UNIVERSITY OF BALAMAND

Faculty of Health Sciences

Nursing Program
NURSING PROCESS
NURS 241, NURS242 and NURS248

Student Name ____leya elleik___________________ Clinical

date_22/9/2022___________

Nursing care plan / 100

Student Work Evaluation
A- Assessment Tool /35 %
B- List of Nursing Diagnosis / Collaborative /15%
Problems
C- Elaboration of ND/CP (2) /30%
D- Scientific Research /10%
E- Medications Research /10%

A- ASSESSMENT TOOL /95 (35%)

PATIENT GENERAL INFORMATION /5

Admission Date: ----
Pt. Initials: -------E.T------------------- Rm #: ---636-------------
19/9/2022------------------------
Health insurance: -------------------------------------- Source of Information X Patient
Age: ---55- Other: -------------------------------------------
Gender: X Male Female
years old----
Residence: -----mazraat
Nationality: X Lebanese Other: ------------------
yachouh---------------------------
Marital status
Single X Married Widow (er) Divorced
Education level: ---- Occupation: --senior
# of persons in charge: -------------
university------------------ administrator-----------------------------
Economic level: Good Moderate X Low
Chief Complaint: ------------Bone Marrow
transplant------------------------------------------------------------------------------------------------------------
Medical Diagnosis: ---------Multiple
myeloma------------------------------------------------------------------------------------------------------------
PAST MEDICAL HISTORY (DATE)
Diabetes Mellitus type I Diabetes Mellitus type II Heart diseases (5years)
X Hypertension Asthma COPD
X Cancer Kidney diseases Epilepsy
CVA Trauma Mental disorders (describe): -----------
Others:

SURGICAL HISTORY (DATE)

Inguinal hernia (30 years)

FAMILY HISTORY
Brother had prostate cancer

Prepared by VG and PG 2017 Updated by V.G , H.Ch, CA, Summer 2022

 SOCIAL HISTORY
Smoking: Current; Packs/Day: none Previous (quit __yrs. ago) X66 never
Alcohol: never Quantity: Frequency :none
RISK FOR
X Fall Skin breakdown Aspiration Bleeding × Infection

HISTORY AND EVOLUTION OF PRESENT ILLNESS /10

(From the date of admission until the date of the interview WITH tests, radiology investigations upon admission. )
Mr. E.T a 55-year-old male patient, was admitted on 19/9/2022 at 11:15 AM for bone marrow transplant

History goes back to approximately 10 years ago when Mr. ET discovered his myeloma on December 2009,
after pain he felt in his vertebrae. Patient went through plasma cytoma, ERM, and went through 10 sessions
of radiotherapy, plus 16 cures of chemotherapy.
In approximately 2010 Mr. ET went through bone marrow transplant, the transplant was a success for
approximately 11 years and the patient went back home until November 2021 when patient experienced pain
in the sternum which he thought because it was of his cardiac arrest that also happened in 2021, but turns out
patient has relapsed. Patient went through radiotherapy and VRD on his sternum.
Patient also records history of hypertension, anxiety, retinal detachment, tetany in the left ear (uncurable),
and BPH. (benign prostatic hyperplasia)
Patient went through inguinal hernia surgery 30 years ago.

On 20/9/2022 the patient started phases for bone marrow transplant, first he started with mobilization where
chemotherapy (melphalan) was started for 5 days.
CBC blood tests where ordered and a decrease in the level of white blood cells (3.92 10*3/ul),neutrophils
(76.2%),lymphocytes(13.8%), eosinophils(0.8%),R.B.(4.10 10*6/ul),Hemoglobin(12.4 g/dl), hematocrit
(37.1%),R.D.W(16.6%). This is because of nadir after treatment of chemotherapy.
Ultrasound of abdominopelvic, and chest x-ray was performed to rule out any possible infections that would
cause complications. Abdominopelvic is normal no severity in the report. Chest x-ray was normal heart is
normal size lungs are clear and ribcage is intact.
On 21/9/2022, 4 bags of stem cells where transplant (CD34=802) in the patient’s body with ozot.
Patient was given antiallergic medication (cortisol, antihistamines). GCSF- injections (neutromax) to start
increasing the level of immunity of the patient.
Today on 22/9/2022, the patient is day 1 post- transplant and day 2 chemotherapy.
Patient is taking several medications including:
Seroxat 10mg PO daily
Decadron 5mg IV day one before melphalan
Primperan 10 mg IV Q8hrs
Zofron 8 mg IV BID
Neutromax 300 mg BID
ASpirin 100 mg /PO/daily
Concur 1.25mg/PO/Daily
Risek 40 mg IV daily
Bactrim 160 mg PO Monday-Wednesday-Friday
Fluconazol 100 mg PO daily
Cyclovex 400 mg PO BID
Silosin 8 mg PO daily
Triltec 1.25 mg PO Monday-Wednesday-Friday
Lipitor 49mg /PO/daily

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Page 2
 Aloprex 0.5mg PO daily
Melphalan 200mg in 500ml IV NSS over 30 minutes
DWS% 500ml Q24hrs
Sns 1e IV Q24hrs.

On 23/9/2022 patient E.T is on post chemotherapy day 4 and post transplant day 2.

