Cancer Nursing Care Plan

 

Cancer Nursing Care Plan

Nursing Diagnosis

Anticipatory Grieving
May be related to
  • Anticipated loss of physiological well-being (e.g., loss of body part; change in body function); change in lifestyle
  • Perceived potential death of patient
Possibly evidenced by
  • Changes in eating habits, alterations in sleep patterns, activity levels, libido, and communication patterns
  • Denial of potential loss, choked feelings, anger
Desired Outcomes
  • Identify and express feelings appropriately.
  • Continue normal life activities, looking toward/planning for the future, one day at a time.
  • Verbalize understanding of the dying process and feelings of being supported in grief work.
Nursing Interventions
  • Expect initial shock and disbelief following diagnosis of cancer and traumatizing procedures (disfiguring surgery, colostomy, amputation).
    • Rationale: Few patients are fully prepared for the reality of the changes that can occur.
  • Assess patient and SO for stage of grief currently being experienced. Explain process as appropriate.
    • Rationale: Knowledge about the grieving process reinforces the normality of feelings and reactions being experienced and can help patient deal more effectively with them.
  • Provide open, nonjudgmental environment. Use therapeutic communication skills of Active-Listening, acknowledgment, and so on.
    • Rationale: Promotes and encourages realistic dialogue about feelings and concerns.
  • Encourage verbalization of thoughts or concerns and accept expressions of sadness, anger, rejection. Acknowledge normality of these feelings.
    • Rationale: 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.
  • Be aware of mood swings, hostility, and other acting-out behavior. Set limits on inappropriate behavior, redirect negative thinking.
    • Rationale: Indicators of ineffective coping and need for additional interventions. Preventing destructive actions enables patient to maintain control and sense of self-esteem.
  • Be aware of debilitating depression. Ask patient direct questions about state of mind.
    • Rationale: Studies show that many cancer patients are at high risk for suicide. They are especially vulnerable when recently diagnosed and discharged from hospital.
  • Visit frequently and provide physical contact as appropriate, or provide frequent phone support as appropriate for setting. Arrange for care provider and support person to stay with patient as needed.
    • Rationale: Helps reduce feelings of isolation and abandonment.
  • Reinforce teaching regarding disease process and treatments and provide information as appropriate about dying. Be honest; do not give false hope while providing emotional support.
    • Rationale: Patient and SO benefit from factual information. Individuals may ask direct questions about death, and honest answers promote trust and provide reassurance that correct information will be given.
  • Review past life experiences, role changes, and coping skills. Talk about things that interest the patient.
    • Rationale: Opportunity to identify skills that may help individuals cope with grief of current situation more effectively.
  • Note evidence of conflict; expressions of anger; and statements of despair, guilt, hopelessness, “nothing to live for.”
    • Rationale: Interpersonal conflicts or angry behavior may be patient’s way of expressing and dealing with feelings of despair or spiritual distress and could be indicative of suicidal ideation.
  • Determine way that patient and SO understand and respond to death such as cultural expectations, learned behaviors, experience with death (close family members, friends), beliefs about life after death, faith in Higher Power (God).
    • Rationale: These factors affect how each individual deals with the possibility of death and influences how they may respond and interact.
  • Identify positive aspects of the situation.
    • Rationale: Possibility of remission and slow progression of disease and new therapies can offer hope for the future.
  • Discuss ways patient and SO can plan together for the future. Encourage setting of realistic goals.
    • Rationale: Having a part in problem solving and planning can provide a sense of control over anticipated events.
  • Refer to visiting nurse, home health agency as needed, or hospice program, if appropriate.
    • Rationale: Provides support in meeting physical and emotional needs of patient and SO, and can supplement the care family and friends are able to give.

