Chart 15- Nursing care for cancer pts PDF

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Chart 15-7

PLAN OF NURSING CARE

The Patient With Cancer NURSING DIAGNOSIS: Risk for infection related to inadequate defenses related to myelosuppression secondary to radiation or antineoplastic agents GOAL: Prevention of infection Nursing Interventions

Rationale

1.

1.

Assess patient for evidence of infection. a. Check vital signs every 4 hours. b. Monitor white blood cell (WBC) count and differential each day. c. Inspect all sites that may serve as entry ports for pathogens (IV sites, wounds, skin folds, bony prominences, perineum, and oral cavity). 2. Report fever (≥38.3°C [101°F] or ≥38°C [100.4°F] for >1 hour) (see Table 15-10), chills, diaphoresis, swelling, heat, pain, erythema, exudate on any body

Signs and symptoms of infection may be diminished in the immunocompromised host. Prompt recognition of infection and subsequent initiation of therapy will reduce morbidity and mortality associated with infection.

Expected Outcomes

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2.

Early detection of infection facilitates early intervention.

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Demonstrates normal temperature and vital signs Exhibits absence of signs of inflammation: local edema, erythema, pain, and warmth Exhibits normal breath sounds on auscultation Takes deep breaths and coughs every 2 hours to prevent respiratory dysfunction and infection. Exhibits absence of pathogens on cultures Avoids contact with others with infections Avoids crowds All personnel carry out hand hygiene after each voiding and bowel movement. Excoriation and trauma of skin are avoided.

surfaces. Also report change in respiratory or mental status, urinary frequency or burning, malaise, myalgias, arthralgias, rash, or diarrhea. 3. Obtain cultures and sensitivities as indicated before initiation of antimicrobial treatment (wound exudate, sputum, urine, stool, blood).

4.

Initiate measures to minimize infection. a. Discuss with patient and family: 1. Placing patient in private room if absolute WBC count 72 hours. b. Povidone–iodine is effective against many grampositive and gram-negative pathogens. c. Allows observation of site and removes source of contamination d. Once introduced into the system, microorganisms are capable of growing in infusion sets despite replacement of container and high flow rates. e. Infusion Nursing Society collaborates with other nursing subspecialties in determining guidelines for IV access care. 6. Reduces risk for skin abscesses.

7.

Avoid insertion of urinary catheters; if catheters are necessary, use aseptic technique. 8. Educate patient or family member to administer granulocyte (or granulocyte-macrophage) colony-stimulating factor when prescribed. 9. Advise patient to avoid exposure to animal excreta, discuss dental procedures with primary provider, avoid vaginal douche, and avoid vaginal or rectal manipulation during sexual contact during the period of neutropenia.

7.

Rates of infection greatly increase after urinary catheterization. 8. Granulocyte colony-stimulating factor decreases the duration of neutropenia and the potential for infection. 9.

Minimizes exposure to potential sources of infection and disruption of skin integrity

NURSING DIAGNOSIS: Risk for impaired skin integrity: erythematous and wet desquamation reactions to radiation therapy GOAL: Maintenance of skin integrity Nursing Intervention 1.

a.

In erythematous areas:

Avoid the use of soaps, cosmetics, perfumes, powders, lotions, and ointments; non– aluminum-based deodorant may be used on intact skin.

Rationale 1.

Care to the affected areas must focus on preventing further skin irritation, drying, and damage.

a.

These substances may cause pain and additional skin irritation and damage.

Expected Outcomes 

  

Avoids use of soaps, powders, and other cosmetics on site of radiation therapy States rationale for special care of skin Exhibits minimal change in skin Avoids trauma to affected skin region (avoids shaving, constricting and irritating clothing, extremes of temperature, and the use of adhesive tape)

b.

Use only lukewarm water to bathe the area.

b.

Avoiding water of extreme temperatures and soap minimizes additional skin damage, irritation, and pain.

   

c.

Avoid rubbing or scratching the area.

c.

Rubbing, scratching, or both will lead to additional skin irritation, damage, and increased risk of infection.

d.

Avoid shaving the area with a straight-edged razor.

d.

