NURSING DIAGNOSIS

1. NURSNG DAGNOSS
KnowIedge deficit reIated to chemotherapy
OBJECTVE
Patient was able to understand treatment plan and
procedures after health education within 1-2 days.
NURSNG NTERVENTON
Asses patient knowledge level related to
chemotherapy through interview during admission in
wad. Noted facial expression looked confuse. Patient
did enquire the about of chemotherapy. The patient
level of education patient was set as a baseline data
and for appropriate nursing care.
Explain to patient purpose of chemotherapy to ensure
patient understand purpose of chemotherapy :
- To shrink the tumour before giving other therapies
(Neoadjuvant)
- To cure the cancer cells and to avoid from
metastasis.
- Control the tumour to avoid metastasis.
Provide patient regarding information for promote
better understanding including :
- Name of each drug to be given.
- Routes of administration of drug.
- Frequent and duration of administration of each
drug e.g. bolus or infusion, weekly or daily.
- Time line between administration of drugs to allow
sufficient amount of time for normal cell to recover.
- Follow up process and studies to evaluate
effectiveness and side effect of therapy.

Explain to patient regarding side effect of
chemotherapy and self management :
a. Nausea and vomiting
- Antiemetic to reduced of symptom e.g. V Maxolon
10mg TDS.
- Take small amount diet but frequently to avoid
patient feelling nausea.
- Avoid heavy meals or unpleasant aroma.
b. Stomatitis
- Encourage patient for oral hygiene e.g. gargle
mouth before, after eating and bed time because
of the side effect of 5-Fu.
- Use soft tooth brush.
- Avoid tobacco and alcohol that irritate oral mucosa.
c. Alopecia
d. Explain that side effect will be reversible. Re
growth of hairs will occur within 4 weeks after
chemo completion.
e. Decreased WBC
- Avoid infection e.g. crowds and person with URT
infection
- Encourage hand washing routine. ( good hand
hygiene)
Advice patient to take a least 3L of fluids per day to
reduced toxicity in body.
Advice patient to wear long sleeve and hat during
outdoor to minimize hyper -pigmentation and
photosensitivity.
EVALUATON
Patient develops better understanding in regards to
chemotherapy management and treatment.

2. NURSNG DAGNOSS
AItered in comfort fatigue due to side effect reIated the
chemotherapy.
OBJECTVE
Patient was able to participate in daily activities
gradually without asistance.


NURSNG NTERVENTON
Assess past experiences with tiredness or fatigue by:
Determine if tiredness and fatigue are perceived as
being similar or dissimilar states.
Determine tiredness frequency, time of occurrence
during the day or week and the duration.
Determine physical emotional, mental symptoms that
occur when individual claims tired/ fatigue/
exhausted.
Determine the causes the fatigue and what prevents
or relives the tiredness to establish baseline patterns.
Educate patient potential causes of fatigue so that
patient will be able to plan himself. For example :
nadequate rest or pacing of activities.
nadequate nutritional intake, exercise and sleep.

Teach rationale and measure that may prevent
fatigue example:
Encourage patient to drink at least 3 litres per day of
water to maintain adequate hydration and to excrete
cell destruction and products toxin that may be
associated with fatigue.
Advise patient to take balanced nutritionally with
complete diet emphasizing on complex carbohydrates
that provide sustained energy supply
Educate patient to schedule activities during the day
and throughout the week to avoid becoming
frequently tired. Organize a ideal schedule for an
adequate rest and sleep periods to allow for full
energy recovery before undertaking additional
activities.
Encourage patient to reduce unnecessary energy
expenditure by using assistive devices or by placing
equipment and supplies within easy reach.


EVALUATON
Condition patient very well after treatment. This was clearly
seen as patient claims he was able to perform daily activity
on his own.
3. NURSNG DAGNOSS
Nutrition, aIteration in Iess than body requirements
reIated to dysphagia.
OBJECTVE
Patient identifies measures to obtain adequate nutrition:
Selects appropriate foods
dentify nutritional supplements.
NURSNG NTERVENTON
Assess patient's ability to swallow liquids and solid
foods.
Maintain patient in high fowler's position during
meals. Use of gravity helps move food or fluid
downward in the gastro intestinal tract to reduce
the risk of aspiration.
Encourage intake of food patient can swallow eg:
pudding, hot cereal, soup, blended foods and
semisolid food are most easily swallowed because
of consistency and weight. Thin foods are most
difficult, gravy or sauce added to dry foods
facilitates swallowing.
Encourage small frequent meals consisting of soft,
easily swallowed foods.
Monitor swallowing before and during each
feeding.
Monitor food and fluid intake to keep track of
amount of intake per
day for assessment.
mplement swallowing technique to prevent
aspiration of food:
Patient inhales.
Place small amount of food on tongue.
Wait for 30 seconds between bites.
Consult with dietician for a nutritional assessment
dietary modifications, and dietary supplementation.