Patient is admitted for a blood tests (CBC) results showed:

W.B.C=(17.61 *10^3/ul)/
Neutrophils=(97.7%)/hemoglobin=(11.6g/dl)/hematocrit=(34.2%)/plateles=(132*10^3/ul)/
Creatinine=(0.81mg/dl)/potassium=(4.3mmol/l)
Concur dosage was increased to half (concur 2.5 mg instead of 1.25mg) as advised by his physician Dr. Naser.
Rest of medication was given as regular :

Decadron 5mg IV day one before melphalan

Primperan 10 mg IV Q8hrs
Zofron 8 mg IV BID
Neutromax 300 mg BID
ASpirin 100 mg /PO/daily
Concur 2.5mg/PO/Daily
Risek 40 mg IV daily
Bactrim 160 mg PO Monday-Wednesday-Friday
Fluconazol 100 mg PO daily
Cyclovex 400 mg PO BID
Silosin 8 mg PO daily
Triltec 1.25 mg PO Monday-Wednesday-Friday
Lipitor 49mg /PO/daily
Aloprex 0.5mg PO daily
Melphalan 200mg in 500ml IV NSS over 30 minutes
DWS% 500ml Q24hrs
Sns 1e IV Q24hrs.

In addition patient reported nausea so he was given primperan 10 mg PO at 9:00 P.M (22/9)

Medications /5
Medications in the last 3 months
Name Dose/ route/ frequency Indication
Seroxat 10mg/PO/daily Antidepressants/thought to be

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Page 3
 linked to drug’s inhibition of CNS
neuronal uptake of serotonin
Concur 1.25 mg/PO/daily Antihypertensive /selectively
blocks cardiac
adenoreceptors,reducing HR
Bactrim 160mg/PO/Monday-Wednesday- Antibiotic/sulfamethoxazole,
friday decreases bacterial folic acid
synthesis and is bacteriacidal
cyclovix 400mg/PO/BID Antivirals /interferes with DNA
synthesis and inhibits viral
multiplication
silosin 8mg/PO/daily BPH drug/causes relaxation of
smooth muscles in the prostate
Triltec 1.25mg/PO/Daily Antihypertensive /potent
vasoconstricter
Atrovastatin 40mg/PO/daily Antiilipemics/inhibits early
cholesterol biosynthesis

Medications prescribed in the present hospitalization

Name Dose/ route/ frequency Indication
Seroxat 10mg/PO/daily Antidepressants/thought to be
linked to drug’s inhibition of CNS
neuronal uptake of serotonin
Alfa fresh 10ml/PO/TID Mouthwash
Medistan 10ml/PO/TID Mouthwash
Decadron 5mg/IV/day 1 before melphalon Glucocorticoid/antiallergy
Primperan 10mg/IV/Q8hrs Antiematic/reduces nausea
zofron 8mg/IV/BID Antiemetic/reduces nausea has a
stronger effect than primperan
neutromax 300mg/IV/BID GSCF (Growth factor)/increases
level of immunity
Aspirin 100mg/PO/daily -antiplatelet/antiaggregant
triltec 1.25mg/PO/Monday-Wednesday- - Antihypertensive /potent
friday vasoconstricter
Concur 2.5mg/PO/Daily - Antihypertensive /selectively
liptor 40mg/PO/daily blocks cardiac
adenoreceptors,reducing HR
- Antiilipemics/inhibits early
cholesterol biosynthesis
Risek 40mg/IV/daily -antiacid/decreases acid in the
stomach/ppi
Bactrim 160mg/PO/Monday-Wednesday- -antibiotic/ bacteriacidal
friday
fluconazol 100mg/PO/daily -antifungal/
cyclovex 400mg/PO \/daily Antivirals /interferes with DNA
synthesis and inhibits viral
multiplication
Silosin 8mg/PO/daily -BPH drug/causes relaxation of
Sns 1e/IV/Q24hrs smooth muscles in the prostate
Melphalan 200mg in 500ml nss over 30 -chemotherapy used to kill all cells
mins /IV in the body

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Page 4
 1. Health Perception/health promotion/ Health management Pattern /5
Weight: -------66KG---------------- Height: -------165------------------
Vital Signs: BP: ----- T°C: ------
HR: ---100------------ Respiration: ----16bpm-------------
128/78------- 36.3-------------
Specific measures taken by the patient to promote or maintain his/her health:
No X Yes If yes, describe: 3 main meals without snacks/ fast food (THE
Diet/Nutrition PATIENT IS ADVISED ON A LOW FAT LOW SALT DIET TO
PREVENT FURTHER COMPLICATIONS)
Weight
X No Yes If yes, describe:
management
Regular exercise X No Yes If yes, describe:
X Dressing, X toileting, X ambulating, X transferring X
ADL X Personal hygiene
eating
If yes, describe: CHEST X-RAYS (incase of infection):heart normal
Screening tests No X Yes
in size lungs are clear costophrenic angles are free rib cage is intact.
If yes, describe: General blood test CBC: wbc:3.92 10*3/ul/
Regular physical neutrophils 76.2%/hemoglobin=12.4g/del/hematocrit=37.1%(these
No X Yes
checkups findings are generally low but that’s normal because patient was
taking chemotherapy at the time blood tests were taken.) (19/9/2022)
Recent change in
X No Yes If yes, describe:
lifestyle
Allergies: X No Yes If yes, specify:
Allergy to medications NONE Allergy to Food/ environment
Others : ------ Type of reaction: ---------
Not known
NONE------------ NONE-------------------------------------
Previous hospitalizations: (date & experience)

Previous hospitalization was approximetly in august patient went for chemotherapy treatment, patient was
comfortable and finished his treatment normally.

