Problem 1: Fatigue r/t decreased hemoglobin and diminished oxygen-carrying capacity

General Goal: Decrease signs and symptoms of fatigue

Predicted Outcomes: The patient will learn energy management skills that are needed to conserve
energy at times of fatigue, nutrient management to provide adequate energy; sleep enhancement to
encourage periods of rest and sleep on the day of care

Nursing Interventions: Patient Response:

1. Restrict environmental stimuli
2. Promote adequate nutritional intake
3. Make patient/family aware of signs and
symptoms of over exertion with activity
1. Gives patient time for rest, sleep, and
recovery
2. Patient will be able to properly balance
intake of fats, carbs, proteins, vitamins,
and minerals to provide energy resources
3. Patient/ family will monitor for changes
in HR, O2 saturation, and RR (this will
reflect the patient’s tolerance for activity)

Evaluation: The patient was free of signs and symptoms of fatigue on the day of care; patient was taught
to take periods of rest to avoid over exertion; patient was encouraged to finish his dinner completely
(before being rewarded with his iPad)
Problem 2: Altered tissue perfusion r/t insufficient hemoglobin and hematocrit levels

General Goal: Patient will maintain maximum tissue perfusion to vital organs (as evidenced by warm
and dry skin, present and strong pulses, vitals within patient’s normal range, balanced I&O, absence of
edema, alert LOC

Predicted Outcomes: Patient will exhibit growing tolerance to activity; patient will show no further
worsening/ repetition of deficits; patient will engage in behavior/ actions to improve tissue perfusion on
day of care

Nursing Intervention: Patient Response:

1. Check for optimal fluid balance and note
urine output
2. Teach patient what to do if they
experience orthostatic hypotension
3. Check mental status, LOC, and ICP
1. Patient hydration status will be
maintained
2. Patient will learn to remain seated for
several minutes before standing, rising
slowly, and to sit down immediately if
feeling dizzy; have someone present
when standing
3. Elevate HOB to 45 degrees to promote
venous outflow from brain to reduce
pressure

Evaluation: Patient was compliant with his care and was able to walk multiple laps around the unit
(avoiding the worsening of symptoms); patient demonstrated normal sensations and movement as
appropriate
Problem 3: Fear/ Anxiety r/t situational crisis (cancer)

General Goal: Patient should appear relaxed and report nervousness/ anxiety has been reduced to a
manageable level

Predicted Outcome: Patient will display appropriate range of feelings with lessened fear; patient will
demonstrate use of effective coping skills on day of care

Nursing Interventions: Patient Response:

1. Encourage patient to share thoughts and
feelings
2. Maintain frequent contact with patient
3. Be aware of effects of isolation (required
by immunosuppression/ radiation)
1. Provides patient with opportunity to
express their fears and promotes solving
said situation
2. Provides patient assurance that they are
not alone and fosters trust
3. Sensory deprivation may result when
sufficient stimulation is not available;
may intensify feelings of fear and anxiety

Evaluation: Patient was able to demonstrate different emotions; patient learned that he enjoyed playing
with one of his toys (he mentioned it was able to calm him down when feeling flustered)
Problem 4: Risk for infection r/t inadequate secondary defense and immunosuppression

General Goal: Patient will not show any signs or symptoms of infection

Predicted Outcome: Identify and participate in interventions to prevent / reduce risk of infection and
achieve timely healing (as appropriation) on day of care

Nursing Intervention: Predicted Outcome:

1. Emphasize personal hygiene 1. Patient recognized when to wash their
2. Promote good handwashing procedures hands to limit potential sources of
by staff and visitors infection and secondary overgrowth
3. Monitor temperature 2. Teach proper handwashing skills and limit
visitors who may have infections to
maintain the patient’s optimal health
3. If patient’s temperature elevates, early
recognition is crucial to enhance
appropriate therapy to be started
promptly

Evaluation: Patient followed appropriate blood stream infection prevention procedures to prevent an
infection from developing
Problem 5: Acute pain r/t disease process and side effects of various cancer therapy agents

General Goal: Maximize pain relief with minimal interference of ADL’s

Predicted Outcomes: Patient will follow prescribed medication regimen and demonstrate use of
relaxation skills and diversional activates (as indicated for the patient’s individual situation) on day of
care

Nursing Interventions: Patient Response:

1. Provide non-pharmacological comfort
measures and diversional activities
2. Encourage stress management
3. Acknowledge and accept the client’s pain
1. Patient enjoyed playing with the iPad,
students, and toys in his room
2. Pain produces stress and increases the
patients focus on self (which in turn
increases the patient’s level of pain)
3. Challenging or undermining the patient’s
pain reports results in an unhealthy
therapeutic relationship that may hinder
pain management and deteriorate
rapport

