NURSING CARE PLAN
NAME OF STUDENT:
NAME OF CLIENT:
DIAGNOSIS OR CLINICAL IMPRESSION: Laryngeal Cancer
CUES
S: NURSING HEALTH HISTORY
- 58 years old male
- With family history of hypertension
and stroke
- Lifestyle: 69 pack years, chronic
alcoholic, past illegal drug user
- Had history of fever after radiation
therapy but was resolved with
medications
- Increase in intake of food and
vegetables was initiated
- Doctor prescribed 1.5L of fluid
intake
- Radiation therapy finished 1 0 days
PTA, 3rd cycle of chemotherapy
- Post-surgical client,
immunosuppressed, chronically ill
O: PHYSICAL EXAMINATION
- Vital signs:
 RR – 20 breaths/min
 BP – 120/70mmHg, L arm
 PR- 67/min, L arm, radial
 T-35.9^C
- Skin graft over mouth extending to
neck
- Mark from tracheostomy, midline,
neck, 0.5 cm diameter
- Lateral mouth erosions
- Decreased intake of food, difficulty
swallowing (blenderized feeding)
LABORATORY RESULTS
(02/14/11) Hgb: 84 g/L LOW
RBC: 2.80 10^12/L LOW
NURSING
DIAGNOSIS
Risk for
Infection r/t
compromis
ed immune
defenses
secondary
to cancer
BACKGROUND
KNOWLEDGE
RISK FOR INFECTION
is defined as “at
increased risk for
being invaded by
pathogenic
organisms”.
(Doenges, 2004)
Presence of a healing
wound may still be
subjected to different
scenarios wherein
certain pathogens,
both virulent and
opportunistic, may
get involved. Proper
hygiene and
environmental
sanitation may be
practiced to decrease
the chances of
getting infection.
Such activities like
proper handwashing
and using
disinfectants are
some. (Microbiology
for the Health
Sciences, Burton &
Engelkirk, 1996)
Increased risk of
infection in clients
with chemotherapy
treatments due to
destruction of rapidly
DATE OF ASSIGNMENT:
CIVIL STATUS: AGE: SEX:
WARD: CI
BED:
GOALS AND OBJECTIVES
GOAL:
By the end of the duty, Mr. C will
demonstrate no signs of infection.
NURSING INTERVENTIONS AND
RATIONALE
During nursing intervention, the
student nurse will:
By the end of the shift,
the client will be able to:
1. Maintain strict asepsis when
performing procedures to client.
1. Not acquire any
infective organism.
EVALUATION
OBJECTIVES:
By the end of the nursing
intervention, the client will:
1. Not develop further breaks from
primary defenses
R: Asepsis will prevent client
from entry o organisms thus,
protecting her from infection.
2. Exercise meticulous
handwashing before and after
handling patient. R: Frequent,
meticulous handwashing greatly
decreases the chanced of
spreaing infection.
3. Check presence of invasive
devices and monitor their
present condition. R: Checking
of condition of lines or devices,
their duration of attachment will
help the nurse identify possible
sources of infection, which she
then can remove.
4. Monitor vital signs especially
temperature every 4 hours. R:
Fever or hypothermia may
indicate presence of infection.
HCT: 0.249% LOW
WBC: 6.88 10^9/L NORMAL
Neutrophil 0.745 HIGH
Lymphocyte = 0.112 LOW
Mono = 0.103 NORMAL
Eoso = 0.300 NORMAL
Baso = 0.001 NORMAL
dividing
hematopoietic cells,
resulting in
immunosuppression.
(Gale, 1994)
5. Check incisions/ wounds for
signs of infection. R: Skin and
2. Achieve timely wound healing
with no infection.
mucosa provide first line
defense against
microorganisms.
6. Cleanse mouth erosions, if
not contraindicated. R: Ensures
that wound is free from
infection- causing organisms
and is kept clean to prevent
infections.
2. Cleanliness and
hygiene are maintained at
wound sites and bed
sides.
7. Provide meticulous skin care
(cleansing bath) R: To prevent
skin breakdown which is a
possible way of infection.
8. Assist with oral care (Orahex)
if needed. R: Provides care if
3. Identify techniques to prevent
skin infection
client is unable.
9. Promote frequent and
adequate fluid intake. R: To
liquefy secretions and facilitate
expectorations to prevent stasis
of body fluids and promotes
moist mucus membranes.
