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NURSING CARE PLAN FOR KNOWN CASE OF PAPILLARY THYROID CANCER

ASSESSMENT
NURSING
SCIENTIFIC
OBJECTIVES
DIAGNOSIS
ANALYSIS
CUES (Objective):
PROBLEM: Risk for
Cancer cells can get
Within the shift,
1. Known case of
infection
into the bone marrow Client will be able
Papillary thyroid
where blood cells are to prevent risk of
CA with Spinal
ETIOLOGY:
made. The cancer
infection as
Cord Mass with
Related to
cells then compete
evidenced by
Mestastasis to
inadequate
with the normal bone remaining afebrile
bone cervical
secondary defenses
marrow cells for
(Temperature
area
(immunosuppression) space and nutrients.
ranging from
2. 13 Radiation
If too many normal
36.5C-37.5C) and
Therapy sessions
bone marrow cells
achieve timely
3. Neutropenia 0.94
are destroyed or
healing as possible.
(Normal Values:
pushed out of the
0.50-0.70)
bone marrow, the few
4. Prolonged stay in
cells that are left
the hospital (more
wont be able to
than 1 week)
make enough white
5. Bed bound since
blood cells (WBCs) to
August 20**
fight infection.
6. On antibiotic
Therapy
Neutropenia have a
higher risk of
developing serious
infections because
they do not have
enough neutrophils to
destroy organisms
that cause infection.
Radiotherapy also
destroys the cancer
cellsand mormal cells
in the treated area.
Radiation can also
affect the cells in the
bone marrow.

INTERVENTIONS
1. Promote good
handwashing
procedures by staff
and visitors. Screen
and limit visitors
who may have
infections. Place in
reverse isolation as
indicated.
2. Monitor temperature

3. Reposition
frequently; keep
linens dry and
wrinkle-free.

4. Monitor CBC with


differential WBC and
granulocyte count,
and platelets as
indicated.

RATIONALE

EVALUATION

1. Protects patient from


sources of infection,
such as visitors and
staff who may have
an upper respiratory
infection (URI).

After a series of
nursing
intervention,
Patient will be
able to prevent
risk of infection
as evidenced by
Body
temperature og
37.2C, Vital
signs within
normal limits and
no reports of
increased
weakness and
fatigue.

2. Temperature
elevation may occur
(if not masked by
corticosteroids or
anti-inflammatory
drugs) because of
various factors
(chemotherapy side
effects, disease
process, or infection).
Early identification of
infectious process
enables appropriate
therapy to be started
promptly.

3. Reduces pressure
and irritation to
tissues and may
prevent skin
breakdown (potential
site for bacterial
growth).

4. Bone marrow activity


may be inhibited by
effects of

5. Promote adequate
rest and exercise
periods.

6. Avoid or limit
invasive procedures.
Adhere to aseptic
techniques.

chemotherapy, the
disease state, or
radiation therapy.
Monitoring status of
myelosuppression is
important for
preventing further
complications
(infection, anemia, or
hemorrhage) and
scheduling drug
delivery.
5. Limits fatigue, yet
encourages sufficient
movement to prevent
stasis complications
(pneumonia,
decubitus, and
thrombus formation).
6. Reduces risk of
contamination, limits
portal of entry for
infectious agents.