Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nursing Responsibilities

TRAMADOL 50mg ANALGESIC, Binds to mu-opoid  CNS: sedation, Relief of moderate to  Contraindicate BEFORE:
1cap q8 centrally acting receptors & inhibits the dizziness or moderately severe d with allergy Assessment:
reuptake of vertigo, pain. to tramadol or  History:
norepinephrine & headache, opiods or acute hypersensitivity to
serotonin; causes many confusion, intoxication tramadol; pregnancy;
effects similar to the dreaming, with alcohol, acute intoxication with
opoids—dizziness, sweating, opiods or alcohol, opiods,
somnolence, nausea, anxiety, psychoactive psychotropic drugs, or
constipation—but does seizures drugs. other centrally acting
not have the respiratory  CV:  Use cautiously analgesics; lactation;
depressant effects. hypotension, in pregnancy, seizures, concomitant
tachycardia, lactation, use of CNS
bradycardia seizures, depressants or MAOIs;
 DERMATOL concomitant renal or hepatic
OGIC: dysfunction or impairment; past or
sweating, hepatic present history of
pruritus, rash, impairment. opiod addiction.
pallor, urticaria  Physical: skin color,
 GI: nausea, texture, lesions;
vomiting, dry orientation, reflexes,
mouth, bilateral grip strength,
constipation, affect; P,auscultation,
flatulence BP, bowel sounds,
 OTHER: normal output; LFT’s,
potential for renal function tests.
abuse, DURING:
anaphtylactoid  Control environment
reactions, (temp., lighting) if
sweating or CNS
effects occur.
 Warning:limit use in
patients with past or
present history of
addiction to or
dependence on opiods.
AFTER:
 You may experience
these side effects:
dizziness, sedation,
acuity (avoid driving
or performing tasks
that require alertness);
nausea, loss of appetite
(lie quietly, eat
frequent small meals)
 Report severe nausea,
dizziness, severe
constipation.

Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nursing Responsibilities
Prednisone 15mg/ Corticosteroid Enters target cells and  CNS: Vertigo,  Replacement  Contraindicated  Do not stop taking the drug
5ml 3-5ml TID after binds to intracellular headache, therapy in adrenal with infections, without consulting your
meals and afternoon corticosteroid receptors, paresthesias, cortical especially health care provider.
snacks thereby initiating many insomnia, seizures, insufficiency tuberculosis, fungal  Avoid exposure to
complex reactions that psychosis, cataracts,  Hypercalcemia infections, infections.
are responsible for its increased IOP, associated with amebiasis, vaccinia  Report unusual weight gain,
anti-inflammatory and glaucoma (long-term cancer and varicella, and swelling of the extremities,
immunosuppressive therapy)  Short-term antibiotic-resistant muscle weakness, black or
effects.  CV: Hypotension, management of infections; lactation. tarry stools, fever,
shock, hypertension various  Use cautiously with prolonged sore throat, colds
and CHF secondary inflammatory and kidney or liver or other infections,
to fluid retention, allergic disorders, disease, worsening of the disorder
thromboembolism, such as rheumatoid hypothyroidism, for which the drug is being
thrombophlebitis, fat arthritis, collagen ulcerative colitis taken.
embolism, cardiac diseases (eg, SLE), with impending  Instruct the patient to take
arrhythmias dermatologic perforation, drug with food or milk.
 Electrolyte diseases (eg, diverticulitis, active  The oral solution may be
imbalance: Na+ pemphigus), status or latent peptic diluted in juice or other
and fluid retention, asthmaticus, and ulcer, inflammatory flavored diluent or semi-
hypokalemia, autoimmune bowel disease, solid food before using.
hypocalcemia disorders CHF, hypertension,  Monitor patient’s blood
 Endocrine: Growth  Hematologic thromboembolic pressure, sleep patterns, &
retardation, disorders: disorders, potassium level.
decreased thrombocytopenia osteoporosis,  Weigh patient daily &
carbohydrate purpura, seizure disorders, report sudden weight gain
tolerance, diabetes erythroblastopenia diabetes mellitus; to prescriber.
mellitus, cushingoid  Ulcerative colitis, hepatic disease;
state (long-term acute exacerbations pregnancy (monitor
effect), increased of multiple sclerosis infants for adrenal
blood sugar, and palliation in insufficiency).
increased serum some leukemias and
cholesterol, lymphomas
 decreased T3 and T4  Trichinosis with
levels, HPA neurologic or
suppression with myocardial
systemic therapy involvement
longer than 5 days
 GI: Peptic or
esophageal ulcer,
pancreatitis,
abdominal
distention, nausea,
vomiting, increased
appetite, weight gain
(long-term therapy)
 Hypersensitivity:
Hypersensitivity or
anaphylactoid
reactions
 Musculoskeletal:
Muscle weakness,
steroid myopathy,
loss of muscle mass,
osteoporosis,
spontaneous
fractures (long-term
therapy)
 Other:
Immunosuppression,
aggravation or
masking of
infections; impaired
wound healing; thin,
fragile skin;
petechiae,
 ecchymoses,
purpura, striae;
subcutaneous fat
atrophy.

Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nursing Responsibilities

Dolan Syrup Analgesic Anti-inflammatory,  CNS: headache,  Relief of s/s of  Contraindicated  Assess history: allergy to
(Ibuprofen) NSAID analgesic and antipyretic dizziness, rheumatoid with allergy to ibuprofen
Propionic acid activities larely related to somnolence, arthritis and ibuprofen,  Assess physical: skin
derivative inhibition of insomnia, fatigue, osteoarthritis salicylates, or color, lesions,
prostaglandin synthesis; tiredness, tinnitus  Relief of mild to other NSAIDs ophthalmologic
exact mechanisms of  CV: hypertension, moderate pain  Contraindicated evaluation, audiometric
action are not known. palpitations,  Treatment of for treatment of evaluation, peripheral
arrhythmia, heart primary perioperative pain sensation, BP, P, R, cbc,
failure dysmenorrhea after coronary clotting times
 GI: nausea,  Fever reduction artery bypass graft  Administer drug with food
dyspepsia, GI pain,  Unlabeled uses:  Use cautiously or after meals if GI upset
diarrhea, vomiting, prophylactic for with CV occurs.
constipation, migraine; abortive dysfunction,  Use drug only as
flatulence, GI treatment for hypertension, suggested; avoid overdose.
bleeding migraine peptic ulceration,  Avoid over the counter
 GU: dysuria, renal GI bleeding, drugs.
impairment, pregnancy,  Instruct client to report for
menorrhagia lactation, impaired any side effects.
 HEMATOLOGIC: hepatic and renal  Report sore throat, fever,
bleeding, platelet function. rash, itching, weight gain,
inhibition with swelling, changes in
higher doses, vision, black tarry schools.
 neutropenia,
eosinophilia,
leukopenia,
pancytopenia,
thrombocytopenia
 RESPIRATORY:
dyspnea,
hemoptysis,
bronchospasm,
rhinitis
 OTHER:
peripheral edema,
anaphylactoid
reactions to
anaphylactic shock
 Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nursing Responsibilities

Ponstan NSAID Anti-inflammatory, CNS: Headache,  Relief of  Contraindicate BEFORE:

(Mefenamic acid) analgesics, and dizziness, somnolence, moderate pain d with 1. Assess history: allergies;
8F 5ml TID in antipyretic activities insomnia, fatigue, when therapy hypersensitivit renal, hepatic, CV, GI
between Dolan syrup related to inhibition of tiredness, tinnitus, will not exceed y to conditions; pregnancy;
prostaglandin synthesis, ophthalmic effects. 1 week. mefenamic lactation.
exact mechanism of DERMATOLOGIC:  Treatment of acid, aspirin 2. Assess physical condition:
action are not known. Rash, pruritus, primary allergy, and as skin color and lesions;
sweating, dry mucous dysmenorrheal treatment of orientation, reflexes,
membranes, stomatitis. . perioperative ophthalmologic and
GI: Nausea, dyspepsia, pain with audiometric evaluation,
GI pain, diarrhea, coronary peripheral sensation; edema;
vomiting, constipation, artery bypass adventitious sounds; liver
flatulence. grafting. evaluation; CBC, clotting
GU: Dysuria, renal  Use cautiously time, LFTS, renal function
impairment. with asthma, test; serum electrolytes, stool
HEMATOLOGIC: renal or guaiac.
Bleeding, platelet hepatic DURING:
inhibition with higher impairment, 1. Be aware that patient may
doses, neutropenia, peptic ulcer be at an increased risk for CV
eosinophilia, disease, GI events, GI bleeding; monitor
leukopenia, bleeding, accordingly.
pancytopenia, hypertension, 2. Give with milk or food to
thrombocytopenia, heart failure, decrease GI upset.
agranulocytosis, pregnancy, 3. Arrange for periodic
granulocytopenia, lactation. ophthalmologic examinations
aplastic anemia, during long term therapy.
decreased Hgb or Hct, 4. If overdose occurs, institute
bone marrow emergency procedures------
depression, supportive therapy and
menorrhagia. induced emesis, activated