Evaluation: Patient was compliant with his medication and used the iPad and toys as diversion activities
to distract him from feeling pain
Problem 6: Anticipatory grief r/t anticipated loss of physiological well being d/t changes in health status
and lifestyle

General Goal: Continue normal life activates keeping daily routine as similar as possible

Predicted Outcomes: Patient will identify and express feelings appropriately and maintain eating habits,
activity levels, sleep patterns and communication patterns on day of care

Nursing Interventions: Patient Response:

1. Assess patient and his parents for stage
of grief currently being experienced
2. Be aware of mood swings, hostility, and
other acting out behaviors
3. Visit frequently and provide physical
contact (as appropriate)
1. Overall, they were at the acceptance
stage of grief
2. Patient will be notified of limits on
inappropriate behavior and learn how to
redirect negative thinking
3. Helps reduce patient feelings of isolation
and abandonment

Evaluation: Patient was able to notify me when he was feeling sad; patient was able to finish his meal
and complete multiple laps around the unit; patient was able to communicate with staff appropriately
Problem 7: Risk for impaired skin integrity r/t effects of radiation and chemotherapy

General Goal: Take measures to protect and heal any damaged areas of skin/ underlining tissue

Predicted Outcomes: Patient will deny pain and be without swelling; nurse will help prevent injury and
the formation of new wounds

Nursing Intervention: Patient Response:

1. Monitor for skin color changes (redness,
swelling, warmth, pain, and other skins of
infection)
2. Monitor patient’s continence status
3. Administer antibiotics and antifungals as
needed
1. Assessment of the patient’s skin
showed no impending problems
2. Patient remained continent (reduced
risk for chronically moist skin leading
to breakdown)
3. Patient prescribed fluconazole and
levofloxacin (complaint with taking
medication)

Evaluation: Patient reported no pain, was absent of edema, stayed dry and has no new development of
wounds
Problem 8: Risk for Activity Intolerance r/t reduced energy stores as a side effect of medication

General Goal: Maintain/ increase activity intolerance

Predicted Outcomes: Patient will actively participate in ADL’s without physiological signs of intolerance
(avoiding increases in pulse rate, RR, and BP)

Nursing Interventions: Patient Responses:

1. Evaluate reports of fatigue
2. Provide quiet environment and
uninterrupted rest periods
3. Implement energy saving techniques
1. Note when fatigue interferes with
participation in ADL’s
2. Restores energy needed for activity and
cellular regeneration and/or tissue
healing
3. Maximize patient’s available energy for
self-care tasks

Evaluation: Patient was able to independently eat his dinner and exercise (laps around the unit) without
signs of fatigue
 Problem 2:Problem 3: Fearperfusion
Altered tissue and anxiety
r/t r/t
Problem 1: Fatigue r/t decreased
insufficientsituational
hemoglobin crisis
and(cancer)
hemoglobin and diminished oxygen-
hematocrit levels
carrying capacity  Threat of death
 Hemoglobin Separation from family
9.5 (11.5-13.0)
 Low RBC 3.1 (3.9-5)
 Hematocrit Disruption
25.3 (34-39)in normal day to
 Pain
day routine
 Emotional stress
 Side effects of medication

Problem 4: Risk for

infection r/t inadequate
Problem 8: Risk for secondary defense and
activity intolerance r/t immunosuppression
Reason For Needing Health Care
reduced energy stores
as a side effect ofHepatoblastoma, Acute Myeloid Leukemia  Low WBC 0.31
Count Recovery,
medication (5.5-15.5)
Key Assessments:  Chemotherapy
 Chemotherapy  Decreased
 Fever
 Chronic disease hemoglobin
 Thrombocytopenia
 Disease  Patient is
 Neutropenia
prevention currently taking
 Nutrition/
 Fatigue fluid status Fluconazole and
Levofloxacin
(medications
that fight
infection in the
body)

Problem 5: Acute pain r/t

Problem 7: Risk for
Problem 6: Anticipatory
disease
grieving
process
r/t and side
impaired skin integrity r/t
anticipated loss of physical
effectswell
of various
being d/t
cancer
effects of radiation and
change in health status
therapy
and lifestyle
agents
chemotherapy
  death
Perceived potential Reports
of of pain
 Impaired tissue
patient  Distraction
perfusion
 More time spent beingconstantly
in the being
 Altered sensation
hospital versus at home
provided
with to patient
family  Guarding behaviors
 Restlessness