Cancer Nursing Care Plans

Cancer Nursing Care Plans

Cancer Nursing Care Plans

What is Cancer?

This broad general term refers to illnesses marked by uncontrolled cell proliferation. Cancer can occur in any body tissue and is not a single disease entity. Failure to regulate the growth of cells and maturation can result in the development of Cancer. The symptoms may vary based on the specific Cancer. The treatment may involve surgery, chemotherapy, and radiation therapy.

Nursing Care Plans for Cancer.

Nurses have a significant role to play in caring for cancer patients. The care plans for Cancer include assessing the patient, supporting different therapies like radiation and chemotherapy, promoting proper nutrition, managing pain, and offering emotional support.

Nursing care plans and nursing Diagnosis for Cancer

  1. Acute Pain
  2. Altered Nutrition: Less Than Body Requirements
  3. Fear/Anxiety
  4. Grieving
  5. Risk for Altered Family Process
  6. Risk for Altered Oral Mucous Membranes
  7. Risk for Altered Sexuality Patterns
  8. Risk for Constipation/Diarrhea
  9. Risk for Fluid Volume Deficit
  10. Risk for Impaired Skin Integrity
  11. Risk for Infection
  12. Situational Low Self-Esteem

1.Acute Pain

Cancer patients regularly experience acute pain because of the invasive nature of the illness. The presence of cancer cells in the body can result in pressure, inflammation, or damage to the surrounding nerves and tissues, leading to the body’s natural response of perceiving it as painful. This pain may be associated with Cancer and procedures like chemotherapy, radiation therapy, surgery, or other forms of treatment and significantly affect the overall quality of life of the patient.

Nursing Diagnosis

  • Acute Pain

Possible cause of Acute pain

  • Side effects of different cancer therapies.
  • The disease process like destruction, nerve tissue, inflammation, compression, or obstruction of nerve pathways.

The presence of the following may indicate acute pain

  • Autonomic responses and restlessness.
  • Distraction or guarding behavior.
  • Self-focusing or narrow focusing
  • Changes in muscle tone, such as facial pain mask.
  • Reports of Pain

Desired nursing care outcomes

  • The patient is expected to demonstrate the utilization of relaxation mechanisms and engage in activities that divert attention from pain as needed.
  • The patient is expected to adhere to the medication treatment regimen.
  • The patient is expected to experience reduced pain relief and control with little interference with daily activities.

Nursing Assessment and Rationale

Nursing Assessment Rationale
Using verbal or numeric rating scales, ascertain the pain history, including frequency, duration, location, and intensity. Determine the measures used for pain relief. This information is essential for establishing a baseline and evaluating the intervention’s effectiveness. Chronic pain lasting more than 6 months may impact the choice of therapy, and acute pain may recur within chronic pain requiring professional interventions. Pain is personalized and involves both emotional and physical responses.
Identify the triggers or timing of breakthrough Pain that may occur when using around-the-clock agents like IV, patch medication, or oral. The pain may be experienced towards the end of the dosing period signifying the need for a short dose interval or higher dose. Pain may occur spontaneously or be caused by known triggers requiring short half-life agents for supplemental doses or rescue.

 

Nursing Intervention and Rationale

Nursing Intervention Rationale
Understand the potential pain caused by various cancer treatments (biotherapy, radiation, surgery, chemotherapy) and provide the patient with information and the family about what to expect. Different procedures and treatments can cause discomfort like burning skin, incisional pain, headaches, and low back pain. Invasive procedures used in diagnosing and treatment of Cancer may also be related to pain
Use non-medical techniques to comfort the patient, like backrubs, repositioning, and massage, and passive activities like watching television and listening to music. The techniques help to promote relaxation and help the clients to focus their attention.
Promote stress-coping skills or complementary therapies like relaxation, aromatherapy, or guided imagery. These techniques help patients actively participate in non-pharmacological pain management and increase their sense of control. Pain can lead to muscle tension and stress which may exacerbate the pain and make it difficult to manage.
Consider using cutaneous stimulation like cold or heat and massage. It is vital to minimize muscle spasms, inflammation, and associated pain.
Recognize the possible barriers to cancer pain management arising from clients or the healthcare system. Patients may not record pain because of fear that their disease is a belief that pain is deserved, worse, or concerns about side effects from pain. The healthcare system’s problems may include inadequate reimbursement, insufficient pain assessment, patient addiction, or treatment cost.
Assess pain relief regularly and adjust medication as recommended. The objective is to control while reducing interruption in the patient’s daily activities.
Inform the patient and family about the expected therapeutic impacts of pain management and ways of managing side effects. This aids in setting realistic goals and builds confidence in the patient’s ability to handle pain.
Discuss with the patient alternative or complementary therapies like acupressure or acupuncture. The alternatives provide relief or reduction of pain without medication-associated impacts.

