Human Development
Autism (ASD – Autism Spectrum Disorder)
*4 - Behaviors Compare client development to the expected age/development stage and report any deviations
BOX 22.1 Behaviors Common with ASD
• Not responding to own name by 1 year (e.g., appears not to hear)
• Doesn’t show interest by pointing to objects or people by 14 months of age
• Doesn’t play pretend games by 18 months of age
• Avoids eye contact
• Prefers to be alone
• Delayed speech and language skills
• Obsessive interests (e.g., gets stuck on an idea)
• Upset by minor changes in routine
• Repeats words or phrases over and over
• Flaps hands, or rocks or spins in a circle; answers are unrelated to questions
• Unusual reactions to sounds, smells, or other sensory experiences
ADHD (Attention-Deficit / Hyperactivity Disorder)
*1 - Parent Teaching Educate Client about Health promotion and Maintenance Recommendations
Felter Notes:
• Monitor weight loss
• Collaborate with school and caregivers
• Teach behavioral therapy > use reinforcement and reward system
• Age-appropriate consequences
• Refer families to local support groups and the national ADHD support group.
• Medications are not a cure but help control attention and lower level of impulsiveness.
Lippincott
Include the child's family or caregiver in your teaching, when appropriate. Provide information according to their individual
communication and learning needs. Be sure to cover:
• importance of behavior therapy and use of limits and positive feedback
• examples of rewards and positive reinforcements for good behavior
• need to develop realistic expectations
• medication regimen, including drugs, dosages, frequency, schedule of administration, and proper technique for applying a
patch, if ordered
• intended effects of medication therapy and possible adverse reactions, including signs and symptoms that warrant
practitioner notification
• possible periodic drug cessation to determine the continued need for medication
• effects of medications on sleep and measures to promote sleep
• effects of medications on appetite and appropriate suggestions for sound nutritional choices, including small, frequent
meals
• effects of medication on mental health
• importance of continued follow-up and ongoing evaluation to determine the effectiveness of therapy and to evaluate
growth and development
• possibility of dose adjustments of medications (by the child's primary care practitioner) to achieve the most benefit with
the least amount of side effects.
Videbeck 431
CLIENT AND FAMILY EDUCATION - ADHD
• Include parents in planning and providing care.
• Refer parents to support groups.
• Focus on child’s strengths as well as problems.
• Teach accurate administration of medication and possible side effects.
• Inform parents that child is eligible for special school services.
• Assist parents in identifying behavioral approaches to be used at home.
• Help parents achieve a balance of praising child and correcting child’s behavior.
• Emphasize the need for structure and consistency in child’s daily routine and behavioral expectations.
*2 - Nursing Management Educate client about home management of care
Felter Notes:
• Educate on Medications
• Give with meals / after meals to avoid appetite suppression
• Administer doses early in the day to avoid sleeplessness
• Keep drugs safely stored to prevent accidental ingestion with younger children & abuse with other children & adolescents
Slide 17
• Educate on medications
• Give with meals or after meals to avoid appetite suppression
• Administer doses early in the day to avoid sleeplessness
• Keep drugs safely stored to prevent accidental ingestion with younger children and abuse with other children and
adolescents.
• Monitor for weight loss
• Important to collaborate with school and other caregivers.
• Teach behavioral Therapy – use positive reinforcement and reward system
• Age-appropriate consequences.
• Refer families to local support groups and the national ADHD support group.
Videbeck 429
NURSING INTERVENTIONS - ADHD
• Ensuring the child’s safety and that of others
o Stop unsafe behavior.
o Provide close supervision.
o Give clear directions about acceptable and unacceptable behavior.
• Improved role performance
o Give positive feedback for meeting expectations.
o Manage the environment (e.g., provide a quiet place free of distractions for task completion).
• Simplifying instructions/directions
o Get child’s full attention.
o Break complex tasks into small steps.
o Allow breaks.
• Structured daily routine
o Establish a daily schedule.
o Minimize changes.
• Client/family education and support
o Listen to parent’s feelings and frustrations.
(Videbeck 425-426)
Nursing Interventions
Rationale
Identify the factors that aggravate and alleviate the client’s
performance.
The external stimuli that exacerbate the client’s problems can be
identified and minimized. Likewise, ones that positively influence the
client can be effectively used.
Provide an environment as free from distractions as possible. Institute
interventions on a one-to-one basis. Gradually increase the number of
environmental stimuli.
The client’s ability to deal with external stimulation is impaired.
Engage the client’s attention before giving instructions (i.e., call the
client’s name and establish eye contact).
The client must hear instructions as a first step toward compliance.
Give instructions slowly, using simple language and concrete
directions.
The client’s ability to comprehend instructions (especially if they are
complex or abstract) is impaired.
Ask the client to repeat instructions before beginning tasks.
Repetition demonstrates that the client has accurately received the
information.
Separate complex tasks into small steps.
The likelihood of success is enhanced with less complicated
components of a task.
Provide positive feedback for completion of each step.
The client’s opportunity for successful experiences is increased by
treating each step as an opportunity for success.
Allow breaks, during which the client can move around.
The client’s restless energy can be given an acceptable outlet, so he or
she can attend to future tasks more effectively.
State expectations for task completion clearly.
The client must understand the request before he or she can attempt
task completion.
Initially, assist the client in completing tasks.
If the client is unable to complete a task independently, having
assistance will allow success and will demonstrate how to complete
the task.
Progress to prompting or reminding the client to perform tasks or
assignments.
The amount of intervention is gradually decreased to increase client
independence as the client’s abilities increase.
Give the client positive feedback for performing behaviors that come
close to task achievement.
This approach, called shaping, is a behavioral procedure in which
successive approximations of a desired behavior are positively
reinforced. It allows rewards to occur as the client gradually masters
the actual expectation.
Gradually decrease reminders.
Client independence is promoted as staff participation is decreased.
Assist the client to verbalize by asking sequencing questions to keep
on the topic (“Then what happens?” and “What happens next?”).
Sequencing questions provide a structure for discussions to increase
logical thought and decrease tangentiality.
Teach the client’s family or caregivers to use the same procedures for
the client’s tasks and interactions at home.
Successful interventions can be instituted by the client’s family or
caregivers using this process. This will promote consistency and
enhance the client’s chances for success.
