NANDA: RISK FOR INJURY RELATED TO CHEMOTERAPY

Problem: Pain
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Acute pain After 8 After 8 hours of After 8
The 17y/o related to hours of nursing hours of
client diagnosis, nursing intervention, the nursing
verbalized treatment, intervention student nurse to: intervention,
that he feels and the patient Goal
pain on the physiologic will: -Use partially
on the IV sit effects of pharmacologic TO minimize met.
and that leukemia as Child will and non- discomfort
body at evidence experience pharmacologic
general. by: child no pain or interventions
crying, verbalize a before painful
reluctant to pain scale procedures. To determine
Objective move, of at least baseline data
Change in moderate Assess pain and
-Facial v/s and and monitor for v/s q4 To prevent pain.
grimace facial verbalize
grimace. comfort
-Crying Administer
analgesics as
-Reluctant to prescribed
move.

Change in Child will

V/S receive
prompt
appropriate
-Protects treatment of -To provide
hand when complication psychological This will reduce
examiner counseling to the the anxiety of
tries to family of the the family
assess the client by prying members.
site with them.

: NOC
NIC
Pain control
Pain level Pain
Disruptive management
V/S effect
T=37.5 °C

RR=27cpm

PR=130
14bpm

Bp
90/80mmHg

Pain scale:
6/10

NANAD: Anxiety
Problem: Fear

Assessme Intervention
Diagnosis Planning Evaluation
nt Action Rationale
Subjective Fear related After 8 After 8 hours of The nursing Goal met
to hours of nursing intervention, interventions
The 16 y/o diagnostic nursing the nurse will: provided are
client procedures, intervention aimed:
verbalized and the patient
that he is treatment will:
scared of as
the coming manifested
procedure by the child
that the Reduced Explain procedures
appearing fear related carefully at child’s To reduce fear
doctor said worried
they will to level of of unknown.
before the diagnostic understanding
perform. procedure, and
lack of treatment
control and procedures. Explain to the child
outburst
what will take place To distract
Objective to make him see child from pain
Appeared and hear and feel.
worried NOC
Fear control Comply with child’s To encourage
Withdrawal requests if possible cooperation
and support
Anger child’s coping
Lack of skills
cooperatio
n
V/S
Provide child with To reduce
some means of pain
involvement with the
T=37 °C procedures like
holding equipment
and putting on the
RR=35cpm Bandage or even
counting

PR=114bp
m

Pain scale:
2

.
Drug Mechanism Indication Contraindicatio Effects Nursing
 of action n Responsibility
Generic name: palliative Not to be used in weight loss, Pre
melphalan Cross-links treatment patients whose loss of appetite, Check the
strands of of multiple disease has weakness, doctor’s order
cellular DNA myeloma demonstrated a blistering skin or
Brand name: and and for the prior resistance acne, Check the
interferes palliation of to this agent. nausea, patient’s name
Alkeran with RNA non- vomiting, Check the 12
respectable Patients who diarrhea, rights of
Classification: epithelial have white patches or medication
-Alkylating drug carcinoma demonstrated sores inside your administration
of the hypersensitivity mouth or on your
-Nitrogen ovary. to melphalan lips, Check V/s to
mustered should not be temporary hair obtain base line
given the drug. loss, or information.
-category D skin itching and
rash Intra

Adverse effects Explain the

Dosage: Severe bone reason for the
marrow medication
6 mg (3 tablets) suppression with
daily resulting Tell the patient
infection or to take the
bleeding may medication in an
Route: occur. empty stomach
PO
IV Tell patient to
take tablet with
some ounces of
water
Frequency:
2mg q6hrs Post

Monitor v/s
Color Monitor uric acid
level to promote
white, film- RBC production
coated, round, Advise patient to
biconvex tablet report any pain
or redness on
the IV site.
No
breastfeeding

Drug Mechanis Indication Contraindicatio Effects Nursing

 m of action n Responsibility
Generic Cross-links Thiotepa has Contraindicated Gastrointestinal: Pre
name: strands of also been used in patients with a Nausea,
cellular parenterally in known vomiting, Assess the
Thiotepa DNA and the palliative hypersensitivity abdominal pain, client’s
interferes treatment of (allergy) to this anorexia. condition
with RNA adenocarcinoma preparation. Check the 12
of the breast Renal: Dysuria, rights of drug
and ovary. Therapy is urinary administration
probably retention. There
Brand name: contraindicated in have been rare Explain to the
Adenocarcinom cases of existing reports of patient
a of the breast. hepatic, renal, or chemical cystitis Check vital
bone-marrow or hemorrhagic signs
Adenocarcinom damage. cystitis following
a of the ovary intravesical, but Explain the
Classification not parenteral possible side
: administration of effects to the
thiotepa. client
Alkylating
Pregnancy D Respiratory:
Prolonged Intra
apnea
Tell the patient
Dosage: to avoid
exposure to
0.2-0.4 mg/kg Adverse effects
cold or cold
1-4 weeks
Hypersensitivity objects
Reactions:
Allergic
Form:
reactions - rash,
Injection urticaria,
laryngeal Post
15 and 30 mg edema, asthma,
vials anaphylactic
Capsule shock,
wheezing. patient should
notify the
Local Reactions: physician in
Route:
Contact the case of any
IV dermatitis, pain sign of
at the injection bleeding
Frequency: site. (epistaxis,
Category D easy bruising,
change in color
of urine, black
 stool) or
infection (fever,
chills) or for
Color possible
pregnancy to
Blue patient or
partner.

Drug Mechanism Indicatio Contraindicatio Effects Nursing

of action n n Responsibilit
y
Generic For use in Contraindicated Hot Pre
name: men with to patients with: Flashes Assess the
acts as an client’s
prostate
inhibitor of Sexual condition
cancer.
pituitary Dysfunctio Check the 12
Goserelin gonadotropi Hypersensitivity
n rights of drug
acetate n secretion Decreased administration
Erections Explain to the
when intolerance to Lower patient
administered tartrazine (yellow Urinary Check vital
in the dye #5), alcohol, Tract signs
Brand name: biodegradabl table sugar, Symptoms Explain the
e Lethargy possible side
saccharin
formulation. Pain effects to the
ZOLADEX (worsened client
in the first
Contraindicated
30 days Intra
with allergy to
Classificatio Edema Tell the
acetaminophen patient to
n:
avoid
Antineoplastics exposure to
for hormone cold or cold
balance. objects

Post

Dosage:
patient should
3.6 mg for 28 notify the
days physician in
the case of
any sign of
Route: bleeding
(epistaxis,
subcutaneous easy bruising,
change in
color of urine,
Frequency: black stool) or
infection
3.4 mg (fever, chills)
18weeks or for possible
pregnancy to
patient or
partner

Color
Yellow