The use of razors may lead to additional irritation and disruption of skin integrity and increased risk of infection.

e.

Avoid applying hot-water bottles, heating pads, ice, and adhesive tape to the area.

e.

Avoiding extreme temperatures minimizes additional skin damage, irritation, burns, and pain.

f.

Avoid exposing the area to sunlight or cold weather.

f.

Sun exposure or extreme cold weather may lead to additional skin damage and pain.

Reports change in skin promptly Demonstrates proper care of blistered or open areas Exhibits absence of infection of blistered and opened areas. Wound is free of development of eschar.

g.

Avoid tight clothing in the area. Use cotton clothing.

g.

Allows air circulation to affected area

h.

Topical agents such as Aquaphor, Radiacare gel, aloe vera, or Biafine (Valeant may be used, and low- or mediumpotency corticosteroid cream may be given if pruritus is present.)

h.

May aid healing; however, evidence supporting the benefits of topical agents is lacking.

2.

If wet desquamation occurs:

2.

Open weeping areas are susceptible to bacterial infection. Care must be taken to prevent introduction of pathogens.

a.

Do not disrupt any blisters that have formed.

a.

Disruption of skin blisters disrupts skin integrity and may lead to increased risk of infection.

b.

Avoid frequent washing of the area.

b.

Frequent washing may lead to increased irritation and skin damage, with increased risk of infection.

c.

Blistering of skin represents progression of skin damage.

c.

Report any blistering.

d.

Use prescribed creams or ointments; topical antibacterial creams may help to dry a wet wound (e.g., Silvadene cream)

d.

Anecdotally believed to decrease irritation and inflammation of the area and promote healing; although a variety of products are used in many settings, there are few randomized controlled trials with evidence to support one product or intervention over another.

e.

If area weeps, apply a nonadhesive absorbent dressing.

e.

Easier to remove and associated with less pain and trauma when drainage dries and adheres to dressing.

f.

If the area is without drainage, moisture and vapor-permeable dressings, such as hydrocolloids and hydrogels on noninfected areas, have been used in many settings.

f.

May promote healing; however, randomized controlled clinical trial support is lacking in the setting of moist desquamation. Hydrocolloid dressings may enhance comfort.

g.

Consult with wound-ostomycontinence nurse (WOCN) and primary provider if eschar forms.

g.

Eschar must be removed to promote healing and prevent infection. WOCNs have expertise in the care of wounds.

NURSING DIAGNOSIS: Impaired oral mucous membrane: stomatitis

GOAL: Maintenance of intact oral mucous membranes Nursing Intervention

Rationale

Expected Outcomes

1.

1.



Assess oral cavity daily using the same assessment criteria or rating scale. 2. Identify individuals at increased risk for stomatitis and related complications.

3.

Instruct patient to report oral burning, pain, areas of redness, open lesions on oropharyngeal mucosa and lips, pain associated with swallowing, or decreased tolerance to temperature extremes of food. 4. Encourage and assist as needed in oral hygiene.

Preventive 1. Advise patient to avoid irritants such as commercial mouthwashes, alcoholic beverages, and tobacco.

Provides baseline for later evaluation; maintains consistency in assessment findings 2. Patient and treatment variables are associated with the incidence and severity of stomatitis as well as related complications such as delayed healing and infection. 3. Identification of initial stages of stomatitis will facilitate prompt interventions, including modification of treatment as prescribed by primary provider.

4.

1.

Patients who are having discomfort or pain, or other symptoms related to the disease and treatment, may require encouragement and assistance in performing oral hygiene. Oral hygiene is maintained to prevent complications of stomatitis, such as infection. Alcohol content of mouthwashes and tobacco smoke will dry oral tissues and potentiate breakdown.



States rationale for frequent oral assessment and hygiene Factors associated with the incidence, severity, and complications are identified prior to initiation of cancer treatment Oral mucosal assessment is conducted at baseline and on an ongoing basis. Oral hygiene practices are initiated prior to development of stomatitis. Identifies signs and symptoms of stomatitis to report to nurse or primary provider Participates in recommended oral hygiene regimen Avoids mouthwashes with alcohol Brushes teeth and mouth with soft toothbrush Uses lubricant to keep lips soft and nonirritated Avoids hard-to-chew, spicy, hot foods or other irritating foods Maintains adequate hydration

 

Exhibits clean, intact oral mucosa Exhibits no ulcerations or infections of

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  

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2.