Explain and demonstrate “positive parenting” techniques to family or
caregivers, such as time-in for good behavior or being vigilant in
identifying and responding positively to the child’s first bid for
attention; special time, or guaranteed time spent daily with the child
with no interruptions and no discussion of problem-related topics;
ignoring minor transgressions by immediate withdrawal of eye contact
or physical contact and cessation of discussion with the child to avoid
It is important for parents or caregivers to engage in techniques that
will maintain their loving relationship with the child while promoting,
or at least not interfering with, therapeutic goals. Children need to
have a sense of being lovable to their significant others that is not
crucial to the nurse–client therapeutic relationship.
secondary gains.*
Menopause
*5 - Patient Teaching – Hormone Replacement Therapy (HRT) Provide education to client about expected age related changes
Hormone Replacement Therapy approved for relief of vasomotor symptoms and prevention of osteoporosis.
• Estrogen, or estrogen plus progestin
• Give the lowest effective dose for the shortest duration
• Thromboembolic disease and breast cancer are risks for combined HRT
• Local Estrogen is recommended for isolated atrophic vaginal symptoms.
• Uterus give both, no Uterus only Estrogen
• Unopposed Estrogen causes hyperplasia of uterine lining, increase risk for uterine cancer
HRT contraindicated:
• HX of BC
• Vas thrombosis
• Impaired liver cancer
• Uterine Cancer Undiagnosed uterine bleeding
Menopause – Physiological Changes
Chart 56-14 HEALTH PROMOTION
Strategies for Women Approaching Menopause
• An annual physical examination can help screen for problems and promote general health.
•
Changes in lifestyle (e.g., diet, activity) to promote health and wellness.
• A nutritious diet (decrease fat and calories, increase fiber and whole grains) and weight control will enhance physical and
emotional well-being.
• Exercise for at least 30 minutes 3 or 4 times a week to maintain good health.
• Involvement in outside activities is beneficial in reducing anxiety and tension.
•
Recognize the following about sexual activity:
• Sexual functioning may be enhanced at midlife.
• Frequent sexual activity helps to maintain the elasticity of the vagina.
• Contraception is advised until 1 year passes without menses.
• Safer sex is important at any age.
•
Strategies and methods to prevent or manage potential problems:
• Hot flashes: See primary provider to discuss hormone replacement therapy (HRT) indications (lowest dose for shortest
period of time) and alternative therapy (e.g., vitamin therapy, black cohosh, and other herbal preparations). Fatigue and
stress may worsen hot flashes.
• Itching or burning of vulvar areas: See primary provider to rule out dermatologic abnormalities and, if appropriate, to
obtain a prescription for a lubricating or hormonal cream.
• Dyspareunia (painful intercourse) due to vaginal dryness: Use a water-soluble lubricant (e.g., K-Y Jelly, Astroglide,
Replens), hormone cream, or contraceptive foam.
• Decreased perineal muscle tone and bladder control: Practice Kegel exercises daily (contract the perineal muscles as
though stopping urination; hold for 5–10 seconds and release; repeat frequently during the day).
• Dry skin: Use mild emollient skin cream and lotions to prevent dry skin.
• Weight control: Join a weight reduction support group such as Weight Watchers or a similar group if appropriate, or
consult a registered dietitian for guidance about the tendency to gain weight, particularly around the hips, thighs, and
abdomen.
• Osteoporosis: Observe recommended calcium and vitamin D intake, including calcium supplements, if indicated, to slow
the process of osteoporosis; avoid smoking, alcohol, and excessive caffeine, all of which increase bone loss. Perform
weight-bearing exercises. Undergo bone density testing when appropriate.
• Risk for urinary tract infection (UTI): Drink 6–8 glasses of water daily as a possible way to reduce the incidence of UTI
related to atrophic changes of the urethra.
• Vaginal bleeding: Report any bleeding after 1 year of no menses to the primary provider immediately, no matter how
minimal.
Aging
*6 - Age-related changes of body systems Aging Process: Provide care and education for the adult client 65 years and over
Brunner p 196
TABLE 11-1 Age-Related Changes in Body Systems and Health Promotion Strategies
Changes
Cardiovascular System
Decreased cardiac output; diminished
ability to respond to stress; heart
rate and stroke volume do not
increase with maximum demand;
slower heart recovery rate; increased
blood pressure
Respiratory System
Increase in residual lung volume;
decrease in muscle strength,
endurance, and vital capacity;
decreased gas exchange and diffusing
capacity; decreased cough efficiency
Integumentary System
Decreased subcutaneous fat, interstitial
fluid, muscle tone, glandular activity,
and sensory receptors, resulting in
atrophy and decreased protection
against trauma, sun exposure, and
temperature extremes; diminished
secretion of natural oils and
perspiration; capillary fragility
Reproductive System
Female: Vaginal narrowing and
decreased elasticity; decreased
vaginal secretions
Male: Gradual decline in fertility, less
firm testes, and decreased sperm
production
Male and female: Slower sexual response
Musculoskeletal System
Loss of bone density; loss of muscle
strength and size; degenerated joint
cartilage
Genitourinary System
Decrease in detrusor muscle
contractility, bladder capacity, flow
rate, ability to withhold voiding;
increase in residual urine
Male: Benign prostatic hyperplasia
Female: Relaxed perineal muscles;
detrusor instability leads to urge
incontinence; urethral dysfunction
(stress urinary incontinence)
Subjective and Objective Findings
Health Promotion Strategies
Complaints of fatigue with
increased activity
Increased heart rate recovery time
Optimal blood pressure: ≤120/80
mm Hg
Prehypertension: >120–139/80–89
mm Hg
Hypertension: ≥140/90 mm Hg
Exercise regularly; pace activities; avoid
smoking; eat a low-fat, low-salt diet;
participate in stress-reduction activities;
check blood pressure regularly; adherence
to medications; weight control (body mass
index <25 kg/m2).
Fatigue and breathlessness with
sustained activity; decreased
respiratory excursion and
chest/lung expansion with less
effective exhalation; difficulty
coughing up secretions
Exercise regularly; avoid smoking; take
adequate fluids to liquefy secretions;
receive yearly influenza immunization and
pneumonia vaccine at 65 years of age; avoid
exposure to upper respiratory tract
infections.
Thin, wrinkled, and dry skin;
increased fragility, more easily
bruised, and sunburned;
complaints of intolerance to
heat; prominent bone
structure
Limit sun exposure to 10–15 minutes daily for
vitamin D (use protective clothing and
sunscreen); dress appropriately for
temperature; stay hydrated; maintain a safe
indoor temperature; take shower rather
than hot tub bath if possible; lubricate skin
with lotions that contain petroleum or
mineral oil.
Female: Painful intercourse;
vaginal bleeding following
intercourse; vaginal itching
and irritation; delayed orgasm
Male: Less firm erection and
delayed erection and
achievement of orgasm
Female: May require vaginal estrogen
replacement; gynecology/urology follow-up;
use a lubricant with sexual intercourse.