Nursing Diagnosis

Situational Low Self-Esteem
May be related to
  • Biophysical: disfiguring surgery, chemotherapy or radiotherapy side effects, e.g., loss of hair, nausea/vomiting, weight loss, anorexia, impotence, sterility, overwhelming fatigue, uncontrolled pain
  • Psychosocial: threat of death; feelings of lack of control and doubt regarding acceptance by others; fear and anxiety
Possibly evidenced by
  • Verbalization of change in lifestyle; fear of rejection/reaction of others; negative feelings about body; feelings of helplessness, hopelessness, powerlessness
  • Preoccupation with change or loss
  • Not taking responsibility for self-care, lack of follow-through
  • Change in self-perception/other’s perception of role
Desired Outcomes
  • Verbalize understanding of body changes, acceptance of self in situation.
  • Begin to develop coping mechanisms to deal effectively with problems.
  • Demonstrate adaptation to changes/events that have occurred as evidenced by setting of realistic goals and active participation in work/play/personal relationships as appropriate.
Nursing Interventions
  • Discuss with patient and SO how the diagnosis and treatment are affecting the patient’s personal life, home and work activities.
    • Rationale: Aids in defining concerns to begin problem-solving process.
  • Review anticipated side effects associated with a particular treatment, including possible effects on sexual activity and sense of attractiveness and desirability (alopecia, disfiguring surgery). Tell patient that not all side effects occur, and others may be minimized or controlled.
    • Rationale: Anticipatory guidance can help patient and SO begin the process of adaptation to new state and to prepare for some side effects (buy a wig before radiation, schedule time off from work as indicated).
  • Encourage discussion of concerns about effects of cancer and treatments on role as homemaker, wage earner, parent, and so forth.
    • Rationale: May help reduce problems that interfere with acceptance of treatment or stimulate progression of disease.
  • Acknowledge difficulties patient may be experiencing. Give information that counseling is often necessary and important in the adaptation process.
    • Rationale: Validates reality of patient’s feelings and gives permission to take whatever measures are necessary to cope with what is happening.
  • Evaluate support structures available to and used by patient and SO.
    • Rationale: Helps with planning for care while hospitalized and after discharge.
  • Provide emotional support for patient and SO during diagnostic tests and treatment phase.
    • Rationale: Although some patients adapt or adjust to cancer effects or side effects of therapy, many need additional support during this period.
  • Use touch during interactions, if acceptable to patient, and maintain eye contact.
    • Rationale: Affirmation of individuality and acceptance is important in reducing patient’s feelings of insecurity and self-doubt.
  • Refer for professional counseling as indicated.
    • Rationale: May be necessary to regain and maintain a positive psychosocial structure if patient and SO support systems are deteriorating.

Nursing Diagnosis

Acute Pain
May be related to
  • Disease process (compression/destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation)
  • Side effects of various cancer therapy agents
Possibly evidenced by
  • Reports of pain
  • Self-focusing/narrowed focus
  • Alteration in muscle tone; facial mask of pain
  • Distraction/guarding behaviors
  • Autonomic responses, restlessness (acute pain)
Desired Outcomes
  • Report maximal pain relief/control with minimal interference with ADLs.
  • Follow prescribed pharmacological regimen.
  • Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.
Nursing Interventions
  • Determine pain history (location of pain, frequency, duration, and intensity using numeric rating scale (0–10 scale), or verbal rating scale (“no pain” to “excruciating pain”) and relief measures used. Believe patient’s report.
    • Rationale: Information provides baseline data to evaluate effectiveness of interventions. Pain of more than 6 mo duration constitutes chronic pain, which may affect therapeutic choices. Recurrent episodes of acute pain can occur within chronic pain, requiring increased level of intervention. Note: The pain experience is an individualized one composed of both physical and emotional responses.
  • Determine timing or precipitants of “breakthrough” pain when using around-the-clock agents, whether oral, IV, or patch medications.
    • Rationale: Pain may occur near the end of the dose interval, indicating need for higher dose or shorter dose interval. Pain may be precipitated by identifiable triggers, or occur spontaneously, requiring use of short half-life agents for rescue or supplemental doses.
  • Evaluate and be aware of painful effects of particular therapies (surgery, radiation, chemotherapy, biotherapy). Provide information to patient and SO about what to expect.
    • Rationale: A wide range of discomforts are common (incisional pain, burning skin, low back pain, headaches), depending on the procedure and agent being used. Pain is also associated with invasive procedures to diagnose or treat cancer.
  • Provide nonpharmacological comfort measures (massage, repositioning, backrub) and diversional activities (music, television)
    • Rationale: Promotes relaxation and helps refocus attention.
  • Encourage use of stress management skills or complementary therapies (relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and therapeutic touch).
    • Rationale: Enables patient to participate actively in nondrug treatment of pain and enhances sense of control. Pain produces stress and, in conjunction with muscle tension and internal stressors, increases patient’s focus on self, which in turn increases the level of pain.
  • Provide cutaneous stimulation (heat or cold, massage).
    • Rationale: May decrease inflammation, muscle spasms, reducing associated pain. Note: Heat may increase bleeding and edema following acute injury, whereas cold may further reduce perfusion to ischemic tissues.
  • Be aware of barriers to cancer pain management related to patient, as well as the healthcare system.
    • Rationale: Patients may be reluctant to report pain for reasons such as fear that disease is worse; worry about unmanageable side effects of pain medications; beliefs that pain has meaning, such as “God wills it,” they should overcome it, or that pain is merited or deserved for some reason. Healthcare system problems include factors such as inadequate assessment of pain, concern about controlled substances or patient addiction, inadequate reimbursement or cost of treatment modalities.
  • Evaluate pain relief and control at regular intervals. Adjust medication regimen as necessary.
    • Rationale: Goal is maximum pain control with minimum interference with ADLs.
  • Inform patient and SO of the expected therapeutic effects and discuss management of side effects
    • Rationale: This information helps establish realistic expectations, confidence in own ability to handle what happens.
  • Discuss use of additional alternative or complementary therapies (acupuncture and acupressure).
    • Rationale: May provide reduction or relief of pain without drug-related side effects.