Brush with soft toothbrush using nonabrasive toothpaste for 90 seconds after meals and at bedtime; allow toothbrush to air dry before storing; floss at least once daily or as advised by the clinician; patients who have not previously flossed regularly should not initiate flossing during stomatoxic treatment; rinse mouth four times a day with a bland rinse (normal saline, sodium bicarbonate, or saline and sodium bicarbonate); avoid irritating foods (acidic, hot, rough, and spicy); use water-based moisturizers to protect lips. 3. Consider use of oral ice chips during stomatoxic chemotherapy infusions.

4.

Consider use of low level laser therapy.

5.

Consider administration of Palifermin as prescribed for patients receiving high-dose chemotherapy.

2.

3.

Limits trauma and removes debris. Patients who have not previously flossed regularly do initiate flossing during stomatoxic treatment due to potential for injury to the oral mucosa and increased susceptibility to infection.

Oral cryotherapy has demonstrated reduced oral mucositis incidence, severity, and pain; improved quality of life; and minimizes chances of complications of oral mucositis 4. Low energy level laser therapy has demonstrated decreased severity, duration, and pain associated with stomatitis. 5. Palifermin, a recombinant keratinocyte growth factor (KGF) that stimulates the growth of cells lining the mouth and intestinal tract, has been shown to decrease

   

oral cavity Exhibits no evidence of bleeding Reports absent or decreased oral pain Reports no difficulty swallowing Exhibits healing (reepithelialization) of oral mucosa within 5–7 days (mild stomatitis)

6.

Maintain adequate hydration.

7.

Provide written instruction and education to patients on the above items.

Mild stomatitis (generalized erythema, limited ulcerations, small white patches: Candida) 1. Use normal saline mouth rinses every 1–4 hours. 2. Use soft toothbrush or toothette. 3. Remove dentures except for meals; be certain that dentures fit well. 4. Apply water-soluble lip lubricant. 5. Avoid foods that are spicy or hard to chew and those with extremes of temperature. Severe stomatitis (confluent ulcerations with bleeding and white patches covering >25% of oral mucosa) 1. Obtain tissue samples for culture and sensitivity tests of areas of infection. 2. Assess ability to chew and swallow; assess gag reflex. 3. Use oral rinses (may combine in

the severity and duration of stomatitis. 6. Maintenance of hydration prevents mucosal drying and breakdown. 7. Written information reinforces patient education and provides the patient and family with a source.

1.

Assists in removing debris, thick secretions, and bacteria 2. Minimizes trauma 3. Minimizes friction and discomfort



4. 5.



1.

2.

Promotes comfort Prevents local trauma

Assists in identifying need for antimicrobial therapy

Patient may be in danger of aspiration 3. Facilitates cleansing and

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Exhibits healing of oral tissues within 10–14 days (severe stomatitis) Exhibits no bleeding or oral ulceration Consumes adequate fluid and food Exhibits absence of dehydration and weight loss Exhibits no evidence of infection

a. b.

Adheres to oral care regimen Exhibits healing of oral tissues within 10–14 days (severe stomatitis)  Consumes adequate fluid and food

solution saline, anti-Candida agent, such as Mycostatin, and topical anesthetic agent [described later]) as prescribed, or place patient on side and irrigate mouth; have suction available. 4. Remove dentures.

4.

5.

Use toothette or gauze soaked with solution for cleansing. 6. Use water-soluble lip lubricant.

5.

7.

Provide liquid or pureed diet.

7.

8.

Monitor for dehydration.

8.

9.

Minimize discomfort.

provides for safety and comfort

  

6.

Prevents trauma from ill-fitting dentures Limits trauma and promotes comfort Promotes comfort and minimizes loss of skin integrity Ensures intake of easily digestible foods without chewing Decreased oral intake and ulcerations potentiate fluid deficits.

a.

