Cues SUBJECTIVE: Madali akong mapagodAs verbalized.

OBJECTIVE: >Pale >Weak in appearance >Limited body movements >Lethargy V/S taken as follows: TEMP: 36 PR: 92 RR: 26 BP: 130/90

Nursing Diagnosis Fatigue r/t Hypermetabolic state, competition between body and tumor for nutrients, and stressors associated with cancer

Scientific explanation Fatigue is one of the most common symptoms in patients with cancers because the cell needed nutrients to function but it is being used up by the cancer cells more rapidly thus leaving the healthy cells to starve and die.

Objectives >After 30 minutes of nursing intervention the patients watcher will be able to assess factors that contribute to fatigue and be able to avoid or alleviate fatigue.

Nursing Interventions >Assist watcher to implement strategies to minimize fatigue like, Quite environment, bright ambiance, and good room air circulation. >Teach the watcher ways to conserve patients energy like assisting in feeding, and when going to the bathroom. >Instruct the watcher to aid the patient in alternating periods of rest and activity.

Rationale >Identifying sources of fatigue aids in selecting appropriate and individualized interventions.

Evaluation After 30 minutes of nursing interventions the patients watcher was be able to assess factors that contribute to fatigue and patient was able to conserve energy by performing alternating periods of rest and activities.

>Plan patients daily activities lessen stress and helps to conserve energy.

>It is beneficial to the patient to have a regular light exercise or ROM exercises may decrease fatigue and facilitate coping, whereas lack of physical activity and too much rest can actually contribute to deconditioning and associated fatigue. >To prevent bed sores or decubitus ulcer formations and promote circulation.

>Turn patient side to side every 2 hours.

Cues SUBJECTIVE: masakit ang tiyan ko As verbalized. Pain rated 7/10 OBJECTIVE: >Facial grimace >Pale >Cold and clammy skin >Weak in appearance V/S taken as follows: TEMP: 36 PR: 92 RR: 26 BP: 130/90

Nursing Diagnosis Pain r/t surgical procedure and tissue inflammation.

Scientific explanation Pain associated with cancer maybe acute or chronic, nociceptors are free nerve endings in the skin and some organs that respond to intense potentially damaging stimuli. Such stimuli maybe mechanical or chemical that transmits stimuli and produce pain.

Objectives >After 30 minutes of nursing intervention the pain scale will be lowered from 7/10 to 3/10

Nursing Interventions >Performed assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain. >Teach the use of nonpharmacologic techniques (e.g.relaxation, music therapy) before pain occurs or increases; and along with other pain relief measures. >Placed the patient in her most comfortable position.

Rationale >Pain is a subjective experience and must be described by the client in order to plan effective treatment.

Evaluation After 30 minutes of nursing interventions the pain scale lowered from the rate of 7/10 to 2/10.

>The use of nonpharmacologic pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications.

> Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external distraction. >The patient itself can determine what position suites her in relieving pain.

> Create a quiet, nondisruptive environment with dim lights and comfortable temperature when possible. >Placed some guarding material such as rolled towel or cloth. >Administered drug as ordered. Diclofenac Na IV every 12 hours.

>To prevent the area from being moved and reduce pain stimulation. >To relieve pain faster.

Cues

Nursing Diagnosis

Scientific explanation

Objectives

Nursing Interventions

Rationale

Evaluation

SUBJECTIVE: Nahihirapan ako huminga As verbalized. OBJECTIVE: >Deep shallow breathing >Slight Cyanotic nail beds > V/S taken as follows: TEMP: 36 PR: 92 RR: 26 BP: 130/90

Ineffective breathing Secondary lung pattern r/t altered cancer produce oxygen supply. tumors that interfere with the main function of the lung, which is to provide the bloodstream with oxygen to be carried to the entire body.

After 4 hours of nursing interventions the patient will demonstrate improved ventilation and adequate oxygenation.

> Note respiratory rate, depth, and ease of respirations. Observe for the use of accessory muscles, pursed lip breathing, changes in skin or mucous membrane color.