 

2.Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis

  • Imbalanced Nutrition: Less Than Body Requirements

Imbalanced nutrition is related to

  • Poorly controlled pain, fatigue, emotional distress
  • Hypermetabolic state related to Cancer and
  • Outcomes of radiation, chemotherapy, and surgery include nausea, gastric irritation, taste distortion, and anorexia.

Imbalanced nutrition is indicated by

  • Constipation or diarrhea, abdominal cramping
  • Inflamed buccal cavity, sore
  • Loss of appetite, Inadequate dietary intake, actual/perceived inability to consume food.
  • Reduced muscle mass/subcutaneous fat

Possible outcome

  • The patient is to participate in particular measures aimed at enhancing dietary intake/ stimulating appetite.
  • The patient is expected to demonstrate progressive weight gain/stable weight and be free of malnutrition symptoms.
  • The patient is expected to communicate an understanding of personal interference to sufficient intake.

Nursing Assessment and Rationale

Nursing Assessment Rationale
Watch daily food consumption; ensure the patient adheres to the prescribed food diary This strategy helps to identify nutritional deficiencies and strengths.
Measure weight, triceps skinfold thickness, and height daily or as instructed. Confirm the recent amount of weight lost. If the measurements are below optimum standards, the primary source storage (fat tissue) has been depleted.
Examine mucus and skin membrane for delayed wound healing, pallor, and swollen parotid glands. This assessment aid in evaluating protein and calorie malnutrition, especially when measurements of anthropometrics and weight are below average.
Gastric secretions, hematest stools. Antimetabolite therapies can prevent the regeneration of epithelial cells in GI tract. This may result in mild redness and extreme ulceration accompanied by bleeding.
Assess the laboratory research as instructed (albumin or albumin, serum transferrin, total lymphocyte count) Analyzing laboratory studies helps validate the extent of malnutrition and biochemical imbalance. This analysis impacts the choice of nutritional measures. It is important to note that anticancer treatments interfere with nutrition research. Therefore, all outcomes should be associated with the client’s medical condition.

 

Nursing Interventions and Rationale

Nursing Interventions Rationale
Encourage intake of high-calorie, adequate fluid, and nitrite-rich diet. Encourage intake of supplements and smaller or regular meals during the day. Metabolic tissue and waste removal require more fluids, and supplements can ensure sufficient proteins and calories are consumed.
Develop a conducive dining environment, and encourage sharing of meals. This makes mealtime lively and enhances intake.
Promote open communication about anorexia. Anorexia is a source of family emotional distress who may want to feed patients regularly. The family may feel frustrated and rejected when the patient refuses to eat.
Adjust nutritional intake before and after treatment. Provide liquids one hour prior to or after meals. The effectiveness of nutritional adjustment is highly personalized in relieving posttherapy nausea. The patient must conduct trials to find the best solution or combination.
Regulate environmental factors (noise, noxious or strong odors). Avoid spicy, fatty, or overly sweet foods. This may trigger vomiting or nausea responses.
Encourage the utilization of relaxation methods, guided imagery, moderate exercise, and visualization before meals. This measure helps to reduce the severity or prevent the onset of nausea, reduce anorexia, and improve the patient’s oral intake.
Take appropriate measures for patients who experience psychogenic nausea and vomiting. Antiemetic medications are usually infective in treating psychogenic nausea and vomiting before chemotherapy.
Assess the efficiency of antiemetics. Different patients’ response to medications varies. It is possible that the first-line antiemetic treatment may not be effective; hence, modification of the treatment plan or the addition of multiple drugs to the therapy is necessary.
Refer the patient to a nutritionist or dietitian. These specialists provide a dietary plan that meets the patient’s needs and minimizes the risks of micronutrient deficiencies and protein and calorie malnutrition.

 

3.Fear/Anxiety

Nursing Diagnosis

  • Anxiety
  • Fear

It might be associated to

  • Death threat
  • A crisis caused by a situation like Cancer
  • Separation from family due to hospitalization and treatments, the contagion of feeling, or interpersonal transmission.
  • Interaction pattern, role function, threat, socioeconomic status, or health change.

Fear/anxiety is Demonstrated by

  • Activation of the sympathetic nervous system and physical complaints.
  • A sensation of powerlessness, incompetence, and despair.
  • Voicing worries about changing one’s circumstances.
  • Increased anxiety, tremors, difficulty sleeping, and uneasiness.

Possible nursing care outcome

  • After nursing care, the patient will demonstrate varied desired emotions and reduced levels of apprehension.
  • The patient will appear calm and state that they can manage their anxiety.
  • The patient is expected to demonstrate proficiency in utilizing effective coping techniques and actively engage in the treatment plan.