Height loss; prone to fractures;
kyphosis; back pain; loss of
strength, flexibility, and
endurance; joint pain
Weight-bearing exercise regularly (3 times a
week); recommend bone density screening;
take calcium and vitamin D supplements as
prescribed.
Urinary retention; irritative
voiding symptoms including
frequency, feeling of
incomplete bladder emptying,
multiple nighttime voiding
Urgency/frequency syndrome;
decreased “warning time”;
drops of urine lost with cough,
laugh, position change
Drink adequate fluids but limit drinking in
evening; avoid bladder irritants (e.g.,
caffeinated beverages, alcohol, artificial
sweeteners); do not wait long periods
between voiding; empty bladder completely
when voiding; wear easily manipulated
clothing; consider urologic workup.
Women: perform pelvic floor muscle exercises,
preferably learned via biofeedback
TABLE 11-1 Age-Related Changes in Body Systems and Health Promotion Strategies
Changes
Gastrointestinal System
Decreased sense of thirst, smell, and
taste; decreased salivation; difficulty
swallowing food; delayed esophageal
and gastric emptying; reduced
gastrointestinal motility
Subjective and Objective Findings
Health Promotion Strategies
Risk of dehydration, electrolyte
imbalances, and poor
nutritional intake; complaints
of dry mouth; complaints of
fullness, heartburn, and
indigestion; constipation,
flatulence, and abdominal
discomfort; risk for aspiration
Use ice chips, mouthwash; brush, floss, and
massage gums daily; receive regular dental
care; eat small, frequent meals; sit up while
and after eating and avoid heavy activity
after eating; limit antacids; eat a high-fiber,
low-fat diet; limit laxatives; toilet regularly;
drink adequate fluids.
Slower to respond and react;
learning may take longer;
increased vulnerability to
delirium with illness,
anesthesia, even changes in
environmental cues such as a
room change; increased risk of
fainting and falls
Pace teaching; with hospitalization, encourage
visitors; enhance sensory stimulation; with
sudden confusion, look for cause;
encourage slow rising from a resting
position and practice fall prevention
measures
Special Senses
Vision: Presbyopia; diminished ability to
focus on close objects; decreased
ability to tolerate glare; pupils
become more rigid and lenses more
opaque; decreased contrast
sensitivity; decrease in aqueous
humor
Holds objects far away from face;
complains of glare; poor night
vision and “dry” eye; difficulty
adjusting to changes in light
intensity; decreased ability to
distinguish colors
Hearing: Presbycusis; decreased ability
to hear high-frequency sounds;
tympanic membrane thinning and
loss of resiliency; difficulty with
sound discrimination especially in
noisy environment
Gives inappropriate responses;
asks people to repeat words;
strains forward to hear; can
result in social isolation and
increases vulnerability for
delirium during hospitalization
Wear eyeglasses and use sunglasses outdoors;
avoid abrupt changes from dark to light; use
adequate indoor lighting with area lights
and nightlights; use large-print books; use
magnifier for reading; avoid night driving;
use contrasting colors for color coding;
avoid glare of shiny surfaces and direct
sunlight.
Recommend a hearing examination; reduce
background noise; face person; enunciate
clearly; speak with a low-pitched voice; use
nonverbal cues; rephrase questions.
Taste and smell: Decreased ability to
taste and smell
Decreased recognition of familiar
smells including recognizing
spoiled food or a gas stove left
on; decreased enjoyment of
food; uses excessive sugar and
salt
Nervous System
Decrease in brain volume and cerebral
blood flow. Reduced speed in nerve
conduction
Encourage use of lemon, spices, herbs;
recommend smoking cessation.
Immunity
Tuberculosis (TB)
*7 - Isolation Interventions (Patient) Apply principles of infection control/understand communicable disease and the modes of
organism transmission
•
•
•
Latent TB Infection
Infected with M. tuberculosis
Do not have symptoms of TB disease
Cannot infect others
•
•
•
Active TB Infection
Infected with M. tuberculosis
Have symptoms of TB disease
Can transmit M. tuberculosis to others
Chart 23-8 TRANSMISSION PREVENTION
Centers for Disease Control and Prevention Recommendations for Preventing Transmission of Tuberculosis in Health Care Settings
1. Early identification and treatment of persons with active TB
a. Maintain a high index of suspicion for TB to identify cases rapidly.
b. Promptly initiate effective multidrug anti-TB therapy based on clinical and drug-resistance surveillance data.
2. Prevention of spread of infectious droplet nuclei by source control methods and by reduction of microbial contamination of
indoor air
a. Initiate AFB isolation precautions immediately for all patients who are suspected or confirmed to have active TB and who
may be infectious. AFB isolation precautions include the use of a private room with negative pressure in relation to
surrounding areas and a minimum of six air exchanges per hour. Air from the room should be exhausted directly to the
outside. The use of ultraviolet lamps and/or high-efficiency particulate air filters to supplement ventilation may be
considered.
b. Persons entering the AFB isolation room should use disposable particulate respirators that fit snugly around the face.
c. Continue AFB isolation precautions until there is clinical evidence of reduced infectiousness (i.e., cough has substantially
decreased and the number of organisms on sequential sputum smears is decreasing). If drug resistance is suspected or
confirmed, continue AFB precautions until the sputum smear is negative for AFB.
d. Use special precautions during cough-inducing procedures.
3. Surveillance for TB transmission
a. Maintain surveillance for TB infection among health care workers (HCWs) by routine, periodic tuberculin skin testing.
Recommend appropriate preventive therapy for HCWs when indicated.
b. Maintain surveillance for TB cases among patients and HCWs.
c. Promptly initiate contact investigation procedures among HCWs, patients, and visitors exposed to an untreated, or
ineffectively treated, patient with infectious TB for whom appropriate AFB procedures are not in place. Recommend
appropriate therapy or preventive therapy for contacts with disease or TB infection without current disease. Therapeutic
regimens should be chosen based on the clinical history and local drug-resistance surveillance data.
Chart 23-7 RISK FACTORS
Tuberculosis
• Close contact with someone who has active TB. Inhalation of airborne nuclei from an infected person is proportional to the
amount of time spent in the same air space, the proximity of the person, and the degree of ventilation.
• Immunocompromised status (e.g., those with HIV infection, cancer, transplanted organs, and prolonged high-dose
corticosteroid therapy).
• Substance abuse (IV/injection drug users and alcoholics).
• Any person without adequate health care (the homeless; impoverished; minorities, particularly children <15 years and young
adults between ages 15 and 44 years).
• Preexisting medical conditions or special treatment (e.g., diabetes, chronic kidney injury, malnourishment, selected
malignancies, hemodialysis, transplanted organ, gastrectomy, and jejunoileal bypass).