Blood transfusions:
Blood group: ----------A positive--------------------- Date of transfusion: ------19/8/2022-------------------------
Indications: --------low platelets------------------------ Reactions: -----none----------------------------------
Vaccination history:
X COVID 19 -----------------3----------# of doses?
X Influenza X Hepatitis B
----------
Knowledge/ perception of the present illness
Patient is alert and is knowledgeable about his illness and the procedure he is going to do.

Knowledge/ perception of the current medications

Patient is knowledgeable about medication he is taking and for what cause.

Expectations of therapy:
Success of bone marrow transplant.

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Page 5
 Nursing Diagnosis:
Risk for infection related to low immunity secondary to chemotherapy (melphalan) .
2. Nutrition & metabolism /10

Diet: Current: ----------3 meals per day (patient is strict about eating
Usual: --------3 meals per day---------------------------------- healthy , so he was forcing himself to eat during stage 2 of bmt
although he was a bit nauseated)-----------------------------------
Appetite: Normal X Decreased Increased
Teeth condition: X Normal Dentures Caries
Difficulty with:NONE
Chewing Swallowing Tasting Smell Following diet
Having:
Anorexia X Nausea Vomiting Indigestion
Weight loss/gain -------Kg Mouth Soreness Hematemesis Pyrosis (heartburn)
Hyperlipidemia Obesity Jaundice Ascites
Eating pattern :
X Normal
Enteral: NG tube feeding Gastrostomy , PEG Jejunostomy
Parenteral: ----------------------------------------------------------
a. Endocrine:
Change in heat/cold tolerance: X No Yes If yes, describe: ----------------------------------------------------
Recent unexplained changes in weight: X No Yes If yes, describe: ------------------------------------
If yes, what type & since when? ------------------
Presence of Diabetes mellitus: X No Yes
-------------------------------------------------------
Presence of diabetic complications: X No Yes If yes, specify:
Coronary artery disease Peripheral vascular disease Nephropathy
Neuropathy Retinopathy Hypoglycemia
Hyperglycemia Diabetic foot ulcer
Endocrine disorders: X No Yes If yes, specify:
Hypothyroidism Hyperthyroidism Others: ----------------------------------
b. Skin/Mucosa:
State:
X Normal Moist Dry Warm Cool Dehydrated Diaphoretic
Color:
X Healthy Cyanotic Pale Jaundiced
Mottled Ashen Flushed Cyanotic
Integrity:
X Ecchymosis Hematomas Dermatitis Eczema Petechiae
Oral Mucous membrane: NONE Healthy Dry
Lesions in: Lips Gums Tongue Other: -------------------
Abnormality in:
Conjunctiva Sclera Nail beds Delayed healing Other retinal detachment
Edema: X No Yes
Generalized Localized Dependent Periorbital Pitting
If yes, describe location and depth as 1= 2mm, 2= 4mm 10-15sec, 3= 6mm 1-2 min, 4= severe 8mm, 2-5min)
----------------------------------------------------------------------------------------------------------------
Wounds X No Yes, If yes, describe (location, type, and

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 characteristics):---------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------
Drains/Tubes/Catheters ( Jugular, PICC Line, Implantable chamber): No Yes, If yes, describe (location,
type, and characteristics):
------------------------------------------------------------------------------------------------------------------------------------
Nursing Diagnosis:
dysfunctional gastrointestinal motility related to melphalan secondary to bone marrow transplant manifested by
nausea and grimacing while eating.
Impaired skin integrity related to trauma secondary to multiple myeloma manifested by ecchymosis on the left arm

3. Elimination /10
a. Bowel Pattern:
Intact skin X Symmetrical Distention Ascites Others
Peristalsis :
X Present Absent Hypoactive Hyperactive
Abdomen:
Soft Board like Tender Rebound tenderness
Murphy’s sign Mc Burney’s sign Bladder palpable
Digital rectal exam
X Yes, If yes describe: ---the urinary bladder shows thin walls and clear contents, postvoid
No residue is not significant, the prostate measures around 40-45 g, and no free intraperitoneal
fluid.--------------------------------------------------------------------------
Hemorrhoids: X No Yes
Bowel Elimination:
x Normal Colostomy Ileostomy
Characteristics of stool:
Color: ------- Consistency: --------------------------- Frequency: -----2 per
brown------------------------ day---------------------------
Diarrhea Constipation Melena Hematochezia Incontinence
Use of laxatives (type and frequency): ---------
none--------------------------------------------------------------------------------------
b. Urinary Pattern:
Urine color
X Clear Turbid Concentrated Hematuria

Intake / output over 24 hrs

Fluid intake: --------1- Urinary output: ----2 Balance: -------0-500
2LITERS-------------------- LITERS--------------------- ml-------------------------
Urinary Elimination / Micturition
Adequate Polyuria Oliguria Anuria
Dysuria Urgency Hesitancy Retention
Colic pain Incontinence If yes, describe: ------------------------------------------------------------------
X Normal Foley Catheter Suprapubic catheter Urostomy
Nursing Diagnosis:
Urge urinary incontinence related to silosin medication (causes bladder relaxation
… secondary to BPH manifested by frequently waking up at night to urinate.