Nursing Assessment and Rationale

Nursing Assessment Rationale
Evaluate the patient’s and family’s experience with Cancer, including what they have discussed with the doctor and how they respond. Experience evaluation helps clarify any misunderstanding and anxiety patients and families may have about the diagnosis.
Determine various stages and degrees of grief experienced by the client and their family. This information is essential in planning appropriate interventions based on the patient’s coping behavior, such as denial, withdrawal, or anger.
Document any ineffective coping technics like poor social interactions, giving up on daily activities, helplessness, or normal source of enjoyment. Recognizing personal problems is vital in supporting the client and their family to develop effective coping strategies.
Monitor self-denial and depression signs like anger, withdrawal, and improper remarks. It helps to determine the potential for suicidal ideations and examines the patient’s risk level. The cancer patient may experience physical symptoms, spiritual distress, and guilt and feel suicide is the best option.

 

Nursing Interventions and Rationale

Nursing Interventions Rationale
Develop a safe and open environment where the patient feels comfortable sharing their feelings without criticism or judgment This helps to enhance a sense of dignity and control.
Encourage the expression of the patient’s feelings and thoughts. It provides an opportunity to address misunderstandings and real fears about the diagnosis.
Maintain regular contact with the client providing support and comfort as needed. Touch and talking with the client can help minimize isolation feelings and develop trust.
Be mindful of isolation effects like sensory deprivation which can intensify feelings of anxiety, alienation, and fear. Reduce the use of masks and isolation clothing when possible. Sensory deprivation results from inadequate stimulation and may increase feelings of alienation, fear, and anxiety.
Help the patient and family identify and clarify fear and develop coping skills to deal with them. Counseling and support may be essential to aid patients in recognizing that coping and control techniques are available.
Provide precise and consistent information about prognosis and diagnosis, and do not argue about the patient’s perception of the illness. This helps minimize anxiety and allows the patient to make an appropriate decision.
Allow expression of fear, despair, and anger without confrontation. Reassure them what they feel is normal. Accepting patients’ feelings enables them to deal with the illness.
Discuss the preferred treatment, including its objectives and possible side effects. This helps to prepare the patient for treatment like chemotherapy, radiation, surgery, and organic-specific treatment.
Explain treatment procedures and provide honest answers to client questions. It helps to promote therapeutic relationships and ensure continuity of care.
Encourage interaction between patient and support system to minimize isolation. Minimizes the feelings of isolation.

 

4.Grieving

Cancer patients usually experience significant losses like independence, physical function, or their lives, resulting in strong emotional responses. Grieving is usually included as a nursing diagnosis in a Cancer care plan to help the patient process their feelings with the support of their healthcare providers.

Nursing Diagnosis

  • Grieving

Grieving may be demonstrated by

  • Changes in eating habits
  • Activity levels
  • Sleep patterns
  • Libido
  • Denial
  • Communication pattern

Desired outcomes may include

  • The patient is to express their feelings appropriately.
  • Continuing normal life activities and
  • Felling supported in the grief process.
  • Understanding the dying process.

Nursing Assessment and Rationale

Nursing Assessment Rationale
Evaluate the current stages of grief experienced by the patient and family. Clarify the process appropriately. Knowledge of the client and family’s grief stages can improve normalizing their reactions and feelings, resulting in effective coping techniques.
Review the patient’s experience, coping mechanisms, and interests to identify skills needed to help them to manage grief. Identifying the client’s strengths and resources promotes the development of personalized care plan.
Note the signs of anger, conflict, despair, hopelessness, guilt, and suicidal ideation. These are indicators of the patient’s way of coping with spiritual distress. Identifying these indicators can result in early measures and prevent psychological harm.
Determine how beliefs, death experiences, cultural expectations, and faith may influence patients’ responses to their disease and mortality. Care providers can better support patients’ needs and preferences by identifying the client’s unique spiritual and cultural background.

 

Nursing Interventions and Rationale

Nursing Interventions Rationale
Expect disbelief and shock following a cancer diagnosis or traumatic procedures, and provide the necessary support Acknowledging the client’s emotional state and providing empathetic care can enhance their coping skills and improve their psychological well-being.