10. Encourage to apply lubricant
(petroleum jelly) to lips and skin
graft. R: Keeps areas moist.
11. Encourage frequent position
changes/ambulation, coughing,
and deep breathing exercises.
R: To promote ventilation in all
lung segments and aids in
mobilizing secretions to prevent
pneumonia.
12. Provide health teaching on:
- possible individual causes of
infection to establish an
3. Developed resistance
to infection through
techniques
information background for the
patient.
- techniques to prevent or
reduce risk of infection to
initialize learning of patient.
- proper handwashing technique
to client because it is the most
basic technique to prevent
infection.
- thorough handwashing
technique to other patients and
caregivers to encourage client to
practice learned skill.
- avoidance of people with
respiratory infections and
respiratory diseases
- effect of chemotherapy and
radiation therapy on body
S: NURSING HEALTH HISTORY
- 58 years old male
- With family history of hypertension
and stroke
- Lifestyle: 69 pack years, chronic
alcoholic, past illegal drug user
- Reports difficulty swallowing
- SO verbalized that client only eats
a few spoons during lunch and
dinner, but occasionally looks for
food in between meal times
- Chemotherapeutic drug: Cis-5FU
O: PHYSICAL EXAMINATION
- Vital signs:
 RR – 20 breaths/min
 BP – 120/70mmHg, L arm
 PR- 67/min, L arm, radial
- Upper and lower extremities: nail
beds pale, 1 sec capillary refill
- Peripheral pulses: regular
- Difficulty in swallowing
- Height: 160 cm
Weight: 46.5 kg
Cachexic with distinct bony
Imbalanced
Nutrition:
Less than
Body
Requiremen
ts related
to
decreased
intake and
early
satiety
secondary
to nausea
and
vomiting
and
difficulty
swallowing
IMBALANCED
NUTRITION: LESS
THAN BODY
REQUIREMENTS is
defined as “Intake of
nutrients insufficient
to meet metabolic
needs” (Doenges,
2004).
Medicine looks on
nausea and vomiting
as pathophysiological
responses
accompanying certain
tumors and tumor
locations and as
unavoidable sideeffects in some forms
of therapy. Medical
treatment involves
prescribing
antiemetics and
sedation to reduce
GOAL: By the end of the duty, the
client will maintain nutritional
status, minimize weight loss and
experience less nausea and
vomiting.
During the nursing intervention,
the student nurse will:
After the nursing
intervention, the client
will:
1. Teach mother the possible
predisposing factors that lead to
undernourishment of patient. R:
1. Identified all
predisposing factors that
lead to undernourishment
of patient
OBJECTIVES:
By the end of the nursing
intervention, the client will:
1. Identify predisposing factors
that lead to undernourishment of
patient
To initiate learning.
2. Provide information regarding
the dietary plan for the client. R:
To provide ongoing support and
increase
likelihood
of
accomplishing dietary goals.
2. Follow the dietary plan for
patient
3. Instruct patient to avoid
unpleasant sights, odor, sounds
in the environment during
mealtime. R: Decrease in
2. Followed the dietary
plan for patient as
evidenced by the
following:
prominences
(+) skin pallor
-Smooth, warm, dry skin with fair
turgor
(+) muscle wasting
Pale conjuctiva, mucosa and
nailbeds
(+) thinning of hair
LABORATORY RESULTS
(02/14/11) Hgb: 84 g/L LOW
RBC: 2.80 10^12/L LOW
HCT: 0.249% LOW
Ca: 2.17 mmol/L
Na: 140 mmol/L
K: 3.5 mmol/L (Borderline)
Mg: 0.8 mmol/L
symptom occurrence
or emotional distress,
and managing any
associated
nutriotional deficits or
F&E imbalances.
Nausea is a vague
but distinctly
disagreeably queasy
feeling in the
stomach and a
tightening sensation
in the throat
accompanied by a
strong revulsion
toward food and
eating. It is usually
preceded by
anorexia. Vomiting is
a sudden, powerful
oral expulsion of
stomach contents.
This two often follows
the negative effect on
eating, sleeping and
controlling activities. (
The Cancer
Experience, Carnevali,
1990)
appetite can be stimulated with
noxious stimuli.
4. Suggest foods that are
preferred and well tolerated by
the patient, preferably highcalorie and high-protein foods.