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 4. Activity/Rest /15
a. Respiratory System
Chest
X Symmetrical Asymmetrical Barrel chest Scoliosis Other: ----------------

Respirations
Rate: -------- Deep Shallow X Regular Tachypnea Bradypnea Orthopnea
Dyspnea Use of intercostal muscles Nasal flaring Cough
Sputum production : ----------------
NONE-----------------------------------------------------------------------------------------------
X Symmetry of breath
Pursed lip breathing Clubbing of the fingers
movements
Hemoptysis Pulse oximetry (SPO2): ---------
Vesicular breath sounds:
X Clear Diminished Absent Symmetrical on both sides
Abnormal breath sounds: none
Wheezing Crackles Rhonchi Stridor
If yes state the location: ---------------------------------------------------------------------------------------------------------
Therapeutic modalities: none
Oxygen therapy: Nasal cannula Facemask Non rebreather mask L/min ------------
Chest tube, specify: Location, characteristics of drainage ( color, quantity, …)
----------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------

Nursing Diagnosis:

b. Cardiovascular System
BP:--- HR: ---67----- X
irregular, If irregular describe:
128/78----- regular
-----------------------------
X X S1 and S2
X Mitral Erb’s point X Pulmonic X Epical Pulse
Palpitations heard
Murmurs X No Yes If yes, describe: ------------------------------------------------------------------------
Peripheral pulses: (describe as: 0= no pulse, 1= weak, 2= normal, 3= bounding)
Brachial(R) - Brachial(L) -
Carotid (R) --2-- Carotid (L) --2-- Radial (R) --2-- Radial (L) -2---
2--- 2---
Dorsalis pedis(R) Dorsalis pedis (L)
--2-- -2---
X Capillary refill < 3sec Jugular vein distention
Signs of arterial insufficiency NONE
Intermittent claudication Calf aching/cramping Cool/cold temperature
Leg numbness Atrophic skin Foot ulcer
Signs of venous insufficiency
Homan's sign Elevation pallor Shiny skin
Loss of hair on extremities Leg edema (uni/bilateral) Varicose veins

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 Foot ulcer If foot ulcer present, describe: ------------------------------------------------------------------------------
Therapeutic modalities:NONE
Angioplasty Pacemaker ICD other: ------------------------------------------
Nursing Diagnosis:

c. Mobility and Activities of Daily Living

Activity level ( level 1= no assistance needed to level 4 = completely dependent): ------3--------------------------
Current activity level: --------------------------3---------------- Fatigue
Need assistance with:
X None Walking Sitting Toileting Bathing Eating/Drinking
Mobility Impairments:
Unable to assess Deformity Amputation Fractures Tremors
History of Falling Impaired Limb None
Gross Motor Movements:
Normal Abnormal Comments
Gait X
Posture X Since patient had multiple myeloma in the vertebrae
Cant perform ROM exercises because of risk of bone
ROM x
fractures
Muscle tone:
Normal Rigid x Spastic Flaccid
Therapeutic modalities:
Cast Traction other: ------------------------------------------
Nursing Diagnosis:

Risk for physical trauma related to low immunity secondary to multiple myeloma manifested by bone
weakness and muscle spasticity

d. Sleep and Rest:

Hours of sleep/day: --8 hrs, Insomnia X No Yes If yes, describe _________________________
(interrupted sleep)------------
Sleeps on more than one pillow x No Yes
Use of medications or sleeping aids x No Yes If yes, describe______________________________________
Nursing Diagnosis:
Disturbed sleeping pattern related to frequent urination secondary to BPH manifested by frequent waking up to go to
the bathroom and being unable to sleep for 8 hrs straight.

5. COGNITION/PERCEPTION /5
a. Mental Status
Oriented : X time X place X person
Problems in memory X No Yes If yes, describe: ----------------------------------------------------------------
Communication difficulties:
Verbal X No Yes If yes, describe: -------------------------------------------------------------------------------
AphasiaX No Yes If yes, describe: -------------------------------------------------------------------------------
Written X No Yes If yes, describe: -------------------------------------------------------------------------------

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 X Cooperative Agitated Delusions Hallucinations
b. Neurological Status
Level of Consciousness:
X Alert Confused Lethargic Stupor Comatose Syncope
c. Motor Function
X Normal Unsteadiness/Imbalance Paraplegia Hemiplegia Quadriplegia
d. Sensory Function
Deficit with pain, temperature, touch sensation? X No Yes related to ------------------------------------------------
Dizziness Headaches (types, location, frequency): ------------------------------------------------------------------
Numbness, Tingling, Burning (location): ----------------------------------------------------------------------------------
Presence of seizure X No
How often? ------------------------- When was the last seizure? ---------------
Yes
Deficit of vision/hearing No X If yes, describe: ----RETENAL
Yes DETACHMENT----------------------------------------------------------
Problem in the assessment of the 12 cranial nerves X No Yes, if yes, describe:
---------------------------------------
e. Reflexes
Eyes (describe size, equality, reaction to light PERRLA):
Left: retinal detachment in the left eye so he sees blurred vision
Right: pupils equal reactive to light accommodation
Corneal reflex x Present Absent Gag reflex x Present Absent
Babinski Present x Absent Other: ------------------------------------------------------------
Nursing Diagnosis: ineffective vision related to blurry vision in the left eye secondary to retinal detachment
manifested by visual eye exam