> Respiration may be increased as a result of pain or as an initial compensatory mechanism to accommodate for loss of lung tissue. Increased work of breathing and cyanosis may indicate increasing oxygen consumption and energy expenditures and reduced respiratory reserve. > Airway obstruction impedes ventilation, impairing gas exchange. > Maximizes lung expansion and drainage of secretions.

After 4 hours of nursing intervention the patient was able to demonstrate improved ventilation and adequate oxygenation.

> Maintain patent airway by positioning, suctioning, use of airway adjuncts. > Reposition frequently, placing patient in sitting positions and supine to side positions. > Encourage or assist with deep breathing exercises and pursed lip breathing as appropriate. > Administer supplemental oxygen via nasal cannula, partial rebreathing mask, or high humidity face mask at 2 liters per minute as ordered

> Promotes maximal ventilation and oxygenation and reduces or prevent atelectasis.

> Maximizes available oxygen, especially while ventilation is reduced because of pain.

Cues

Nursing Diagnosis Disturbed body image r/t changes in appearance secondary to chemotherapy or radiation.

Scientific explanation

Objectives

Nursing Interventions

Rationale

Evaluation

SUBJECTIVE: Nalalagas ang buhok ko As verbalized. OBJECTIVE: >Alopecia >Poor skin integrity >Dry cracked lips V/S taken as follows: TEMP: 36 PR: 92 RR: 26 BP: 130/90

Hair loss occurs because chemotherapy targets all rapidly dividing cells healthy cells as well as cancer cells. Hair follicles, the structures in the skin filled with tiny blood vessels that make hair, are some of the fastest-growing cells in the body. If you're not in cancer treatment, your hair follicles divide every 23 to 72 hours. But as the chemo does its work against cancer cells, it also destroys hair cells. Within a few weeks of starting chemo, you may lose some or all of your hair.

After 20 minutes of nursing interventions the patient will be able to learn ways to cope with hair loss, good skin integrity and maintain self esteem.

.> Advised the watcher that they can use wigs, hats, large clothing to cover bald spots.

.> Used for aesthetic purposes to hide bald spots and elevate self esteem.

>Advised watcher to comb hair gently without touching the scalp area and remove any fallen hair.

>To maintain proper grooming and hygiene.

After 20 minutes of nursing interventions the patient learned ways to cope with hair loss and ways to achieve good skin integrity. >The watcher learned how to perform proper skin care to the patient to promote skin integrity.

>Teach the watcher how to maintain proper skin care to >Advised patients watcher to promote skin perform careful skin care integrity. regimen by gently rubbing with the use of lukewarm water. >Advised watcher to provide loose fitting clothes for the patient to wear. > Advised watcher to avoid excessive shampooing, pat hair dry, avoid hair spray and hair dye.

>To prevent any further skin irritation, drying of skin and damage.

>To avoid clothes constriction, blisters and moisture formation.

>To minimize the amount of hairloss due to chemicals and rough handling of hair when drying.

Name of Drug

Method of Administration

Mechanism of Action

Adverse Reaction

Special Consideration

Nursing Responsibilities

Generic Name: Diclofenac Na

IV / q12 / 20mg

Brand Name: Lasix

Classification: Nonsteroidal AntiInflammatory Drugs (NSAIDs)

diclofenac has shown anti-inflammatory, analgesic and antipyretic effects. Inhibition of prostaglandin biosynthesis which has been demonstrated in experiments is considered to be fundamental to the mechanism of action of diclofenac. Prostaglandins play a major role in the pathogenesis of inflammation, pain and fever. Indications: Relief of pain & inflammation in various conditions

None

Side Effects: None

-To prevent nocturia, give per Orem and intramuscular preparations in the morning. Give second dose in early afternoon. -monitor weight, blood pressure, and pulse rate routinely with long term use and during rapid dieresis.