R:
Foods preferred,
well
tolerated, and high in calories
and protein maintain nutritional
status
during
periods
of
increased metabolic demand.
5. Encourage adequate fluid
intake, but limit fluids at
mealtime.
R:
Fluids
are
necessary to eliminate wastes
and
prevent
dehydration.
Increased fluids with meals can
lead to early satiety.
6. Suggest smaller, more
frequent meals. R: Smaller,
more frequent meals are better
tolerated because early satiety
does not occur.
7. Promote relaxed, quiet
environment during mealtime
with increased social interaction
as
desired.
R: A quiet
environment
promotes
relaxation. Social interaction at
mealtime increases appetite.
8. Consider cold foods, if
desired. R: Cold, high protein
foods are often more tolerable
and less odorous than hot
foods.
9. Advocate high-protein foods
in between meals. Snacks add
protein and calories to meet







reported decreasing
anorexia and
increased interest in
eating
demonstrated normal
skin turgor
used appropriate
imagery and
relaxation before
meals
consumed diet high
in required nutrients
carried out oral
hygiene before meals
reported decreasing
episodes of nausea
and vomiting
participated in
increasing levels of
activity
nutritional requirements.
3. Verbalize understanding of
causative factors and necessary
interventions
10. Encourage frequent oral
hygiene. R: Oral hygiene
stimulates
appetite
and
increases saliva production.
11.
Use
distraction
or
conversation before and during
chemotherapy. R: Decreases
3.Verbalized
understanding of the
need for lifestyle
modifications of patient
anxiety which can contribute to
nausea and vomiting.
12. Position patient properly at
mealtime. R: Proper body
position and alignment are
necessary to aid chewing and
swallowing.
4. Demonstrate progressive weight
gain toward goal
15.Encourage to verbalize
understanding of the treatment
plan for client R: to enable the
independency in implementation
of it.
16. Instruct to monitor weight
of patient every week and
record it on a weekly log. R: To
4.Demonstrated
progressive weight gain
toward goal.
have a baseline for either
development or deviation from
goal
S: NURSING HEALTH HISTORY
- 58 years old male
- With family history of hypertension
and stroke
- Lifestyle: 69 pack years, chronic
alcoholic, past illegal drug user
- Reported occasional episodes of
chest pain/heaviness, dyspnea
- Radiation therapy finished 1 0 days
PTA
- Reports decreased level of activity
compared to condition prior to
illness
Ineffective
Peripheral
Tissue
Perfusion
related to
Decreased
oxygen
carrying
capacity of
the blood
and
increased
oxygen
INEFFECTIVE
PERIPHERAL TISSUE
PERFUSION is defined
as decrease in
oxygen resulting in
the failure to nourish
tissues at the
capillary level
(Doenges, 2004).
Chemotherapy causes
myelosuppresion
which results to
GOAL:
By the end of the shift, Mr. C will
maintain optimal tissue perfusion
to vital organs
OBJECTIVES:
NOC: Circulatory Monitoring
1. Display hemodynamic stability.
During nursing intervention, the
student nurse will:
By the end of the shift,
Mr. C will be able to:
NIC: Circulatory Care
1. Monitor hemodynamic
stability indicators (vital signs,
peripheral pulses, capillary refill
time, pallor, skin temperature,
1. Display hemodynamic
stability by having the
following within normal
parameters:
- Has no DOB
- Reports dizziness when suddenly
sits up
O: PHYSICAL EXAMINATION
- Vital signs:
 RR – 20 breaths/min
 BP – 120/70mmHg, L arm
 PR- 67/min, L arm, radial
- Upper and lower extremities: nail
beds pale, 1 sec capillary refill
- Peripheral pulses: regular
- Difficulty in swallowing
- (+) pallor: conjunctiva
LABORATORY RESULTS
(02/14/11) Hgb: 84 g/L LOW
RBC: 2.80 10^12/L LOW
HCT: 0.249% LOW
MCV: 88.9 fL
MCH: 30 pg
demand
secondary
to chronic
illness
anemia. Anemia
presents with a
decreased level of
Hemoglobin
concentration.
(Gale, 1994)
vital signs) and compare with
baseline. Rationale: They are
the baseline to indicate the
status of cardiac output.
Weakness,
immobility, fatigue
and inactivity typically
increase with
advanced cancer as a
result of the disease,
treatment,
inadequate nutritional
intake or dyspnea.
