NURSING INTERVENTIONS

GOAL: To maintain nutrition

o Diet: appropriate to age level
o Increase calories, protein and iron
o Supplemental vitamins
o Small frequent fdgs.
o Increase fluid intake
o Between-meal supplements
o Encourage family to provide client with favorite foods
o Hyperalimentation
o Prevent and/or decrease complications associated with nutrition

GOAL: To maintain normal elimination pattern

o Encourage verbalization
o Provide adequate fluids and fiber in diet
o Prevent and/or decrease complicated of diarrhea
o Fresh fruits and vegetables should be eaten only after they have been cooked, peeled or
washed thoroughly
o Prevent UTI
o Assess for the dev’t of vesicovaginal or rectovaginal fistulas
o Minimize embarrassment of incontinence and provide hygiene measures

GOAL: To prevent and/or decrease infectious process

o Encourage verbalization
o Careful assessment of the temp elevations
o Administer abx
o Meticulous personal hygiene
o Isolation from others with communicable disease
o Frequent assessment for potential infection process
o Explain that skin rx. After radiation therapy may not develop from 10-14 days and may not
subside until 2-4 weeks after tx

GOAL: To prevent and/or decrease Hematological complications

o Encourage verbalization
o Evaluate for decreasing platelet levels and thrombocytopenia
o Administer platelets and whole blood transfusions as indicated
o Evaluate areas of potential bleeding
o Nosebleed (epistaxis)
o Urinary tract (hematuria0
o Stool (melena)
o Mucous membranes
o Anemia
o Maintain adequate rest
o Maintain adequate oxygenation
o Assess for problems with erythropoiesis
o Evaluate respiratory and cardiac systems
o Encourage a diet high in protein, vitamins and iron.

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GOAL: To maintain activity level
o Encourage daily activities within limitations of disease process
o Assist client to evaluate activity patterns and encourage periods of rest
o Avoid fatigue
GOAL: To relieve pain
o Evaluate client’s and family’s response to pain
o Evaluate characteristics of pain
o Promote general comfort
o Administer medication for pain relief

GOAL: To recognize complications specific to radiation and chemotherapy

o Alopecia
o Hemorrhage problems
o GIT problems
o Bone marrow depression (myelosuppression)
o Thrombocytopenia
o Anemia
o Neutropenia
o Skin reactions
o Decreased immune response

GOAL: To recognize oncological emergencies life-threatening problems arising tumor

progression of treatment response
o OBSTRUCTIVE EMERGENCIES:
o Superior vena caval syndrome
o Spinal cord compression
o Third space syndrome
o Intestinal obstruction
o Bronchial airway obstruction
o METABOLIC EMERGENCIES
o Syndrome of inappropriate antidiuretic hormone
o Hypercalcemia
o Tumor lysis syndrome
 Hyperuricemia
 Hyperphosphatemia
 Hypekalemia
 Hypocalcemia
o INFILTRATIVE EMERGENCIES
o Cardiac tamponade
o Carotid artery rupture
o DISSEMINATED INTRAVASCULAR COAGULATION

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GOAL: To effectively manage pain to provide client’s optimal rest and pain relief
o Assess quality, intensity, timing, and location of pain
o Identify provoking and alleviating factors affecting pain tolerance
o Evaluate level of consciousness and level of sedation before and after pain therapies
o Discuss question regarding addiction to narcotic analgesics
o Assist client with non-pharmacological pain therapies
o BENEFFITS OF CRITICAL THINKING SKILLS by a nurse during pain management of post-op
patient
o Enhancing the nurse’s client decisions making
o Planning the best nursing actions to assist the patient
o Increasing the accuracy of the nurse’s judgements
o Helping identify the patient’s priority needs
o Layer pain mgt. strategies as needed
o Analgesics with sedative
o Biofeedback with aromatherapy
o Provide a calm, healthy environment with appropriate lighting and personal belongings
o Advocate for PCA when appropriate
o Medicate with narcotic and non-narcotic analgesics as requires
o Assess effectiveness of therapies and medication and modify as necessary
o When appropriate, suggest hospice care, which can provide compassion, concern and support
for the dying.
GOAL: To decrease or limit exposure to infection
o Limit number of people having direct contact with the client
o Good oral hygiene
o Client should avoid coming in direct contact with animal excreta
o Teach client to take his temp daily and report temp over 100’F or 38’C
o Use antipyretics carefully
o Peak of neutropenia
o Teach client about and manage induced skin reactions

GOAL: Terminal cancer: THE ATTRIBUTES SHOULD A NURSE ACKNOWLEGE AT THE END
OF LIFE
o Maintain one’s dignity
o Maintaining a sense of humor
o Resolving unfinished business with family
o Saying goodbye to important people
o They wanted to be mentally alert not sedated
o They may plan their own funeral arrangements

GOAL: Counselling a family of a client who died from terminal cancer

o Listening actively without judgements
o Encouraging time with the body of the decreased at the time of death
o Assisting the family member in further identifying the meaning of the loss in practical terms
o The family should be advised to minimize change
o The nurse should listen actively and provide practical feedback as app.
o The nurse should assist family in grieving by allowing ample time to repeat the story of the
death, come to understand the meaning of death and then move to acceptance
o The should be set by the grieving family
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