NURSING CARE PLAN
NAME OF STUDENT:
NAME OF PATIENT:
DIAGNOSIS OR CLINICAL IMPRESSION: Gastric cancer T3N3M0, s/p radical near total gastrectomy, roux-en-y gastrojejunostomy; currently on 3 rd 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 for elevated
monocyte count
Low Hgb, Hct, MCH, MCHC
(anemia)
On 3rd cycle of chemotherapy
(epirubicin-cisplatin-
CIVIL STATUS: Single
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.
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
DATE OF ASSIGNMENT:
WARD: I BED NO.: AGE: SEX: Male
GOALS AND
NURSING INTERVENTIONS AND RATIONALE EVALUATION
OBJECTIVES
Goal: The student nurse will: After the nursing
The patient will have intervention, the client will:
effective protection.
Objectives:
After the nursing
intervention, the
client will be able to:
NOC: Immune NIC: Bleeding precautions
status, Blood Infection Protection
coagulation, Risk Risk identification
control
Monitor for signs of infection and bleeding and worsening
Manifest no signs of anemia:
infection and a. Vital Signs ( ) Manifested normal vital
bleeding Fever/tachycardia may suggest developing infection. signs
Tachycardia and tachypnea may also be indicative of
compensation for the anemia.
b. Signs of infection at insertion site of IV line (warmth, ( )Manifested no signs of
redness, swelling, discharge, odor, pain or tenderness) infection in IV insertion site
The IV line is a possible site of entry of opportunistic
pathogens.
c. Breath sounds and sputum production ( ) Manifested clear breath
Presence of adventitious breath sounds such as rales and sounds and absence of
sputum production suggest the presence of respiratory sputum production
infection.
d. White coating in tongue ( ) Manifested no white
Fungal infections can occur. coating in the tongue
e. CBC results ( ) CBC results manifested:
These laboratory tests help detect abnormalities that place __No signs of infection
the patient at risk for bleeding and infection. Due to __ No worsening of the
myelosuppression caused by the chemotherapy, the number indicators of anemia
and type of WBCs required to fight infection is decreased. __ Platelets within
Anemia is also common. Platelets are usually decreased, acceptable limits
thus placing the patient at high risk for bleeding.
fluorouracil 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
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
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.
f. Fatigue, weakness, shortness of breath, alteration in ( ) Manifested absence of
mental status symptoms of anemia
These symptoms occur due to the body’s altered tissue
perfusion caused by anemia.
g. Indicators of bleeding abnormalities (bruising, easy ( ) Manifested no signs of
bleeding, petechiae, bleeding gums, and nosebleed, bleeding
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
Perform the the patient. Proper hand hygiene is one of the best ways to
necessary stop transmission of infection.
precautions needed
to prevent infection. Perform IV site care. ( ) Dry, intact dressing of IV
This is done prevent accumulation of bacteria and thus site, (-)
prevent infection. inflammation/pain/tenderss
Facilitate wearing surgical mask of patient when he is not ( ) Wore mask when he is
alone in his room. not alone in the room
This protects the patient from sources of infection.
Advise patient to avoid fresh, unpeeled fruits and vegetables; ( ) Verbalized that she will
uncooked meat; unprocessed/uncooked animal products; and consume a neutropenic diet
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.
Discuss and demonstrate proper hand washing technique to ( ) Return demonstrated
the patient and watcher. proper handwashing
Demonstrate proper This is done to reduce the entry of organisms into the patient. technique
hand washing
technique Facilitate adequate rest and hydration (daily fluid intake of at ( ) Achieved adequate rest
least 1 1/2 L). ( ) Able to drink at least 1
Perform ways to These are important in infection prevention and control. ½ L of water per day
enhance resistance
to infection Assist in meticulous oral care. ( )Demonstrated proper
Gums and oral mucosa may bleed easily because of altered meticulous oral care
Perform the clotting. Moreover, chemotherapeutic drugs can cause