• Immigration from or recent travel to countries with a high prevalence of TB (southeastern Asia, Africa, Latin America,
Caribbean).
• Institutionalization (e.g., long-term care facilities, psychiatric institutions, prisons).
• Living in overcrowded, substandard housing.
• Being a health care worker performing high-risk activities: administration of aerosolized pentamidine and other medications,
sputum induction procedures, bronchoscopy, suctioning, coughing procedures, caring for the immunosuppressed patient,
home care with the high-risk population, and administering anesthesia and related procedures (e.g., intubation, suctioning).
*8 - PPD / Mantoux Assessment (TB Tests) Follow correct policy and procedures when reporting a client with a communicable
disease
The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening
for latent M. tuberculosis infection.
Figure 23-3 • The Mantoux test for tuberculosis.
A. Correct technique for inserting the needle involves depositing the purified protein derivative (PPD) subcutaneously with the
needle bevel facing upward.
B. The reaction to the Mantoux test usually consists of a wheal, a hivelike, firm welt.
C. To determine the extent of the reaction, the wheal is measured using a commercially prepared gauge.
a. A reaction occurs when both induration and erythema (redness) are present.
b. After the area is inspected for induration, it is lightly palpated across the injection site, from the area of normal
skin to the margins of the induration.
c. The diameter of the induration (not erythema) is measured in millimeters at its widest part, and the size of the
induration is documented. Erythema without induration is not considered significant.
i. The size of the induration determines the significance of the reaction.
ii. A reaction of 0 to 4 mm is considered not significant.
iii. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.
1. It is defined as positive in patients who are HIV positive or have HIV risk factors and are of
unknown HIV status, in those who are close contacts of someone with active TB, and in those
who have chest x-ray results consistent with TB.
iv. An induration of 10 mm or greater is usually considered significant in people who have normal or mildly
impaired immunity.
1. A significant reaction indicates past exposure to M. tuberculosis or vaccination with bacille
Calmette-Guérin (BCG) vaccine.
a. The BCG vaccine is given to produce a greater resistance to development of TB.
b. BCG has between 60% and 80% protective efficacy against severe forms of TB; its overall
efficacy is variable
*9 - Evaluation of Treatment Effectiveness
Apply principles of infection control/understand communicable disease and the modes of organism transmission
Individuals with TB disease must meet 3 criteria to be considered non-infectious:
1. Three consecutive negative AFB smears collected in 8–24-hour intervals
2. Clinical improvement of symptoms
3. Compliance with treatment regime for 2 weeks or longer
*10 - Multiple Medication Regimen Educate client about medications
The multiple-medication regimen that the patient must follow can be quite complex. Understanding of the medications, schedule,
and side effects is important.
• The nurse educates the patient that TB is a communicable disease and that taking medications is the most effective means
of preventing transmission.
o The major reason treatment fails is that patients do not take their medications regularly and for the prescribed
duration.
▪ This may be due to side effects or the complexity of the treatment regimen.
▪ Risk factors for nonadherence to the drug regimen include patients who have previously failed to
complete the course of therapy; patients who are physically, emotionally or mentally challenged; patients
unable to pay for medication; patients actively abusing illicit substances; and patients who do not
understand the importance of treatment (Reichman & Lardizabal, 2015).
• The nurse educates the patient to take the medication either on an empty stomach or at least 1 hour before meals, because
food interferes with medication absorption (although taking medications on an empty stomach frequently results in
gastrointestinal upset).
o Patients taking INH should avoid foods that contain tyramine and histamine (tuna, aged cheese, red wine, soy
sauce, yeast extracts), because eating them while taking INH may result in headache, flushing, hypotension,
lightheadedness, palpitations, and diaphoresis. Patients should also avoid alcohol because of the high potential for
hepatoxic effects.
o In addition, rifampin can alter the metabolism of certain other medications, making them less effective.
▪ These medications include beta-blockers, oral anticoagulants such as warfarin (Coumadin), digoxin,
quinidine, corticosteroids, oral hypoglycemic agents, oral contraceptives, theophylline, and verapamil
(Calan, Isoptin).
▪ This issue should be discussed with the primary provider and pharmacist so that medication dosages can
be adjusted accordingly.
• The nurse informs the patient that rifampin may discolor contact lenses and that the patient may want to wear eyeglasses
during treatment.
• The nurse monitors for other side effects of anti-TB medications, including:
o hepatitis, neurologic changes (hearing loss, neuritis), and rash. Liver enzymes, BUN, and serum creatinine levels
are monitored to detect changes in liver and kidney function. Sputum culture results are monitored for AFB to
evaluate the effectiveness of the treatment regimen and adherence to therapy.
• The nurse instructs the patient about the risk of drug resistance if the medication regimen is not strictly and continuously
followed.
• The nurse carefully monitors vital signs and observes for spikes in temperature or changes in the patient’s clinical status.
o Caregivers of patients who are not hospitalized are taught to monitor the patient’s temperature and respiratory
status. Changes in the patient’s respiratory status are reported to the primary provider.
• For patients at risk of nonadherence, programs used in the community setting may include comprehensive case
management and directly observed therapy (DOT).
o In case management, each patient with TB is assigned a case manager who coordinates all aspects of the patient’s
care. DOT consists of a health care provider or other responsible person who directly observes that the patient
ingests the prescribed medications. Although successful, DOT is a resource intensive program (Reichman &
Lardizabal, 2015).
Multiple Medication Regimen (continued)
TABLE 23-4 First-Line Antituberculosis Medications for Active Disease
Commonly Used
Agents
Isoniazid (INH)
Adult Daily
Dosagea
5 mg/kg
(300 mg
maximum
daily)
Rifampin (Rifadin)
10 mg/kg
(600 mg
maximum
daily)
Rifabutin
(Mycobutin)
5 mg/kg
(300 mg
maximum
daily)
10 mg/kg
(600 mg twice
weekly)
Rifapentine
(Priftin)
Pyrazinamide
15–30 mg/kg
(2 g maximum
daily)a
Ethambutol
(Myambutol)
15–25 mg/kg
(1.6 g maximum
daily dose)a
Most Common Side
Effects
Peripheral neuritis,
hepatic enzyme
elevation,
hepatitis,
hypersensitivity
Hepatitis, febrile
reaction, purpura
(rare), nausea,
vomiting
Hepatotoxicity,
thrombocytopenia
Hyperuricemia,
hepatotoxicity, skin
rash, arthralgias, GI
distress
Optic neuritis (may
lead to blindness;
very rare at 15
mg/kg), skin rash
Drug Interactionsb
Nursing Considerationsa
Phenytoin—synergistic
Antabuse
Alcohol
Bactericidal
Pyridoxine is used as
prophylaxis for neuritis.