RESPIRATORY: charcoal, and/or osmotic

Dyspnea, hemoptysis, cathartic.
pharyngitis, AFTER:
bronchospasm, rhinitis. 1. Instruct patient to take drug
with foods; take only the
OTHER: Peripheral prescribed dosage; do not take
edema, anaphylactoid the drug longer than one
reactions to week.
anaphylactic shock. 2. Instruct to discontinue drug
and consult health care
provider if rash, diarrhea, or
digestive problems occur.
 Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nursing Responsibilities

Catapres 75mg ½ tab Antihypertensive Clonidine treats high Body as a Whole:  Used to treat  Catapres tablets  Assess allergies to
BID A2- adrenergic blood pressure by Fatigue, fever, hypertension should not be catapres.
agonist stimulating α2 receptors headache, pallor, (high blood used in patients  Assess if there are any
in the brain, which weakness, and pressure). with known history of: heart disease
decreases cardiac output withdrawal syndrome.  Catapres has also hypersensitivity or severe coronary artery
and peripheral vascular Also reported were a been used to to clonidine disease; a heart rhythm
resistance, lowering weakly positive relieve alcohol disorder; a history of
blood pressure. It has Coombs' test and withdrawal, as an heart attack or stroke;
specificity towards the increased sensitivity to aid in methadone kidney disease; or
presynaptic α2 receptors alcohol. and opiate  Take Catapres exactly as
in the vasomotor center Cardiovascular: detoxification, as it was prescribed. Do not
in the brainstem. This Bradycardia, an aid in quitting take the medication in
binding decreases congestive heart smoking, to treat larger amounts, or take it
presynaptic calcium failure, diabetic diarrhea, for longer than
levels, and inhibits the electrocardiographic to treat Tourette's recommended by the
release of abnormalities Syndrome. doctor.
norepinephrine (NE). (i.e.,sinus node arrest,  Catapres has also  Catapres is usually taken
The net effect is a junctional bradycardia, been used to in the morning and at
decrease in sympathetic high degree AV block reduce bedtime. Follow doctor's
tone. and arrhythmias), menopausal instructions.
orthostatic symptoms, flushing, to treat  Store Catapres at room
palpitations, Raynaud's postherpetic temperature away from
phenomenon, syncope, neuralgia, to treat moisture, heat, and light.
and tachycardia. Cases ulcerative colitis,
of sinus bradycardia and to diagnose
and atrioventricular pheochromocyto
block have been ma.
reported, both with and
without the use of
concomitant digitalis.
Central Nervous
System: Agitation,
anxiety, delirium,
delusional perception,
hallucinations
(including visual and
auditory), insomnia,
mental depression,
nervousness, other
behavioral changes,
paresthesia,
restlessness, sleep
disorder, and vivid
dreams or nightmares.
Dermatological:
Alopecia,
angioneurotic edema,
hives, pruritus, rash,
and urticaria.
Gastrointestinal:
Abdominal pain,
anorexia, constipation,
hepatitis, malaise, mild
transient abnormalities
in liver function tests,
nausea, parotitis,
pseudo-obstruction
(including colonic
pseudo-obstruction),
salivary gland pain,
and vomiting.
Genitourinary:
Decreased sexual
activity, difficulty in
micturition, erectile
dysfunction, loss of
libido, nocturia, and
urinary retention.
Hematologic:
Thrombocytopenia.
Metabolic:
Gynecomastia,
transient elevation of
blood glucose or serum
creatine
phosphokinase, and
weight gain.
Musculoskeletal: Leg
cramps and muscle or
joint pain.
Oro-otolaryngeal:
Dryness of the nasal
mucosa.
Ophthalmological:
Accommodation
disorder, blurred
vision, burning of the
eyes, decreased
lacrimation, and
 dryness of eyes.

Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nursing Responsibilities
Ondansetron tab 4mg Antiemetic Blocks specific receptor  CNS: headache,  Prevention of nausea  Allergy to  Assess allergy to
TID sites (5-HT3), which are dizziness, and vomiting ondansetron ondansetron.
associated with nausea drowsiness, associated with  Use cautiously  Assess physical: skin color,
and vomiting in the emetogenic cancer
shivers, malaise, with pregnancy texture, orientation,
chemotherapy in
chemoreceptor trigger fatigue, weakness, and lactation. reflexes, abdominal
patients older then 6
zone, centrally and at myalgia months examination, urinary
specific sites  CV: chest pain,  Prevention of post- output.
peripherally. It is not hypotension operative nausea and  Ensure that the timing of
known whether its  DERMATOLOGI vomiting drug doses corresponds to
antiemetic actions are C: pruritus that of the chemotherapy or
from actions at the  GI: abdominal radiation.
central, peripheral, pain, constipation  Administer drug 1-2 days
combined sites.  GU: urinary following completion of
retention chemotherapy or radiation.
 Local: pain at  Report for any side
injection site effects: headache,
dizziness, drowsiness,
shivers, malaise, fatigue,
weakness, myalgia
 Report continued nausea
and vomiting, pain on
injection site, chest pain,
palpitations

Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nursing Responsibilities
Doxorubicin Antibiotic Cytotoxic: binds to DNA  CV: cardiac  To produce  Allergy to  Assess allergy to
Antineoplastic and exhibits DNA toxicity, heart regression on the doxorubicin, doxorubicin.
synthsis in susceptible failure, following malignant  Assess physical: T, skin
cells, causing cell death neoplasms: acute color, lesions, weight, hair,
phlebosclerosis melanoma,
lymphoblastic nailbeds, local injection site,
 DERMATOLOGIC leukemia, acute
kidney sarcoma,
auscultation, peripheral
: complete but myeloblastic large bowel perfusuion pulses, ECG, R,
reversible alopecia, leukemia, Wilms’ sarcoma, brain adventitious sounds, liver
hyperpigmentation tumor, tumors, CNS evaluation, mucous
of nail beds and neuroblastoma, soft metastases, membranes, CBC, LFTs,
dermal creases, tissue and bone myelosuppression uric acid levels.
facial flushing sarcoma, Hodgkin , cardiac disease  Do not give IM or
 GI: nausea, and non-Hodgkin’s  Use cautiously subcutaneously because
vomiting, lymphomas with impaired severe local reaction and
mucositis, anorexia,  Liposomal form: hepatic function, tissue necrosis occurs.
treatment of AIDS-  Monitor injection site for
diarrhea previous courses
related Kaposi’s extravasation : reports of
 GU: red urine sarcoma, ovarian
of doxorubicin,
burning or stinging.
 HEMATOLOGIC: cancer that has prior mediastinal
Discontinue, and restart in
myelosuppression, progressed. irradiation, another vein. Local
hyperuricemia due current subcutaneous extravasation.
to cell lysis cyclophosphamid Local infiltration with
 HYPERSENSITIVI e therapy corticosteroid may be
TY: fever, chills, ordered. Flood area with
urticaria, normal saline, apply cold
anaphylaxis compress to area. If
ulceration begins, arrage
 LOCAL: severe consultation with plastic
local cellulitis, surgeon.
vesication and  Monitor patient’s response
tissue necrosis if frequently at beginning of
extravasation therapy. Serum uric acid
occurs level, cardiac output (listen
 OTHER: for S3) CBC changes may
carcinogenesis require a decrease in the
 dose, consult with physician,
risk of heart failure,
myelosuppression, liver
damage. Record doses
received to monitor total
dosage; toxic effects are
often dose related, as total
dose approaches 550mg/m2.
 Ensure adequate hydration
during the course of therapy
to prevent hyperuricemia.
 Instruct client to prepare a
calendar for days to return
for drug therapy.
 Avoid pregnancy while
using this drug.
 Arrange for regular medical
follow check-up.
 Report for any side effects.
 Report for difficulty of
breathing, sudden weight
gain, swelling, burning or
pain at injection site, unusual
bleeding, bruising.
DRUG STUDY
 NURSING CARE
PLAN
Patient: Epis, Argean May
Age: 6 years old
Diagnosis: Anaplastic large cell lymphoma

