UNIVERSITY OF SANTO TOMAS

COLLEGE OF NURSING
Espaa Boulevard Sampaloc, Manila Philippines 1015
Tel. No. 046-1611 loc.8241 l Telefax: 731-5738 l Website: www.ust.edu.ph

PATIENT CARE RECORD - NURSING CARE PLAN

DATE
September
17,2014

CUES/CLUES
(+) Cervical cancer
(liver and bone
metastasis)
On chemotherapy
WBC: 3.20 x
10^9g/L

NURSING
DIAGNOSIS
Risk for infection
secondary to
immunosuppression
related to
chemotherapy and
immunosuppresant
agents

SCIENTIFIC
RATIONALE

OBJECTIVE

Patients
receiving
chemotherapy are more
likely or predisposed to
be at risk for infection.
Chemotherapy works in
the
destruction
of
cancer cells but it also
destroys white blood
cells in the process
which
makes
the
patients WBC count low,
a
condition
called
neutropenia hence the
risk for infection.

After 2-3 hours of nursing

interventions the patient
will be able to:

These cancer-fighting
drugs work by killing
fast-growing cells
in the bodyboth good
and bad. These drugs kill
cancer cells
as well as healthy white
blood cells.

NURSING
INTERVENTION
1.

Identify risk factors for

infection such as fever.

ANALYSIS

EVALUATION

Promote good handwashing

procedures by staff and
visitors. Screen/limit visitors
who may have infections.
Place in reverse isolation as
indicated.

1. Protects patient from

sources of infection,
such as visitors and
staff who may have an
upper respiratory
infection (URI)

After 2-3 hours of

nursing interventions
the patient was able to:

Emphasize personal hygiene.

2. Limits potential
sources of infection
and/or secondary
overgrowth.

Remained afebrile and

achieved timely healing.

Identify risk factors for

infection such as fever.

2.
Remain afebrile and
achieve timely healing as
appropriate.
Identify and participate in
interventions to
prevent/reduce risk of
infection.

3.

Monitor temperature.
3. Temperature elevation
may occur (if not
masked by
corticosteroids or
anti-inflammatory
drugs) because of
various factors, e.g.,
chemotherapy side
effects, disease
process, or infection.
Early identification of
infectious process
enables appropriate
therapy to be started
promptly.

After 2-3 days of nursing

interventions the patient
will be able to:
Verbalize understanding
towards health teachings
and will be able to know
them by heart.
By the time of discharge,
patient and relatives
should have been able to
practice aseptic
techniques taught by the
nurse.

4.

Encourage fluids.

4. Adequate fluid intake

enhances immune
system and aids
natural defense

Identified and
participated in
interventions in
preventing/reducing
infection.
After 2-3 days of
nursing interventions
the patient was be able
to:
Verbalized
understanding towards
health teachings and
was able to know them
by heart.
By the time of
discharge, patient and
relatives have been able
to practice aseptic

mechanisms.
5.

Assess all systems (e.g., skin,

respiratory, genitourinary) for
signs/symptoms of infection
on a continual basis.

5. Early recognition and

intervention may
prevent progression to
more serious
situation/sepsis.

6.

Reposition frequently; keep

linens dry and wrinkle-free.

6. Reduces pressure and

irritation to tissues
and may prevent skin
breakdown (potential
site for bacterial
growth).

7.

Promote adequate
rest/exercise periods.

7. Limits fatigue, yet

encourages sufficient
movement to prevent
stasis complications,
e.g., pneumonia,
decubitus, and
thrombus formation.

8.

Stress importance of good

oral hygiene.

8. Development of
stomatitis increases
risk of infection/
secondary
overgrowth.

9.

Avoid/limit invasive
procedures. Adhere to
aseptic techniques.

9. Reduces risk of
contamination, limits
portal of entry for
infectious agents.

10. Monitor CBC with differential

WBC and granulocyte count,
and platelets as indicated.

10. Bone marrow

activity may be
inhibited by effects of
chemotherapy, the
disease state, or
radiation therapy.
Monitoring status of
myelosuppression is

techniques taught by
the nurse.

important for
preventing further
complications (e.g.,
infection, anemia, or
hemorrhage) and
scheduling drug
delivery.
11. Obtain cultures as indicated.

11. Identifies causative

organism(s) and
appropriate therapy.

12. Administer antibiotics as

indicated

12. May be used to treat

identified infection or
given prophylactically
in
immunocompromised
patient.