2. Display absent episodes of
pallor and coldness on extremities.
Bone marrow
depression after
certain types of
chemotherapy and
radiation theraoy
often results to
decreased production
of RBC and
thrombocytopenia.
Because of decreased
RBC, and hemoglobin
concentration, the
carrier of oxygen to
the different parts of
the body and the
periphery is less.
Because of these,
ineffective tissue
perfusion ensues.
(Porth, 2007)
3. Reduce workload of the heart.
2. Provide skin and foot care. R:
Prevents skin integrity problems
and decreases chances of
hypothermia.
3. Keep extremities warm
through warm sponge bath. R:
blood pressure
heart rate
respiratory rate
temperature
peripheral pulses
capillary refill time
nail beds, color
2. Display absent
episodes of:
pallor
coldness on
extremities
This prevents hypothermia.
4. Place Mr. C in semi-Fowler’s
position or his preferred position
of comfort. If not preferred,
recommend orthopneic position.
Rationale: This position
decreases workload of
breathing, and venous return
and preload to the heart.

Arterial Interference:
Head and chest
elevated, and
extremities in
dependent position

Do not use pillows
under knees.
5. Elevate head of bed to 30
degrees or as tolerated or
preferred. R: This promotes
venous drainage from the head.
6. Advise to change position at
least every 2 hours during
waking time. R: Prevents
pooling of blood.
7. Promote a calm and restful
activities that reduce the
workload of the heart.
environment using script for
Noninvasive Measure combining
relaxation, rhythmic breathing,
and imagery. Rationale:
Reduction in myocardial oxygen
demand can be achieved by
allowing for rest and relaxation
periods.
8. Stress importance of avoiding
straining/ bearing down,
especially during defecation. R:
Valsalva maneuver causes vagal
stimulation, reducing heart rate
(bradycardia), which may be
followed by rebound
tachycardia, both of which
impairs cardiac output.
9. Instruct on increasing fiberrich foods and increase in liquid
diet to avoid Valsalva maneuver
on defecation. R: Fiber and
water soften wastes excreted
and avoids constipation.
4. Maintain normal level of fluid
balance.
NOC: Neurocognitive
5. Display normal neurologic
status.
10. Measure intake and output
every shift. R: Monitoring for
increased fluid in the body is
vital in knowing fluid
imbalances.
4.
NIC: Neurologic Management
[4150]
11. Monitor neurologic status:
Glasgow Coma Scale, papillary
size and response,
cardiovascular and respiratory
status in accordance with
schedule. R: Routine
neuroassessment can cause
slight increases in intracranial
pressure.
5. Demonstrate within
normal parameters:
papillary size and
response
Glasgow coma scale
13. Provide comfort measures.
Gently touch face or hand. Talk
quietly with patient. R: This
relaxes and calms patient.
NIC: Activity Tolerance [0005]
NIC: Energy Management
[0180]
6. Demonstrate adequate
response to activities.
14. Observe patient's schedule.
Allow rest periods between all
activities. R: Rest between
7. Demonstrate increased selfmanagement of ADL's.
activities provides time for
energy conservation and
recovery. Heart rate recovery
following activity is greatest at
the beginning of a rest period.
15. Perform light range of
motion exercises but in between
rest periods allowed . R: Light
exercise will promote normal
sleep/rest pattern.
16. Discourage client from
wearing constricting clothes. R:
Decreases circulation of blood.
17. Assist patient in prioritizing
tasks in life and seeking
assistance from family/friends in
those tasks patient is unable to
perform. R: Conserves energy.
8. Perform relaxation strategies.
18. Instruct on possible
relaxation strategies. R:
Relaxation strategies help
conserve energy and decrease
stress.
9. State other possible
19. Inform on other possible
and nonpharmacologic
6. Demonstrate decreased
episodes of:
increase in ICP
increase in blood
pressure
7. Report absent:
difficulty of breathing at
rest
difficulty of breathing in
mild exertion.
8. Display adequate
management of activities
and rest.
9. Display:
Light range-of-motion
(ROM) exercises in bed,
progressing to sitting
10. Display absent:
Chest discomfort
Hypotension
Tachycardia or
arrhythmia
Cool, moist, cyanotic
extremities
11. Accurately perform
a chosen relaxation
strategy.