 

Promote a non-judgmental environment and utilize therapeutic communication strategies to facilitate open dialogue and realistic expression of concerns and feelings. Promoting a supportive environment can enhance trust and improve communication between patients and care providers.
Encourage the client to express their thoughts and feelings, such as anger, rejection, and sadness, and reassure the patient that they are normal Recognizing and validating patients’ emotions helps them feel supported and heard, enhancing emotional expression and healing.
Observe mood swings and hostility, among other negative behavior, and encourage positive thinking to minimize further harm. Identifying and redirecting negative behavior can reduce escalation and improve the patient’s sense of control and self-esteem.
Be aware of depressive signs and ask direct questions about the client’s mental state. Earlier diagnosis and treatment of depression can enhance the quality of life and reduce the instances of suicide.
Provide regular phone or physical support to minimize isolation and arrange for a care provider or support person to provide company to the patient. Social support can enhance the patient’s emotional well-being and help them feel less lonely during challenging moments.
Provide factual information concerning disease treatment, process, and dying, besides providing emotional support and evading false hopes. Honest and emotional support can enhance trust and minimize fear and anxiety about the illness process and outcome.
Not the positive aspects of the situation, like possibilities of new therapies and emissions. Focus on positive aspects promotes hope and enhances the patient’s psychological well-being.
Refer the patient to home health agencies, visiting nursing and hospice programs as prescribed to provide additional support to the patient and family. Providing additional resources can enhance the emotional and physical well-being of the client and alleviate some burden on friends and family.

 

5.Risk for Altered Family Process

Nursing Diagnosis

  • Risk for Altered Family Process

The following are risk factors for the Altered Family Process

  • Developmental: projected loss of a family member.
  • Transitional or situational crises: Altered roles and change in economic status due to long-term disease.

Maybe Demonstrated by

  • It is not applicable. Signs and symptoms cannot be used to diagnose a potential risk. The nursing interventions for fluid volume deficit are focused on preventing the problem from occurring rather than treating it after occurring.

Possible outcome

  • The patient is expected to empower and support a sick member to handle the problem in their way.
  • The patient is expected to share their emotions freely
  • The patient is expected to actively participate in finding suitable solutions for the problem.

Nursing Assessment and Rationale

Nursing Assessment Rationale
Assess the family structure, including extended family, neighbors, and friends. It helps in identifying potential care providers and sources of patient support.
Analyze the communication patterns and interactions among family members. This helps to identify issues that may hinder the family’s ability to help the patient or cope with the diagnosis and treatment of Cancer.
Evaluate the roles and hopes of every family member and promote talking about them. Everyone in the family may have their perception of the situation, and sharing these expectations/perceptions helps enhance understanding.
Evaluate the direction of energy and problem-solving efforts. It helps to assess the best interventions that are more effective in assisting the patient and family
Note the religious and cultural beliefs of the patient and family. These beliefs significantly impact the patient and family’s reaction toward disease diagnosis and treatment.

 

Nursing Interventions and Rationale

Nursing Interventions Rationale
Listen to helpless expressions. This expression helps identify possible psychological barriers hindering the patient’s cooperation with the treatment regimen.
Interact with family in an empathetic, respectful, and warm manner. Provide the needed support, either written or verbally. It provides the family members with empathy and enhances self-esteem and competence to handle current situations.
Encourage the patient to use appropriate ways to express anger positively. When the patient is dealing with difficulties, it is normal to express anger. Appropriate expression of anger promotes progress toward grieving resolution.
Encourage the use of past coping strategies. Most patients with experience have developed effective coping strategies in dealing with the current situation.
Recognize the challenges of the situation (diagnosis, treatment, or possibility of death). Encourage the family and patient to accept the reality they are facing.
Emphasis on the effectiveness of open communication between family members. It helps enhance understanding and enables the family to communicate clearly and effectively resolve problems.
Refer the patient to family therapy, support groups, and clergy as indicated. Most patients may require additional support to resolve disorganization problems accompanying cancer diagnosis.

 

6.Risk for Altered Oral Mucous Membranes

Nursing Diagnosis

  • Risk for Impaired Oral Mucous Membrane

Risk factors for altered oral mucous membranes include

  • Malnutrition, dehydration, NPO restriction lasting for about 24 hours
  • Side effects of radiation and chemotherapy agents like antimetabolites.

Maybe Demonstrated by

  • It is not applicable. Signs and symptoms cannot be used to diagnose a potential risk. The nursing interventions for fluid volume deficit are focused on preventing the problem from occurring rather than treating it after emerging.

Possible outcome

  • The patient is expected to show skills in recovering or preserving the health of their oral mucosa
  • The client’s mucous membrane is expected to be intact with moisture and pink color without signs of ulcers or inflammation.
  • The patient is expected to communicate their understanding of the factors causing their condition.

Nursing Assessment and Rationale

Nursing Assessment Rationale
Conduct periodic evaluations of oral hygiene and dental health This is essential in identifying prophylactic treatment needs before radiation or chemotherapy and provides a basis for future comparison.
Educate patients and monitor signs of thrush (oral superinfection). Timely identification of symptoms enhances prompt treatment.
Culture-suspicious oral lesions It helps in the identification of possible organisms that causes oral infection and recommend possible drug therapy.