Monitor AST and ALT
Rifampin increases metabolism of
oral contraceptives, quinidine,
corticosteroids, coumarin
derivatives and methadone,
digoxin, oral hypoglycemics. PAS
may interfere with absorption
of rifampin
Avoid protease inhibitors.
Bactericidal
Orange urine and other
body secretions
Discoloring of contact lenses
Monitor AST and ALT
Orange-red coloration of
body secretions, contact
lenses, dentures
Use with caution in older
adults or in those with
renal disease
Bactericidal
Monitor uric acid, AST, and
ALT
Bacteriostatic
Use with caution with renal
disease or when eye
testing is not feasible.
Monitor visual acuity,
color, and
discriminationc
Combinations: INH 150-mg and 300+ rifampin (e.g.,
mg caps
Rifamate)
(2 caps daily)
Pulmonary TB is treated primarily with anti-TB agents for 6 to 12 months. A prolonged treatment duration is necessary to ensure
eradication of the organisms and to prevent relapse. The continuing and increasing resistance of M. tuberculosis to TB medications is
a worldwide concern and challenge in TB therapy. Several types of drug resistance must be considered when planning effective
therapy:
• Primary drug resistance: Resistance to one of the first-line anti-TB agents in people who have not had previous treatment
• Secondary or acquired drug resistance: Resistance to one or more anti-TB agents in patients undergoing therapy
• Multidrug resistance: Resistance to two agents, isoniazid (INH) and rifampin. The populations at greatest risk for multidrug
resistance are those who are HIV positive, institutionalized, or homeless.
The increasing prevalence of drug resistance points out the need to begin TB treatment with four or more medications, to ensure
completion of therapy, and to develop and evaluate new anti-TB medications.
o
o
First-line anti-tuberculosis drugs include: isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide (PZA);
rifabutin (RBT) and rifapentine (RPT) may also be used as first-line drugs
Second-line anti-tuberculosis drugs include: streptomycin (SM), cycloserine, capreomycin, p-aminosalicylic acid,
levofloxacin, moxifloxacin, gatifloxacin, amikacin/kanamycin, ethionamide
Rheumatoid Arthritis (RA)
*11 - Patient Safety Instructions Educate client about medications
• No cure, but treatment focuses on preventing and limiting joint damage, loss of function, and managing pain.
• Balance Exercise with rest. Program includes ROM and muscle-strengthening.
• Healthy diet high in vitamins, protein and iron
• Relaxation techniques, heat applications, splints and assistive devices
Medications
• NSAIDs, salicylates – anti-inflammatory and analgesic
o SE – GI distress, GI bleeding, nausea, diarrhea, constipation
• Corticosteroids – anti-inflammatory
o Sodium retention, GI perforation, osteoporosis, mood swings, depression, susceptibility to infection,
hyperglycemia
• DMARDs – Disease modifying antirheumatic drugs – suppress overactive immune and inflammatory system
*12 - Clinical Manifestations Identify pathophysiology related to an acute or chronic condition
1. RA autoimmune properties can affect other systems including the eyes, lungs, heart blood vessels, salivary glands, CNS and
PNS and bone marrow.
2. S/S of extra-articular disease include:
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Fever
Weight loss
Fatigue
Muscle atrophy
Lymphadenopathy
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Raynaud phenomenon
Anemia
Thrombocytosis,
Pleural effusions
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Pericarditis
Endocarditis
Cardiac conduction
abnormalities
Neuropathies
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Scleritis
Episcleritis
Splenomegaly
Dry eyes and membranes
*13 - Drug Therapy and Cautions Identify a contraindication to the administration of a medication to the client
• Medications
o NSAIDs, salicylates – anti-inflammatory and analgesic
▪ Side Effects – GI distress, GI bleeding, nausea, diarrhea, constipation
o Corticosteroids – anti-inflammatory
▪ Sodium retention, GI perforation, osteoporosis, mood swings, depression, susceptibility to infection
o DMARDs – Disease modifying antirheumatic drugs – suppress overactive immune and inflammatory system
▪ Suppress autoimmune response
▪ Alter disease progression
▪ Stop or decrease further tissue damage on joints, cartilage and organs
▪ Have been found to halt progression of bone loss and destruction
▪ Can induce remission.
▪ Should be started within 3 months of onset of symptoms.
▪ 2 Types
• Nonbiologic or conventional synthetic – Hydroxychloroquine, sulfasalazine and Methotrexate,
slow acting and take several weeks to work
• Biologic – newer drugs that target individual molecules and tend to work more quickly than
conventional, given after other meds have been tried. Abatacept, adalimumab, etanercept and
infliximab.
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•
Treatment of early RA often involves therapy with methotrexate (Rheumatrex). The rapid anti-inflammatory effect of
methotrexate reduces clinical symptoms in days to weeks. It is also inexpensive and has a lower toxicity compared to other
drugs.
o Side effects include bone marrow suppression and hepatotoxicity.
o Methotrexate therapy requires frequent laboratory monitoring, including CBC and chemistry panel.
Sulfasalazine (Azulfidine) and the antimalarial drug hydroxychloroquine (Plaquenil) may be effective DMARDs for mild to
moderate disease.
o They are rapidly absorbed, relatively safe, and well-tolerated medications.
The synthetic DMARD leflunomide (Arava) blocks immune cell overproduction.
o Its efficacy is similar to methotrexate and sulfasalazine with side effects of severe liver injury, diarrhea, and
teratogenesis.
▪
In women of childbearing age, pregnancy must be excluded before therapy is initiated
Anaphylaxis
Hinkle 1065
*14 - Prioritization Prioritize the delivery of client care
1. Airway, breathing pattern, and vital signs are assessed. (ABC!)
2. The patient is observed for signs of increasing edema and respiratory distress.
3. Prompt notification of the rapid response team, the provider, or both is required.
4. Rapid initiation of emergency measures (e.g., intubation, administration of emergency medications, insertion of
intravenous lines, fluid administration, and oxygen administration) is important to reduce the severity of the reaction and
to restore cardiovascular function.
5. The nurse documents the interventions used and the patient’s vital signs and response to treatment.
6. The patient who has recovered from anaphylaxis needs an explanation of what occurred, instruction about avoiding future
exposure to antigens, and how to administer emergency medications to treat anaphylaxis.
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Initially, respiratory and cardiovascular functions are evaluated. If the patient is in cardiac arrest, cardiopulmonary
resuscitation (CPR) is instituted
Supplemental oxygen is provided during CPR or if the patient is cyanotic, dyspneic, or wheezing.