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
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
necessary dryness of the oral mucosa, thus making it more prone to
precautions needed injury.
to prevent and ( ) Adhered to avoiding hot
monitor for bleeding Encourage soft diet and advise him to avoid hot foods/liquids. foods and eating soft diet
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
( ) Refrained from eating
Advise client to refrain from eating dark food such as dark foods
chocolates.
This is to facilitate monitoring of occult bleeding.
( )Stated all early signs of
Report the following to the nurse/doctor. developing infection,
Identify early signs of -Cough/colds worsening anemia, and
developing infection, -Pus in urine presence of clotting
worsening anemia, - Development of white coating in the oral cavity especially abnormalities he has to
and presence of the tongue report to the nurse or
clotting abnormalities -Pain/tenderness in IV site physician
he has to report to - Bruising, easy bleeding, petechiae, bleeding gums, and
the nurse or nosebleed, occult bleeding
physician - Weakness
- Shortness of breath, alteration in mental status
Early detection of these signs and symptoms are needed in
order to immediately address the problem.
Goal: After the nursing
The patient will take The student nurse will: intervention, the client will:
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 NIC: Nutritional monitoring
status: food and fluid Nutritional management
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 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
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 treatment-
related symptoms, and improve
quality of life. Chemotherapy-
induced toxicity may also have
more severe effects on patients
with pre-existing malnutrition.
(Tian, et.al. The Effects of
Nutrition Status of Patients with
Digestive System Cancers on
Prognosis of the Disease.
Cancer of Nursing. 2008)
intake
State the need for Provide health teaching about proper nutrition and its ( ) Stated that proper
proper nutrition in his importance in client’s recuperation. nutrition is needed to
condition. Adequate nutrition can minimize the adverse effects of enhance resistance to
treatment and decrease treatment-related symptoms infection and enhance
treatment results
Pinpoint the Assist patient in determining the quantity and quality of foods ( ) Stated the diet
deficiencies in his that he is not eating that he should be taking in. modifications correctly
daily intake. 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.
State the diet Diet modifications to reduce risk of recurrence of neoplastic ( ) Selected quantity and
modifications he has growth and to improve nutrition during chemotherapy quality of foods that he
to make to achieve -Increase intake of cooked vegetables and peeled/canned would eat from the food
optimal nutrition fruits. This is done to reduce risk of exposure to pathogens. choices in the neutropenic
- Reduce intake of fatty foods and smoked foods. This is diet
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 ( ) Manifested weight
usually unpleasant to the patient’s taste. increase of at least 1 pound
Weigh patient daily with same set of clothes at the same time
of the day.
This is done to assess improvements in weight.
( ) Verbalized improvement
Perform ways to Assist patient to a sitting position before eating or feeding. of appetite
enhance appetite 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.
Ectomorph, cachexic
Sunken periorbital region
(+) Dental caries, (+) missing
teeth
(+) ill-fitting dentures
(+) muscle wasting in lower
extremities, mid-thigh
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
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. Carpenito-
Moyet, 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 The student nurse will: After the nursing
nursing interventions, intervention, the client will:
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 NIC: Teaching (Disease process and management)
behavior, Decision making suppor
Knowledge: Disease
Process and
Management
Explore with the patient and the caregiver the benefits and ( ) Stated perceived
State perceived barriers in performing therapeutic regimen management for benefits and barriers to
benefits and barriers cancer. performing therapeutic
to performing The health belief model states that one’s perception of regimen
therapeutic regimen barriers and benefits of disease affect health seeking
condition behaviors.
Identifiy the risk Describe the nature (risk factors and manifestations) of ( ) Identified his risk factors
Stated that his family is very factors and cancer. and manifestations of
supportive in his treatment manifestations of This would be a brief review so that the patient fully cancer
cancer understands his disease condition. This enhances adherence
Verbalized that he wants to to regimen.
improve on his treatment State the name use ( ) Stated the name and use
regimen so that the tumor of his drugs Discuss the name and general use of his drugs. of each drugs
growth will not recur This is done in order to increase her level of compliance with
his chemotherapy drugs as well as pre-chemo drugs
(metoclopramide and diphenhyrdramine).
Demonstrate proper ( ) Performed ambulation
exercise Discuss the importance of ambulation and range of motion and range of motion
exercise (with demonstration) exercises
Demonstrate stress ( ) Demonstrated stress and
and pain Discuss and demonstrate stress and pain management pain management
management strategies. strategies
Deep breathing exercise
Self-Hypnosis
Imagery
State ways to ( ) Stated strategies to
enhance sleep and Discuss the strategies that help tom enhance sleep. enhance sleep
rest Rest and sleep are important in increasing resistance to
infections during chemotherapy. It also reduces stress. ( )Verbalized enhanced
sleep and rest

Verbalize ( ) Verbalized commitment

commitment to Explore feelings about current therapeutic regimen to adhere to prescribed
adhere to prescribed management. therapeutic regimen for
therapeutic regimen cancer
for cancer
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, 12 th 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. 11 th 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