UNIVERSITY OF SANTO TOMAS

COLLEGE OF NURSING
Espaa Boulevard Sampaloc, Manila Philippines 1015
Tel. No. 046-1611 loc.8241 l Telefax: 731-5738 l Website: www.ust.edu.ph

PATIENT CARE RECORD - NURSING CARE PLAN

DATE
September 19,
2014

CUES/ CLUES

NURSING
DIAGNOSIS

SCIENTIFIC
RATIONALE

Subjective:
Malala na yung sakit
ko, kumalat na nga sa
atay at buto ko e.
Nakakatakot na
talaga. Di ko din nga
alam kung
magtatagal pa ang
buhay ko.

Death Anxiety
Related to Stage IV
Cervical Cancer
Liver and Bone
metastasis

Having cancer
especially Stage IV
cancer usually fear
the patient of
death. Patient is
experiencing death
anxiety which is
the morbid,
abnormal or
persistent fear of
one's own death or
the process of her
dying and fearful
that she might die
anytime.

Objective:
Stage IV Rectal
Cancer that
metastasis in the
liver.
Restlessness and
shakiness

OBJECTIVE
Short term:
After 6-8 hours of nursing
intervention the patient
will:
Be able to feel safe to
discuss more about his
feelings with regards of
the situation.
Be able to feel more
comfortable about the
situation and with the
environment.
Be able to feel that there
are people whom he can
share his fears with.
Patients caregiver will be
more
caring
and
compassionate in taking
care of the client.
Long term:
After 3-4 days of nursing
intervention the patient
will:
Be more hopeful about

NURSING
INTERVENTION

ANALYSIS

EVALUATION

1. Assess patient/SO for stage of

grief
currently
being
experienced. Explain process
as appropriate

1. Knowledge about the grieving

process reinforces the
normality of feelings/reactions
being experienced and can
help patient deal more
effectively with them.

After 6-8 hours of

nursing interventions
patient:

2. Provide open, nonjudgmental

environment. Use therapeutic
communication
skills
of
Active-Listening,
acknowledgment, and so on.

2. Promotes and encourages

realistic dialogue about
feelings and concerns

3. Review patients previous

experience
with
cancer.
Determine what the doctor
has told patient and what
conclusion
patient
has
reached

3. Clarifies patients perceptions;

assists in identification of
fear(s) and misconceptions
based on diagnosis and
experience with cancer.

4. Encourage verbalization of
thoughts/concerns and accept
expressions of sadness, anger,
rejection.
Acknowledge
normality of these feelings.

4. Patient may feel supported in

expression of feelings by the
understanding that deep and
often conflicting emotions are
normal and experienced by
others in this difficult
situation.

5. Provide open environment in

which patient feels safe to
discuss feelings or to refrain

5. Helps patient feel accepted in

present condition without
feeling judged, and promotes

Was able to discuss his

feelings about the
situation and was more
comfortable about it
and
with
the
environment.
Patients caregiver was
able to demonstrate
more compassion with
the client.
After 3-4 days of
nursing interventions
client:
Was able to realize how
beautiful life is and
realize that there still
hope.
Was able to be more
faithful to God and trust
Him with everything.

the situation and see the

brighter side.
Be more prayerful and
will be closer to God.

from talking.

sense of dignity and control.

6. Maintain frequent contact

with patient. Talk with and
touch patient as appropriate.

6. Provides assurance that

patient is not alone or
rejected; conveys respect for
and acceptance of the person,
fostering trust.

7. Assist patient in recognizing

and clarifying fears to begin
developing coping strategies
for dealing with these fears.

7. Coping skills are often stressed

after diagnosis and during
different phases of treatment.
Support and counseling are
often necessary to enable
individual to recognize and
deal with fear and to realize
that control/coping strategies
are available.

8. Provide accurate, consistent

information
regarding
diagnosis and prognosis. Avoid
arguing
about
patients
perceptions of situation.

8. Can reduce anxiety and enable

patient to make
decisions/choices based on
realities.

Be more optimistic about

the situation.

UNIVERSITY OF SANTO TOMAS

COLLEGE OF NURSING
Espaa Boulevard Sampaloc, Manila Philippines 1015
Tel. No. 046-1611 loc.8241 l Telefax: 731-5738 l Website: www.ust.edu.ph

PATIENT CARE RECORD - NURSING CARE PLAN

DATE
September 20,
2014

CUES/CLUES
Body weight 20% or
more under ideal
for height and
frame, decreased
subcutaneous
fat/muscle mass.
Weight loss.

NURSING
DIAGNOSIS
Altered Nutrition:
Less Than Body
Requirements

SCIENTIFIC
RATIONALE

OBJECTIVE

Nutritional status can

be affected by disease
or injury states (cancer.
During times of illness
adequate nutrition
plays an important role
in healing and
recovery.

After 2-3 days of nursing

intervention the patient will
be able to:
Verbalize understanding
of the need for balance
nutrition.
Demonstrate stable
weight/progressive
weight gain toward goal
with normalization of
laboratory values and
be free of signs of
malnutrition.
Verbalize
understanding of
individual interferences
to adequate intake.
Participate in specific
interventions to
stimulate
appetite/increase
dietary intake.