Nursing Interventions and Rationale

Nursing Interventions Rationale
Encourage adequate fluid intake as the patient tolerates it. Sufficient fluids help to maintain mucous membrane moisture and minimize cracking.
Discuss the impacts of alcohol intake and smoking. Alcohol consumption and smoking activities are believed to cause further irritation and dry the mucous membrane.
Suggest adjustments in dietary intake, like avoiding acidic juices, spicy or hot food, popsicles, blenderized food, and ice cream. This adjustment makes it easier for patients to soothe their mouths and swallow food.
Emphasis use of hard candy, mints, and artificial saliva as recommended. It helps provide moisture, stimulate secretions during dehydration, and lower saliva production.
Initiate and encourage oral hygiene regimen.
  • Avoid using lemon or glycerine swabs or commercial mouthwashes: rinsing the mouth prior to meals enhances the sense of taste.
  • Use waterPik cautiously or floss gently: it helps to remove particles in the mouth after the meal that can lead to bacterial growth. Note that gums may be injured by water under pressure. 
  • Use foam swabs oft or soft toothbrush: prevents trauma to fragile and delicate tissues.
  • Use mouthwash prepared from water, a dilute solution of baking soda or hydrogen peroxide, and warm saline: rinsing the mouth prior to food and during bedtime dilutes mouth acids and reduces xerostomia.
  • Ensure lips are moist with lip balm or gloss, Chapstick, and K-Y Jelly: aids in preventing tissue cracking and drying and promotes comfort.
Discuss areas of improvement and provide practical guidance on good oral care. Products with phenol or alcohol may worsen irritation and dryness of the mucous membrane.
Emphasis on evaluation of oral cavity regularly. Record changes in the integrity of mucous membrane (reddened, dry). Record mouth burning reports, ability to swallow, change in the quality of voice, sense of taste, blood-tinged emesis, and development of viscous or thick saliva. During treatment, good care is essential in managing stomatitis complications.
Refer the patient to a dentist prior to commencing neck or head radiation or chemotherapy. Prophylactic assessment and repair work prior to therapy minimizes the risk of infection.
Administer recommended medication
  • Antinausea agents: prevent nausea related to oral stimulation, primarily when provided prior to the mouth care program.
  • Opioid analgesics: it is essential for acute, moderate, or severe oral pain.
  • Antifungal mouthwash: antibacterial Biotane and nystatin are essential in preventing and treating secondary oral infection.

 

 

7.Risk for Altered Sexuality Patterns

Nursing Diagnosis

  • Ineffective Sexuality Pattern

The risk factors for ineffective sexuality patterns may include

  • Anxiety or fear
  • Lack of privacy/ SO
  • Severe fatigue
  • Illness, structure, and medical treatment
  • Skill or knowledge deficit about altered body function, alternative actions to health-related transitions.

Ineffective sexuality patterns may be Demonstrated by

  • It is not applicable. Signs and symptoms cannot be used to diagnose a potential risk. The nursing interventions for fluid volume deficit are focused on preventing the problem from occurring rather than treating it after occurring.

Possible outcome

  • The patient is expected to demonstrate an understanding of the impact of Cancer and treatment on sexuality and how to manage associated issues.
  • The patient is expected to uphold sexual activities at the possible levels.

Nursing Interventions and Rationale.

Nursing Interventions Rationale
Consider referring the client to a sex therapist for additional support as indicated. This recognizes that some patients may need specialized care in managing sexual problems associated with Cancer and treatment.
Respect the patient’s privacy while providing them with privacy when in the hospital. Knock the door before entering and wait for permission. This helps the patient understand that sexual needs do not end due to hospitalization. They also understand that it is essential to express a non-judgmental attitude toward sex.
Inform the patient of the known side effects of recommended cancer treatment on sexuality. This can help the patient and their family prepares for the changes.
Educate the patient and family about the effects of Cancer and treatment on sexuality. Provide adequate information on this problem and encourage seeking help in adaptation. This helps acknowledge the situation’s legitimacy, as sexuality plays a significant role in all aspects of life.

 

8.Risk for Constipation/Diarrhea

Nursing Diagnosis

  • Diarrhea
  • Constipation

Risk for Constipation/Diarrhea includes

  • Low-bulk diet, low fluid intake, use of narcotics or opiates, lack of exercise.
  • Carcinoma of the colon, Hormone-secreting tumor.
  • GI mucosa irritation due to radiation therapy or chemotherapy, malabsorption of fat.

Maybe Demonstrated by

  • It is not applicable. Signs and symptoms cannot be used to diagnose a potential risk. The nursing interventions for fluid volume deficit are focused on preventing the problem from occurring rather than treating it after emerging.