Administer analgesics as indicated:

  • Opioids: codeine, morphine (MS Contin), oxycodone (oxycontin) hydrocodone (Vicodin), hydromorphone (Dilaudid), methadone (Dolophine), fentanyl (Duragesic); oxymorphone (Numorphan);
    • Rationale: A wide range of analgesics and associated agents may be employed around the clock to manage pain. Note: Addiction to or dependency on drug is not a concern.
  • Acetaminophen (Tylenol); and nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, ibuprofen (Motrin, Advil);
    • Rationale: Effective for localized and generalized moderate to severe pain, with long-acting and controlled-release forms available.
  • peroxicam (Feldene);
    • Rationale: Routes of administration include oral, transmucosal, transdermal, nasal, rectal, and infusions (subcutaneous, IV, intraventricular), which may be delivered via PCA. IM use is not recommended because absorption is not reliable, in addition to being painful and inconvenient. Note: Research is in process for oral transmucosal agent (fentenyl citrate [oralet]) to control breakthrough pain in patients using fentanyl patch.
  • indomethacin (Indocin);
    • Rationale: Adjuvant drugs are useful for mild to moderate pain and can be combined with opioids and other modalities.
  • Corticosteroids: dexamethasone (Decadron);
    • Rationale: May be effective in controlling pain associated with inflammatory process (metastatic bone pain, acute spinal cord compression and neuropathic pain).