Epinephrine, in a 1:1000 dilution, is given subcutaneously in the upper extremity or thigh and may be followed by a
continuous intravenous infusion.
Antihistamines and corticosteroids should not be given in place of epinephrine. However, they may also be given as adjunct
therapy
Intravenous fluids (e.g., normal saline solution), volume expanders, and vasopressor agents are given to maintain blood
pressure and normal hemodynamic status.
In patients with episodes of bronchospasm or a history of bronchial asthma or chronic obstructive pulmonary disease,
aminophylline and corticosteroids may also be given to improve airway patency and function.
Patients who have experienced anaphylactic reactions and received epinephrine should be transported to the local
emergency department (ED) for observation and monitoring because of the risk for a “rebound” or delayed reaction 4 to 8
hours after the initial allergic reaction.
*16 - Treatment Evaluate client response to medication
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Mild systemic reactions - consist of peripheral tingling and a sensation of warmth, possibly accompanied by a sensation of
fullness in the mouth and throat. Nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes can also
be expected. The onset of symptoms begins within the first 2 hours after the exposure.
Moderate systemic reactions - may include flushing, warmth, anxiety, and itching in addition to any of the milder
symptoms. More serious reactions include bronchospasm and edema of the airways or larynx with dyspnea, cough, and
wheezing. The onset of symptoms is the same as for a mild reaction.
Severe systemic reactions - have an abrupt onset with the same signs and symptoms described previously. These symptoms
progress rapidly to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty
swallowing), abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac arrest and coma may follow.
Severe reactions are also referred to as anaphylactic shock
Ideal response to treatment (epinephrine, corticosteroids, etc) would be reversal of the above symptoms. As stated in the
prioritization section, observe for rebound reactions and administer additional epinephrine and interventions, as needed.
*15 - Patient Education Educate client on medication self-administration procedures
All patients who have experienced an anaphylactic reaction should receive a prescription for auto-injectable epinephrine devices.
The nurse instructs the patient and family in their use and has the patient and family demonstrate correct administration
Chart 37-3 PATIENT EDUCATION
Self-Administration of Epinephrine
The nurse instructs the patient to:
1. After removing the EpiPenautoinjector from its carrying tube, grasp the unit with the orange tip (injecting end) pointing
downward. Form a fist around the unit with the orange tip down; with your other hand, remove the blue safety release cap.
2.
Hold the black tip near outer thigh. Swing and jab firmly into the outer thigh until a click is heard with the device perpendicular
(90-degree angle) to the thigh. Do NOT inject into buttocks.
3.
Hold firmly against the thigh for approximately 10 seconds. Remove the unit from the thigh, and gently massage the injection
area for 10 seconds. Call 911 and seek immediate medical attention. Carefully place the used autoinjector unit, needle-end
first, into the device storage tube without bending the needle. Screw on the storage tube completely, and take it with you to
the hospital emergency room.
Inflammatory Bowel Disease (IBD)
*17 - Assessment Recognize trends and changes in client condition and intervene as needed
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Chron’s - Manifestations
Insidious onset with prominent right lower quadrant abdominal
pain and diarrhea unrelieved by defecation.
Crampy abdominal pains due to difficulty of intestinal content to
pass through the constricted lumen.
Decrease food intake due to discomfort, which in turn diminishes
nutritional requirements.
Weight loss, malnutrition, and secondary anemia occurs.
Client is usually thin and maybe emaciated due to inadequate
food intake and diarrhea
Fever and leukocytosis
Steatorrhea (i.e., excessive fat in the feces)
Anorexia
Abscesses (e.g intra-abdominal and anal), fistulas, and fissures
are common.
Manifestation outside of the G.I. tract include: arthritis, skin
lesions, conjunctivitis, and oral ulcers
May have periods of remission and exacerbation.
Chron’s - Assessment and Diagnostics
A procto-sigmoidoscopy initially done to determine whether the
recto-sigmoid area is inflamed.
Stool specimen for occult blood or to examine for steatorrhea.
A barium study of the upper GI tract that shows a “string sign” on
x-ray film of the terminal ileum, indicating the constriction of a
segment of intestine ( most conclusive diagnostic aid).
Endoscopy, colonoscopy, and intestinal biopsies may be used to
confirm the diagnosis.
A barium enema may show ulcerations (the cobblestone
appearance), fissures, and fistulas.
CT scan may show bowel wall thickening and fistula formation.
CBC- to assess hematocrit and hemoglobin levels.
Elevated WBC’s
Elevated ESR (estimated sed. rate)
Decreased albumin and protein levels (indicating malnutrition)
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Ulcerative Colitis - Manifestations
Clinical course is usually one of exacerbations and remissions.
Predominant symptoms include:
o Diarrhea
o Passing mucus and pus in stool
o
Left lower quadrant abdominal pain
o
Intermittent tenesmus (rectal spasms)
o
Rectal bleeding
o May pass 10 to 20 liquid stools daily
o Pallor
o Anemia
o Fatigue
o Rebound tenderness RLQ
o Anorexia
o Weight loss, fever, vomiting and dehydration
Ulcerative Colitis – Assessment and Diagnostic Findings
Assess for tachycardia, hypotension, tachypnea, fever, and pallor.
Assess hydration and nutritional status.
Examine abdomen for bowel sounds, distention, and tenderness.
Stool is positive for blood.
Lab test results reveal low hematocrit and hemoglobin levels in
addition to an elevated white blood cell count, low albumin levels,
and an electrolyte imbalance.
Elevated anti-neutrophil cytoplasmic antibody levels are common
Abdominal x-ray to determine cause of symptoms.
A barium enema to show mucosal irregularities, focal strictures or
fistulas, shortening of the colon, and dilation of bowel loops.
Colonoscopy to show friable, inflamed mucosa with exudate and
ulcerations.
Colonoscopy assists in defining the extent and severity of the
disease.
CT scanning, MRI, and ultrasound studies can identify abscesses and
perirectal involvement.