Possible outcomes

  • The patient is expected to uphold a typical bowel pattern and be consistent.
  • The patient is expected to demonstrate an understanding of factors and proper actions for their situations.

Nursing Assessment and Rationale

Nursing Assessment Rationale
Obtain information about the patient’s elimination habits. This information acts as the reference point for future evaluations and assessments of the effectiveness of the treatment.
Examine bowel sounds. Record bowel movements such as consistency and frequency, especially after a few days (3 to 5) of Vinca alkaloid therapy. This assessment is essential in identifying constipation or diarrhea issues, which may be early symptoms of neurotoxicity.
Track the patient’s input and output, and weight. This is essential in preventing electrolyte imbalance, weight loss, and dehydration due to constipation or diarrhea.
Monitor for impaction, especially when the patient is not experiencing a BM in the last three days or if they are experiencing abdominal cramping, headaches, or distention. Additional interventions are essential to address these issues.
Check the patient’s serum electrolytes as recommended. Electrolyte imbalances can affect the normal functioning of the GI.

Nursing Interventions and Rationale

Nursing Interventions Rationale
Provide IV fluids as prescribed IV fluids are vital in preventing hydration and diluting chemotherapy agents and minimizing the risk of side effects.
Provide prescribed anti-diarrhea medication. This is essential in controlling severe diarrhea.
Provide laxatives, enemas, and stool softeners as needed. Prophylactic utilization of these measures is essential in the prevention of complications in patients with reduced motility, with poor bowel habits before treatment, or those already receiving Vinca alkaloid,
Encourage a high intake of fluids of about 2000 ml daily, eat high-fiber food, and exercise regularly. This is essential in preventing constipation by enhancing stool consistency, stimulating peristalsis, and reducing dehydration caused by diarrhea.
Adjust the patient’s diet as needed, such as reducing high-fat foods like fried foods, butter, nuts, high-fiber content foods, and foods that cause gas or diarrhea, like chili, baked beans, and cabbage. GI stimulant significantly increases bowel frequency and worsen stool-linked issues.
If necessary, encourage eating small but regular meals low in residue, with appropriate carbohydrates and protein like eggs, cooked cereals, and bland cooked vegetables. This is believed to minimize gastric irritation and aid in resting the bowel when experiencing diarrhea by preventing the intake of high-fiber diets.

 

9.Risk for Fluid Volume Deficit

This is a condition or state where fluid output is more than fluid intake. It usually happens when electrolytes and water from ECF are lost in the same proportions. The sources of fluid loss include polyuria, increased perspiration, and gastrointestinal tract. Some fluid volume deficit risk factors include diarrhea, vomiting, sweating, reduced intake, GI suctioning, hemorrhage, and osmotic diuresis. Fluid volume deficit could be a chronic or acute condition managed in the home setting, hospital, and outpatient center.

Nursing Diagnosis

  • Risk for Fluid Volume Deficit

Risk for Fluid Volume Deficit

  • Compromised fluid intake.
  • Hypermetabolic state
  • Excessive loss via diarrhea, vomiting, wounds, or indwelling tubes.

Maybe Demonstrated by

  • It is not applicable. Signs and symptoms cannot be used to diagnose a potential risk. The nursing interventions for fluid volume deficit are focused on preventing the problem from occurring rather than treating it after occurring.

Possible outcome

  • The patient’s vital signs will remain stable, their skin will have good elasticity, their capillaries will refill regularly, their mucus membrane will be moist, and they will produce the appropriate amount of urine, all indicating adequate fluid balance.

Nursing Assessment and Rationale

Nursing Assessment Rationale
Monitor output and intake and establish particular gravity, accounting for all output sources, including diarrhea, draining wounds, and vomiting. Calculate the 24-hour balance A reduced renal output, negative fluid balance, and concentrated urine show looming dehydration and the need for increased fluid replacement.
Weigh the client as instructed This helps to measure the changes in fluid balance accurately
Observe critical signs, and assess capillary refill and peripheral pulses. Indicates sufficiency of circulating volume.
Evaluate moisture of mucous membranes and skin turgor and document reports of thirst. These indirectly indicate hydration status and degree of fluid deficit.
Monitor for symptoms of hemorrhage, such  as from puncture sites, petechiae, ecchymosis or mucous membranes. Early identification of a cancer illness enhances prompt interventions.
Check laboratory research such as complete electrolytes, serum albumin, and blood count Provides significant insight into hydration levels and corresponding deficits.