Consult primary provider for use of topical anesthetic, such as dyclonine and diphenhydramine, or viscous lidocaine.

a.

Alleviates pain and increases sense of well-being; promotes participation in oral hygiene and nutritional intake

b.

Administer systemic analgesics as prescribed.

b.

Adequate management of pain related to severe stomatitis can facilitate improved quality of life, participation in other aspects of activities of daily living, oral intake, and verbal communication.

Exhibits absence of dehydration and weight loss Exhibits no evidence of infection Reports absent or decreased discomfort or pain

c.

Perform mouth care as described.

c.

Promotes removal of debris, healing, and comfort

NURSING DIAGNOSIS: Impairment of skin integrity related to rash GOAL: Maintenance of skin integrity Nursing Intervention Prevention 1. Instruct patients to avoid sunlight through use of protective clothing, use of sun screen with SPF of 30 with physical blockers (zinc oxide, titanium dioxide), or avoidance of direct sun exposure. 2. Maintain adequate oral hydration. 3. Avoid long hot showers or baths, harsh soaps and laundry detergents, perfumes, and nonhypoallergenic cosmetics. 4. Apply emollients; apply hydrocortisone 1% cream with moisturizer at least twice daily; administer doxycycline 100 mg twice per day or minocycline, as prescribed Treatment 1. Apply topical treatment as prescribed: clindamycin 1%, fluocinonide 0.05% cream twice a

Rationale

Expected Outcomes

1.



Many agents are associated with photosensitivity; sunburn would intensify inflammation associated with rash and potentiate loss of skin integrity

2.

Prevents skin dryness related to dehydration 3. Prevents skin irritation, dryness, flaking, and inflammation

4.

Minimizes dryness, flaking, and disruption of skin integrity.

1.

Recommended as treatment to minimize skin disruption and prevent infection by Multinational

  



Sun exposure will be limited; no development of sun burn Absence of dehydration Participates in skin care regimen as instructed Absence of dryness, flaking

Rash severity does not interfere with level of comfort and adherence to targeted

day, or alclometasone 0.05% cream twice a day 2. For severe papulopustular rash: Administer systemic treatment as prescribed: doxycycline 100 mg twice per day; minocycline 100 mg daily; or isotretinion at low doses of 20–30 mg per day 3. Assess for development of infection: obtain cultures of pustules and administer appropriate antibiotics as prescribed by the physician

Association of Supportive Care in Cancer (MSACC) 2. Recommended as treatment to minimize skin disruption and prevent infection by Multinational Association of Supportive Care in Cancer (MSACC) 3.





therapy as prescribed; absence of local or systemic infection Rash severity does not interfere with level of comfort and adherence to targeted therapy as prescribed; absence of local or systemic infection Local infection is controlled; absence of bacteremia and sepsis

Prompt recognition and treatment of infection are necessary to prevent bacteremia, sepsis, and further patient compromise

NURSING DIAGNOSIS: Impaired tissue integrity: alopecia GOAL: Maintenance of tissue integrity; coping with hair loss Nursing Intervention

Rationale

Expected Outcomes

1.

1.



Discuss potential hair loss and regrowth with patient and family; advise that hair loss may occur on body parts other than the head. 2. Explore potential impact of hair loss on self-image, interpersonal relationships, and sexuality. 3. Prevent or minimize hair loss through the following: a.

Use scalp hypothermia and scalp tourniquets, if appropriate.

Provides information so that patient and family can begin to prepare cognitively and emotionally for loss 2. Facilitates coping and maintenance of interpersonal relationships 3. Retains hair as long as possible.

   

a.

Decreases hair follicle uptake of chemotherapy (not used for patients with leukemia or lymphoma because tumor cells

 

Identifies alopecia as potential side effect of treatment Identifies positive and negative feelings and threats to self-image Verbalizes meaning that hair and possible hair loss have for him or her States rationale for modifications in hair care and treatment Uses mild shampoo and conditioner, and shampoos hair only when necessary Avoids hair dryer, curlers, sprays, and other stresses on hair and scalp Wears hat or scarf over hair when

may be present in blood vessels or scalp tis...