6. PAIN/ DISCOMFORT /5
Pain: x No Yes. If yes, describe:
P - Provocating and precipitating factors, relieving factors: none
Q - Quality of pain (eg. burning, stabbing, gnawing, shooting, lancinating): none
R- Radiation: none
S- Severity (use an appropriate intensity scale eg:1-10, or other):none
T-Timing: none
U- Understanding: none
Effect on daily activities/ relationships/job/enjoyment of life:none

Facial grimacing X No Yes Guarding affected area x No Yes

Emotional response: ---------------------------------------------------------------------------------
Nursing Diagnosis:

7. SEXUALITY- REPRODUCTION /5
a. Female
Menstruation
Regular Irregular Menopause Vaginal discharges
Number of pregnancies Delivery: Term Premature Sexual concerns
Breast examination

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Page 10
 Normal Color: No Yes Symmetrical: No Yes
Nipple: Normal Inverted Discharge: No Yes
Presence of lymph nodes: No Yes Painful No Yes, Location:
Presence of mass: No Yes
b. Male
Penile lesions, discharge, bleeding X Prostate enlargement Sexual concerns
Nursing Diagnosis:

8. PSYCOSOCIAL INTERACTIONS /5
a. Self –perception (ego integrity)
Affection/Mood
x
Calm Fearful Introvert Euphoric Irritable Hopeless Sad
Anxious
Compromised human dignity Low self esteem
b. Role Relationship
Role within the family structure: ---
Number of children: --------3-------------------------
father-----------------------
Home Situation
Living alone x With family members Financial concerns
Interaction pattern with family
x Active Passive Non-compliant Non-responsive Other: ---------------------------------------
Interaction pattern with staff
x Active Passive Non-compliant Non-responsive Other: ---------------------------------------
How does the family feel about hospitalization? The family is a bit sad that the patient has relapsed but they are
hopeful for the transplant
Who is the family member most supportive of patient? children
c. Coping and stress
Stressors identified by patient: the patient is anxious and stressed because of the chemotherapy and low immunity, and
the thought of getting nauseated because of medication (neutromax)
Reaction to stress: patient is clearly anxious and always guards himself
Coping mechanisms of patient: o top of all that patient is still hopeful for the bone marrow transplant since he has
done it before and it was a success
d. Values and beliefs
Does the disease / hospitalization cause spiritual or cultural distress? Explain briefly.
none
Nursing Diagnosis:
Anxiety related to side effects of myphlon chemotherapy (nausea) secondary to bone marrow transplant manifested by
feeling “restless”, and repitive question regarding normal physical assessment.

DIAGNOSTIC TESTS /5
Date Test/results Normal values Interpretations
1. Blood test
CBC: --WBC=3.92*10^3/UL -Wbc=(4-10)*10^3/ul -white blood
Neutrophils=76.2% -- neutrophils=(40- cells are lower
lymphocytes=13.8% 67)% than normal
monocytes=8.9%-- lymphocytes=(20- because of

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 -eosinophils:0.8% 40)% chemotherapy
basophils=0.3 % monocytes=(2-10)% treatment
RBC=4.10*10^6/UL eosinophils=(1-6)% (neutropenia)
hemoglobin =12.4g/dl basophils(0-2)% same with
hematocrit=37.1% RBC=(4.5- lymphocytes
MCV=90.5 fL 5.5)*10^6/ul -
MCH=30.2pg Hemaglobin=(13-
MCHC=33.4g/dl 17)g/dl
RDW=16.6% Hematocrit=(40-
Platelets=217*10^3/ul 54)% -hemaglobin
MPV=9.2fL------------------------------------------------------------ MCV=(83-100)Fl iss low because
----------------------------------------------------------------------------- MCH=(27-32)pg of
----------------------------------------------------------------------------- MCHC=(31-37)g/dl chemotherapy
----------------------------------------------------------------------------- RDW=(11.5-14.5)% treatement
----------------------------------------------------------------------------- Platelets=(150- during
-------------------------------------------------------------------- 500)*10^3/ul mobilization
MPV=(7.1-11.1)fL -hematocrit
Coagulation Studies: levels decrease
PTT:---------- INR: -1--------- TP: ---------- during
Others: --------none------------------------------------------------- chemotherapy
------------------------------------------------------------------ treatment

FBS (Glucose): --------- HbA1C ----------

SGOT/ AST---------- SGPT/ ALT---------- LDH ----------
Serum albumin----------
Serum protein ----------
Serum bilirubin ----------
Na---------- K-4.3mmol--------- Ca----------
Mg---------- Cl----------
T3---------- T4--------- TSH----------
SH----------
Creatinine level –0.74mg/dl-------- BUN/ Urea -------------

Cardiac enzymes analyses : -------

none-----------------------------------------------------------------------
-------------------------------------
Blood cultures: ------------
none-----------------------------------------------------------------------
---------------------------------------------
Others blood tests:
-----------------
none-----------------------------------------------------------------------
--------------------------------------------------------------