-Take the blood pressure reading before administering the drug -Aspirin: Concomitant administration of diclofenac and aspirin is not recommended. -Anticoagulants: Caution should be exercised while administering anticoagulants with diclofenac since interactions of anticoagulants have been seen with other NSAIDs. -Digoxin, Methotrexate, Cyclosporine, Lithium: Patients who begin taking diclofenac or those who increase their diclofenac dose while taking these drugs should be observed closely, particularly if renal functions are impaired. In case of digoxin, serum level should be maintained. -Oral Hypoglycemic Drugs: Isolated cases have been reported of hypoglycemic and hyperglycemic reactions necessitating an adjustment in the dosage of antidiabetic drugs in treatment with diclofenac. -Diuretics: Concomitant treatment of diclofenac with potassium-sparing diuretics may raise serum potassium levels, which should therefore be monitored.

Contraindications: None

Name of Drug

Method of Administration

Mechanism of Action

Adverse Reaction

Special Consideration

Nursing Responsibilities

Generic Name: Tranexamic acid

500 mg every 6 hours

Inhibits bacterial DNA gyrase and prevents DNA, replication, transcription, repair, and recombination in susceptible bacteria. Indications: Treatment & prophylaxis of hemorrhage associated w/ excessive fibrinolysis.

None

Brand Name: Xanfib Classification: Antifibrinolytic

Side Effects: None

- Predisposition to thrombosis, subarachnoid hemorrhage or hemorrhage due to disseminated intravascular coagulation. Careful monitoring of blood coagulation. -Existing extravascular clots, hematuria; renal impairment. Perform regularly eye exam & liver function test during longterm use. Avoid rapid IV administration. Contraindications: None

-Caution should be taken while currently administrating of estrogens because it may increase the potential for thrombus formation. -Tranexamic acid should not be mixed with blood. -The drug is a synthetic of amino acid, and should not be mixed with solutions containing penicillin.

Name of Drug

Method of Administration

Mechanism of Action

Adverse Reaction

Special Consideration

Nursing Responsibilities

Generic Name: Ipratropium + Salbutamol

Nebulization every 6 hours

Brand Name: Pulmodual

Ipratropium is an anticholinergic agent that produces a local, sitespecific effect rather than a systemic effect. It appears to produce bronchodilation by inhibition of cholinergic receptors on bronchial smooth muscle. Indications: Treatment of reversible bronchospasm associated w/ obstructive airway diseases in patients who require more than single bronchodilator.

None

Side Effects: None

Classification: Antiasthmatic & COPD Preparations

- Patients w/ prostatic hypertrophy, bladder neck obstruction, narrow-angle glaucoma; risk of paradoxical bronchospasm; hyperthyroidism, CV disease, arrhythmias, susceptibility to QTinterval prolongation, HTN & DM. Pregnancy & lactation.

-Tell the patient that drug may be taken with or without meals. -Reassure the the patient inhale the drug and not trough the mouth it decreases its effectivity. -Advice patient that they might experience dry mouth, nausea, constipation, headache, fine tremors.

Contraindications: None

Name of Drug

Method of Administration

Mechanism of Action

Adverse Reaction

Special Consideration

Nursing Responsibilities

Generic Name: Piperacillin Na + tazobactam Na Brand Name: Pletzolyn Classification:

Intra venous push every 12 hours

Ipratropium is an anticholinergic agent that produces a local, site-specific effect rather than a systemic effect. It appears to produce bronchodilation by inhibition of cholinergic receptors on bronchial smooth muscle. Indications:

None

Side Effects: None

- Serious & occasionally fatal hypersensitivity reactions including shock, pseudomembranous colitis, bleeding manifestations, neuromuscular excitability or convulsions, monitor electrolyte levels. Pregnancy & lactation. Contraindications: None

-Perfomed ANST to determine sensitivity to antibiotics -The duration of therapy should be guided by the severity of the infection and the patients clinical and bacteriological progress. -Treatment with amino glycoside is continued in patients from whom pseudomonas is isolated. -Advice patient that they might experience rash, pruritus, diaphoresis, syncope, tremor, convulsions, vertigo, phlebitis, injection site reaction, headache, nausea, fever, dizziness, insomnia and agitation.

Antibacterial Treatment of systemic &/or local bacterial infections caused by susceptible organisms; UTI, lower resp tract infections, intraabdominal; skin & skin structure, bone & joint, gynecological bacterial infections in neutropenic patients, bacterial septicemia & polymicrobial infections.