Episcopal Diocese of Southern Philippine

BRENT HOSPITAL AND COLLEGES INCORPORATED

R.T Lim Boulevard, Zamboanga City
COLLEGE OF NURSING

Faiza A. Salawie
BSN 3-A

NURSING CARE PLAN

BREAST CANCER

ASSESSMENT NURSING
GOAL/ PLAN INTERVENTION RATIONALE EVALUATION
CUES DIAGNOSIS

SUBJECTIVE CUES: Acute pain After 8 hrs of INDEPENDENT: INDEPENDENT: After 8 hrs. of
“Dati po akong nag related to post- nursing 1. Perform pain 1. To assess etiology nursing intervention
undergo ng Mastectomy operative intervention the assessment and contributing the patient was able
sa left side breast ko incision at left patient will be able 2. Monitor vital signs factors. to improve, feel
noong November 1, breast to improve comfort 3. Instruct patient to 2. Usually altered in comfort and report
2021. Ang sakit parin secondary to and report pain report pain as soon as acute pain. pain scale of 5/10
ng parte kung saan ako mastectomy as scale from 8/10 to possible. 3. Timely intervention and all the goals are
na operahan hanggang evidence by to 5/10: 4. Provide quiet is more likely to be met.
ngayon.” As verbalized pain scale of environment and successful in
by the patient. 8/10. a. Verbalize comfort measures. alleviating pain.
understanding 5. Encourage deep 4. To provide non-
OBJECTIVE CUES: of the cause of breathing and some pharmacological
•Pain scale of 8/10 at pain. diversional activities pain management
the site of operation. b. Identify ways 6. Encourage 5. To lessen sense of
•Sharp, intermittent to alleviate ambulation but note anxiety and
pain radiating from the pain. when pain occurs associated muscle
post-surgical site to left c. Participate in 7. Encourage adequate tension.
arm care and rest periods. 6. To promote
•Slightly redness on the pharmacologica circulation and
incision l regimen determine tolerance.
 d. Demonstrate DEPENDENT :
7. To prevent fatigue.
•Facial grimace use of 1. Administer analgesic
DEPENDENT:
relaxation as ordered
1. To maintain
VITAL SIGNS techniques to 2. Identify specific
acceptable level of
•BP: 120/80 reduce pain. signs and symptoms
pain
•PR: 88bpm of infection on the
2. To promptly
•RR: 18bpm surgical site.
identify underlying
•T: 36.4
condition
COLLABORATIVE:
1. Recommend and
COLLABORATION:
provide for
1. Promotes active, not
individualized physical
passive role.
therapy.
PROSTATE CANCER

ASSESSMENT NURSING
GOAL/ PLAN INTERVENTION RATIONALE EVALUATION
CUES DIAGNOSIS

SUBJECTIVE CUES: Fear related to After 4 hours of INDEPENDENT: 1. Clarifies patient’s After 4 hours of
“Natatakot ako sa situational nursing 1. Review patient’s perceptions and nursing
karamdaman ko” as crisis. interventions, the previous experience assist in interventions, the
verbalized by patient. patient will display with cancer. identification of patient was able to
appropriate range of 2. Encourage patient to fears and display appropriate
OBJECTIVE CUES: feelings and lessened share thoughts and misconceptions range of feelings
•Increased tension. fear. feelings. based on diagnosis and lessened fear.
•Restlessness. 3. Maintain frequent and experience with
•Hopelessness. contact with patient. cancer.
Talk with and touch 2. Provides
VITAL SIGNS patient as opportunity to
•BP: 110/90 appropriate. examine realistic
•PR: 92 4. Provide accurate, fears and
•RR: 20 consistent misconceptions
•T: 37.2 information regarding about diagnosis.
diagnosis and 3. Provides assurance
prognosis. that patient is not
5. Explain procedures, alone or rejected
providing opportunity and fostering trust.
for questions and 4. Can reduce anxiety
honest answers. and enable patient
6. Promote calm, quiet to make decision
environment. and choices based
on realities.
5. Accurate
information allows
patient to deal more
 effectively with the
situation, thereby
reducing anxiety
and fear.
6. Facilitates rest,
conserves energy,
COLLABORATIVE:
and may enhance
coping abilities.
1. Refer for additional
resources for
COLLABORATIVE:
counseling or support
1. Maybe useful from
as needed.
time to time to
assist patient in
dealing with
anxiety.
CERVICAL CANCER

