XII.

Nursing Care Plan

Nursing Diagnosis #1
Ineffective tissue perfusion related to decreased Hgb concentration in blood secondary to
blood loss as manifested by dizziness, behavioral changes, pale conjunctiva, poor capillary refill
of 3-4 seconds and low Hgb level

Nursing Inference
Normally, the kidneys make the hormone erythropoietin which signals the bone marrow
to produce red blood cells. Cancer can disrupt this process by slowing erythropoietin production.
Iron uptake is higher in tumor than in normal cells. Cancer patients’ red blood cells also wear out
faster than normal and are not replaced as quickly as they are needed. Additionally, cancer may
cause bleeding, in which was present in our patient, results in blood loss. Fewer red blood cells
as well mean there is less hemoglobin to carry oxygen throughout the body.

Nursing Goal
After 2-3 days of rendering appropriate nursing interventions, the patient will
demonstrate increased perfusion by manifesting being alert and being well oriented as well as not
being restless anymore, also patient will have absence of dizziness as well pinkish conjunctiva.

Nursing Interventions
Intervention Rationale
1) Administer Blood Transfusion To maximize tissue perfusion
2) Encourage bed rest To conserve energy and to lower O2 demand
3) Encourage to eat nutritious foods rich in To increase Hgb count
Iron and Vitamin C
4) Identify necessary changes in lifestyle eg. To promote wellness
Do stay around people who smokes
5) Demonstrate/encourage use of relaxation To decrease tension level
of techniques and exercises
6) Administer TRANEXAMIC ACID as To control bleeding
ordered
Nursing Evaluation
After 3 days of rendering appropriate nursing interventions, the patient demonstrated an
increased perfusion by manifesting being alert and being well oriented as well as not being
restless anymore, also patient manifested an absence of dizziness as well pinkish conjunctiva and
CBC has returned to normal levels.

Nursing Diagnosis #2
Acute Pain related to compression secondary to the presence of tumor manifested by
reports of pain, grimacing face, and pain scale of 4/10.

Nursing Inference
Pain may be caused by direct pressure of the mass on sensory nerves, particularly where
space is restricted. Inflammation also contributes to pain because of increased pressure on the
nerves and irritation on nerve endings by chemical mediators. Secondary causes of pain include
infection, ischemia and bleeding. Blood can be irritating to tissues and if it collects in an area,
can cause pressure on the nerves.

Nursing Goal
After 30 mins-1 hour of rendering appropriate nursing interventions, the reported mild
acute pain will be relieved or controlled, will verbalize methods to promote relief and will
demonstrate use of relaxation skills and diversional activities.

Nursing Interventions
Intervention Rationale
1) Provide comfort measures like change of To provide nonpharmacological methods to
position relieve pain
2) Provide calm environment and make time to This is helpful in alleviating anxiety and
listen to and maintain frequent contact with refocusing attention, which can relieve pain.
patient.
3) Note when pain occurs for example only Because timely intervention is more likely to
during ambulation or every evening be successful in alleviating pain
 4) Encourage verbalization of pain and accept To assist patient to explore methods of
patients description of pain alleviation or control of pain
5) Observe for nonverbal cues Because observations may or may not be
congruent with verbal reports indicating need
for further evaluation.

Nursing Evaluation
After 1 hour of rendering appropriate nursing interventions, the reported mild acute pain
was relieved and controlled, the patient verbalizes methods to promote relief and will
demonstrated use of relaxation skills and diversional activities.

Nursing Diagnosis # 4
Impaired home maintenance related to individual disease as manifested by verbalization
of financial crises

Nursing Inference
Mrs. Ursa claims that she is the one who takes care of their household as well as her
whole family’s needs. She also says that her husband is also sick and aged. Their daughter who
is in high school had to stop going to school to take care of both of her parents.

Nursing Goal
After 1-2 hours of rendering health teachings patient will be able to demonstrate
appropriate, effective use of resources.

