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: AGE: SEX: Male DIAGNOSIS OR CLINICAL IMPRESSION: Gastric cancer T3N3M0, s/p radical near total gastrectomy, roux-en-y gastrojejunostomy; currently on 3rd cycle of chemotherapy CUES Subjective: Does not currently wear protective mask when there are other people in the room Demonstrated improper handwashing technique Reduced dietary intake from 4 cups of rice per meal to 1 cup of rice due to altered taste upon initiation of chemotherapy Objective: BMI: 17.64 kg/m2 (underweight) Cachexic Dry, rough skin Pale gums and oral mucosa Pale nail beds 2/15/11 CBC results: WBC and differential count normal except NURSING DIAGNOSIS AND BACKGROUND KNOWLEDGE Ineffective protection r/t compromised immune response and clotting mechanisms secondary to myelosuppresion Ineffective protection is the state in which an individual experiences a decrease in the ability to guard against internal or external threats, such as illness of injury. It represents a broad diagnostic category under which Impaired Tissue/Skin Integrity, Impaired Oral Mucous Membrane, and Risk for Bleeding, and Risk for Infection (Carpenito-Moyet, L. Handbook of Nursing Diagnosis, 12th ed. (2008). Lippincott Williams and Wilkins) Please refer to the last page for the pathophysiologic diagram of the patient’s condition. GOALS AND OBJECTIVES Goal: The patient will have effective protection. Objectives: After the nursing intervention, the client will be able to: NOC: Immune status, Blood coagulation, Risk control Manifest no signs of infection and bleeding NURSING INTERVENTIONS AND RATIONALE The student nurse will: EVALUATION After the nursing intervention, the client will:
NIC: Bleeding precautions Infection Protection Risk identification Monitor for signs of infection and bleeding and worsening anemia: a. Vital Signs Fever/tachycardia may suggest developing infection. Tachycardia and tachypnea may also be indicative of compensation for the anemia. b. Signs of infection at insertion site of IV line (warmth, redness, swelling, discharge, odor, pain or tenderness) The IV line is a possible site of entry of opportunistic pathogens. c. Breath sounds and sputum production Presence of adventitious breath sounds such as rales and sputum production suggest the presence of respiratory infection. d. White coating in tongue Fungal infections can occur. e. CBC results These laboratory tests help detect abnormalities that place the patient at risk
( ) Manifested normal vital signs ( )Manifested no signs of infection in IV insertion site ( ) Manifested clear breath sounds and absence of sputum production ( ) Manifested no white coating in the tongue ( ) CBC results
for elevated monocyte count Low Hgb, Hct, MCH, MCHC (anemia) On 3rd cycle of chemotherapy (epirubicin-cisplatinfluorouracil regimen)Day 2 as of 2/16/11 With ongoing 1 L PNSS + 750 mg 5 Fluorouracil received at ~350 cc level running at 11 gtts/min inserted on the dorsum of left hand; intact dressing; (-) inflammation; (-) tenderness
Most chemotherapeutic drugs cause bone marrow suppression which results to leucopenia, thrombocytopenia, and anemia. This therefore increases the risk of infection and bleeding tendencies. Moreover, the nutrional status of the patient has an effect on the resistance of the patient to fight off infections. Nutrition is also a key factor in the oxygen-carrying capacity of the blood in the patient. (Smeltzer, S. et. al. Textbook of Medical-Surgical Nursing. 11th ed. (2008). Lippincott Williams and Wilkins). Nutrition also has an impact on the patient’s immune function and outcome of cancer treatments (Tian, et.al. The Effects of Nutrition Status of Patients with Digestive System Cancers on Prognosis of the Disease. Cancer of Nursing. 2008) This is the priority problem because infections in the patient undergoing chemotherapy are
Perform the necessary precautions needed to prevent infection.
for bleeding and infection. Due to myelosuppression caused by the chemotherapy, the number and type of WBCs required to fight infection is decreased. Anemia is also common. Platelets are usually decreased, thus placing the patient at high risk for bleeding. f. Fatigue, weakness, shortness of breath, alteration in mental status These symptoms occur due to the body’s altered tissue perfusion caused by anemia. g. Indicators of bleeding abnormalities (bruising, easy bleeding, petechiae, bleeding gums, and nosebleed, occult bleeding) These can be caused by low platelet count as the bone marrow is further suppressed. Perform aseptic technique in all procedures. This reduces the possibility of introduction of pathogens to the patient. Proper hand hygiene is one of the best ways to stop transmission of infection. Perform IV site care. This is done prevent accumulation of bacteria and thus prevent infection. Facilitate wearing surgical mask of patient when he is not alone in his room. This protects the patient from sources of infection. Advise patient to avoid fresh, unpeeled fruits and vegetables; uncooked meat; unprocessed/uncooked animal products; and yogurt and other fluid with lactobacilli such as Yakult. (Neutropenic diet). Eating a neutropenic diet is recommended in order to limit exposure to pathogens in fresh fruits and vegetables and uncooked meat.