ASSESSMENT NURSING
GOAL/ PLAN INTERVENTION RATIONALE EVALUATION
CUES DIAGNOSIS

SUBJECTIVE CUES: Acute Pain related to The patient INDEPENDENT: INDEPENDENT: After 8 hrs. of
abdominal cramping will report a 1. Assess the patient’s 1. To create a baseline nursing intervention
The patient verbalized
as evidenced by pain pain score of 0 vital signs. Ask the set of observations the patient was able
“Napakasakit talaga ng
score of 10 out of out of 10. patient to rate the for the patient. The to report pain scale
bandang puson ko at
10, guarding sign on pain from 0 to 10 10-point pain scale of 0/10.
hindi ako makagalaw
abdomen, and describe the is a globally
ng maayos.”. restlessness, and pain he/she is recognized pain
irritability. experiencing. rating tool that is
2. Reposition the both accurate and
OBJECTIVE CUES: patient in his/her effective.
comfortable/preferr 2. To promote optimal
•Pain scale of: 8/10 ed position. patient comfort and
•facial grimace 3. Encourage pursed reduce anxiety/
•restlessness restlessness.
lip breathing and
VITAL SIGNS deep breathing 3. To allow the patient
exercises. to relax while at rest
•BP: 120/80 and to facilitate
effective stress
•PR: 90bpm DEPENDENT: management and
•RR: 20bpm allow enough
1. Administer oxygenation.
•T: 36.5 analgesics/ pain
medications as DEPENDENT:
prescribed. 1. To provide pain
relief to the patient.
OVARIAN CANCER

ASSESSMENT NURSING
GOAL/ PLAN INTERVENTION RATIONALE EVALUATION
CUES DIAGNOSIS

OBJECTIVE CUES: Risk for infection After 3hrs of INDEPENDENT: INDEPENDENT: After 3hrs of
related to nursing 1. Monitor WBC 1. Elevated total WBC nursing
•Inadequate immunity
pharmaceutical intervention, count. count indicates intervention the
•Chemotherapy
•Invasive procedure agents and the client will 2. Wash hands before infection. patient was able to
•Increased environment immunosuppressant. gain doing any 2. To decrease transfer understand how to
exposure knowledge in procedure. of pathogens. recognize early
infection 3. Teach patient how 3. hand washing signs and
control and to properly wash prevents spread of symptoms of
will hands before and pathogens to other infection
understand after meals and after objects and food.
using bathroom, 4. Diarrhea or loose
how to
bedpan, or urinal. stools may indicate
recognize early
4. Instruct patient to need to discontinue
signs and report incidents of or change antibiotic
symptoms of loose stools or therapy.
infection. diarrhea. 5. Reduce risk of cross-
5. Provide reverse contamination.
isolation as 6. To prevent exposure
indicated. of client.
6. Monitor 7. To promote wellness.
visitors/caregivers. 8. To reduce existing
7. Review individual risk factors
nutritional needs,
appropriate exercise DEPENDENT:
program, and need 1. To determine
for rest. effectiveness of
therapy and presence
DEPENDENT: of side effects.

1. Assist with medical

procedures.
2. Administer and
monitor medication
regimen and note
client’s response.
LUNG CANCER

