CORDILLERA CAREER DEVELOPMENT COLLEGE

Buyagan, Poblacion, La Trinidad, Benguet

COLLEGE OF HEALTH EDUCATION

NCM – 106

NURSING CARE PLAN

ON
THE EFFECTS OF CHEMOTHERAPY

 Fatigue related to altered body chemistry: side effects of Chemotherapy secondary to breast cancer.
 Disturbed Body Image: Alopecia related to the effects of Chemical Distraction.
 Risk for deficient fluid volume related to effects of chemotherapy.

SUBMITTED BY: CECIL C. PABLO

SUBMITTED TO: MA’AM JIWANI MAE LAROZA

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING RATIONALE EVALUATION


S – “kanaun ak mababanog
uray lang ag kuti ak ti bassit
kt mabannog ak, isunga
kailangan dak iassist jai
watcher ko”, as verbalized by
the patient.
O – Body weakness noted,
Ineffective role performance,
BP – 90/70 mmHg
RR – 22 cpm
PR – 75 bpm
(+) chemo
Nursing Diagnosis:
Fatigue related to altered body
chemistry: side effects of
Chemotherapy secondary to
breast cancer.
ASSESSMENT
S – “Paggising ko kanina
napansin ko na nalalagas na
yung buhok ko, nakakalbo na
ako”, as verbalized by the
patient.
PROBLEM
Fatigue often gets worse
during chemotherapy
especially on the first session
and it may get better until the
next treatment. In addition,
experiencing fatigue is
common on those having
chemotherapy because it
destroys healthy cells in
addition to the targeted cancer
cells.
Fatigue may occur as the body
tries to repair the damage to
healthy cells and tissues.
Also, cancers can increase the
body’s need for energy,
weakens the muscles, cause
damage to certain organs or
alter the body’s hormones
may contribute to fatigue.
EXPLANATION OF THE
PROBLEM
Chemotherapy may cause hair
loss all over the body — not
just on the scalp. Sometimes it
includes eyelash, eyebrow,
armpit, pubic and other body
STO – After 2 hours of
rendering nursing care and
therapeutic communication,
patient will be able to
understand and demonstrate
proper techniques of rest
periods:
1. Take frequent periods
of rest, especially
when going to the
restroom, standing
and walking.
Also, the patient will be able
to understand the importance
of consuming a well balanced
diet.
LTO – After 3 days of nursing
intervention with medical
management, the patient will
be able to do activities of
daily living independently.
The patient will be able to
report improved sense of
energy.
OBJECTIVES
STO – After 2 days of nursing
intervention the patient will
be able to recognize alopecia
as the side effects of
chemotherapy and start
INTERVENTIONS
 Monitor vital signs  To evaluate fluid  Goal met, after 2
status and hours of therapeutic
cardiopulmonary interventions, patient
response to activity. was able to
understand and
 To extend activity demonstrate proper
 Encourage to use of time/conserve energy techniques of rest
assistive devices. for other tasks. periods.
 To avoid fall or  He was able to
injury. understand the
 Instructed in methods importance of
to conserve energy.  In order to save consuming balanced
energy for the other diet.
tasks he/she needs to
do.
 Encouraged  To promote energy.
nutritionally dense,
easy to prepare and
consume foods, and
avoidance of caffeine  After 3 days of
and high sugar foods nursing intervention,
and beverages. patient the patient
reports improved
 Assisted with self- sense of energy
care needs; assisted in  To prevent further  Patient managed to
ambulation as needed. injury. perform activities of
daily living without
any assistance.
NURSING RATIONALE EVALUATION
INTERVENTIONS
 Discussed with the  Aids in defining  After 2 days of
patient and family concerns to begin nursing intervention
how the therapy is problem solving the patient recognized
affecting the hair. process. Provides alopecia as the side
information so patient effects of

O – Brittle hair, falls when
lathered, breaks of at the
surface of the scalp.
Anxious behavior.
Avoids looking at or touching
the body part.
Nursing Diagnosis –
Disturbed Body Image:
Alopecia related to the effects
of Chemical Distraction.
ASSESSMENT
S – “namin lima en nga
nagsarsarwa manipud idi
agsapa”, as verbalized by the
patient’s watcher.
O – Weak in appearance,
poor skin turgor, sunken
eyeballs. Emesis basin at bed
hair also falls out. Some
chemotherapy drugs are more
likely than others to cause
hair loss, and different doses
can cause anything from a
mere thinning to complete
baldness.
Presence of alopecia is
another form of tissue
disruption common in patients
with cancer who receive
chemotherapy. The extent of
alopecia depends on the dose
and duration of therapy. This
cause damage in stem cells
and hair follicles.
EXPLANATION OF THE
PROBLEM
Vomiting occur when
chemotherapy drugs stimulate an
area of the brain called the
chemoreceptor trigger zone.
Deficient Fluid Volume is
decreased intravascular,
interstitial, and/or intracellular
fluid. This refers to dehydration,
water loss alone without change in
certain steps for medications
in hair care and treatment.
Seek information and actively
pursue growth.
LTO – After 5 days of nursing
intervention the patient will
be able to verbalize an
understanding of body
changes.
Verbalize relief of anxiety and
adaptation to actual or altered
body image.
OBJECTIVES
STO – After 4 hours of
nursing interventions, the
patient will be able to
identify individual risk
factors and appropriate
interventions.
and family can begin chemotherapy.
to prepare cognitively  Started to maintain
and emotionally for hygiene and hair
loss. grooming
 Validates reality of
patient’s feelings and
 Acknowledged gives permission to
difficulties patient take whatever  After 5 days of
may be experiencing. measures are nursing intervention,
Give information that necessary to cope the patient was able to
counseling is often with what is verbalized relief of
necessary and happening. anxiety and
important in the adaptation to
adaptation process.  To begin to actual/altered image.
 Encouraged the incorporate changes  Identify positive and
patient to look into the body. negative feelings to
at/touch affected body  Facilitates coping. self image. States that
part. hair loss is temporary.
 Offer positive
reinforcement for
efforts made (e.g.,
wearing makeup or
using wigs)
NURSING RATIONALE EVALUATION
INTERVENTIONS
 Monitor vital signs.  To evaluate fluid  After 4 hours of
status and nursing intervention,
cardiopulmonary the patient and
family acknowledged
response to activity.
the individual risk
 Provides information factors of vomiting
about overall fluid
 Monitor intake and and appropriate
output, estimate balance, as well as interventions.
guidelines for fluid
insensible fluid loss.
replacement.
side. Pale conjunctiva and sodium.  To note signs of
mucus membrane. dehydration, such as
dry skin and mucous  After 3 days of
Vital Signs as follows: membranes, poor nursing
LTO – After 3 days of  Assessed skin and skin turgor, and interventions, the
T: 36.6 nursing interventions, the oral mucous delayed capillary client maintains fluid
PR: 86 bpm patient will maintain fluid membrane. refill. volume at functional
RR: 18 cpm volume at a functional level  To stop or limit fluid level and has good
BP: 110/70 as evidenced by good skin losses. skin turgor and moist
turgor and balanced intake mucous membrane.
and output.
NURSING DIAGNOSIS: Demonstrates behaviors in  This enhances
Risk for deficient fluid order to maintain fluid cooperation with the
volume related to effects of volume.  Administer regimen and
chemotherapy. medications as achievement goals.
prescribed.

 Engage patient and

client in fluid
management plan.