Chron’s
Inflammation anywhere in GI tract
Can affect eyes, skin, joints
May appear in patches
May extend through entire thickness of bowel
Lifelong
Small intestine can get smaller and smaller
Weight loss
Pain - Diarrhea
Ulcerative Colitis
Limited to large intestine
Occurs – Rectum and Colon
Continuous pattern
Inflammation – Inner lining of intestines
Diarrhea – blood and pus
Rectal bleeding (bright red)
Weight loss
*18 - Long-term Steroid Therapy Complications Evaluate client response to medication
• Weight gain / Moon face
• Lost appetite
• Hyperglycemia
• Weakened immune system
o Risk for infection
o Risk for illness
o Delayed healing
• Adrenal suppression
o Do not abruptly stop drug (Taper slowly)
▪ Addisonian Crisis
• HTN
• Glaucoma / Vision changes
• Muscle wasting
• Osteoporosis
*19 - Patient Education Educate client regarding an acute or chronic condition
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Disease process / pathophysiology
Manifestations
Triggers / Exacerbations
o Foods to avoid (popcorn, nuts, corn, high residue)
Dietary modifications
o High protein
o High calorie
o Vitamin supplementation in Chron’s (B12 and Folic Acid)
Complications
o Long-term complications
Treatments
o Surgeries
o Medications
▪ Side effects of medications
*20 - Serious Disease Complications Recognize trends and changes in client condition and intervene as needed
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Chron’s
Intestinal obstruction or stricture formation
Perianal disease
Fluid and electrolyte imbalances
Malnutrition due to malabsorption
Fistula: entero-cutaneous (i.e., an abnormal opening
between the small bowel and the skin)
Abscess formation due to internal fistula with fluid
accumulation and infection.
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Ulcerative Colitis
Toxic megacolon-inflammation into muscular layer,
inhibiting contraction and leading to colonic distention.
Perforation
Bleeding due to ulceration, vascular engorgement, and
highly vascular granulation tissue.
Multiple Sclerosis (MS) - Felter is checking on this one*
*21 – DMARDS (Disease Modifying Anti-Rheumatic Drugs) Reinforce education to client regarding medications
Decrease the size and # of plaque
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2 Types
1.
2.
Suppress autoimmune response
Alter disease progression
Stop or decrease further tissue damage on joints, cartilage and organs
Have been found to halt progression of bone loss and destruction
Can induce remission.
Should be started within 3 months of onset of symptoms.
Nonbiologic or conventional synthetic – Hydroxychloroquine, sulfasalazine and Methotrexate, slow acting and take several weeks
to work
Biologic – newer drugs that target individual molecules and tend to work more quickly than conventional, given after other meds
have been tried. Abatacept, adalimumab, etanercept and infliximab.
*22 - Treatment / Medications Evaluate appropriateness and accuracy of medication order for the client
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Immunosuppressive to decrease frequency of Relapses
o Azathioprine and Cyclosporin
o Watch for infections
Corticosteroids – to decrease the Inflammation
o Prednisone
o Watch for infections, risk for hyperglycemia, GI bleed, personality changes and weight gain
Antispasmodics
o Valium (Diazepam)
o Baclofen – watch for muscle weakness
Immunomodulators – help regulate immune system
o Interferon Bet-1A (Avonex) and Beta 1b (Betaseron) SE – flu like symptoms
Anticonvulsants – used to stop paresthesia
o Carbamazepine
Stool softeners – constipation
Anticholinergics – oxybutynin for overactive bladder – relaxes bladder muscle
Cholinergic – Bethanechol – muscle stimulate – helps empty bladder
Propanol (Beta Blocker) – for tremors – blocks nerve impulse to muscles, used for elevated BP so monitor BP
Benzodiazepine – Clonazepam, Diazepam – uses as muscle relaxant
*23, 24 - Patient Education Educate client about treatments and procedures
• No cure, treatment options are for symptoms relief and continued support.
o
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•
Promotion of physical mobility, avoidance of injury, achievement of bladder and bowel continence, promotion of speech
and swallowing mechanisms, improvement of cognitive function, development of coping strengths, improved home
maintenance, and adaptation to sexual dysfunction (major goals)
Goals of treatment: to delay the progression of the disease, manage chronic symptoms, and treat acute exacerbations.
o Symptoms requiring intervention include spasticity, fatigue, bladder dysfunction, and ataxia
Pharmacologic Therapy
o Disease modifying therapies are immuno-modulators and immunosuppressive agents
▪
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▪
▪
▪
o
Interferon- (side effects flu-like symptoms, potential liver failure, fetal anomalies, depression)
Glatiramer acetate (Copaxone)- reduce rate of relapse in RR ( may take 6 months for evidence of immune
response).
Methylprednisolone IV exerts anti-inflammatory effects by acting on T cells and cytokines- side effects: mood
swings, weight gain, electrolyte imbalances
Mitoxantrone (Novantrone) reduces clinical relapses in secondary progressive or worsening RR. Side effects:
cardiac toxicity, maximum lifetime dose that can be administered.
Complications with these drugs: cardiac, hepatic enzyme elevation malignancies, herpes viral infections,
mascular edema.
Symptom Management
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Baclofen (Lioresal) is medication of choice for treating spasticity.
Benzodiazepines (diazpam or Valium) may treat spasticity.
Nerve blocks for disabling spasms and contractures
Amantadine (Symmetrel), pemoline (Cylert) treat fatigue
Beta-adrenergic blockers (propranolol or Inderal) treat ataxia
Anti-seizure agent gabapentin (Neurontin) and benzodiazepines (clonazepam or Klonopin) treat ataxia.
▪
Anticholinergic, alpha-adrenergic blockers, antispasmodic agents for bladder and bowel problems.
*26 – Clinical Manifestations Identify pathophysiology related to an acute or chronic condition
1. Cause: Genetic Predisposition and environmental factors
2. Affects both males and females, but affects women 2X’s more
3. Average age of onset is between 20-40
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Can Be vague, which can delay diagnosis.
Can be varied and multiple, depending on location of lesion/lesions.
Main Symptoms:
o Fatigue, especially of lower legs
o Muscle spasticity – 90% present, especially of lower legs
o Muscle weakness
o Pain or Paresthesia
o Difficulty in coordination, loss of balance
o Other symptoms:
▪ Dysphagia and dysarthria
▪ Visual disturbances – diplopia, nystagmus
▪ Tinnitus, vertigo, decrease in hearing
▪ Uhthoff’s sign (increase in temperature causes visual disturbances)
▪ Memory loss, impaired judgement, trouble thinking
▪ Bowel dysfunction – constipation, fecal incontinence
▪ Bladder dysfunction – urgency, nocturia, retention
▪ Sexual dysfunction – difficulty achieving an orgasm, loss of libido
Systemic Lupus Erythematosis (SLE)
*25 - Clinical Manifestations – Nephritis Identify pathophysiology related to an acute or chronic condition
PPT
50% experience renal manifestations
o Proteinuria
o cellular casts
o nephrotic syndrome
o 10% develop renal failure – one of the leading causes of death from SLE
Hinkle 1098
Nephritis as a result of SLE, also referred to as lupus nephritis, occurs due to a buildup of antibodies and immune complexes that
cause damage to the nephrons. Serum creatinine levels and urinalysis are used in screening for renal involvement. Early detection
allows for prompt treatment so that renal damage can be prevented. Renal involvement may lead to hypertension, which also
requires careful monitoring and management
From https://www.allinforlupusnephritis.com/about-lupus-nephritis/signs-andsymptoms#:~:text=Clinical%20signs%20of%20lupus%20nephritis%20include%3A%201%20Leakage,the%20kidneys%20as%20confirm
ed%20through%20a%20kidney%20biopsy
Lupus Nephritis Classes and Related Signs and Symptoms
• In the early stages of lupus nephritis, there are very few signs that anything is wrong. In fact, some patients have no specific
symptoms. Kidney problems often start around the same time that lupus symptoms appear.
