VI. Nursing Diagnosis
• Acute or chronic pain
• Impaired skin integrity
• Impaired oral mucous membrane
• Risk for injury
• Risk for infection
• Fatigue
• Imbalanced nutrition: less than body requirements
• Risk for imbalanced fluid volume
• Disturbed body image
• Deficient knowledge
• Ineffective coping
• Social isolation
VII. Nursing Management
Promote measures that relieve pain and discomfort
• Assess the client’s pain, rule out any complications of treatment therapy or disease process, provide pain management as needed, and evaluate the effectiveness of pain medication.
• Use distraction, relaxation technique, and imagery before, during, and after chemotherapy.
Promote measures that maintain intact skin integrity
• Never apply ointment, powder, lotion, heat, ice or other substances to the treatment field unless prescribed by the radiotherapist.
• Avoid washing off target marks made by the radiation therapist.
• Wash with water only, patting skin dry.
• Shave with an electric razor only in the treatment area.
• Teach the client to avoid sun exposure to the treatment site.
• If the client suffers hair loss from therapy, instruct him to cover his head when out doors to prevent body heat loss or sunburn.
Promote measures that maintain the oral mucosa.
• Assess
• Encourage oral hygiene only as prescribed by the radiation therapist, warn the client to avoid commercial and lemon and glycerin products, as these promote drying and irritation.
• Recommend the use of a soft toothbrush or “toothette.”
• Instruct the client to remove dentures except for eating.
• Advise the client to avoid extremely hot or cold foods, spices and citrus juices.
• Advise the client to avoid smoking and alcohol intake.
• Instruct the client to report any redness, open lesions, decreased tolerance to temperature of food and discomfort that interferes with nutritional intake and lasts more than 2 days.
Promote measures to prevent injury from abnormal bleeding.
• Monitor platelet count, and notify the health care provider if it drops below 100,000/mm3
• Teach the client to avoid aspirin products.
• Instruct the client on the signs and symptoms of hemorrhage.
• Observe the client’s skin frequently for ecchymoses and petechiae.
• Instruct the client to avoid cuts, bruises, or other trauma; instruct client to shave with an electric razor and keep nails short.
Promote measure to identify and prevent infection
• Monitor WBC count, and notify the health care provider if it drops below 2,000/mm3.
• Explain the client’s increased vulnerability to infection; caution against exposure to upper respiratory and other infections.
• Encourage frequent handwashing and overall cleanliness.
• Institute standard precautions at all times. Maintain the client in reverse isolation, if needed.
Promote measure to help decrease the client’s fatigue and increase his activity level.
• Reassure the client that fatigue commonly results from radiation, chemotherapy, bone marrow transplant, and blood transfusion and is not an indicator of worsening disease.
• Provide for rest periods during the day, especially before and after priority activities.
• Help the client rearrange daily schedule and organize activities to conserve energy.
Promote measures that ensure adequate nutritional intake.
• Promote a high-protein, high-calorie diet (if the client is not diabetic)
• Provide a bland diet as indicated.
• Adjust the client’s diet before and after treatment according to food preferences.
• Provide refreshing mouth care before meals.
Promote measures that ensure adequate fluid and electrolyte balance.
• Weigh the client daily, noting any weight loss
• Assess for dehydration, checking skin turgor and the oral mucosa
• Maintain accurate intake and output records
Promote measures to enhance body image
• Take an honest, gentle, caring approach, encouraging the client to express fears and feelings of loss.
• Inform the client if hair loss is expected.
• Explain that the hair that regrows may differ in color or texture. If hair loss is the result of radiation therapy to the head, prepare the client to understand that alopecia is expected.
• Never communicate that hair loss is an insignificant problem compared with life-threatening alternatives; the client’s emotional needs may be as great as physical needs.
• Encourage the client and significant others to share concerns about altered body image regarding sexuality or sexual concerns and to explore alternatives to sexual expression.
Promote measures that address preventing complications of cancer therapy.
• Assess the client’s compliance with prescribed medication regimen (e.g. steroids)
• Observe for evidence of infection and bleeding
• Monitor for urinary-system complications (hematuria, dysuria, frequency)
Instruct the client and his family about the disease process and treatments, and provide necessary information for self-care
• Provide oral instructions and written materials
• Encourage return demonstration of all teaching when applicable.
Promote measures that help the client and his family cope effectively with the disease process and the grieving process.
• Allow and encourage verbalization of anger, sadness or resentment by the client and significant others
• Determine available resources and support systems
Provide measures to reduce social isolation
• Provide frequent staff checks on the client, with time to talk whenever possible
• Promote diversionary activities, such as television, radio, hobbies depending on mobility.
Provide nursing interventions for the client undergoing surgery for cancer.
• Assess the abdominal stoma for edema, pink color, small amount of mucus drainage, and no excessive bleeding (nursing interventions for the client with colon cancer undergoing a colostomy)
• Discuss alternate forms of communication (e.g. esophageal speech, electronic larynx)
• Instruct the client to avoid restrictive clothing on the affected side, with no blood draws or heavy objects on the affected side (nursing interventions for the client with breast cancer undergoing mastectomy)
Provide nursing intervention for the client undergoing radiation therapy.
• Discuss with the client the special precautions that must be adhered to during radiation therapy
• When counseling a client about possible adverse effects, be sure to emphasize the benefits of therapy. The severity of adverse effects depends on the radiation dosage, type of radiation, proximity of tumor to skin surface and size of treatment field.
Provide nursing interventions for the client undergoing chemotherapy.
• Special care must be taken during administration of vesicant agents, because extravasation can cause tissue necrosis and damage to underlying tendons, nerves, and blood vessels. Only specially trained health care providers and nurses should administer vesicants.
• Stop the infusion any time vein patency is in question.
• Provide nursing care for activity intolerance because most anticancer agents depress bone-marrow function, resulting in decreased blood-cell production.
• Provide nursing care for risk for infection and abnormal bleeding because myelosuppression decreases WBC and platelet counts.
Provide nursing interventions for the client undergoing bone marrow transplantation.
• Assess for signs and symptoms of graft-versus-host disease, a syndrome induced by donor T lymphocytes acting against host tissues.
Provide nursing intervention for a client receiving immunotherapy
• Ensure that clients undergoing immunotherapy receive the same nursing care as any client undergoing cancer treatment.
Provide nursing interventions for a client receiving immunotherapy with biologic response modifiers (BRMs)
• Be sure to gain familiarity with each agent given and its potential adverse effects.
Provide nursing interventions for a client receiving gene therapy.
• Ensure that clients undergoing gene therapy receive the same nursing care as any client undergoing cancer treatment.