NURSING CARE PLAN NAME OF STUDENT: NAME OF CLIENT: DIAGNOSIS OR CLINICAL IMPRESSION: Laryngeal Cancer CUES S: NURSING HEALTH

HISTORY - 58 years old male - With family history of hypertension and stroke - Lifestyle: 69 pack years, chronic alcoholic, past illegal drug user - Had history of fever after radiation therapy but was resolved with medications - Increase in intake of food and vegetables was initiated - Doctor prescribed 1.5L of fluid intake - Radiation therapy finished 1 0 days PTA, 3rd cycle of chemotherapy - Post-surgical client, immunosuppressed, chronically ill O: PHYSICAL EXAMINATION - Vital signs: RR 20 breaths/min BP 120/70mmHg, L arm PR- 67/min, L arm, radial T-35.9^C - Skin graft over mouth extending to neck - Mark from tracheostomy, midline, neck, 0.5 cm diameter - Lateral mouth erosions - Decreased intake of food, difficulty swallowing (blenderized feeding) LABORATORY RESULTS (02/14/11) Hgb: 84 g/L LOW RBC: 2.80 10^12/L LOW NURSING DIAGNOSIS Risk for Infection r/t compromis ed immune defenses secondary to cancer BACKGROUND KNOWLEDGE RISK FOR INFECTION is defined as at increased risk for being invaded by pathogenic organisms. (Doenges, 2004) Presence of a healing wound may still be subjected to different scenarios wherein certain pathogens, both virulent and opportunistic, may get involved. Proper hygiene and environmental sanitation may be practiced to decrease the chances of getting infection. Such activities like proper handwashing and using disinfectants are some. (Microbiology for the Health Sciences, Burton & Engelkirk, 1996) Increased risk of infection in clients with chemotherapy treatments due to destruction of rapidly GOALS AND OBJECTIVES GOAL: By the end of the duty, Mr. C will demonstrate no signs of infection. OBJECTIVES: By the end of the nursing intervention, the client will: 1. Not develop further breaks from primary defenses 1. Maintain strict asepsis when performing procedures to client. R: Asepsis will prevent client from entry o organisms thus, protecting her from infection. 2. Exercise meticulous handwashing before and after handling patient. R: Frequent, meticulous handwashing greatly decreases the chanced of spreaing infection. 3. Check presence of invasive devices and monitor their present condition. R: Checking of condition of lines or devices, their duration of attachment will help the nurse identify possible sources of infection, which she then can remove. 4. Monitor vital signs especially temperature every 4 hours. R: Fever or hypothermia may indicate presence of infection. 1. Not acquire any infective organism. DATE OF ASSIGNMENT: CIVIL STATUS: AGE: SEX: WARD: CI BED: NURSING INTERVENTIONS AND RATIONALE During nursing intervention, the student nurse will: EVALUATION By the end of the shift, the client will be able to:

HCT: 0.249% LOW WBC: 6.88 10^9/L NORMAL Neutrophil 0.745 HIGH Lymphocyte = 0.112 LOW Mono = 0.103 NORMAL Eoso = 0.300 NORMAL Baso = 0.001 NORMAL

dividing hematopoietic cells, resulting in immunosuppression. (Gale, 1994)

2. Achieve timely wound healing with no infection.

5. Check incisions/ wounds for signs of infection. R: Skin and mucosa provide first line defense against microorganisms. 6. Cleanse mouth erosions, if not contraindicated. R: Ensures that wound is free from infection- causing organisms and is kept clean to prevent infections. 7. Provide meticulous skin care (cleansing bath) R: To prevent skin breakdown which is a possible way of infection. 8. Assist with oral care (Orahex) if needed. R: Provides care if client is unable. 9. Promote frequent and adequate fluid intake. R: To liquefy secretions and facilitate expectorations to prevent stasis of body fluids and promotes moist mucus membranes. 10. Encourage to apply lubricant (petroleum jelly) to lips and skin graft. R: Keeps areas moist. 11. Encourage frequent position changes/ambulation, coughing, and deep breathing exercises. R: To promote ventilation in all lung segments and aids in mobilizing secretions to prevent pneumonia. 12. Provide health teaching on: - possible individual causes of infection to establish an 2. Cleanliness and hygiene are maintained at wound sites and bed sides.