Cues Nursing Diagnosis Rationale Goal of Care Nursing Intervention Rationale Evaluation
Subjective: Risk for infection Infection and bleeding, After 1-2 days of INDEPENDENT: INDEPENDENT:
“pinapalimpyo ko related to altered often the result of nursing intervention,
permi amun room immune response diminished production client will be: 1. Monitor 1. Temperat
didi para diri maka- because of lymphoma of WBCs and platelets, temperature. ure elevation may
impeksyon akon and leukopenia caused secondary to treatment  Remain afebrile occur because of
anak” as verbalized by chemotherapy are common cause of and achieve various factors, eg.,
by the mother death in clients with timely healing as chemotherapy side
cancer. The time after appropriate. effects, disease
Objective: chemotherapy  Identify and process or infection.
 Dust particles administration when the participate in the
surrounding WBC or platelet count is intervention to 2. Assess all 2. Early
the room the lowest point is prevent/ reduce systems (eg., skin, recognition and
 WBC count: referred to as nadir. For risk of infection. respiratory, intervention may
5.8 x 10 9/L most chemotherapeutic genitourinary) for s/s prevent progression
 Presence of agents, the nadir occurs of infection on a to more serious
bacteria in the 7-14 days after drug continual basis. situation/ sepsis.
urine administration. The
etiology of infection 3. Promote
Vital signs: BP: associated with cancer is good handwashing 3. Protects
110/70mmHg multifactorial. Some procedures by staff patient from sources
P: 122bpm cancers cause specific and visitors. Screen of infection, such as
R: 24cpm defects in the immune or limit visitors who visitors and staff
T: 37.4 response. Side effects of may have infections. who may have an
Wt: 19kgs treatment can result in Place in reverse upper respiratory
H: 115cm myelosuppression isolation as infection.
(decreased RBCs, indicated.
WBCs, platelets). An
impaired integumentary 4. Emphasiz
system increases e personal hygiene.
vulnerability to 4. Limits
infection. Neutropenia potential source of
predisposes the client to infection/ secondary
infection, especially 5. Promote overgrowth.
infection by adequate rest/
opportunistic exercise periods. 5. Limits
endogenous organisms. fatigue, yet
More than half of the encourages sufficient
infections in clients with movement to prevent
neutropenia are 6. Stress stasis of
associated with importance of good complications.
organisms from the local oral hygiene.
environment. 6. Develop
ment of stomatitis
Source: Medical- increases the risk of
Surgical Nursing by DEPENDENT: infection. Secondary
Black and Hawks Vol. 1 growth.
page 290 1. Administer
antibiotics as DEPENDENT:
indicated.
(Doxorubicin) 1. M
ay be used to treat
identified infection
or given
COLLABORATIVE: prophylactically in
immunocompromis
1. ed patient.
differential WBC
and granulocyte COLLABORATIVE:
count, and platelet as
indicated. 1.
2. may be inhibited
by the effects of
chemotherapy, the
disease state or
radiation therapy.
 2.

Evaluation
Cues Nursing Diagnosis Rationale Goal of Care Nursing Intervention Rationale

Subjective: Acute pain related to Although pain does not After 30 minutes of INDEPENDENT: INDEPENDENT: GOALS
“ masakit akon tiyan!” compression of nerve usually arise suddenly nursing intervention, PARTIALLY MET
tissue/ body organs or unexpectedly, it is client will: 1. Assess pain history, Information provides
Objective: often regarded as an  Report maximal location of pain, baseline data to Patient still feels
 Headache oncologic emergency pain control frequency, duration evaluate need for abdominal pain
 Hypogastric because it is such a with minimal and intensity. effectiveness of
pain pervasive problem. As interference interventions. She was able to
 Guarding many as one third with ADLs. follow prescribed
behavior clients in an active  Follow 2. Evaluate or be aware A wide range of pharmacological
 Protective treatment and 60% to prescribed of painful effects of discomforts are regimen
gestures 90% clients with pharmacologica particular therapies common depending on
 Positioning to advanced cancer have l regimen (eg., surgery, the procedure/ agent She was able to
avoid pain pain. Pain interferes  Demonstrate radiation, being used. demonstrate use of
 Expressive with the ability to enjoy use of chemotherapy, diversional activities
behavior activities and relaxation skills biotherapy.
( irritable, relationships that are and diversional
moaning in meaningful. When activities as 3. Provide non- Promotes relaxation
pain) cancer causes pain, indicated for pharmacological and helps refocus
some probable causes individual comfort measures attention.
 Diaphoresis
include the pressure of situation. (eg., massage,
 Pain
a tumor on one of the respositioning, back
assessment
body's organs or on rub) and diversional
scale:
bone or nerves. activities (eg. Music,
Sometimes cancer can television)
Vital signs:
cause pain when blood
BP: 110/70mmHg
vessels become 4. Provide cutaneous
P: 122bpm
obstructed by the stimulation (eg. Heat May decrease
R: 24cpm
T: 37.4 tumor. There are a or cold compress) inflammation and
Wt: 19kgs variety of treatments muscle spasms,
Height: 115cm for cancer and some of reducing associated
them are less than 5. Inform patient/ SO pain.
pleasant. However, of the expected
please remember that therapeutic effects This information helps
not all people being and discuss establish realistic
treated for cancer management of side expectations,
experience all of the effects. confidence in own
array of side effects of ability to handle what
these treatments. A side happens.
effect one person feels DEPENDENT:
may never happen to DEPENDENT:
another. It is also very 6. Administer
important to remember medications as A wide range of
that many treatment- indicated analgesics and
related side effects can ( Ponstan, Dolan associated agents may
be successfully syrup, tramadol) be used around the
prevented in some clock to manage pain.
cases, and treated if
they occur. 3.

