, or other anthropometric standards, patient’s chief source interventions, the patient was
“Occurrence of Requirements related to the patient will measurements as of stored energy is depleted. able participate in specific
vomiting sessions.” consequences of participate in specific appropriate. interventions to stimulate
As verbalized by the chemotherapy as interventions to • Metabolic tissue needs are appetite/increase dietary intake
significant others of increased as well as fluids to
evidence by reported stimulate
the patient. eliminate waste products.
inadequate food intake appetite/increase • Encourage patient to eat
Objective: and altered taste dietary intake high-calorie, nutrient-rich
sensation. diet, with adequate fluid
• Received pt. intake. Encourage use of
lying in bed, supplements and frequent • Makes mealtime more
conscious or smaller meals spaced enjoyable which may enhance
and awake. throughout the day. intake.
• Hyperactive
bowel • Create pleasant dining
sounds atmosphere; encourage • To relieve posttherapy nausea.
noted patient to share meals Patient must experiment to find
• Pale with family and friends. best solution or combination.
conjuncitva
and mucus • Control environmental • Nausea and vomiting are
membrabe factors such as strong or frequently the most disabling
noted noxious odors or noise. side effects of chemotherapy
• Weakness Avoid overly sweet,
and fatigue fatty, or spicy foods.
• Vital Signs
Temp: 36.5 • Administer antiemetic as
C prescribed by the
RR: 20 cpm physician.
PR: 87 bpm
O2Sat: 98%
BP: 140/90
mmHg
 CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

1. Assess patient for evidence of 1. Signs and symptoms of infection may be

Chart Dx: infection: diminished in the immunocompromised
Breast Cancer a. Check vital signs every 4 hours. host. Prompt recognition of infection
b. Monitor WBC count and and subsequent initiation of therapy will
differential each day. reduce morbidity and mortality associated
Risk for infection, related c. Inspect all sites that may serve as with infection. After 8 hours of nursing
After 8 hours of nursing entry ports for pathogens interventions, patient demonstrates
Present of surgical to altered immunologic interventions, the intravenous sites, wounds, skin normal temperature and
incision site from response and related to patient will be able to
recent modified surgical incision as folds, bony prominences, Wound infection is accompanied by signs vital signs. Patient are able
identify and
radical mastectomy on modified radical demonstrate perineum, and oral cavity). of inflammation and a delay in healing. demonstrate intervention to prevent
the right breast of the mastectomy is performed. interventions to prevent d. Inspect the wound for swelling, and reduce risk of infection.
patient. or reduce risk of unusual drainage, odor redness, or Surgical incision site exhibits
infection. The patient separation of the suture lines absence of signs of inflammation:
will achieve timely local edema, erythema, pain, and
Physical assessment
wound healing and be
findings include: 2. Report fever ≥38.3°C (101°F), 2. Early detection of infection facilitates warmth.
free from signs and
T: 37.8°C chills, diaphoresis, swelling, heat, early intervention.
symptoms of infection.
BP: 120/80 pain, erythema, exudate on anybody
P: 92 surfaces. Also report change in
R:19
respiratory or mental status, urinary
O2: 94%
frequency or burning, malaise,
myalgias, arthralgias, rash, or
diarrhea.
3. Obtain cultures and sensitivities as 3. These tests identify the organism and
indicated before initiation of indicate the most appropriate
antimicrobial treatment (wound antimicrobial
exudate, sputum, therapy. Use of inappropriate antibiotics
urine, stool, blood). enhances proliferation of additional flora
and encourages growth of antibiotic
resistant organisms.

4. Initiate measures to minimize 4. Exposure to infection is reduced.

infection.
a. Discuss with patient and family
• Placing patient in private room a. Preventing contact with pathogens
if absolute WBC count helps prevent infection.
<1,000/mm3
• Importance of patient avoiding
contact with people who have
 known or recent infection or
recent vaccination
b. Instruct all personnel in careful b. Hands are significant source of
hand hygiene before and after contamination.
entering room.
c. Avoid rectal or vaginal c. Incidence of rectal and perianal
procedures (rectal temperatures, abscesses and subsequent systemic
examinations, suppositories; infection is high. Manipulation may
vaginal tampons). cause disruption of membrane integrity
and enhance progression of infection.
d. Use stool softeners to prevent d. This minimizes trauma to tissues.
constipation and straining.
e. Assist patient in practice of e. This prevents skin irritation.
meticulous personal hygiene.
f. Instruct patient to use electric f. Minimizes skin trauma.
razor.
g. Encourage patient to ambulate in g. Minimizes chance of skin breakdown
room unless contraindicated. and stasis of pulmonary secretions.
h. Avoid fresh fruits, raw meat, fish, h. Fresh fruits and vegetables harbor
and vegetables if absolute WBC bacteria not removed by ordinary
count <1,000/mm3; also remove washing. Flowers and potted plants are
fresh flowers and potted plants. also sources of organisms.
equipment containing water.
i. Each day: change drinking water, i. Stagnant water is a source of infection.
denture cleaning fluids, and
respiratory equipment containing
water.

5. Assess intravenous sites every day 5. Nosocomial staphylococcal septicemia is

for evidence of infection: closely associated with intravenous
a. Change intravenous sites every catheters.
other day. a. Incidence of infection is increased
b. Cleanse skin with povidone- when catheter is in place >72 hr.
iodine before arterial puncture or b. Povidone-iodine is effective against
venipuncture. many gram-positive and gram-
negative pathogens.
c. Change central venous catheter c. Allows observation of site and
dressings every 48 hours. removes source of contamination.
 d. Change all solutions and infusion d. Once introduced into the system,
sets every 48 hours. microorganisms are capable of
growing in infusion sets despite
replacement of container and high
flow rates.

6. Avoid intramuscular injections. 6. Reduces risk for skin abscesses.

7. Avoid insertion of urinary catheters; if 7. Rates of infection increase after urinary

catheters are necessary, use strict aseptic catheterization.
technique.

8. Teach patient or family member to 8. Granulocyte colony-stimulating factor

administer granulocyte (or granulocyte decreases the duration of neutropenia and
macrophage) colony-stimulating factor the potential for infection.
when prescribed.