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Saint Louis University
School of Nursing
Graduate School Program
CASE ANALYSIS
In partial fulfillmentOf the requirements
In Oncology Nursing
Submitted to:
Ms. Florence Pulido, RMT,RN,MN
Professor
Submitted by:
BANIQUED, Charmaine Acosta
Submitted on:
March 15, 2012
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A. Identify all the Nursing Diagnoses for M.C.1. Chemotherapy- Related Nursing Diagnoses
a. Anxiety related to prescribed chemotherapy, insufficient knowledge ofchemotherapy, and self-care measures
b. Knowledge deficitc. Altered comfort related to gastrointestinal cell damage, stimulation of vomiting
center, fear, and anxiety
d. Altered nutrition: less than body requirements related to anorexia, taste changes,persistent nausea/vomiting, and increased intestinal mobility
e. Altered oral mucous membrane related to dryness and epithelial cell damagesecondary to chemotherapy
f. Fatigue related to effects of anemia, malnutrition, persistent vomiting, and sleeppattern disturbanceg. Activity intolerance related to imbalance between oxygen supply and demand
h. High risk for colonic constipation related to autonomic nerve dysfunctionsecondary to Vinca alkaloid administration and inactivity
i. Fluid volume deficient related to intestinal cell damage, inflammation, andincreased intestinal mobility secondary to diarrhea
j. High risk for impaired skin integrity related to persistent diarrhea, malnutrition,prolonged sedation, and fatigue
k. Self-concept disturbance related to change in lifestyle, role, alopecia, and weightloss
l. Grieving related to changes in life style, role, finances, functional capacity, bodyimage, and health losses
2. Radiation Therapy- Related Nursing Diagnosesa. Anxiety related to prescribed radiation therapy and insufficient knowledge of
treatments and self-care measures
b. Knowledge deficitc. High risk of altered oral mucous membrane related to dry mouth or inadequate
oral hygiene
d. Impaired skin integrity related to effects of radiation on epithelial and basal cellsand effects of diarrhea on perineal area
e. altered comfort related to stimulation of the vomiting center and damage to thegastrointestinal mucosa cells secondary to radiation
f. Fatigue related to systemic effects of radiation therapyg. Activity intolerance related to imbalance between oxygen supply and demandh. Altered comfort related to damage to sebaceous and sweat glands secondary to
radiation
i.
Self-concept disturbance related to alopecia, skin changes, weight loss, andchanges in role relationships and life styles
j. Grieving related to changes in life style, role, finances, functional capacity, bodyimage, and health losses
k. Altered family processes related to imposed changes in family roles, relationships,and responsibilities
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3. Surgery- Related Nursing DiagnosesPREOPERATIVE PERIOD
a. Anxiety/fear related to surgical experience, loss of control, unpredictable outcome, andinsufficient knowledge of preoperative exercises and activities, and postoperative
changes and sensations,
b. Anxiety related to impending surgery and insufficient knowledge of preoperativeroutines, intra-operative activities, and postoperative self-care activities
c. Knowledge deficitPOSTOPERATIVE PERIOD
a. Disturbed body image related to surgeryb. Risk for altered respiratory function related to immobility secondary to post-anesthesia
state and pain
c. Impaired skin integrity related to mechanical trauma secondary to surgeryd. Tissue trauma related to surgical incisione. Risk for infection related to increased susceptibility to bacteria secondary to woundf. Pain related to surgical interruption of body structure, flatus, and immobilityg. Risk for altered nutrition: less than body requirements related to increased protein and
vitamin requirements for wound healing and decreased intake secondary to pin, nausea,
vomiting, and diet restrictions
h.
Risk for colonic constipation related to decreased peristalsis secondary to immobility andeffects of anesthesia and narcotics
i. Activity intolerance related to pain and weakness secondary to anesthesia, tissue hypoxia,and insufficient fluid and nutrient intake
j. Risk for ineffective management of therapeutic regimen related to insufficient knowledgeof care of operative site, restrictions (diet, activity), medications, signs an symptoms of
complications, and follow-up care
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B. Nursing Care Plan1. After initial discussion with the physician
Nursing DiagnosisSubjective and Objective
DataGoals- Objectives Nursing intervention Expected outcome
Fear/Anxiety related to
Situational crisis (cancer)
S> Express concerns regarding
changes in life events, feelings
of helplessness, hopelessness,
inadequacy
O>Increase tension, shakiness,
apprehension, restlessness,
insomnia
>Sympathetic stimulation
(increase in vital signs),
somatic complaints (voice
quivering, shakiness)
>Note mild to moderate
anxiety (irritability, impaired
attention)
GOALS: Demonstrate
problem-solving skills
LTO:
>Use resources/support
systems properly.