3. Identify techniques to prevent skin infection

3. Developed resistance to infection through techniques

information background for the patient. - techniques to prevent or reduce risk of infection to initialize learning of patient. - proper handwashing technique to client because it is the most basic technique to prevent infection. - thorough handwashing technique to other patients and caregivers to encourage client to practice learned skill. - avoidance of people with respiratory infections and respiratory diseases - effect of chemotherapy and radiation therapy on body
S: NURSING HEALTH HISTORY - 58 years old male - With family history of hypertension and stroke - Lifestyle: 69 pack years, chronic alcoholic, past illegal drug user - Reports difficulty swallowing - SO verbalized that client only eats a few spoons during lunch and dinner, but occasionally looks for food in between meal times - Chemotherapeutic drug: Cis-5FU O: PHYSICAL EXAMINATION - Vital signs: RR 20 breaths/min BP 120/70mmHg, L arm PR- 67/min, L arm, radial - Upper and lower extremities: nail beds pale, 1 sec capillary refill - Peripheral pulses: regular - Difficulty in swallowing - Height: 160 cm Weight: 46.5 kg Cachexic with distinct bony Imbalanced Nutrition: Less than Body Requiremen ts related to decreased intake and early satiety secondary to nausea and vomiting and difficulty swallowing IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS is defined as Intake of nutrients insufficient to meet metabolic needs (Doenges, 2004). Medicine looks on nausea and vomiting as pathophysiological responses accompanying certain tumors and tumor locations and as unavoidable side-effects in some forms of therapy. Medical treatment involves prescribing antiemetics and sedation to reduce symptom occurrence or emotional distress, GOAL: By the end of the duty, the client will maintain nutritional status, minimize weight loss and experience less nausea and vomiting. OBJECTIVES: By the end of the nursing intervention, the client will: 1. Identify predisposing factors that lead to undernourishment of patient 1. Teach mother the possible predisposing factors that lead to undernourishment of patient. R: To initiate learning. 2. Provide information regarding the dietary plan for the client. R: To provide ongoing support and increase likelihood of accomplishing dietary goals. 2. Follow the dietary plan for patient 3. Instruct patient to avoid unpleasant sights, odor, sounds in the environment during mealtime. R: Decrease in 2. Followed the dietary plan for patient as evidenced by the following: 1. Identified all predisposing factors that lead to undernourishment of patient During the nursing intervention, the student nurse will: After the nursing intervention, the client will:

prominences (+) skin pallor -Smooth, warm, dry skin with fair turgor (+) muscle wasting Pale conjuctiva, mucosa and nailbeds (+) thinning of hair LABORATORY RESULTS (02/14/11) Hgb: 84 g/L LOW RBC: 2.80 10^12/L LOW HCT: 0.249% LOW Ca: 2.17 mmol/L Na: 140 mmol/L K: 3.5 mmol/L (Borderline) Mg: 0.8 mmol/L

and managing any associated nutriotional deficits or F&E imbalances. Nausea is a vague but distinctly disagreeably queasy feeling in the stomach and a tightening sensation in the throat accompanied by a strong revulsion toward food and eating. It is usually preceded by anorexia. Vomiting is a sudden, powerful oral expulsion of stomach contents. This two often follows the negative effect on eating, sleeping and controlling activities. ( The Cancer Experience, Carnevali, 1990)

appetite can be stimulated with noxious stimuli.