Nursing Interventions
Intervention Rationale
1) Determine degree of disability To assess contributing factors
2) Discuss home environment To determine ability to care for self and
identify potential health and safety hazards
3) Help client to identify options for To help patient create/maintain a growth-
financial assistance promoting environment
4) Plan oppurtunities for family To prevent burnout or strain
members to have respite from care
 of patient

Nursing Diagnosis #4
Risk for fluid volume deficiency related to active fluid volume loss secondary to blood
loss

Nursing Inference
Cancer may cause bleeding, in which was present in our patient. The increase in
size and shape of the tumor causes compression of the blood vessels, this result to a decrease in
the oxygen distribution to the organs which results to necrosis therefore causing an erosion of
blood vessels which result to bleeding.

Nursing Goal
After 1-2 hours or rendering nursing interventions patient will be able to identify
individual risk factors and demonstrate behaviors of lifestyle changes to prevent development of
fluid volume deficit.
Nursing Intervention
Intervention Rationale
1) Encourage oral intake like fluids To maximize fluid intake
between meals and water
2) Monitor intake and output balance To ensure accurate picture of fluid status
being aware of insensible losses
3) Review laboratory data To prevent occurrence of deficiet
4) Discuss individual risk To promote wellness
factors/potential problems and
specific interventions

Nursing Diagnosis # 5
Risk for infection related to inadequate secondary defenses secondary to decreased hemoglobin

Nursing Inference
 Normally, the kidneys make the hormone erythropoietin which signals the bone
marrow to produce red blood cells. Cancer can disrupt this process by slowing erythropoietin
production. Iron uptake is higher in tumor than in normal cells. Cancer patients’ red blood cells
also wear out faster than normal and are not replaced as quickly as they are needed. Additionally,
cancer may cause bleeding, in which was present in our patient, results in blood loss.

Nursing Goal
After 1-2 hours of rendering appropriate health teachings, patient will be able to verbalize
understanding of individual risk factors, identify interventions to prevent/reduce risk for
infection and to demonstrate techniques and lifestyle changes to promote safe environment

Nursing Intervention
Intervention Rationale
1) Provide regular catheter/perineal careTo reduce risk for UTI
2) Stress proper hand washing techniques To provide a first line defense against
nosocomial infections or cross contamination
3) Encourage to eat nutritious foods rich To increase hemoglobin count and to boost
in vitamins and nutrients especially immune system
Iron and Vitamin C
4) Administer and monitor medication To correct existing risk factors
regimen
5) Administer blood transfusion as To increase hemoglobin level
ordered

Nursing Diagnosis #6
Anticipatory grieving related to potential loss of life as manifested by alteration in
activity level such as withdrawing herself from the world.

Nursing Inference
The patient refused to undergo chemotherapy or any other procedure that may prolong
her life because she claims that she does not have enough financial means. By doing so, she is
aware of what her condition has in store for her, and claims that she is in the process of
acceptance. The only thing that makes her anxious is eventually leaving her daughter and her
family.
Nursing Goal
After 2-3 hours of health teachings patient will be able to identify and express feelings
freely and effectively as well as look forward and/or plan for future, one day at a time.

Nursing Interventions
Intervention Rationale
1) Determine patient’s perception of To assess degree of fear and reality of threat
anticipated loss and meaning to her perceived by the patient
2) Observe patient’s body language and To determine current response to anticipated
check out meaning with the patient and loss
note congruency with verbalizations.
3) Stay with the patient and make To eliminate fear
arrangements to have someone else be
there
4) Provide open environment and trusting To promote a free discussion of feelings and
relationship concerns
5) Support planning with family for To promote wellness
dealing with reality
6) Be honest when answering questions To enhace sense of trust and nurse-patient
and in providing information relationship

Nursing Evaluation
After 2-3 hours of health teachings, patient was able to identify and express feelings
freely and effectively as well as she was able to look forward and plan for future, one day at a
time.