manifested: __No signs of infection __ No worsening of the indicators of anemia __ Platelets within acceptable limits ( ) Manifested absence of symptoms of anemia ( ) Manifested no signs of bleeding
( ) Dry, intact dressing of IV site, (-) inflammation/pain/te nderss ( ) Wore mask when he is not alone in the room ( ) Verbalized that she will consume a neutropenic diet
harder to evaluate because the body cannot mount adequate immune response to the infection. Thus, the infections usually worsen and become fatal to the immunocompromised patient.
proper hand washing technique Perform ways to enhance resistance to infection Perform the necessary precautions needed to prevent and monitor for bleeding
Discuss and demonstrate proper hand washing technique to the patient and watcher. This is done to reduce the entry of organisms into the patient. Facilitate adequate rest and hydration (daily fluid intake of at least 1 1/2 L). These are important in infection prevention and control. Assist in meticulous oral care. Gums and oral mucosa may bleed easily because of altered clotting. Moreover, chemotherapeutic drugs can cause dryness of the oral mucosa, thus making it more prone to injury. Encourage soft diet and advise him to avoid hot foods/liquids. This will help prevent trauma to oral cavity. Hot foods cause vasodilation, thereby increasing bleeding tendencies. Moreover, the patient has missing teeth and ill fitting dentures which makes it harder to chew Advise client to refrain from eating dark food such as chocolates. This is to facilitate monitoring of occult bleeding. Report the following to the nurse/doctor. -Cough/colds -Pus in urine - Development of white coating in the oral cavity especially the tongue -Pain/tenderness in IV site - Bruising, easy bleeding, petechiae, bleeding gums, and nosebleed, occult bleeding - Weakness - Shortness of breath, alteration in mental
( ) Return demonstrated proper handwashing technique ( ) Achieved adequate rest ( ) Able to drink at least 1 ½ L of water per day ( )Demonstrated proper meticulous oral care
( ) Adhered to avoiding hot foods and eating soft diet
Identify early signs of developing infection, worsening anemia, and presence of clotting abnormalities he has to report to the nurse or physician
( ) Refrained from eating dark foods ( )Stated all early signs of developing infection, worsening anemia, and presence of clotting abnormalities he has to report to the nurse or physician
status Early detection of these signs and symptoms are needed in order to immediately address the problem. Subjective: Unintended weight loss of 70 kg to 51.5 kg in a span of 13 months Reported decrease in food intake during the first 2 cycles of chemotherapy because of decreased appetite secondary to altered taste Difficulty chewing because of missing teeth and ill-fitting dentures Eats with small feedings 3x a day. ‘.” Does not usually like the food served as ration so watcher buys food in Bayanihan for him Because of altered taste and impaired chewing, he just adds water to his rice and eats it, sometimes even without viand Usual dietary intake before gastrectomy: 4 cups of rice and 1 Imbalanced nutrition: less than body requirements related to decreased intake secondary to altered taste Imbalanced Nutrition: Less than Body Requirements is the state in which an individual, who is not NPO, experiences or is at risk for inadequate intake or metabolism of nutrients for metabolic needs with or without weight loss. (Carpenito-Moyet, L. Handbook of Nursing Diagnosis, 12th ed. (2008). Lippincott Williams and Wilkins) Nutrition has an impact on the patient’s immune function and outcome of cancer treatments. Adequate nutrition can minimize the adverse effects of treatments, decrease treatmentrelated symptoms, and improve quality of life. Chemotherapy-induced toxicity may also have more severe effects on patients with preexisting malnutrition. Goal: The patient will take in nutritional requirements in accordance with his activity level and metabolic needs. Objectives: At the end of the nursing interventions, the client will be able to: NOC: Nutritional status: food and fluid intake State the need for proper nutrition in his condition. Pinpoint the deficiencies in his daily intake. The student nurse will: After the nursing intervention, the client will:
NIC: Nutritional monitoring Nutritional management Provide health teaching about proper nutrition and its importance in client’s recuperation. Adequate nutrition can minimize the adverse effects of treatment and decrease treatment-related symptoms Assist patient in determining the quantity and quality of foods that he is not eating that he should be taking in. This will make client aware of the foods he should be taking in. The amount is important because the goal for the patient is weight gain. The quality is also important because nutrients are needed in order to enhance resistance to infection. Diet modifications to reduce risk of recurrence of neoplastic growth and to improve nutrition during chemotherapy -Increase intake of cooked vegetables and peeled/canned fruits. This is done to reduce ( ) Stated that proper nutrition is needed to enhance resistance to infection and enhance treatment results ( ) Stated the diet modifications correctly
State the diet modifications he has to make to achieve
( ) Selected quantity and quality of foods that he would eat from the food choices in the neutropenic diet
serving of viand for each of the 3 meals Usual dietary intake at home after the gastrectomy: Breakfast: 1 cup rice, 1 serving viand Lunch: 1 cup rice, 1 serving viand Dinner: ½ cup rice, ½ serving viand Usual dietary intake upon initiation of chemotherapy: Breakfast: ½ serving of pansit or ½ cup rice with ½ serving of viand Lunch: ½ cup rice with ½ serving of viand Dinner: ½ cup rice with ½ serving of viand Objective: Height: 171 cm Weight: 51.5 kg BMI: 17.64 kg/m2 (underweight) DBW: 54 kgs Ectomorph, cachexic Sunken periorbital region (+) Dental caries, (+) missing teeth (+) ill-fitting dentures (+) muscle wasting in
(Tian, et.al. The Effects of Nutrition Status of Patients with Digestive System Cancers on Prognosis of the Disease. Cancer of Nursing. 2008)
risk of exposure to pathogens. - Reduce intake of fatty foods and smoked foods. This is done in order to reduce carcinogenic substance -Small frequent feedings of neutropenic diet (every 2 hours) to facilitate absorption. The patient should increase the frequency of meal intake in order to balance it with the amount of food eaten. - Limit spicy, fatty and excessively salty or sweet foods, foods with strong odours and foods not well tolerated. These are usually unpleasant to the patient’s taste. Weigh patient daily with same set of clothes at the same time of the day. This is done to assess improvements in weight. Assist patient to a sitting position before eating or feeding. This will keep the patient’s appetite while anticipating for food. Provide oral care before eating. This can minimize the altered taste and enhance appetite. Advise the patient to add spices in his food in order to mask the altered taste (e.g. add calamansi when eating pansit or add the sauce of preferred viand). This is done to mask the altered taste.