4. Suggest foods that are preferred and well tolerated by the patient, preferably highcalorie and high-protein foods. R: Foods preferred, well tolerated, and high in calories and protein maintain nutritional status during periods of increased metabolic demand. 5. Encourage adequate fluid intake, but limit fluids at mealtime. R: Fluids are necessary to eliminate wastes and prevent dehydration. Increased fluids with meals can lead to early satiety. 6. Suggest smaller, more frequent meals. R: Smaller, more frequent meals are better tolerated because early satiety does not occur. 7. Promote relaxed, quiet environment during mealtime with increased social interaction as desired. R: A quiet environment promotes relaxation. Social interaction at mealtime increases appetite. 8. Consider cold foods, if desired. R: Cold, high protein foods are often more tolerable and less odorous than hot foods. 9. Advocate high-protein foods in between meals. Snacks add protein and calories to meet

reported decreasing anorexia and increased interest in eating demonstrated normal skin turgor used appropriate imagery and relaxation before meals consumed diet high in required nutrients carried out oral hygiene before meals reported decreasing episodes of nausea and vomiting participated in increasing levels of activity

nutritional requirements.
3. Verbalize understanding of causative factors and necessary interventions 10. Encourage frequent oral hygiene. R: Oral hygiene stimulates appetite and increases saliva production. 11. Use distraction or conversation before and during chemotherapy. R: Decreases anxiety which can contribute to nausea and vomiting. 12. Position patient properly at mealtime. R: Proper body position and alignment are necessary to aid chewing and swallowing. 4. Demonstrate progressive weight gain toward goal 15.Encourage to verbalize understanding of the treatment plan for client R: to enable the independency in implementation of it. 16. Instruct to monitor weight of patient every week and record it on a weekly log. R: To have a baseline for either development or deviation from goal During nursing intervention, the student nurse will:

3.Verbalized understanding of the need for lifestyle modifications of patient

4.Demonstrated progressive weight gain toward goal.

S: NURSING HEALTH HISTORY - 58 years old male - With family history of hypertension and stroke - Lifestyle: 69 pack years, chronic alcoholic, past illegal drug user - Reported occasional episodes of chest pain/heaviness, dyspnea - Radiation therapy finished 1 0 days PTA - Reports decreased level of activity compared to condition prior to illness

Ineffective Peripheral Tissue Perfusion related to Decreased oxygen carrying capacity of the blood and increased oxygen

INEFFECTIVE PERIPHERAL TISSUE PERFUSION is defined as decrease in oxygen resulting in the failure to nourish tissues at the capillary level (Doenges, 2004). Chemotherapy causes myelosuppresion which results to

GOAL: By the end of the shift, Mr. C will maintain optimal tissue perfusion to vital organs OBJECTIVES: NOC: Circulatory Monitoring 1. Display hemodynamic stability.

By the end of the shift, Mr. C will be able to:

NIC: Circulatory Care 1. Monitor hemodynamic stability indicators (vital signs, peripheral pulses, capillary refill time, pallor, skin temperature, 1. Display hemodynamic stability by having the following within normal parameters:

- Has no DOB - Reports dizziness when suddenly sits up O: PHYSICAL EXAMINATION - Vital signs: RR 20 breaths/min BP 120/70mmHg, L arm PR- 67/min, L arm, radial - Upper and lower extremities: nail beds pale, 1 sec capillary refill - Peripheral pulses: regular - Difficulty in swallowing - (+) pallor: conjunctiva LABORATORY RESULTS (02/14/11) Hgb: 84 g/L LOW RBC: 2.80 10^12/L LOW HCT: 0.249% LOW MCV: 88.9 fL MCH: 30 pg

demand secondary to chronic illness

anemia. Anemia presents with a decreased level of Hemoglobin concentration. (Gale, 1994) Weakness, immobility, fatigue and inactivity typically increase with advanced cancer as a result of the disease, treatment, inadequate nutritional intake or dyspnea. Bone marrow depression after certain types of chemotherapy and radiation theraoy often results to decreased production of RBC and thrombocytopenia. Because of decreased RBC, and hemoglobin concentration, the carrier of oxygen to the different parts of the body and the periphery is less. Because of these, ineffective tissue perfusion ensues. (Porth, 2007) 2. Display absent episodes of pallor and coldness on extremities.

vital signs) and compare with baseline. Rationale: They are the baseline to indicate the status of cardiac output.

