Case study

ON
Hodgkin lymphoma

SUBMITTED TO: - SUBMITTED BY:-Ms Anjali

Kaushik HARSHITA
(tutor) M.sc (nursing) 2nd year

RUFAIDA COLLEGE OF NURSING

JAMIA HAMDARD, NEW DELHI-62

BIBLIOGRAPHY
 1. https://www.nhs.uk/conditions/hodgkin-lymphoma/treatment/
2. Indian Academy of Pediatric Sixth Edition Published by Jaypee Brothers Medical Publishers (P) LTD
3. OP Ghai, Vinod K Paul, Arvind Bagga, CBS Publishers, Seventh Edition ,Ghai essential of Pediatric Nursing
4. Betz, Sowden , Mosby Pediatric Nursing Reference . Mosby Elsevier , 6th Edition

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTIONS
Incision was Impaired tissue integrity To monitor site of Monitor site of impaired Systematic inspection can Integrity of the skin
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS
made for the related to the surgical impaired tissue tissue integrity at least once identify impending problems was maintained
biopsy. incisionas evidenced by integrity. daily for colour changes, early.
incision done for biopsy. redness, swelling, warmth,
pain, or other signs of Skin wounds may be covered
To provide tissue care infection. with wet or dry dressings,
as needed. Tissue care provided as topical creams or lubricants,
needed. hydrocolloid dressings (e.g.,
DuoDerm) or vapor-
permeable membrane
dressings such as Tegaderm.
To maintain sterility The dressing replaces the
during the wound Keep sterile dressing protective function of the
care. technique during the wound injured tissue during the
To administer care. healing process.
antibiotics as ordered. Antibiotics administered as Sterility will decrease the
ordered. risk of infection.
Do not position Wound infections may be
patient on site of Patient of the patient was managed well and more
impaired tissue kept properly. efficiently with topical
integrity. agents, although intravenous
antibiotics may be indicated.
This is to avoid adverse
effects of external
mechanical forces (pressure,
friction, and shear).
Risk of infection related to To promote hand Promote good hand Protect patient from source Risk of infection
biopsy as evidenced by hygiene movements. washing procedure by staff of infection. decreased by
increased WBC level. and family member. Limit potential sources of promoting hygiene
To promote personal Emphasize personal infection.
hygiene of the patient. hygiene.
It is used to treat infection or
To administer Administer antibiotic as given prophylactically.
antibiotics. prescribed. Temperature elevation may
To monitor Vitals. Monitor temperature. occur.
Mother Imbalanced nutrition less To maintain body Ascertain healthy body Experts like a dietician can Body weight will be
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS
verbalized that than body requirement weight. weight for age and height. determine nitrogen balance maintained.
patient is losing related to the disease Refer to a dietitian for as a measure of the
weight. condition as evidenced by complete nutrition nutritional status of the
Objective data poor weight gain. assessment and methods for patient. A negative nitrogen
Weight 15 kg nutritional support. balance may mean protein
malnutrition. The dietician
can also determine the
To provide a pleasant patient’s daily requirements
environment. of specific nutrients to
Provide a pleasant promote sufficient nutritional
To provide small environment. intake.
meals A pleasing atmosphere helps
Consider six small nutrient- in decreasing stress and is
dense meals instead of three more favourable to eating.
larger meals daily to lessen Eating small, frequent meals
the feeling of fullness. lessens the feeling of fullness
and decreases the stimulus to
vomit.
Subjective data Hyperthermia related to To check the Assessed the general Cooling too quickly may Body temperature is
Mother infection as evidence by temperature of the condition of patient. cause shivering, which 1020 F. Respiration
verbalized patient temperature 102° Forally, patient. Monitor the vital signs of increases the use of energy 20 breath/min.
is suffering from loss of appetite, weakness, the patient. calories and increases the Pulse 100 beats/
fever. and dehydration. metabolic rate to produce min.
To give tepid Provide tepid sponging by heat. Tepid sponge bath
Objective data sponging. using tap water with cotton is given to patient.
Vitals monitored cloths to baby for 15 Antipyretic medications Patient will
Temp 102oF minutes at least. lower body temperature by maintain normal
Administration blocking the synthesis of body temperature as
antipyretic Give Injection PCM (65 prostaglandins that act in the evidenced by vital
medication. mg) as prescribed by the hypothalamus. signs within normal
physician. limits.
Body temperature is
99oF.
Subjective data Sleep pattern disturbance. Discourage long Diversional therapies given Sleeping during odd hours Patient sleep pattern
Mother related to decreased physical periods of sleep to avoid sleeping during can lead to lack of sleep at will be maintained
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS
verbalized there activity, fear, anxiety, during the day day time. night time.
is decrease in inability to assume
sleep timing usual sleep position, frequent Discourage intake of Educated mother regarding
assessments or treatments, foods and fluids high the dietary habits which
Objective data unfamiliar environment, and in caffeine (e.g. should be improved. L-tryptophan is a component
Patient appeared discomfort resulting from Chocolate, coffee, tea, of milk which promotes
dull. current illness/injury. colas) in the evening. Encourage patient to take sleep
milk
Allow client to
continue usual sleep A proper routine can lead to
practices (e.g. proper sleep pateern
Position; time; Advised mother to follow
presleep routines such daily routine.
as reading, watching
television, listening to
music, and
meditating) whenever
possible

Satisfy basic needs

such as comfort and
warmth before sleep.
Reduce A warm; pleasant; well
environmental ventilated environment
distractions. Ensure given to the patient while
good room ventilation sleeping.
Level of Knowledge deficit related to To educate parents or Assess the level of Facilitates planning of Parents or caregiver
understanding. the disease condition as caregiver related to understanding of the preoperative teaching knowledge will
evidenced by frequent the disease condition patient’s parents or program, identifies content increase
questioning caregivers. needs.
Review specific pathology Provides knowledge base
and anticipated surgical from which patient can make
procedure. Verify that informed therapy choices and
appropriate consent has consent for procedure, and
been signed. presents opportunity to
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS
clarify misconceptions.
Use resources teaching Specifically, designed
materials as available. materials can facilitate the
patients learning.
Discuss individual
postoperative pain Increases likelihood of
management plan. Identify successful pain management.
misconceptions patient Some patients may expect to
parents or care givers may be pain-free
have and provide or fear becoming addicted to
appropriate information. narcotic agents.
Mother asking Anxiety related to surgical To decrease the Provide preoperative Can provide reassurance and Anxiety level of
frequent question. procedure and future anxiety of the education including visit alleviate patient’s care giver parents will
wellbeing of the patient caregivers by with or personnel before anxiety, as well as provide decrease.
resolving their doubts surgery when possible. information for formulating
Discuss anticipated things intraoperative care.
that may concern patient Acknowledges that foreign
mask, lights, BP cuff, environment may be
electrodes, etc. frightening, alleviates
associated fears.
Validate source of fear. Identification of specific fear
Provide accurate factual helps patient deal
information. realistically with it. Patient
may have misinterpreted
preoperative information or
have misinformation
regarding surgery. Fears
regarding previous
experiences of self or family
may be resolved.
 Health talk
ON
Expressed breast milk

SUBMITTED TO: - SUBMITTED BY:-Ms Anjali

Kaushik HARSHITA
(tutor) M.sc (nursing) 2nd year
RUFAIDA COLLEGE OF NURSING

JAMIA HAMDARD, NEW DELHI-62