Nursing Diagnosis

Altered Nutrition: Less Than Body Requirements
May be related to
  • Hypermetabolic state associated with cancer
  • Consequences of chemotherapy, radiation, surgery, e.g., anorexia, gastric irritation, taste distortions, nausea
  • Emotional distress, fatigue, poorly controlled pain
Possibly evidenced by
  • Reported inadequate food intake, altered taste sensation, loss of interest in food, perceived/actual inability to ingest food
  • Body weight 20% or more under ideal for height and frame, decreased subcutaneous fat/muscle mass
  • Sore, inflamed buccal cavity
  • Diarrhea and/or constipation, abdominal cramping
Desired Outcomes
  • 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.
Nursing Interventions
  • Monitor daily food intake; have patient keep food diary as indicated.
    • Rationale: Identifies nutritional strengths and deficiencies.
  • Measure height, weight, and tricep skinfold thickness (or other anthropometric measurements as appropriate). Ascertain amount of recent weight loss. Weigh daily or as indicated.
    • Rationale: If these measurements fall below minimum standards, patient’s chief source of stored energy (fat tissue) is depleted.
  • Assess skin and mucous membranes for pallor, delayed wound healing, enlarged parotid glands.
    • Rationale: Helps in identification of protein-calorie malnutrition, especially when weight and anthropometric measurements are less than normal.
  • Encourage patient to eat high-calorie, nutrient-rich diet, with adequate fluid intake. Encourage use of supplements and frequent or smaller meals spaced throughout the day.
    • Rationale: 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.
  • Create pleasant dining atmosphere; encourage patient to share meals with family and friends.
    • Rationale: Makes mealtime more enjoyable, which may enhance intake.
  • Encourage open communication regarding anorexia.
    • Rationale: Often a source of emotional distress, especially for SO who wants to feed patient frequently. When patient refuses, SO may feel rejected or frustrated.
  • Adjust diet before and immediately after treatment (clear, cool liquids, light or bland foods, candied ginger, dry crackers, toast, carbonated drinks). Give liquids 1 hr before or 1 hr after meals.
    • Rationale: The effectiveness of diet adjustment is very individualized in relief of posttherapy nausea. Patients must experiment to find best solution or combination. Avoiding fluids during meals minimizes becoming “full” too quickly.
  • Control environmental factors (strong or noxious odors or noise). Avoid overly sweet, fatty, or spicy foods.
    • Rationale: Can trigger nausea and vomiting response.
  • Encourage use of relaxation techniques, visualization, guided imagery, moderate exercise before meals.
    • Rationale: May prevent onset or reduce severity of nausea, decrease anorexia, and enable patient to increase oral intake.
  • Identify the patient who experiences anticipatory nausea and vomiting and take appropriate measures.
    • Rationale: Psychogenic nausea and vomiting occurring before chemotherapy generally does not respond to antiemetic drugs. Change of treatment environment or patient routine on treatment day may be effective.
  • Administer antiemetic on a regular schedule before or during and after administration of antineoplastic agent as appropriate.
    • Rationale: Nausea and vomiting are frequently the most disabling and psychologically stressful side effects of chemotherapy.
  • Evaluate effectiveness of antiemetic.
    • Rationale: Individuals respond differently to all medications. First-line antiemetics may not work, requiring alteration in or use of combination drug therapy.
  • Hematest stools, gastric secretions.
    • Rationale: Certain therapies (antimetabolites) inhibit renewal of epithelial cells lining the GI tract, which may cause changes ranging from mild erythema to severe ulceration with bleeding.
  • Review laboratory studies as indicated (total lymphocyte count, serum transferrin, and albumin or prealbumin).
    • Rationale: 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 patient’s clinical status.
  • Refer to dietitian or nutritional support team.
    • Rationale: Provides for specific dietary plan to meet individual needs and reduce problems associated with protein, calorie malnutrition and micronutrient deficiencies.
  • Insert and maintain NG or feeding tube for enteric feedings, or central line for total parenteral nutrition (TPN) if indicated.
    • Rationale: In the presence of severe malnutrition (loss of 25%–30% body weight in 2 mo) or if patient has been NPO for 5 days and is unlikely to be able to eat for another week, tube feeding or TPN may be necessary to meet nutritional needs.

Nursing Diagnosis

Risk for Fluid Volume Deficit
Risk factors may include
  • Excessive losses through normal routes (e.g., vomiting, diarrhea) and/or abnormal routes (e.g., indwelling tubes, wounds)
  • Hypermetabolic state
  • Impaired intake of fluids
Desired Outcomes
  • Display adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor, prompt capillary refill, and individually adequate urinary output.
Nursing Interventions
  • Monitor I&O and specific gravity; include all output sources, (emesis, diarrhea, draining wounds. Calculate 24-hr balance).
    • Rationale: Continued negative fluid balance, decreasing renal output and concentration of urine suggest developing dehydration and need for increased fluid replacement.
  • Weigh as indicated.
    • Rationale: Sensitive measurement of fluctuations in fluid balance.
  • Monitor vital signs. Evaluate peripheral pulses, capillary refill.
    • Rationale: Reflects adequacy of circulating volume.
  • Assess skin turgor and moisture of mucous membranes. Note reports of thirst.
    • Rationale: Indirect indicators of hydration status and degree of deficit.
  • Encourage increased fluid intake to 3000 mL per day as individually appropriate or tolerated.
    • Rationale: Assists in maintenance of fluid requirements and reduces risk of harmful side effects  such as hemorrhagic cystitis in patient receiving cyclophosphamide (Cytoxan).
  • Observe for bleeding tendencies (oozing from mucous membranes, puncture sites); presence of ecchymosis or petechiae.
    • Rationale: Early identification of problems (which may occur as a result of cancer or therapies) allows for prompt intervention.
  • Minimize venipunctures (combine IV starts with blood draws). Encourage patient to consider central venous catheter placement.
    • Rationale: Reduces potential for hemorrhage and infection associated with repeated venous puncture.
  • Avoid trauma and apply pressure to puncture sites.
    • Rationale: Reduces potential for bleeding and hematoma formation.
  • Provide IV fluids as indicated.
    • Rationale: Given for general hydration and to dilute antineoplastic drugs and reduce adverse side effects (nausea and vomiting, or nephrotoxicity).
  • Monitor laboratory studies (CBC, electrolytes, serum albumin).
    • Rationale: Provides information about level of hydration and corresponding deficits.