Source: Medical-
Surgical Nursing by
Black and Hawks Vol.
1 page 295-296

Evaluation
Cues Nursing Diagnosis Rationale Goal of Care Nursing Intervention Rationale
Subjective: Fatigue related to Anemia is an important
“ Kulang gud it katurog altered body chemistry: component of cancer- nursing intervention,
niya, permi la hya ng side effects of pain and related fatigue, which is client will be able
hihinigda.un” as other medications, one of the most to:
verbalized by the mother. chemotherapy common and distressing
manifestations
Objective: experienced by the
 Overwhelming client. Fatigue is poorly
lack of energy understood; no one
 Inability to definition describes all
maintain usual experiences. Research
routines on cancer related
 Decreased fatigue is inconclusive.
performance It is difficult to predict
 Disinterest in with certainty which
surroundings interventions will have
 Irritable therapeutic benefit for
which clients. Careful
Vital signs: evaluation of
BP: 110/70mmHg exacerbating and
P: 122bpm relieving factors, the
R: 24cpm effect of daily life and
T: 37.4 personal or cultural
Wt: 19kgs influences as well as
H: 115cm review of laboratory
data add depth to the
assessment of client’s
fatigue and guide
interventions. Any
chemotherapy drug may
cause fatigue, but it
may be a more common
After 1-2 days of INDEPENDENT: INDEPENDENT:
1. Monitor 1.
physiological
response to activity,
 Report improved eg., changes in BP or
sense of energy heart/ respiratory
 Perform ADLs rate.
and participate in
desired activities
at level of ability
2. Performa pain
assessment and 2.
provide pain
management.
3. Plan care to allow for
rest periods.
Schedule activities 3.
for periods when
patient has most
energy.
4. Assist with self care
needs when
indicated; keep bed 4.
GOALS MET
T Patient was able to
olerance varies sit and walk on her
greatly depending own.
on the stage of the
disease process, Perform ADLs and
nutrition state, fluid participate in
balance, and desired activities.
reaction to
therapeutic regimen.
P
oorly managed
cancer pain may
contribute to fatigue.
F
requent rest periods/
naps are needed to
restore/ conserve
energy. Planning
will allow patient be
active at all times
when energy level is
higher, which may
restore a feeling of
well-being and a
sense of control.
W
side effect of drugs
such as vincristine,
vinblastine, and
cisplatin. Fatigue
usually develops after 5. Encourage
several weeks of
chemotherapy. In some,
fatigue lasts a few days,
while others say the
problem persists
throughout the course
of treatment and even
after the treatment is
complete.
Source: Medical-
Surgical Nursing by
Black and Hawks Vol.
1 page 291-292
in low position; eakness may make
assist with ADls difficult to
ambulation. complete or place
patient at risk for
injury during
nutritional intake. activities.
5. A
dequate intake of
nutrients is
necessary to meet
energy needs and
build energy
reserves for activity.
 Evaluation
Cues Nursing Diagnosis Rationale Goal of Care Nursing Intervention Rationale