2. Provide skin and foot care. R: Prevents skin integrity problems and decreases chances of hypothermia. 3. Keep extremities warm through warm sponge bath. R: This prevents hypothermia.

blood pressure heart rate respiratory rate temperature peripheral pulses capillary refill time nail beds, color 2. Display absent episodes of: pallor coldness on extremities

3. Reduce workload of the heart.

4. Place Mr. C in semi-Fowlers position or his preferred position of comfort. If not preferred, recommend orthopneic position. Rationale: This position decreases workload of breathing, and venous return and preload to the heart. Arterial Interference: Head and chest elevated, and extremities in dependent position Do not use pillows under knees. 5. Elevate head of bed to 30 degrees or as tolerated or preferred. R: This promotes venous drainage from the head. 6. Advise to change position at least every 2 hours during waking time. R: Prevents pooling of blood. 7. Promote a calm and restful

3. Participate in activities that reduce the workload of the heart.

environment using script for Noninvasive Measure combining relaxation, rhythmic breathing, and imagery. Rationale: Reduction in myocardial oxygen demand can be achieved by allowing for rest and relaxation periods. 8. Stress importance of avoiding straining/ bearing down, especially during defecation. R: Valsalva maneuver causes vagal stimulation, reducing heart rate (bradycardia), which may be followed by rebound tachycardia, both of which impairs cardiac output. 9. Instruct on increasing fiberrich foods and increase in liquid diet to avoid Valsalva maneuver on defecation. R: Fiber and water soften wastes excreted and avoids constipation. 4. Maintain normal level of fluid balance. 10. Measure intake and output every shift. R: Monitoring for increased fluid in the body is vital in knowing fluid imbalances. NIC: Neurologic Management [4150] 11. Monitor neurologic status: Glasgow Coma Scale, papillary size and response, cardiovascular and respiratory status in accordance with schedule. R: Routine neuroassessment can cause slight increases in intracranial pressure. 5. Demonstrate within normal parameters: papillary size and response Glasgow coma scale

4. Normal level of I&O

NOC: Neurocognitive 5. Display normal neurologic status.

13. Provide comfort measures. Gently touch face or hand. Talk quietly with patient. R: This relaxes and calms patient. NIC: Activity Tolerance [0005] 6. Demonstrate adequate response to activities. NIC: Energy Management [0180] 14. Observe patient's schedule. Allow rest periods between all activities. R: Rest between activities provides time for energy conservation and recovery. Heart rate recovery following activity is greatest at the beginning of a rest period. 15. Perform light range of motion exercises but in between rest periods allowed . R: Light exercise will promote normal sleep/rest pattern. 16. Discourage client from wearing constricting clothes. R: Decreases circulation of blood. 17. Assist patient in prioritizing tasks in life and seeking assistance from family/friends in those tasks patient is unable to perform. R: Conserves energy. 8. Perform relaxation strategies. 18. Instruct on possible relaxation strategies. R: Relaxation strategies help conserve energy and decrease stress. 19. Inform on other possible and nonpharmacologic manage-

6. Demonstrate decreased episodes of: increase in ICP increase in blood pressure

7. Report absent: difficulty of breathing at rest difficulty of breathing in mild exertion. 8. Display adequate management of activities and rest. 9. Display: Light range-of-motion (ROM) exercises in bed, progressing to sitting 10. Display absent: Chest discomfort Hypotension Tachycardia or arrhythmia Cool, moist, cyanotic extremities

7. Demonstrate increased selfmanagement of ADL's.

11. Accurately perform a chosen relaxation strategy.

9. State other possible

12. State other possible

nonpharmacological strategies.

ment of cancer related fatigue [journal]. R: Research on these interventions has yielded positive outcomes in cancer survivors with different diagnoses undergoing a variety of cancer treatments (Mustian, et. al., 2007). - Exercise: Resistance and Walking - Psychosocial: Individual/Group - Yoga, Mindfulness-Based Stress Reduction, Sleep Therapy, Nutrition Therapy, Polarity Therapy

nonpharmacological strategies.