ASSESSMENT NURSING
GOAL/ PLAN INTERVENTION RATIONALE EVALUATION
CUES DIAGNOSIS

Ineffective Airway After 8 hours of 1. Auscultate chest for 1. Noisy respirations, After 8 hours of
Clearance related nursing character of breath rhonchi, and wheezes nursing
to Increased intervention the sounds and presence are indicative of intervention the
amount/viscosity of patient will be of secretions. retained secretions patient was able to
secretions as able to 2. Assist patient and and/or airway demonstrate patent
evidenced by Demonstrate instruct effective obstruction. airway, with fluid
Changes in patent airway, deep breathing and 2. Upright position secretions easily
rate/depth of with fluid coughing with favors maximal lung expectorated, clear
respiration. secretions easily upright position expansion and breath sounds, and
expectorated, (sitting) and splinting improves noiseless
splinting of an the force of cough respirations.
clear breath
incision. effort to mobilize and
sounds, and
3. Observe the amount remove secretions.
noiseless and character of Splinting may be
respirations. sputum or aspirated done by the nurse
secretions. (placing hands
Investigate changes anteriorly and
as indicated. posteriorly over chest
4. Suction if cough is wall) and by the
weak or breath patient (with pillows)
sounds not cleared as strength improves.
by cough effort. 3. Increased amounts of
Avoid deep colorless, blood-
endotracheal or nasi streaked, or watery
tracheal suctioning secretions are normal
in pneumonectomy initially and should
 patient if possible. decrease as recovery
Suction the patient progresses. Presence
as needed and of thick or tenacious,
encourage to begin bloody, or purulent
deep breathing and sputum suggests the
coughing as soon as development of
possible. secondary problems
5. Encourage oral fluid (dehydration,
intake (at least 2500 pulmonary edema,
mL/day) within local hemorrhage, or
cardiac tolerance. infection) that require
6. Assess for pain or correction and
discomfort and treatment.
medicate on a 4. “Routine” suctioning
routine basis and increases risk of
before breathing hypoxemia and
exercises. mucosal damage.
7. Assist with Deep tracheal
incentive suctioning is
spirometer, postural generally
drainage and contraindicated
percussion as following
indicated. pneumonectomy to
8. Use humidified reduce the risk of
oxygen and/or rupture of the
ultrasonic nebulizer. bronchial stump
Provide additional suture line. If
fluids via IV as suctioning is
indicated. unavoidable, it
9. Administer should be done gently
bronchodilators, and only to induce
expectorants, and/or effective coughing.
analgesics as 5. Adequate hydration
indicated. aids in keeping
secretions loose or
enhances
expectoration.
6. Encourages patient to
move, cough more
effectively, and
breathe more deeply
to prevent respiratory
insufficiency.
7. Improves lung
expansion or
ventilation and
facilitates removal of
secretions. Postural
drainage may be
contraindicated in
some patients and in
any event, must be
performed cautiously
to prevent respiratory
embarrassment and
incisional discomfort.
8. Providing maximal
hydration helps
loosen or liquefy
secretions to promote
expectoration.
Impaired oral intake
necessitates IV
supplementation to
maintain hydration.
9. Relieves
bronchospasm to
improve airflow.
Expectorants increase
mucus production
and liquefy and
reduce the viscosity
of secretions,
facilitating removal.
Alleviation of chest
discomfort promotes
cooperation with
breathing exercises
and enhances the
effectiveness of
respiratory therapies.
THYROID CANCER

ASSESSMENT NURSING
GOAL/ PLAN INTERVENTION RATIONALE EVALUATION
CUES DIAGNOSIS

Acute pain related After nursing 1. Monitor the 1. This creates baseline After nursing
to mechanical interventions, patient’s vital signs, information for interventions, the
trauma to the the patient will especially noting for patient condition and patient was able to
tissues secondary be able to report parameters of helps plan for report relief or
to surgery as relief or respiratory function effective care. decreased intensity
evidenced by decreased such as depth, 2. Determining the of pain.
patient reports of intensity of pain. rhythm, and rate. exact perception of
pain. 2. Assess patient’s the patient on pain
perception of pain, sensation helps the
noting how he nurse plan for
determines it effective care for the
according to scale patient.
(with 0 indicating 3. Placing the head and
no pain and 10 to neck in Semi-
denote excruciating Fowler’s position
pain). prevents
3. Position the patient hyperextension of the
in a Semi-Fowler’s neck and relieves
position, ensuring pressure on the suture
the head and neck line. The sandbags at
are supported with each side of the neck
sandbags. help keep the head
4. Teach the patient and neck in the
how to support the midline position.
head and the neck 4. This action prevents
during movements, additional strain on
placing the hands the suture line,
 behind the neck and decreasing pain
slowly moving perception while
when needed. allowing the patient
5. Provide the patient mobility on the head
with cool liquids and neck.
such as juices or 5. Cooled liquids may
popsicles. Ice cream be soothing to the
and sorbet may also throat and neck while
be given. If the also allowing the
patient is allowed to patient to swallow
have oral feeding, easier. Mashed or
he may also be softened foods also
provided with help decrease the risk
softened or mashed of aspiration for
foods. patients who were
6. Prepare to just cleared to take
administer/provide oral feedings.
the patient with an 6. For patients with pain
ice collar if related to an
necessary. edematous incision
site, the ice collar
DEPENDENT: helps reduce swelling
1. Administer and provides pain
prescribed analgesic relief.
and other
medications for pain DEPENDENT:
and/or swelling. 1. These medications
may act to help
relieve pain, reduce
swelling, and provide
overall comfort to the
patient.
LIVER CANCER

