Name: RYHANN IFTIZSAR P. TANUA Section C NSG 125.

6 Oncology Virtual Duty

NURSING CARE PLAN

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Risk for Within my 8 Require good hand washing protocol. Prevents cross-contamination and reduces After my 8 hours
“I noticed I have infection hours duty, I risk of infection. duty, pt.
bruises everywhere, I related to will be able to demonstrated
feel weak and fatigued, inadequate demonstrate Closely monitor temperature. Note correlation Although fever may accompany some forms techniques to
and on-and-off fever.” primary techniques, between temperature elevations between of chemotherapy; progressive hyperthermia promote safe
temperature elevations and chemotherapy
as verbalized by the defenses lifestyle occurs in some types of infections, and fever environment.
treatments.
client. changes to (unrelated to drugs or blood product) occur
promote safe in most leukemia patients. Septicemia may
Objective: environment, Observe for fever associated with tachycardia, occur without fever.
Received pt in bed in achieve timely hypotension, subtle mental changes.
supine position on bed. healing of the Helps reduce fever, which contributes to
Chart Dx: Acute patient. Prevent chilling. Force fluids, administer tepid fluid imbalance, discomfort, and CNS
Myelogenous sponge bath. complications.
Leukemia
Handle patient gently. Keep linens dry and Prevents sheet burn and skin excoriation
wrinkle-free.
• Fatigue,
weakness and May indicate local infection. Open wounds
Inspect skin for tender, erythematous areas; open
body malaise wounds. Cleanse skin with antibacterial solutions may not produce pus because of insufficient
noted. number of granulocytes.
• Vital signs Coordinate procedures and tests to allow for
assessed with uninterrupted rest periods. Conserves energy for healing, cellular
low-grade regeneration.
fever and Encourage increased intake of foods high in
chills. protein and fluids with adequate fiber. Promotes healing and prevents dehydration.
• Easy bruising
Monitor laboratory studies Decreased numbers of normal or mature
especially on CBC, noting whether WBC count falls or
L&R arms and WBCs can result from the disease process or
sudden changes occur in neutrophils;
legs. chemotherapy, compromising the immune
response and increasing risk of infection.
Collaborative
T: 37.1C Administer medications such as antipyretics
P: 80 bpm and antibiotics as prescribed. Leukemia is treated with a combination
R: 19 cpm therapy requiring specific safety
BP: 100/80 mmHg precautions.
 NURSING CARE PLAN

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impaired gas Within my 8 Note respiratory rate, depth, and ease of Respirations may be increased because of pain or After my 8
“Nahihirapan akong exchange hours of duty, respiration. Observe for use of accessory as an initial compensatory mechanism to hours of duty,
huminga simula nung related to pt. will attain muscles, pursed-lip breathing, changes accommodate for the loss of lung tissue; however, pt. attained
lobectomy ko last month removal of normal in skin or mucous membrane color, increased work of breathing and cyanosis may normal
at nang-iitim na yung lung tissue breathing pallor, cyanosis. indicate increasing oxygen consumption and breathing
mga nails ko last week aeb dyspnea. pattern. energy expenditures and/or reduced respiratory pattern.
pa” as verbalized by the reserve.
patient.
Auscultate lungs for air movement and Consolidation and lack of air movement on the
Objective: abnormal breath sounds. operative side are normal in the pneumonectomy
Received pt on bed in a patient; however, the lobectomy patient should
semi-fowler position. demonstrate normal airflow in remaining lobes.
Shortness of breath
noted, hoarse voice, and Assess patient response to activity. Increased oxygen consumption demand and stress
cyanosis observed. Encourage rest periods and limit of surgery can result in increased dyspnea and
Chart Dx: Lung Cancer activities to patient tolerance. changes in vital signs with activity; however, early
mobilization is desired to help prevent pulmonary
Vital signs: complications and to obtain and maintain
T: 37.4C respiratory and circulatory efficiency. Adequate
RR: 29 cbpm rest balanced with activity can prevent respiratory
HR: 120 bpm compromise.
SpoO2: 90%
BP: 100/50 mmHg Fever within the first 24 hr. after surgery is
Note development of fever. frequently due to atelectasis. Temperature
elevation within the 5th to 10th postoperative day
usually indicates a wound or systemic.

Maintain patent airway by positioning, Airway obstruction impedes ventilation, impairing

suctioning, use of airway adjuncts. gas exchange.

Reposition frequently, placing patient in Maximizes lung expansion and drainage of

sitting positions and supine to side secretions.
positions.
Avoid positioning patient with a
pneumonectomy on the operative side;
instead, favor the “good lung down”
position.
Encourage and assist with deep-
breathing exercises and pursed-lip
breathing as appropriate.
Maintain patency of chest drainage
system for lobectomy, segmental or
wedge resection patient.
Administer supplemental oxygen via
nasal cannula, partial rebreathing mask,
or high-humidity face mask, as
indicated.
Monitor and graph ABGs, pulse
oximetry readings. Note hemoglobin
(Hb) levels.
Research shows that positioning patients
following lung surgery with their “good lung
down” maximizes oxygenation by using gravity to
enhance blood flow to the healthy lung, thus
creating the best possible match between
ventilation and perfusion.
Promotes maximal ventilation and oxygenation
and reduces or prevents atelectasis.
Drains fluid from pleural cavity to promote re-
expansion of remaining lung segments.
Maximizes available oxygen, especially while
ventilation is reduced because of anesthetic,
depression, or pain, and during period of
compensatory physiological shift of circulation to
remaining functional alveolar units
Decreasing Pao2 or increasing Paco2 may indicate
the need for ventilatory support. Significant blood
loss can result in decreased oxygen-carrying
capacity, reducing Pao2
 NURSING CARE PLAN

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impaired skin Within my 8 Assess incision site taking note of the To provide comparative baseline data. After my 8
“I have a breast cancer integrity related to hours of duty, size, color, location, temperature, hours of duty,
and I just had a surgery. client will be texture, consistency of wound/lesion if client was able
Lumpectomy where the able to display possible to display
tumor and a small amount progressive To assess the extent of involvement. progressive
of normal tissue around it. improvement Inspect surrounding skin for erythema, improvement in
I want to know what I in wound induration, maceration wound healing.
need to do after my healing. To assess the early progression of wound
surgery” as verbalized by Assess for odors and drains coming out healing, development of hemorrhage or
the client. from the skin or area of injury infection.

Objective: Keep the area clean or dry, carefully To assist the body’s natural process of
• Patient has post- dress wounds, support incision, and repair.
surgical sutures on prevent infection
affected part
• Undergone Encourage an increase in protein and
Lumpectomy on L calorie intake To aid in timely wound healing for the
breast patient.
• Irritation or Encourage adequate rest and sleep
dimpling on the R
breast Encourage early ambulation and Prevents fatigue and provides recuperation
mobilization
With vital signs: To promote circulation and reduce risks
T: 37.1C Use the aseptic technique in associated with immobility.
PR: 65 bpm cleansing/dressing and medicating
RR: 14 cpm lesions Reduces the risk of cross-contamination.
BP: 100/70mmHg
SpO2: 95%