2. Urine test:

Urinalysis: -------------
none-----------------------------------------------------------------------
---------------------------------------------------
Urine Culture------------
none-----------------------------------------------------------------------
-------------------------------------------------
Urine electrolytes ---------
none--------------------------------------------

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 Creatinine clearance ---none-------
Others:
-----------------------------------------------------------------------------
--------------------------------------------------------------

3. Respiratory system:

Chest X-ray: ------the heart is normal size NORMAL

Lungs are clear
Costophrenic angles are free
Rib cage is
intact----------------------------------------------------------------------
-----------------------------------------------------------------------------
--------------------------------------------------------
Arterial blood gases ---------------
none-----------------------------------------------------------------------
-----------------------------------------------------------------------------
-------------------------------------
Sputum analysis/culture -------
none-------------------------------------
-----------------------------------------------------------------------------
-------------------------------------------------------------------------
CT scan/MRI / bronchoscopy of the lungs
----------------------
none-----------------------------------------------------------------------
-----------------------------------------------------------------------------
-------------------------------------------------------
Others:
-----------------------------------------------------------------------------
--------------------------------------------------------------------

4. Cardiovascular system:

ECG: ------------------------
none-----------------------------------------------------------------------
--------------------------------------------------
Echocardiography: ---------
none-----------------------------------------------------------------------
-----------------------------------------------------------------------------
-------------------------------------------
Cardiac catheterization/angiogram: ----
none-----------------------------------------------------------------------
-----------------------------------------------------------------------------
-----------------------------------
Peripheral angiogram-------
none-----------------------------------------------------------------------
-------------------------------------------------
Doppler --------------------
noone----------------------------------------------------------------------
-----------------------------------------------------
Others :
-----------------------------------------------------------------------------
-------------------------------------------------------------------

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Page 13
 5. Musculoskeletal System:

Radiology-x-rays of the bone:

-------------------------
none-----------------------------------------------------------------------
------------------------------------------------------
MRI/ CT Scan: ---------
none-----------------------------------------------------------------------
------------------------------------------------------
EMG: --------------------------
none-----------------------------------------------------------------------
---------------------------------------------
Others:
----------------------------------------------------------------------------- Normal
--------------------------------------------------------------------

6. Gastrointestinal system:

Gastroscopy:
-----------------------------------------------------------------------------
-----------------------------------------------------------------------------
------------------------------------------------------
Abdominal ultrasound: ---abdominal ultrasound was done :
The liver is normal in size and echogenicity . no evidence of
focal hepatic lesions. Adequately distended gallbladder normal
wall thickness with a faint layering sludge and small
nonobstructive gallstones. No pericholecystic fluid. No bile duct
dilation.
The spleen is homogenous and normal in size .
The visualized portions of the pancrease are unremarkable
Both kidneys are normal in size and echogenicity with no
evidence of hydronephrosis soildmasses or
calculi.--------------------------------------------------------------------
-----------------------------------------------------------------------------
-------------------------------------------------------
Colonoscopy: --------------------
none-----------------------------------------------------------------------
------------------------------------------
Stool tests / cultures/ Guaiac: -------
none-----------------------------------------------------------------------
-----------------------------------------------------------------------------
---------------------------------
Others:
-----------------------------------------------------------------------------
-----------------------------------------------------------

7. Urinary :
KUB: ----------------------------none-----------------------------------
------------------------------------------------------------------
Cystoscopy: --------------------
none-----------------------------------------------------------------------
---------------------------
IVU -----------------------
none-----------------------------------------------------------------------

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Page 14
 --------------------------------
CT scann/IRM---------------
none-----------------------------------------------------------------------
-----------------------------
Others
-----------------------------------------------------------------------------
-----------------------------------------------

8. Neurological system:
CT scan/MRI --------------
none-----------------------------------------------------------------------
-----------------------------------------------------------------------------
--------------------------------------------
EEG: ----------------
none-----------------------------------------------------------------------
-----------------------------------------------------------------------------
------------------------------------------------------
Cerebral Angiogram: --------
none-----------------------------------------------------------------------
---------------------------------------------
Lumber puncture: -----
none-----------------------------------------------------------------------
------------------------------------
Others:
-----------------------------------------------------------------------------
-----------------------------------------------

9. Reproductive system:
Pap smear : -------------------
none-----------------------------------------------------------------------
--------------------------
Mammography------------
none-----------------------------------------------------------------------
-------------------------------
Breast ultrasound -------
none-----------------------------------------------------------------------
---------------------------------
Pelvic ultrasound ---a pelvic ultrasound was done:
---the urinary bladder was examined at the capacity of 170ml.it
shows thin walls and clear contents
The postvoid residue measures 25 ml
The prostate measures around 35g
No free intraperitoneal
fluid-----------------------------------------------------------------------
----------------------------------
Digital Rectal exam --------
none-----------------------------------------------------------------------
-----------------------------
PSA blood test: ------
none-----------------------------------------------------------------------
------------------------------------
Others
-----------------------------------------------------------------------------
-----------------------------------------------

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Page 15
Progress Notes (SOAPIE) / 10
Day 1 (Date): --22/9/2022-----------------------------------

--Subjective: Mr. ET 55-year-old male admitted for bone marrow transplant and has multiple myeloma.