12.
nonpharmacological strategies.
management of cancer related
fatigue [journal]. R: Research
on these interventions has
yielded positive outcomes in
cancer survivors with different
diagnoses undergoing a variety
of cancer treatments (Mustian,
et. al., 2007).
- Exercise: Resistance and
Walking
- Psychosocial: Individual/Group
- Yoga, Mindfulness-Based
Stress Reduction, Sleep
Therapy, Nutrition Therapy,
Polarity Therapy
10. Verbalize understanding of
health teaching.
20. Provide health teaching on:
- importance of prioritization of
activities
- recognition of signs of fatigue
(Talk Test)
- asking for family/friends for
help
- effect of Hgb on chemotherapy
- expectation of fatigue as side
effect of chemotherapy
- Importance of protein and iron
in diet
S: NURSING HEALTH HISTORY
- 58 years old male
- With family history of hypertension
and stroke
- Lifestyle: 69 pack years, chronic
alcoholic, past illegal drug user
- Tracheostomy tube removed
- Radiation therapy finished 1 0 days
PTA, 3rd cycle of chemotheraoy
- Post-surgical client (glossectomy),
immunosuppressed, chronically ill
- Reports dysphagia
Readiness
for
Enhanced
Coping
Readiness for
Enhanced Coping is
defines as “A pattern
of cognitive and
behavioral efforts to
manage demands
that is sufficient for
well-being and can be
strengthened.”
(Doenges, 2004).
GOAL: After nursing intervention,
the client will express feelings of
optimism about the present.
OBJECTIVES:
NOC: Coping
During nursing intervention, the
student nurse will:
1. Reports decrease in stress.
1. Review extent of feelings of
anxiety. R: There is a need to
nonpharmacological
strategies.
13. Verbalize
understanding of health
teaching on:
importance of
prioritization of activities
recognition of signs of
fatigue (Talk Test)
asking for family/friends
for help
effect of Hgb on
chemotherapy
expectation of fatigue
as side effect of
chemotherapy
Importance of protein in
diet
After nursing intervention,
the client will be able to:
NIC: Coping Enhancement
know the extent of
disequilibrium and need for
intervention to prevent or
resolve the crisis.
1. Consistently report a
decrease in stress
O: PHYSICAL EXAMINATION
- Vital signs:
 RR – 20 breaths/min
 BP – 120/70mmHg, L arm
 PR- 67/min, L arm, radial
 T-35.9^C
- Skin graft over mouth extending to
neck
- Mark from tracheostomy, midline,
neck, 0.5 cm diameter
- Lateral mouth erosions
- Hoarse/slurred speech
- Coherent, oriented to time person
and place
2. Discuss indication and
method of treatment. R:
Promotes active participation of
client in therapeutic regimen.
2. Verbalize in own
words the relevant
information about
treatment
3. Note expressions of
indecision, dependence on
others, and inability to manage
own ADL's. R: May indicate
need to lean on others for a
time.
2. Uses behaviors to reduce stress.
4. Assess presence of positive
coping skillls/inner strengths e.g
(use of relaxation techniques,
willingness to express feelings,
use of support systems). R: Past
coping skills may be reused to
relieve tension and preserve
individual's sense of control.
3. Demonstrate at 3 least
behaviors to reduce stress
techniques,
feelings,
5. Encourage patient to talk
about what is happening at this
time and what has occurred to
precipitate feelings of anxiety.
R: Provides clues to asses
patient to develop coping and
regain equilibrium.
6. Evaluate ability to understand
events and correct
misconceptions by providing
factual information. R: Assists in
the identification and correction
of perception of reality.
References:

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
Carpenito-Moyet, L. J. (2008) Handbook of Nursing Diagnosis (12th ed.). Philadelphia: Lippincott Williams & Wilkins
Doenges, M., Moorhouse, M. F. & Murr, A. (2006). Nurse’s pocket guide: Diagnoses, prioritized interventions and rationales. Philadelphia: F.A. Davis
Gale, S. (1994). Oncology Nursing. Texas: Skidmore-Roth Co.
Mustian, K.,Morrow, G., Carroll, J., et. al., (2007). Integrative Nonpharmacologic Behavioral Interventions for the Management of Cancer-Related Fatigue. Oncologist
2007;12;52-67. Retrieved from http://www.TheOncologist.com/cgi/content/full/12/suppl_1/52