>Demonstrate use of effective
coping mechanisms and active
participation all throughout the
treatment regimen.
STO:
>Display appropriate range of
feelings and lessened fear.
>Appear relaxed and
report anxiety is reduced to a
manageable level.
Dx> Determine what the
doctor has told patient and
what conclusion patient has
reached.
>Identify stage/degree of grief
patient and SO are currently
experiencing.
>Note ineffective coping, e.g.,
poor social interactions,
helplessness, giving up
everyday functions and usual
sources of gratification.
>Be alert to signs of
denial/depression, e.g.,
withdrawal, anger,
inappropriate remarks.
>Determine presence of
suicidal ideation and assess
potential on a scale of 110.
Tx>Provide open environment
in which patient feels safe to
discuss feelings or to refrain
from talking.
>Fully met if patient:
Demonstrates problem-solving
skills Displays appropriate
range of feelings and lessened
fear.
Appears relaxed and
report anxiety is reduced to a
manageable level.
Demonstrates use of effective
coping mechanisms and active
participation in treatment
regimen.
Uses resources/support
systems properly.
>Partially met if patient:
Has marked difficulty
imploring problem solving
skills because of theoverwhelming feeling of
anxiety
>Unmet if patient:
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>Maintain frequent contact
with patient. Talk with and
touch patient as appropriate.
>Be aware of effects of
isolation on patient when
required by
immunosuppression.
>Provide accurate, consistent
information regarding
diagnosis and prognosis.
>Permit expressions of anger,
fear, despair without
confrontation.
>Give information that
feelings are normal and are to
be appropriately expressed.
>Stay with patient during
anxiety-producing procedures
and consultations.
>Promote calm, quiet
environment.
Edx>Encourage patient to
share thoughts and feelings.
>Educate patient/SO inrecognizing and clarifying
fears to begin developing
coping strategies for dealing
with these fears.
Does not demonstrate
problem-solving skills and
does not able to cope with the
situational crisis.
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>Explain the recommended
treatment, its purpose, and
potential side effects. Help
patient prepare for treatments.
>Explain procedures,
providing opportunity for
questions and honest answers.
>Advise SO to provide
primary and consistent
caregivers
whenever possible.
>Encourage and foster patient
interaction with
support systems
>Advocates in provision of
reliable and consistent
information and support for
SO.
>Include SO as
indicated/patient desires when
major decisions are to be
made.
Ref: Doenges, Marilyn, Nursing Care Plans Guidelines for Individualizing Client Care Across t he Life Span, 7th
ed.
Doenges, Marilyn, Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, 11 th ed.
Videbeck, Sheila, Psychiatric Mental Health Nursing, 3rd ed.
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2. On the admission to hospital at the start of therapy
Nursing DiagnosisSubjective and Objective
DataGoals- Objectives Nursing Interventions Expected Outcome
Anxiety related to prescribed
chemotherapy, insufficient
knowledge of the therapy, and
self-care measures
S> Verbalization of the feeling
of anxiety and the problem
>Asks for information
regarding the related factors
stated
>Statements reflecting
misconceptions
O>Note mild to moderate
anxiety
>Inaccurate follow-through of
instructions and procedures to
be done
GOAL: Exhibit increased
interest/ assume responsibility
for own learning by beginning
to look for information and ask
questions.
OBJECTIVES:
>Participate in learning
process
>Identify interferences to
learning and specific action/s
to deal with them
>Verbalize understanding of
condition/ disease process and
treatment
>Identify relationship of
signs/symptoms to the disease
process and correlate
symptoms with causative
factors
>Perform necessaryprocedures correctly and
explain reasons for the actions
>Initiate necessary lifestyle
changes and participate in
Dx>Determine clients extent
of understanding of thetherapy
>Review disease process withand future expectations from
the patient.
Tx>Premedications given asprescribed
>Implement dietary regimen,as individually appropriate
>Active-listen concerns abouttherapeutic regimen/lifestyle
changes.
Edx>Stress importance of
increased fluid intake.>Inform patient to notice dry
mouth, N/V, diarrhea, feelingof tiredness during the therapy,
possible alopecia as thetherapy progresses, and loss of
appetite. Radiation therapyentails markings on the area to
be exposed and need not to beerased afterwards.