Today 22/9/2022 patient is day 3 post chemotherapy and day1 post bone marrow transplant.
Patient reported no nausea or vomiting. He is having normal bowel movement and normal urine excretion and gas
excretion.

Objective:
Temperature :36.6 Celsius
Heart rate :84 beats per minute
Respiration :16 breathes per minute
Blood pressure :101/62
SPO2:95%
-no blood tests were done today

Assessment: patient is conscious, cooperative, oriented to time, place, and person, patient is calm not as nervous
as when the chemotherapy was administered. Patient is independent in walking and activities of daily living. Patient
can move four limbs’ arms and legs. Patient diet is low salt and low fat to remove any possible complications
(tolerated). Patient is hopeful because he is feeling well today no nausea vomiting, ulcers or dysphagia. Patient has
positive bowel movement, positive stool positive and clear urine. No burning sensation while urinating .skin is intact
and normal no scars or ulcers except a small ecchymosis on his left arm. Patient is breathing properly no sign of
difficulty breathing. heart rate is normal.
Patient has a risk for fall
And risk for pressure ulcers

Planning: since patient is well today:

Help the Mr. ET to walk every day for 15-20 minutes to facilitate venous return and relief
Prevent any pressure ulcers

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Prevent any risk of fall that might occur.

--------------------------------------------------------------------------------------------------Intervention: move patient every

1 hour to a different position and posture
Help patient walk everyday

Raise the rails of the bed and check on patient every 30 minutes to half an hour ---------------------

Evaluation: ---patient is walking (met)

Patient is being changed position every 1 hour(met)
Rails are always raised and nurses check on patient every 30 minutes to one hour so no risk of fall---
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Day 2 (Date): --------23/9/2022--------------------------------

--Subjective: Mr. ET 55 years old male admitted for bone marrow transplant, and is medically diagnosed with
multiple myeloma. today 23/9/2022 patient is on day 4 post chemotherapy and day 2 post-transplant patient
reported “I am a bit nauseated but I have normal bowel movement (no diarrhea0, and overall, I’m eating 3 meals a
day.”—patient also reported positive gas
-Objective: vital signs:
temperature:37.2 Celsius-
SPO2:96-%
Heart rate: 106 bpm (a bit high sense patient has still not take antihypertensive medication)
Blood pressure :103/62
Respiration: 16 breathes per minute
Blood tests were done on 23/9/2022:
CBC:
WBC: (17.61*10^3/ul) (WBC and Neutrophils are high since stem cells are still day 2 post-transplant so they still
haven’t matured)
-Neutrophils (--97.7%)

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Hemoglobin (11.6g/dl)
Hematocrit (34.2%)
Platelets (132*10^3/ul)
Creatinine :0.81 mg/dl
Potassium:4.3 mmol/l-----
-Assessment: patient’s pain score is 0. Patient is conscious cooperative oriented to time, place, and person, patient is
also a bit anxious. He is independent in walking ( no assistance),and is independent in activities of daily
living .patient can move four extremities normally without any struggle (arms and legs).patient’s diets is low salt and
low fat tolerated, and he suffers from minimal nausea, no vomiting no ulcers, and no dysphagia. Abdomen is soft ,
positive bowel movement, gas positive stool positive, no hemorrhoids ,and urine is positive and clear. No burning
sensation while urinating. skin is intact no signs of scars and ulcers. However patient suffers from ecchymosis on the
left hand.(normal symptom of multiple myeloma)
Cardiovascular exam : heart rate is normal s1 and s2 is heard in addition to the valves
(pulmonary ,aortic,mitral,tricuspid) 4 pulses are regular and present in both hands and feet.no feet and arterial
edema related to arterial insufficiency.
Respiratory exam: lungs are clear no coughing, no dyspnea, no secretions ,and regular respiratory rate .
Central line in right jugular vein is present. gauze is regular (no redness or inflammation around it), serum is
working and regular.
Blood return is evident
Treatment is given on time PO and IV, no reaction and as prescribed.----------------------------------------------------------
Patient has a high risk for fall because of muscle spasticity and weak bones
Patient also has a high risk for pressure ulcers since patient is mostly laying on the bed with no enough movement.
-Planning: let patient walk for at least 15 minutes –in hospital corridors if possible, with the assistance of a nurse to
facilitate relief
-Decrease anxiety -----------------------------
Restrict fall risk and pressure injurie
Intervention: --to decrease patient anxiety assure- the patient that if forbid any complication happens that nurses
and doctors will always be here to help and to press on the button for any misunderstanding or any complaint and
also administer Alprox medication (antianxiety)as prescribed by the physician–
Restrict fall risk by checking on patient every one hour and pulling the rails of the bed and making sure that the
button of assistance is beside them.
Decrease pressure ulcers by changing position of patient every 1hour.
Monitor lab results (platelets in any case of hemorrhage)
---Evaluation: patient is walking ad not immobilized to bed(met)
Patient is still a bit anxious but is getting calmer after reassuring (half met)
Rails are always pulled up for any fall risk and patient has not been close to falling at all(met)-

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Lab results and blood tests are normal for each stage of the transplant he is in
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 UNIVERSITY OF BALAMAND
Faculty of Health Sciences
Nursing Program
NURSING PROCESS
NURS 241, NURS242 and NURS248

B. Nursing Care plan

List of Nursing Diagnosis in Priority Order /15

1. Anxiety related to side effects of melphalan chemotherapy (nausea) secondary to bone marrow transplant manifested by
feeling “restless”, and repitive question regarding normal physical assessment
Dysfunctional gastrointestinal motility related to melphalan secondary to bone marrow transplant manifested by nausea and
grimacing while eating.
2.
Impaired skin integrity related to trauma secondary to multiple myeloma manifested by ecchymosis on the left arm.
3.
4. Urge urinary incontinence related to silosin medication (causes bladder relaxation)
secondary to BPH manifested by frequently waking up at night to urinate
5. Ineffective vision related to blurry vision in the left eye secondary to retinal detachment manifested by visual eye exam.