ASSESSMENT NURSING
GOAL/ PLAN INTERVENTION RATIONALE EVALUATION
CUES DIAGNOSIS

SUBJECTIVE CUES: Acute pain related to After 2 hours INDEPENDENT: INDEPENDENT: After 2 hours of
liver enlargement of nursing 1. Monitor VS 1. Pain alters VS nursing
“Napaka sakit ng tiyan
interventions,
ko” as verbalized by the secondary to ascites 2. Perform pain 2. To rule out interventions,
patient. as evidenced by pain will be assessment development of patient was relieved
facial grimace, lessened with a (COLDSPA) every complications by from pain and goals
irritability, scale of 1-10, time pain occurs knowing alleviating are met.
OBJECTIVE CUES: restlessness, anxiety, from 6/10 to 3. Encourage and precipitating
fatigued, clenched 1/10. verbalization of factors
•Pain scale: 6/10 fist, “beaten” look, feeling of pain 3. Pain is subjective
•Facial grimace noted agitation, pallor, 4. Instruct use of &can’t be assessed
•Irritability noted grunting, guarding of relaxation exercise through observation
•Restlessness noted body part andv such as listening to alone
•Anxiety noted erbalization of pain music 4. Promotes relaxation
•Fatigue with a pain scale of 5. Provide comfort and diverts attention
•Clenched fist 6/10 measures such as from pain
•Agitation noted back rubbing & 5. To prove non-
•Pallor changing position pharmacological
•Grunting 6. Teach the patient management
•Guarding of body part relaxation 6. To alleviate pain
(right hypochondriac). techniques like deep 7. Noisy environment
breathing stimulates irritation
7. Provide quiet and
calm environment
COLORECTAL CANCER

ASSESSMENT NURSING
GOAL/ PLAN INTERVENTION RATIONALE EVALUATION
CUES DIAGNOSIS

OBJECTIVE CUES: Acute pain related After 8 hrs. of INDEPENDENT: INDEPENDENT After 8 hrs. of
to post-operative nursing 1. Perform pain 1. To assess etiology nursing
•Pain scale of 8/10
incision as intervention the assessment and contributing intervention the
•facial grimace
evidence by pain patient will be 2. Monitor vital signs factors. patient was able to
VITAL SIGNS: scale of 8/10 able to improve 3. Instruct patient to 2. Usually altered in improve, feel
comfort and report pain as soon as acute pain. comfort and
•BP : 120/80 possible. 3. Timely intervention reported pain in the
report pain scale
•PR : 88bpm 4. Provide quiet is more likely to be scale of 4/10 and
•RR : 18bpm from 8/10 to to
4/10: environment and successful in all the goals met.
•T : 36.4 comfort measures. alleviating pain.
5. Encourage deep 4. To provide non-
breathing and some pharmacological
diversional activities pain management
6. Encourage 5. To lessen sense of
ambulation but note anxiety and
when pain occurs associated muscle
7. Encourage adequate tension.
rest periods. 6. To promote
circulation and
DEPENDENT: determine tolerance.
1. Administer analgesic 7. To prevent fatigue.
as ordered
2. Identify specific DEPENDENT:
signs and symptoms 1. To maintain
of infection on the acceptable level of
surgical site. pain
COLLABORATIVE: 2. To promptly
1. Recommend and identify underlying
provide for condition
individualized
physical therapy. COLLABORATIVE:
1. Promotes active, not
passive role.