>Teach care of the radiationsite (no lotions, mild soap is
Fully met if patient:
>: Exhibited increased interest/
assume responsibility for own
learning by beginning to look
for information and ask
questions.
>Verbalized understanding of
disease process and potentialcomplications.
>Able to correlate symptoms
with causative factors.
>Verbalized understanding oftherapeutic needs.
>Initiated necessary lifestyle
changes and participate intreatment regimen.
Partially met if:
Patient is not able to attain the
goal but can be seen initiating
necessary lifestyle changes
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treatment regimen. advised)>Discuss medication regimen;
neutropenic diet.>Identify signs/symptoms
requiring further medicalconcerns.
and participate in treatment
regimen.
Unmet if:
Patient not able to reached the
goal and no objectives wasmet
Ref: books.google.com.ph/books?isbn=0798619120
Doenges, Marilyn, Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span, 7th ed.
Doenges, Marilyn, Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, 11 th ed.Videbeck, Sheila, Psychiatric Mental Health Nursing, 3
rded.
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3. While hospitalized, 2 days later
Nursing DiagnosisSubjective and Objective
DataGoals- Objectives Nursing Interventions Expected Outcome
Altered nutrition: less than
body requirements related to
anorexia, taste changes,
persistent nausea/vomiting,
and increased intestinal
mobility
S>Reported altered taste
sensation
>Lack of interest in food
O>Loss of weight
>Pale conjunctiva and mucous
membranes
>Poor muscle tone/ weakness
>Poor skin turgor
>Edema of extremities
>Electrolyte imbalances
GOAL:
Client will exhibit no signs or
symptoms of malnutrition by
time of discharge from
treatment (e.g., electrolytes
and blood counts will bewithin normal limits; a steady
weight gain will be
demonstrated; constipation
will be corrected; client will
exhibit increased energy in
participation in activities).
>Demonstrate behaviors,
lifestyle changes to regain
and/or maintain appropriate
weight
Dx> Determine number of
calories required to provideadequate nutrition and realistic
(according to body structureand height) weight gain.
>Strict documentation of
intake, output, and caloriecount. This information isnecessary to make an accurate
nutritional assessment andmaintain client safety.>Determine clients likes and
dislikes, and collaborate with
dietitian>Weigh client daily. Weight
loss or gain is importantassessment information.
>Monitor laboratory values,and report significant changes
to physician.Laboratory
values provide objective data
regarding nutritional status.
Tx >Provide favoritefoods. Client is more likely to
eat foods that he or she
particularly enjoys.
Fully met if:
>Client will exhibit no signs or
symptoms of malnutrition by
time of discharge
>Client has shown a slow,
progressive weight gain during
hospitalization.
>Vital signs, blood pressure,
and laboratory serum studies
are within normal limits.
>Client is able to verbalize
importance of adequate
nutrition and fluid intake.
Partially met if:
>Client has shown a slow,
progressive weight gain duringhospitalization.
>Vital signs, blood pressure,
and laboratory serum studies
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>Ensure that client receives
small, frequent feedings,
including a bedtime snack,
rather than three larger
meals.Large amounts of food
may be objectionable, or even
intolerable, to the client.
>Administer vitamin and
mineral supplements as
indicated
>Stay with client during
meals to assist as needed and
to offer support and
encouragement.
Edx>>Encourage client to
increase fluid consumption
and physical exercise as
tolerated.
>Advise family members or
significant others to bring in
special foods that client
particularly enjoys.
>Explain the importance of
adequate nutrition and fluid
are within normal limits.
>Client is able to verbalize
importance of adequate
nutrition and fluid intake.
>But had not yet attained
normal weight at the time of
discharge.
Unmet if:
>Patient did not attain the goal
and did not manifest any
weight gain
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intake. Client may have
inadequate or inaccurate
knowledge regarding the
contribution of good nutrition
to overall wellness.
Ref:http://www.philippinenursingdirectory.com/nursing-care-plans/imbalanced-nutrition-less-than-body-requirements/Doenges, Marilyn, Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span, 7
thed.
