MR ROMER D LOZADA RN

STUDENT NR 06220005
UST-LEGAZPI- MAN
N222A Medical Surgical Nursing
NCP for Hodgskins Disease and Thrombocytopenia
15 Oct 2022

NURSING CARE PLAN

(HODGSKIN DISEASE)
ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS

SUPPORTIVE Impaired gas Goal/desired  Assessed  Assessment Goal partially met

DATA exchange outcome respiratory gives the
09 1600H November rate, depth, baseline and After 30 to 45
2021 Risk factors may After 30 to 45 pattern and immediate minutes of nursing
include: minutes of nursing quality nursing interventions, the
Subjective Data: Tracheobronchial interventions, patient intervention patient achieve
obstruction: will achieve an effective breathing
“Nahihirapan akong enlarged mediastinal effective breathing  Assessed LOC  Checking the pattern:
huminga“ as nodes and/or airway pattern as LOC gives us - O2 saturation of
verbalized edema (Hodgkin’s evidenced by: baseline of the 99%
and non-Hodgkin’s); current - Mechanical
Objective Data:: superior vena cava  RR of 12 - 20 alertness and Ventilator:
-Course crackles, syndrome (non- Cpm consciousness AC mode BUR
bilateral Hodgkin’s)  02 Saturation of of patient - 20 cpm
-Distended neck 95 - 99% Tv - 360 cc
veins  Decreased  Assessed  Gives us FiO2 - 60
- Dyspnea signs of labored breath sounds assessment of - (+) minimal
-Occasional bilateral breathing through the status of crackles as
wheezes  Absence of auscultation respiratory evidenced by free
-O2 saturation of crackles and airways and of dyspnea,
73.1% wheezes breathing cyanosis and other
- ABG:  Stable Vital patterns signs of
Ph - 7.364 signs respiratory
PaCO2 - 24.7  ABG within  Maintained on  Helps promote distress with
HCO3 - 14.1 usual moderate high gas diffusion normal vital signs
- Pale skin parameters back rest and expansion
- Vital signs:  Absence of of lung airways
BP - 90/ 60 respiratory
PR - 116 distress.  Interpreted  Provides
RR - 25 and correlated baseline and
T - 36.9 ABG result to accurate
patient’s management
current status for our staff and
patients

 Facilitated  Provides
ABG as oxygen-carrying
ordered capacity of the
blood status as
baseline

 Assisted  Emergency
possible management
intubation for intubation
when O2
saturation
dropped to
provide lung
ventilation and
resuscitation

 Hooked to  Adjuncts in
mechnical reducing fatigue
 ventilator with and dyspnea,
the following and conserves
setting as energy for
ordered: cellular
 AC mode regeneration
BUR - 20 cpm and respiratory
 Tv - 360 cc function.
FiO2 - 60
 Back-tapping  Promotes lung
expansion and
reduces lung
secretions
 Turned to Decreases
sides decubitus ulcer and
lung capacity

 Suctioned  Suctioning
secretions as removes
needed obstruction of
 Monitored for secretions since
signs and Hodgkin’s
symptoms of patients are at
desaturation, risk for superior
DOB, dyspnea vena cava
and syndrome,
hypotension which may
result in
tracheal
deviation and
airway
obstruction,
representing an
oncologic
emergency.
 NURSING CARE PLAN
(THROMBOCYTOPENIA)
ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS

09 1600H February
2021 Ineffective Goal/desired  Assessed  Assessment Goal not partially
Peripheral Tissue outcome peripheral gives the met
SUPPORTIVE Perfusion R/T perfusion baseline and
DATA interruption of After 7 days of immediate After 3 days of
venous blood flow nursing nursing nursing
Subjective Data: interventions, patient intervention interventions, the
will achieve an patient still
“Nahirapan akong Risk factors may effective peripheral  Assessed  Checking the manifests:
maglakad, ang sakit include: perfusion as affected areas affected area - minimal
ng paa ko”, as Venous blood flow: evidenced by: of inguinal and gives us decreased leg
verbalized decreased due to swelling baseline of the sensation
decreasing low  Increased severity and - with mild edema
Objective Data:: platelets count sensation on complications of on affected part
 -With swelling (Thrombocytopenias) left leg patient -(+) minimal
of left thigh  Decreased hematomas
associated with unilateral leg -CBC QPC- 90
pain. swelling Platelets
 decreased  Absence of -Absence of
sensation on heamatomas  Assessed  Gives us circulatory distress
the anterior ,  Stable Vital circulation assessment of like severe
posterior, signs perfusion the status of bleeding and
medial and  CBC QPC of through vital circulatory hematomas
lateral aspect of Platelets within signs taking perfusion and
left leg. usual and laboratory lab reports
 With unilateral parameters results
leg swelling.  Absence of
 (+) hematoma circulatory
on inguinal and distress.  Maintained on  Helps promote
pelvic area, left. feet elevated blood and gas
 Bipedal edema ( Modified perfusion and
Gr.II. Trendelenberg prevents edema
 CBC QPC-60 position)
Low Platelets
Count
 Interpreted  Provides
and correlated baseline and
blood results accurate
to patient’s management
current status for our staff and
patients

 Facilitated  Provides
CBC QPC as oxygen-carrying
ordered capacity ad
Platelets count
of the blood
status as
baseline

 Administered  Replacement
10 units of through blood
Platelets as transfusion of
ordered Platelets

 Turned to  Promotes good

sides blood circulation

 Encourage  Promotes good

ROM exercises blood perfusion

 Monitored for  Continual care

signs and is needed to
symptoms of facilitate
decreased monitoring and
senasation, home care as
edemas, needed
bleeding and
hematomas