( ) Manifested weight increase of at least 1 pound
Perform ways to enhance appetite
( ) Verbalized improvement of appetite
lower extremities, midthigh circumference 15 inches Pale nail beds, gums, and oral mucosa 2/5/11 CBC results: Low Hgb, Hct, MCH, MCHC (anemia) Subjective: Adheres with chemotherapy; currently on 3rd cycle of chemotherapy Follows medical advice Exercises when at home Walks around the room when in the hospital Has adequate diversional activities (reading newspaper, talking to brother) He said, “Wala naman akong problema sa pagpapaospital. Kaya nga ako nagpapaospital para magamot.” Does not have fear/anxiety towards the treatment and his condition
Readiness for Effective Therapeutic Regimen Management Readiness for Effective Therapeutic Regimen Management is a pattern in which the individual integrates into daily living a program for treatment of illness and its sequelae that is satisfactory for meeting health goals. CarpenitoMoyet, L. Handbook of Nursing Diagnosis, 12th ed. (2008). Lippincott Williams and Wilkins The patient has verbalized intent to improve on his therapeutic regimen management.
At the end of the nursing interventions, the patient will be able to maintain an effective therapeutic regimen for the management of cancer. At the end of the nursing interventions, the client will be able to: NOC: Compliance behavior, Knowledge: Disease Process and Management State perceived benefits and barriers to performing therapeutic regimen
The student nurse will:
After the nursing intervention, the client will:
NIC: Teaching (Disease process and management) Decision making suppor
Explore with the patient and the caregiver the benefits and barriers in performing therapeutic regimen management for cancer. The health belief model states that one’s perception of barriers and benefits of disease affect health seeking behaviors. Describe the nature (risk factors and manifestations) of cancer. This would be a brief review so that the patient fully understands his disease condition. This enhances adherence to regimen.
( ) Stated perceived benefits and barriers to performing therapeutic regimen ( ) Identified his risk factors and manifestations of cancer ( ) Stated the name
Stated that his family is very supportive in his treatment Verbalized that he wants to improve on his treatment regimen so that the tumor growth will not recur
Identifiy the risk factors and manifestations of cancer State the name use of his drugs
Discuss the name and general use of his drugs. This is done in order to increase her level of compliance with his chemotherapy drugs as well as pre-chemo drugs (metoclopramide and diphenhyrdramine). Discuss the importance of ambulation and range of motion exercise (with demonstration) Discuss and demonstrate stress and pain management strategies. Deep breathing exercise Self-Hypnosis Imagery Discuss the strategies that help tom enhance sleep. Rest and sleep are important in increasing resistance to infections during chemotherapy. It also reduces stress.
and use of each drugs
Demonstrate proper exercise Demonstrate stress and pain management
( ) Performed ambulation and range of motion exercises ( ) Demonstrated stress and pain management strategies
( ) Stated strategies to enhance sleep ( )Verbalized enhanced sleep and rest ( ) Verbalized commitment to adhere to prescribed therapeutic regimen for cancer
State ways to enhance sleep and rest
Verbalize commitment to adhere to prescribed therapeutic regimen for cancer
Explore feelings about current therapeutic regimen management.
Other identified nursing problems: Ineffective peripheral tissue perfusion related to impaired oxygen carrying capacity secondary to anemia PC: Antineoplastic drug reactions References: Carpenito-Moyet, L. Handbook of Nursing Diagnosis, 12th ed. (2008). Lippincott Williams and Wilkins Ridgers, S. Medical-Surgical Nursing Care Plans. (2007). Thomson Learning Asia Smeltzer, S. et. al. Textbook of Medical-Surgical Nursing. 11th ed. (2008). Lippincott Williams and Wilkins Tian, et.al. The Effects of Nutrition Status of Patients with Digestive System Cancers on Prognosis of the Disease. Cancer of Nursing. 2008