10. Verbalize understanding of health teaching.

20. Provide health teaching on: - importance of prioritization of activities - recognition of signs of fatigue (Talk Test) - asking for family/friends for help - effect of Hgb on chemotherapy - expectation of fatigue as side effect of chemotherapy - Importance of protein and iron in diet

13. Verbalize understanding of health teaching on: importance of prioritization of activities recognition of signs of fatigue (Talk Test) asking for family/friends for help effect of Hgb on chemotherapy expectation of fatigue as side effect of chemotherapy Importance of protein in diet After nursing intervention, the client will be able to:

S: NURSING HEALTH HISTORY - 58 years old male - With family history of hypertension and stroke - Lifestyle: 69 pack years, chronic alcoholic, past illegal drug user - Tracheostomy tube removed - Radiation therapy finished 1 0 days PTA, 3rd cycle of chemotheraoy - Post-surgical client (glossectomy), immunosuppressed, chronically ill - Reports dysphagia

Readiness for Enhanced Coping

Readiness for Enhanced Coping is defines as A pattern of cognitive and behavioral efforts to manage demands that is sufficient for well-being and can be strengthened. (Doenges, 2004).

GOAL: After nursing intervention, the client will express feelings of optimism about the present. OBJECTIVES: NOC: Coping 1. Reports decrease in stress.

During nursing intervention, the student nurse will: NIC: Coping Enhancement 1. Review extent of feelings of anxiety. R: There is a need to know the extent of disequilibrium and need for intervention to prevent or resolve the crisis.

1. Consistently report a decrease in stress

O: PHYSICAL EXAMINATION - Vital signs: RR 20 breaths/min BP 120/70mmHg, L arm PR- 67/min, L arm, radial T-35.9^C - Skin graft over mouth extending to neck - Mark from tracheostomy, midline, neck, 0.5 cm diameter - Lateral mouth erosions - Hoarse/slurred speech - Coherent, oriented to time person and place

2. Discuss indication and method of treatment. R: Promotes active participation of client in therapeutic regimen. 3. Note expressions of indecision, dependence on others, and inability to manage own ADL's. R: May indicate need to lean on others for a time. 2. Uses behaviors to reduce stress. 4. Assess presence of positive coping skillls/inner strengths e.g (use of relaxation techniques, willingness to express feelings, use of support systems). R: Past coping skills may be reused to relieve tension and preserve individual's sense of control. 5. Encourage patient to talk about what is happening at this time and what has occurred to precipitate feelings of anxiety. R: Provides clues to asses patient to develop coping and regain equilibrium. 6. Evaluate ability to understand events and correct misconceptions by providing factual information. R: Assists in the identification and correction of perception of reality.

2. Verbalize in own words the relevant information about treatment

3. Demonstrate at 3 least behaviors to reduce stress use of relaxation techniques, willingness to express feelings, use of support systems

References:

Carpenito-Moyet, L. J. (2008) Handbook of Nursing Diagnosis (12th ed.). Philadelphia: Lippincott Williams & Wilkins Doenges, M., Moorhouse, M. F. & Murr, A. (2006). Nurses pocket guide: Diagnoses, prioritized interventions and rationales. Philadelphia: F.A. Davis Gale, S. (1994). Oncology Nursing. Texas: Skidmore-Roth Co. Mustian, K.,Morrow, G., Carroll, J., et. al., (2007). Integrative Nonpharmacologic Behavioral Interventions for the Management of Cancer-Related Fatigue. Oncologist 2007;12;52-67. Retrieved from http://www.TheOncologist.com/cgi/content/full/12/suppl_1/52