Subjective: Anxiety related to After 30 min. of Independent: GOALS MET

“tutusukon naliwat situational crisis Anxiety is a normal nursing intervention, Patient display
ako!! (crys)” as reaction to cancer. One client will be able to: 1. Review patient’s or Clarifies patient’s appropriate range of
verbalized by the may experience anxiety S.O’s previous perception, assist in feelings
patient. while undergoing a  Display experience with identification of fears
cancer screening test, appropriate range cancer. and misconceptions Appear relaxed
Objective: waiting for test results, of feelings and based on diagnosis and
 Increased receiving a diagnosis of lessen anxiety. experiences. Demonstrate effective
tension cancer, undergoing coping mechanisms
 Apprehension cancer treatment, or  Appear relaxed 2. Encourage patient Provides opportunity to
 Irritable anticipating a recurrence and report anxiety to share thoughts examine realistic fears
 Cries a lot of cancer. Anxiety is reduced to and feelings. and misconceptions
 Shaking of associated with cancer manageable level. about diagnosis.
head may increase feelings of
pain, interfere with  Demonstrate use 3. Provide open Helps patient feel
Vital signs: BP: one's ability to sleep, of effective environment in accepted in present
110/70mmHg cause nausea and coping which patient feels condition without
P: 122bpm vomiting, and interfere mechanism and safe to discuss feeling judged and
R: 24cpm with the patient's (and active feelings or to promotes sense of
T: 37.4 his or her family's) participation in refrain from dignity and control.
Wt: 19kgs quality of life. If left treatment talking.
H: 115cm untreated, severe regimen.
anxiety may even 4. Maintain frequent Provides assurance that
shorten a patient's life. contact with patient is not alone or
Persons with cancer will patient. Talk with rejected, conveys
find that their feelings and touch patient as respect for and
of anxiety increase or appropriate. acceptance of the
decrease at different person, fostering trust.
times. A patient may 5. Permit expressions Acceptance of feelings
become more anxious as of anger, fear, allows patient to begin
cancer spreads or despair, without to deal with situation.
treatment becomes more confrontation. Give
intense. information that
feelings are normal
Source: and are to be
Medicine.net.com appropriately
expressed.

6. Promote calm, quiet Facilitates rest, conserve

environment. energy and may enhance
coping abilities.
 Evaluation
Cues Nursing Diagnosis Rationale Goal of Care Nursing Intervention Rationale
Gastrointestinal effects After 1 to 2 days of Independent:
Subjective: Risk for fluid volume of chemotherapy nursing intervention, 1. Monitor I&O Continued negative GOALS MET
“Nagsuka, pero guti deficit related to include nausea and client will be able to: and specific fluid balance,
la man” as verbalized vomiting as an adverse vomiting, anorexia, gravity, include decreasing renal Patient display an
by the mother. effects of alteration in taste,  Display adequate all output output and adequate fluid balance.
chemotherapy weight loss, oral fluid balance as sources. concentration of urine
Objective: leukocytis, diarrhea, evidenced by suggests developing
 Fatigue and constipation. The stable vital signs, dehydration and need
 Drowsy vomiting center in the moist mucous for increased fluid
 Irritable medulla can be membranes, good replacement.
 Nausea stimulated by any of skin turgor, 2. Monitor vital
 Vomiting five different afferent prompt capillary signs, evaluate Reflex adequacy of
pathways or by arousal refill and peripheral circulating volume.
of the chemoreceptor adequate urine pulses and
Vital signs: BP: trigger zone located in output. capillary refill.
110/70mmHg the fourth ventricle of
P: 122bpm the brain. The emetic 3. Assess skin
R: 24cpm potential of a particular turgor and Indirect indicators of
T: 37.4 chemotherapeutic moisture of hydration status or
Wt: 19kgs regimen depends on the mucous degree of deficit.
H: 115cm drugs given, the dose, membranes.
the route of Note reports of
administration and the thirst.
clients susceptibility to
emesis. Uncontrolled
nausea and vomiting, 4. Observe for
among the most feared bleeding Early identification of
treatment related side r tendencies. problems allows for
effects are experienced prompt intervention.
by as many as 60% of
people receiving
chemotherapy and can Dependent:
result in anorexia, d
malnutrition, 5. Provide IV Given for general
dehydration, metabolic (PNSS) fluid as hydration and to dilute
imbalances, indicated. antineoplastic drugs
psychological and reduce adverse
depression and side effects.
decreased immunity.
6. Administer Alleviation of nausea
anti-emetic and vomiting
therapy as decreases gastric
Source: indicated losses and allows for
Medical Surgical (Ondansetron). increased oral intake.
Nursing by Black and
Hawks Vol.1 page 292