Disturbed sleeping pattern related to frequent urination secondary to BPH manifested by frequent waking up to go to the
bathroom and being unable to sleep for 8 hrs. straight.
6.
7. Risk for infection related to low immunity secondary to chemotherapy (melphalan) .

Risk for physical trauma related to low immunity secondary to multiple myeloma manifested by bone weakness and muscle
spasticity
8.
9.

10.

11.

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12.

Nursing Diagnosis Elaboration (2 major ND) /30

Nursing Diagnosis / Scientific Explanation Expected Nursing Rationale of the Evaluation
Collaborative /3 Outcomes / Nursing Interventions Interventions /2
Problems Objectives /5 /3
/2
During autograft of a bone
marrow there are three phases
that the patients go through that
Dysfunctional more than often causes nausea 1-outcome was
gastrointestinal and vomiting: 1- Decrease 1-administer 1-primperan met after
1- Mobilization nausea for primperan decreases nausea administering
motility related to Patient starts chemotherapy to the patient 10mg/IV/Q8hrs 2-food could help primperan
melphalan get rid of all the cells in the body 2- Facilitate 2-try to give patient patient feel better 10mg for the
secondary to bone the abnormal and normal cells. At eating for foods that are less and gain his enegry patient
marrow this time the patient will the patient nauseating to him 2-patient is
transplant obviously be neutropenic and will because of while staying in low eating well all
feel nauseated and may low salt low fat diet 3-helps equalize his 3 meals
manifested by experience vomiting. immunity 3-advise patient to temperature daily.
nausea and At this phase chest x-rays and drink clear or cold difference between
grimacing and abdomen-pelvic ultrasounds are drinks mouth and
lower levels of ordered to check for any sign of 4-monitor therapeutic gastrointestinal
eating than usual infection or abnormality. effect tract.
2- cataphoresis:
During this phase the withdrawal
of stem cells from the bone is

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 started. At this time the patient is
still neutropenic with low
hemoglobin and low platelets and
the immunity is low, GCSF
injections are gradually
administered to boost the immune
system of the patient. Calcium is
also given because large number
of bloods is being taken.
After the stem cells have been
withdrawal the patient can go
back home, and stem cells are
frozen in a bag with ozot
medication in freezer at a very
low temperature.
3- Graff /transplant
At phase three which is the
graph patient is given
another type of
chemotherapy which is called
melphalan which is a really
strong chemotherapy that
leaves the patient in a state of
nadir(which is a state at
which all cells in the body are
killed after chemotherapy
treatment lasts 7-12 days)
and one of the major Sid
effects of this chemotherapy
treatment is it causes extreme
nausea and vomiting for the
patient. After that GCSF
injections are given once
again to help stem cells
proliferate and grow and
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 increase immunity f the
patient. The patient is also
advised while taking
melphalan treatment to eat
ice cubes before 5 minutes of
the treatment during the
treatment for 5 minutes and
after the treatment in half an
hour to prevent ulcers in the
mouth (vasoconstriction
occurs)
Nursing Diagnosis / Scientific Explanation Expected Nursing Rationale of the Evaluation
Collaborative /3 Outcomes / Nursing Interventions Interventions /2
Problems Objectives /5 /3
/2
Impaired skin Multiple myeloma is a type of 1- Decrease
integrity related to blood cancer that targets plasma the amount 1-put the patient in a 1-the amount of 1-outcome is
trauma secondary to cells. of position that rests ecchymosis on the met since
multiple myeloma Plasma cells proliferate ecchymosis their arms and rest hand will decrease ecchymosis are
manifested by interfering with the production of patches on the affected area after resting decreasing each
ecchymosis on the left blood cells and possibly causing the arm 2-administer a 2-heating pads day
arm. soft tissue masses or lytic lesions 2- Decrease heating pack several facilitate 2-Patient did
in the skeleton. the amount times a day after vasodilation which not cause any
In addition to production of of trauma injury allows blood to flow trauma like
abnormal antibodies (monoclonal that might 3-raising injured more readily hitting his hand
proteins) occurs leading to cause limbs about your 3- Prevent any on the sofa or
impaired humoral immunity. ecchymosis heart to prevent swelling that bed so no new
This type of cancer has several painful swelling could cause ecchymosis has
signs and symptoms but evident complication occurs
signs this patient has is bone pain
in the vertebra and ecchymosis.
Ecchymosis: they are painless
round non-blanching pinpoint
lesion are usually purple blue or

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 yellow green up to 3mm and
larger in diameter and arise on
the body as a result of trauma.

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