 

Nursing Interventions and Rationale

Nursing Interventions Rationale
Encourage increasing fluid intake to 300 ml daily for their needs and tolerance. This assists in maintaining recommended fluid levels and minimizes the risk of severe side effects like hemorrhagic cystitis in the clients taking cyclophosphamide.
Reduce venipunctures by combining IV begins with blood draws. Recommend replacement of central venous catheter. It helps to reduce instances of bleeding and infection related to venous puncture.
Apply pressure on puncture sites to avoid trauma. It helps to minimize possible bleeding and the formation of a hematoma.
Provide IV fluids as prescribed They are provided to dilute antineoplastic drugs and general hydration and minimize severe side effects like nephrotoxicity, nausea, and vomiting.

10.Risk for Impaired Skin Integrity

Nursing Diagnosis

  • Risk for Impaired Skin Integrity

Risk factors for impaired skin integrity may include

  • Immunologic deficit.
  • Impacts of chemotherapy and radiation.
  • Anemia, altered dietary state.

Impaired skin integrity may be Demonstrated by

  • It is not applicable. Signs and symptoms cannot be used to diagnose a potential risk. The nursing interventions for fluid volume deficit are focused on preventing the problem from occurring rather than treating it after appearing.

Possible outcome after nursing care

  • The patient is expected to participate in complication-preventive measures and promote healing.
  • The patient is expected to identify measures necessary for a particular condition.

Nursing Assessment and Rationale

Nursing Assessment Rationale
Evaluate skin regularly for the impacts of cancer therapy. Record delayed healing and breakdown. Stress on the significance of reporting open wounds to healthcare givers. It is critical to report open areas to healthcare providers. Radiotherapy may result in a tanning effect or reddening, moist or dry desquamation, hair loss, ulceration, and skin reactions such as hyperpigmentation or allergic rashes. Chemotherapy agents may cause skin reactions like alopecia and pruritus.
Evaluate the IV site, skin, and vein for edema, erythema, wet-like patches, tenderness, swelling, blisters, soreness, burning, itching, and tissue necrosis. Immediately stop antineoplastic agents and seek medical attention if vein flare, extravasation, or phlebitis are present.

 

Nursing Interventions and Rational

Nursing Interventions Rationale
Use mild soap and lukewarm water while bathing. It helps in upholding cleanliness with minimal skin irritation.
Emphasis on gentle skin patting to dry and minimize scratching or rubbing. It helps in reducing trauma and skin friction on sensitive tissue.
Reposition or turn regularly. It is essential in enhancing circulation and preventing unnecessary pressure on tissues and skin.
Evaluate skin care protocols for clients undergoing radiation therapy. Instruct the patient to avoid rubbing or using lotions, soap, ointments, creams, deodorants, or powders on the area. It helps minimize trauma in the treated areas, avoid dermal injury, and prevent interference with the radiation process.
Instruct the patient to evade heat application or wash off tattoos or marks on the skin to identify irritating areas. It helps to prevent dampness or pruritus. Sustenance care is vital until tissue and skin regenerate to a normal state.
Advise on wearing loose, soft cotton clothing, and avoid bras that create pressure. This helps protect the skin from ultraviolet rays and minimize recall reaction problems.
Use prescribed warm compresses or ice packs. The effectiveness of these measures depends on the chemotherapy agents used. Ice can prevent blood flow and localize the drug, while heat can disperse neoplastic antidote or medicine and prevent tissue damage.
Discuss the possible impacts of chemotherapy, like skin peeling, rash, and hyperpigmentation. This is critical in alleviating the patient’s concerns when experiencing these side effects.
The patient receiving methotrexate and 5-fluorouracil should avoid exposure to the sun. If sunburn is present, withhold methotrexate. Sun can worsen impacts like burn spotting with 5-FU or red “flash” area with methotrexate and worsen the medication impact
Wash with water and soap when antineoplastic agents spill on the bare skin of the caregiver or patient immediately. Dilute drugs to minimize risks like chemical burns and skin irritation.
Encourage the patient on the occurrence of alopecia; hair may regrow after chemotherapy but may grow after radiation. This guidance is vital in preparing the patient for baldness. Both men and women are sensitive to hair loss. Depending on radiation dosage, the side effects of radiation on hair follicles may be permanent.
Advise the patient to use protective or sunscreen clothing that allows air circulation. Adjust chemotherapy concentration or dosage if irritation occurs and change the IV site to stop severe reactions.
Use Lubriderm, Aquaphor, Eucerin, or Cornstarch twice daily in the area. These measures help minimize the likelihood of tissue irritation and medication spread into the tissue.

11.Risk for Infection

Nursing Diagnosis

  • Risk for Infection

Risk factors for infection include

  • Invasive procedures.
  • Malnutrition,
  • Insufficient immunosuppression secondary defenses like bone marrow suppression.

Possibly Demonstrated by

  • It is not applicable. Signs and symptoms cannot be used to diagnose a potential risk. The nursing interventions for fluid volume deficit are focused on preventing the problem from occurring rather than treating it after occurring.