Doenges, Marilyn, Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, 11th
ed.
http://www.philippinenursingdirectory.com/nursing-care-plans/imbalanced-nutrition-less-than-body-requirements/http://www.philippinenursingdirectory.com/nursing-care-plans/imbalanced-nutrition-less-than-body-requirements/http://www.philippinenursingdirectory.com/nursing-care-plans/imbalanced-nutrition-less-than-body-requirements/http://www.philippinenursingdirectory.com/nursing-care-plans/imbalanced-nutrition-less-than-body-requirements/8/2/2019 Case Analysis on Lung CA
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4. At home, 2 weeks after starting therapy
Nursing DiagnosisSubjective and Objective
DataGoals- Objectives Nursing Interventions Expected Outcome
Risk for Infection related to
leukopenia secondary to
chemotherapy
O> immunosuppression as
seen in the laboratory results
Goal:
Client will remain free of
infection as evidenced by
temperature remaining within
normal limits.
STO:
Client will verbalize and
integrate in the lifestyle
changes interventions that
prevent infection.
Dx>Monitor vital signs to
check for infection
>Monitor laboratory results,
especially complete blood
count, white blood cell count
(WBC), differential and
absolute neutrophils
>Monitor respiratory, urinary,
mucosal and skin systems
Tx>Practice proper hand-
washing and use aseptic
technique when providing care
Edx>Instruct SO to keep
neutropenic client separate
from others
>Instruct patient to wear mask
as for self-protection
>Teach manifestations of
infection and those to reportimmediately
>Teach measures for
prevention of infection, such
as avoiding crows and not
Fully Met if: The client will
remain free of infection or
seek treatment promptly if
manifestations of infection
appear. The client will
verbalize methods that
minimize this condition
from occurring.
Partially Met if:
Patient remained free of
infection but does not
demonstrate self-care to avoid
infection
Unmet If:
Patient developed infection.
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cleaning fish tanks or litter
boxes
>Reinforce neutropenic diet,
and no fresh flowers in the
room.
>Instruct to avoid uncontrolled
crowds and sources of
infection; balanced diet; skin
care.
Ref: Doenges, Marilyn, Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span, 7th ed.Doenges, Marilyn, Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, 11
thed.
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5. At home, 3 weeks after the start of chemoradiotherapy
Nursing DiagnosisSubjective and Objective
DataGoals- Objectives Nursing Interventions Expected Outcome
Fatigue related to systemic
effects of radiation therapy;
Fatigue related to effects of
anemia, malnutrition,
persistent vomiting, and sleep
pattern disturbance
Secondary to:
>Build up of cellular waste
products associated with rapid
lysis of cancerous and normal
cells exposed to cytotoxic
drugs;
>difficulty resting and
sleeping associated with fear,
anxiety, and discomfort;
>tissue hypoxia associated
with anemia (a result of
malnutrition and
chemotherapy-induced bone
marrow suppression);
S> client's perception of the
severity of fatigue using a
fatigue rating scale
>verbalization of an
unremitting/ overwhelming
lack of energy
>Inability to maintain usual
routines
>Perceive need for additional
energy to accomplish routine
tasks
>Increase in rest requirements
>Disinterest in surroundings
>Decrease performance
O>lethargic
>Drowsy
The client will experience a
reduction in fatigue as
evidenced by:
a.verbalization of feelings of
increased energy
b. ability to perform usual
activities of daily living
c. Identify basis of further
fatigue and ways of
conserving energy
c.increase interest in
surroundings and ability to
concentrate
Dx>Assess for signs and
symptoms of fatigue (e.g.
verbalization of lack of energy
and inability to maintain usual
routines, lack of interest in
surroundings, decreased ability
to concentrate, lethargy)
>Determine the severity of
fatigue
Tx>Assist client to identify
personal patterns of fatigue
(e.g. time of day, after certain
activities) and to plan
activities so that times of
greatest fatigue are avoided.
>Implement measures to
reduce fatigue: perform
actions to promote rest and/or
conserve energy:
*schedule several short restperiods during the day
Fully met if:
>Patient reported improved
sense of energy
>Able to identify basis of
fatigue and individual areas of
control
>Performed ADLs and
participate at desired activities
with minimal rest periods
needed
Partially met if:
Patient reported improvedsense of energy but not yet
able to performed ADLs.
Not met if: Patient does notreport any sense of improved
energy.
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>overwhelming emotional
demands associated with the
diagnosis of cancer and
treatment with
chemoradiotherapy;
>increased energy expenditure
associated with an increase in
the metabolic rate resulting
from continuous, active tumor
growth and increased levels of
certain cytokines (e.g. tumor
necrosis factor, interleukin-1);
>malnutrition;
>effects of medications used
for control of pain, nausea, and
anxiety.