In general, weight lose

develops because of a
negative balance
between intake and
expenditure of calories.
Such a negative balance
may ocur with
decreased calorie
intake and normal
energy expenditure,
with normal
calorie intake but
increased energy
spending, or with
decreased calorie in
take and increased
calorie expenditure.
At the clinical level, an
imbalance can
result from: (1)
inadequate food inges
tion; (2) impaired

NURSING
INTERVENTION
1. Monitor daily food intake;
have patient keep food
diary as indicated.
2. Measure height, weight,
and tricep skinfold
thickness (or other
anthropometric
measurements as
appropriate). Ascertain
amount of recent weight
loss. Weigh daily or as
indicated.
3. Assess skin/mucous
membranes for pallor,
delayed wound healing,
enlarged parotid glands.

4. Encourage patient to eat

high-calorie, nutrient-rich
diet, with adequate fluid
intake. Encourage use of
supplements and
frequent/smaller meals
spaced throughout the day.
5. Create pleasant dining
atmosphere; encourage
patient to share meals with
family/friends.

ANALYSIS
1. Identifies nutritional
strengths/deficiencies.
2. If these measurements fall
below minimum standards,
patients chief source of
stored energy (fat tissue) is
depleted.

3. Helps in identification of
protein-calorie
malnutrition, especially
when weight and
anthropometric
measurements are less
than normal.
4. Metabolic tissue needs are
increased as well as fluids
(to eliminate waste
products). Supplements
can play an important role
in maintaining adequate
caloric and protein intake.
5. Makes mealtime more
enjoyable, which may
enhance intake.

EVALUATION
After 2-3 days of
nursing intervention the
patient will be able to:
Verbalized
understanding of
the need for
balance nutrition.
Demonstrated
stable
weight/progressive
weight gain toward
goal with
normalization of
laboratory values
and be free of signs
of malnutrition.
Verbalized
understanding of
individual
interferences to
adequate intake.
Participate in
specific
interventions to
stimulate
appetite/increase
dietary intake.

digestion and
absorption; (3) external
nutrient lose; (4)
tumor-host competion
for nutrients; or
(5) increased energy
expenditure of the
host. In the cancer
patient, al these
abnormalites may ocur
singly or
incombination, thereby
contributing to weight
lose and eventualy to
the development
of cachexia, the
halmark of cancer.

6.Encourage open
communication regarding
anorexia.

7.Adjust diet before and

immediately after treatment,
e.g., clear, cool liquids,
light/bland foods, candied
ginger, dry crackers, toast,
carbonated drinks. Give
liquids 1 hr before or 1 hr
after meals.
8.Control environmental
factors (e.g., strong/noxious
odors or noise). Avoid overly
sweet, fatty, or spicy foods.
9.Encourage use of relaxation
techniques, visualization,
guided imagery, moderate
exercise before meals.
10.Identify the patient who
experiences anticipatory
nausea/vomiting and take
appropriate measures.

11.Administer antiemetic on a
regular schedule before/
during and after
administration of
antineoplastic agent as
appropriate.

6. Often a source of emotional

distress, especially for SO who
wants to feed patient
frequently. When patient
refuses, SO may feel
rejected/frustrated.

7.The effectiveness of diet

adjustment is very
individualized in relief of
posttherapy nausea. Patients
must experiment to find best
solution/combination. Avoiding
fluids during meals minimizes
becoming full too quickly.
8.Can trigger nausea/vomiting
response.

9.May prevent onset or reduce

severity of nausea, decrease
anorexia, and enable patient to
increase oral intake.
10.Psychogenic
nausea/vomiting occurring
before chemotherapy generally
does not respond to antiemetic
drugs. Change of treatment
environment or patient routine
on treatment day may be
effective.
11.Nausea/vomiting are
frequently the most disabling
and psychologically stressful
side effects of chemotherapy.

12.Evaluate effectiveness of
antiemetic.

13. Review laboratory studies

as indicated, e.g., total
lymphocyte count, serum
transferrin, and albumin/
prealbumin.

14.Refer to
dietitian/nutritional support
team.

12.Individuals respond
differently to all medications.
First-line antiemetics may not
work, requiring alteration in or
use of combination drug
therapy.
13.Helps identify the degree of
biochemical imbalance/
malnutrition and influences
choice of dietary interventions.
Note: Anticancer treatments
can also alter nutrition studies,
so all results must be
correlated with the patients
clinical status.
14.Provides for specific dietary
plan to meet individual needs
and reduce problems
associated with protein/ calorie
malnutrition and micronutrient
deficiencies.