Possible outcome

  • The desired outcome after nursing care is for the patient to uphold optimum body temperature and recover promptly.
  • The patient will recognize and participate in measures to prevent the likelihood of getting an infection.

Nursing Assessment and Rationale

Nursing Assessment Rationale
Monitor patients’ temperature frequently Temperature increases are due to side effects of chemotherapy, infection, or disease process. Timely identification allows for early and appropriate therapy treatment.
Assess the patient’s respiratory, genitourinary systems, and skin frequently for infection signs. Earlier infection identification and measures help stop disease progression to severe conditions or sepsis.
Track CBC with platelets, granulocyte count, and differential WBC as indicated. This helps to keep track of myelosuppression due to radiation, chemotherapy, or disease state, to prevent more complications like anemia, bleeding, or infection, and plan for medication delivery.
Collect cultures as recommended. Culture helps in establishing the causative organisms and effective therapy.

Nursing Interventions and Rationale

Nursing Interventions Rationale
Educate and encourage visitors and staff about hand hygiene. Screen and restrict visitors with infection and put the patient in reverse isolation. This helps to prevent the patient from exposure to sources of illness, such as guests or staff who could be suffering from a respiratory infection of the upper tract.
Focus on the significance of individual hygiene. Reduces possible causes of disease and subsequent excessive growth
Reposition the patient regularly and ensure linens remain dry and free of wrinkles. This helps minimize skin breakdown and reduce bacterial growth.
Encourage enough rest and exercise. Minimizing fatigue while encouraging enough movement to reduce complications like bedsores, pneumonia, and blood clots is important.
Emphasis on the significance of oral hygiene. It helps prevent stomatitis development, risk of infection, and regeneration.
Reduce or avoid invasive techniques. Follow aseptic procedures. Aseptic procedures help minimize contamination risk and reduce portals allowing infectious agent entry.
Administer prescribed antibiotics. It is used to treat identified infections or to patients with compromised immunity.

 

12.Situational Low Self-Esteem

Patients with Cancer regularly experience low situational self-esteem because of the emotional and physical changes caused by the illness and its therapies. Curative and diagnostic agents lead to vulnerability, self-distrust, and reduced self-assurance, which are intensified by various changes in their functional capability, physical appearance, and social capabilities. Such emotions can significantly impact overall health and the ability to manage the challenges of the illness, making it critical for nurses to promote and address individual self-esteem.

Nursing Diagnosis

  • Situational Low Self-Esteem

It may be associated with

  • Psychosocial refers to emotional and social impacts like fear of death, doubts about being accepted by others, a sense of powerlessness, and anxiety and fear.
  • Biophysical: this refers to negative consequences resulting from medical treatments like chemotherapy, radiotherapy, or surgery, which may cause nausea, weight loss, hair loss, vomiting, anorexia, uncontrolled pain, impotence, overwhelming fatigue, and sterility.

It may be Demonstrated by

  • Expression of modifications in person’s lifestyle; concerned about other people’s reaction or reject their change; feeling hopeless, powerless, or helpless;
  • Being preoccupied with the idea of loss or change.
  • Avoiding personal responsibilities such as self-care and reduced consistency in its implementation.
  • Changes in personal perspective or how others perceive one’s role.

The possible outcome

  • The patient is expected to express an understanding of physical changes and embrace their current state.
  • The patient is expected to develop strategies to manage difficulties effectively.
  • The patient is expected to adjust to incidents or changes by actively developing objects and engaging in work, social, and relationships.

Nursing Interventions and Rationale

Nursing Interventions Rationale
Engage the patient and family in a discussion about the impact of diagnosis and treatment on their personal life, work, and home activities. This technique aids in the identification of concerns to start the problem-solving process.
Evaluate the expected side effects of a specific treatment that may impact attractiveness, sexual activity, and desirabilities like loss and disfiguring surgery. Anticipatory guidance is essential in promoting the patient and their family’s adaptation to the changes and preparing for the impacts, like buying wigs before radiation.
Promote personal expression about any concerns regarding Cancer and its impact on their roles as parents, and homeworkers, wage earners. Addressing these concerns can significantly minimize problems interfering with treatment acceptance or exacerbating disease development.
Acknowledge the challenges experienced by the patient. Advise them on the significance of attending counseling sessions and the impact on the adaptation process. It is essential to verify the client’s feelings and allow them to take necessary interventions to cope.
Assess the available support system to the patient and their family. It helps identify the suitable system for care planning in the hospital and after discharge.
Offer emotional support to the family and patient during the diagnosis and treatment. Some patients can adjust to the impacts of cancer treatment, while some need additional support during this period.
Refer the patient for professional counseling as instructed. Counseling may be significant in regaining and upholding a favorable psychosocial structure, specifically if their support systems are deteriorating.
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