*minimize environmental
activity and noise
*limit the number of visitors
and their length of stay
*assist client with self-care
activities as needed
*keep supplies and personal
articles within easy reach
*implement measures to
reduce fear and anxiety
*implement measures to
promote sleep (e.g. encourage
relaxing diversional activities
in the evening, allow client to
continue usual sleep practices
unless contraindicated, reduce
environmental stimuli,
administer prescribed
sedative-hypnotics)
*implement measures toreduce discomfort
>Promote an adequate
nutritional status encourage
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client to maintain a fluid
intake of at least 2500
ml/day to promote elimination
of the by-products of cellular
breakdown
>Administer the following if
ordered for treatment of
anemia:
*folate, iron, epoetin alfa(EPO), blood transfusions (e.g.
packed red blood cells),
peripheral blood stem cell
transplantation
>Facilitate client's
psychological adjustment to
the diagnosis of cancer and the
treatment regimen and its
effects.
Edx>>Advise to increase
activity gradually as tolerated
>Advise to consult appropriatehealth care provider (e.g.
oncology nurse specialist,
physician) if signs and
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C. Schematic Pathophysiology of Lung Cancer
LEGEND:
Diagnostic Test
Nursing Diagnosis
Signs and symptoms
Modifiable Risk Factors
Tobacco smoke
Second hand (passive) smoke
Environmental and occupationalExposures
Dietary deficits
Respiratory diseases
Non
modifiable Risk FactorsGender
Genetics
Genetics predisposition
Carcinogenics agent
will enter the
respiratory tract
It will attack the epithelial
cells/ Lining of the lungs
Transformation of a single
epithelial cell in the
tracheobronchial alwa s
Attachment of a
carcinogen into cells DNA
causing damage
Cellular changes, abnormal
cell growth, and eventually
a malignant cell
Mutations in the K RAS
proto oncogenes will
develop cancer cells
Proto oncogenes will
turn into oncogenes
Chromosomal damage
can lead to heterozygosity
Can cause inactivation of
tumor suppressor genes
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Roles of an Oncology Nurse (Focus: Treatment modality- Standards of Care)
EXPANDING THE ROLE OF THE ONCOLOGY NURSE
NURSING PRACTICE
The involvement of oncology nurses today evolves into practice in a variety of settings,
including acute-care hospitals, outpatient clinics, private oncologists offices, radiation therapy
facilities, home health care agencies and community agencies. This means that as the treatments
in oncology became increasingly complex the oncology nurse needs to be more competitive in
order to provide unique comprehensive patient care.
Aside from the more advanced way of navigating patients who were undertreated which
means earlier detection leads to earlier treatment, expanding the scope of an oncology nurse
especially in the participation in treatment modalities such as chemotherapy, radiotherapy and
hormone therapy also opens a window for bigger opportunities for the nurse to reach out andenhance the delivery of care to help cancer patients. This is somehow a way for the oncology
nurse to practice independently from the physician in terms of giving the chemodrugs. More
nurses involved in the continuity of palliative care. This study somehow provide basis for an
oncology nurse on what they can do in the extent of their service.
Furthermore, this study open our eyes on how diverse could be the field of oncology
nursing as more and more subfields emerge. Hence, the more opportunities for the oncology
nurse to upgrade their skills in delivering anti-cancer-drugs. Not only that, as they are also
pivotal in the duration of treatment because they are not only capable of giving the drugs but
they are also the ones staying with the patient, teaching the possible side-effects and how to
prevent them.
NURSING EDUCATION
In the academe, clinical instructors could also update their supervisory student nurses in
the area of the emerging fields in oncology nursing therefore entails expanding the
responsibilities and more complex procedures that the oncology nurse could do. Though, one is
not trained by those exact procedures on how they are done, as a clinical instructor, imparting
knowledge for an overview or familiarity sake is a very important role of an educator. We never
know, as a nurse educator, mentorship is also a part of our duty and we could touch and inspire
lives of the students who could later realize a calling for this career path.
Tackling on the career path development, which is a topic actually during undergrad, the
emerging subfields of oncology nursing is of concern and can be discussed to help students
realize their potentials.
NURSING RESEARCH
The reason why more and more subfields of oncology nursing emerged is the fact that
this is rooted from a research. If a study conducted sees an opportunity for the need of more
specialized oncology nurse on a particular care of a certain cancer, hence, an opening of a newsubfield for practice. So, it is needless to say that this journal may be used as additional review
of related literatures for related studies to be conducted in the future that may possibly offer
more great opportunities for oncology nurses or for the whole nursing community.