EVALUATON
Patient received adequate nutrition via oral route as
seen by:
The ability of the patient to swallow without difficulty or
pain and being able to complete a plate of rice on each
meal daily.

4. NURSNG DAGNOSS
AItered oraI mucous membrane : Mucositis reIated
side effect to chemotherapy
OBJECTVE
The mucous membrane patient looked moist.
NURSNG NTERVENTON
Asses patient in exhibiting oral cavity, irritation or
ulceration as seen by:
Pink, moist mucosa and tongue
Moist soft lips with undisrupted integrity.
Pink and firm gingival
Clean teeth with no debris.
Watery saliva
No complaints of oral burning or pain.

Advice patient for establish oral hygiene:
Perform oral hygiene regimen before within 30 min
after each meal.
Advice patient for mouthwash 4 hourly for comfort
and moist mucous membrane.
Rinse with a solution of Normal saline or Thymol
gargle.
Use Sodium Bicarbonat with mouthwash to remove
debris from mucosa if the patient was unable to
tolerate brushing his teeth.
Use mouthwash with non alcohol content because
alcohol may initiate irritation of the mucous
membrane.
Remove dentures and bridges and cleanse following
oral hygiene regimen.
Brush teeth using a non abrasive toothpaste and soft
bristled brush if patient can tolerate tooth brushing.
Asses oral cavity daily; example note colour, moisture
and presence of lesions to indentify mucositis .
Encourage patient to take least 3L per day water to
maintain moist membrane mucosa.
Advice patient to apply lubricating jelly to lips if dry or
cracked for oral cavity comfortness.
Obtain order for mild analgesia Viscous xyocaine
10ml tds within 30min before meals for reduced pain.
nform patient to avoid or quit smoking and
consuming alcohol which can lead to dry mucous
membrane.
EVALUATON
condition of the mucous membrane patient improved
with less mucositis.

5. NURSNG DAGNOSS
Nausea and vomiting reIated to side effects of
cispIatin
OBJECTVE
Patient will exhibit minimal sign and symptoms of
nausea and vomiting as hydration status seem to be
fair.
NURSNG NTERVENTON
Assess patient for signs of nausea and vomiting
Does patient have nausea alone or followed by
vomiting
How frequent is nausea and vomiting and the
duration.
Assess hydration status, including: skin turgor, blood
pressure and heart rate.
Monitor intake and output chart to keep track of
amount of intake per day for assessment.
Encourage oral fluids as tolerated to maintain
hydration.
Encourage oral intake and advice patient to take
small amounts of meal but frequently. Minimum
amount of a meal decreases the call for vomit.
Recommend foods with low potential of nausea and
vomiting.eg, dry toast, crackers, cola, and grapes.
Avoid taking milk and milk products as it may cause
nausea and vomiting.
Educate on the methods to prevent nausea and
vomiting:
Small, frequent, nutritious meals.
Allowance of sufficient time for meals.
Rest periods before and after meals.
Administer antiemetic medication as prescribed V
maxalon. Provide medication 30 minutes before
meals to reduce nausea and vomiting.
Administer intravenous therapy (VD) as prescribed if
vomit persist to maintain hydration.

EVALUATON
Patient experiences minimal nausea and not associated
with vomiting.


. NURSNG DAGNOSS
AIteration in nutrition requirement Iess body weight
reIated to disease.
OBJECTVE
Patient able to complete a plate of rice for each meal.
NURSNG NTERVENTON
Asses level of nutrition through measuring height and
weight, and comparing it to the ideal body weight for
height. Methods of consuming food and food
preferences to identify nutritional status of the patient.
Encourage frequent rest periods, particularly before
and immediately after meals to allow digestion and
prevent fullness.
Encourage or provide mouth care before and after
meals and as needed to maintain moist, unimpaired
mucous membrane integrity.
Encourage nutritional drinks e.g. Enercal to maintain
nutritional status.
Encourage family members to actively participate in
patient meal preparation and meal planning to
increase patient appetite.
Assist patient in setting realistic goals such as:
Consume high protein and high-caloric meal such
as meat, fish, egg.
Consume small amount of meal every 2 to 3 hours.
Reducing unpleasant environment stimuli e.g. odour
including those relation for food preparation; vomit
bowl or bedpan and extremes change of temperature
change to allow patient to have a normal meal.
Monitor intake and output chart to keep track of
amount of intake per day for assessment.
Explain general measures; for example routine oral
hygiene, avoidance of extreme food temperature and
alteration of food texture to make it easy to eat and to
maintain adequate nutritional status.
Monitor patient weight each week to recognise the
outcome.
EVALUATON
Patient exhibits stable or improved nutritional status
consistent with disease and maintaining adequate
nutrition.