• Clinical signs of lupus nephritis include:
o Leakage of a high level of protein into the urine (a condition known as proteinuria). Extra protein in the urine
shows up in a clinical laboratory urine test.
o Leakage of blood into the urine (a condition known as hematuria)
o High blood pressure
o Inflammation or scarring of the kidneys as confirmed through a kidney biopsy
Lupus nephritis is divided into 6 different stages or classes based on the results of a kidney biopsy. Your doctor will describe these as
classes. Of those people diagnosed with lupus nephritis, 70% will be diagnosed as having Class 3, 4 or 5. The following table provides
an overview of these different classes as well as certain signs and symptoms that may occur during various stages.
Symptoms of lupus nephritis often include weight gain; swelling in the legs, feet, or ankles; and urine that is foamy, bubbly, or
frothy. Additional signs and symptoms associated with the different classes of lupus nephritis are noted below.
Class 1
Minimal kidney involvement
No obvious symptoms
Minimal mesangial glomerulonephritis
Microscopic amounts of blood in urine (a
Class 2
Some evidence of inflammation in limited
condition known as hematuria) and/or
Mesangial proliferative
areas of the kidneys
excess protein in urine (a condition
glomerulonephritis
known as proteinuria).
Involvement of less than half of the
Class 3
Blood and/or excess protein in urine
network of small blood vessels in the
Focal glomerulonephritis
Possible high blood pressure
kidneys
Involvement of more than half of the
Class 4
Blood and/or excess protein in urine
network of small blood vessels in the
Diffuse proliferative nephritis
Possible high blood pressure
kidneys
Characterized by immune deposits found
around the network of small blood vessels
Class 5
Blood and/or excess protein in urine
Membranous glomerulonephritis
Possible high blood pressure
Different from other forms of lupus
nephritis
Class 6
Damage to more than 90% of the network
Near or total kidney failure (dialysis or
Advanced sclerotic
of small blood vessels in the kidneys
kidney transplant may be needed)
*27 - Clinical Manifestations – General Identify pathophysiology related to an acute or chronic condition
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Skin Manifestations:
o Butterfly shaped rash of the malar region of the face characterized by erythema and edema.
o Discoid lesions are scarring, ring shaped, involving the shoulders arm and upper back.
o Discoid lesions may result in erythematous, scaly plaque on the face, scalp, external ear, and neck, resulting in
alopecia.
o Photosensitivity
Affects all body systems
Most common symptoms
o Fever
o Fatigue/malaise
o Anorexia/weight loss
o Joint pain
o Butterfly (malar) rash across cheeks
and nose
*28 - Clinical Management
Identify pathophysiology related to an acute or
chronic condition
Clinical management includes:
• Recognition and avoidance of disease flares
• Prevention of infection
• Nutritional therapy
• Physical therapy
• Stress reduction
• Avoidance of UV light
• Pharmacologic intervention
o Supportive care – NSAIDS for fever,
arthralgias, arthritis; ASA prevent
thrombosis
o Hydroxychloroquine (Plaquenil) –
antimalaria drug effective for skin
and arthritic manifestations
o Corticosteroid therapy in high doses
o Immunosuppressive agents –
methotrexate and azathioprine
Cellular Regulation
Breast Cancer
*29 - Patient Education Educate client about Medications
Medications force patient into menopause.
Chart 58-10 PATIENT EDUCATION
Managing Side Effects of Adjuvant Hormonal Therapy in Breast Cancer
The nurse instructs the patient in strategies to manage the following side effects:
Hot Flashes
• Wear breathable, layered clothing.
• Avoid caffeine and spicy foods.
• Perform breathing exercises (paced respirations).
• Consider medications (vitamin E, antidepressants) or acupuncture.
Vaginal Dryness
• Use vaginal moisturizers for everyday dryness (e.g., Replens, vitamin E suppository).
• Apply vaginal lubrication during intercourse (e.g., Astroglide, K-Y Jelly).
Nausea and Vomiting
• Consume a bland diet.
• Try to take medication in the evening.
Musculoskeletal Symptoms
• Take nonsteroidal analgesic agents as recommended.
• Take warm baths.
Risk of Endometrial Cancer
• Report any irregular bleeding to a gynecologist for evaluation.
Risk for Thromboembolic Events
• Report any redness, swelling, or tenderness in the lower extremities, or any unexplained shortness of breath.
Risk for Osteoporosis or Fractures
• Undergo a baseline bone density scan.
• Perform regular weight-bearing exercises.
• Take calcium supplements with vitamin D.
• Take bisphosphonates (e.g., alendronate) or calcitonin as prescribed.
TABLE 58-7 Adverse Reactions Associated With Adjuvant Hormonal Therapy Used to Treat Breast Cancer
Therapeutic Agent
Adverse Reactions/Side Effects
Selective Estrogen Receptor Modulator
tamoxifen (Soltamox)
Hot flashes, vaginal dryness/discharge/bleeding, irregular menses, nausea, mood
disturbances, rashes; increased risk for endometrial cancer; increased risk for
thromboembolic events (deep vein thrombosis, pulmonary embolism, superficial
phlebitis)
Aromatase Inhibitors
anastrozole (Arimidex)
letrozole (Femara)
exemestane (Aromasin)
Musculoskeletal symptoms (arthritis, arthralgia, myalgia), increased risk of
osteoporosis/fractures, nausea/vomiting, hot flashes, fatigue, mood disturbances,
rashes
*30 - Assessment Identify pathophysiology related to an acute or chronic condition
Non-invasive
1. ductal carcinoma in situ (DCIS) Cancer cells are in milk ducts and have not invaded surrounding tissue, does not
metastasize, but can be invasive if left untreated. But takes about 10 years to become invasive.
2. Lobular carcinoma in-situ (lCIS)- appears in milk producing glands, but not a true cancer, but person is at higher risk for
getting breast cancer in future. Managed with observation, doesn’t cause symptoms, usually not seen on mammogram
Invasive
• Infiltrating ductal carcinoma – most common
• tumor arises from duct system and invades surrounding tissue.
• Forms a solid mass tumor, skin dimpling or edematous thickening and pitting of breast skin (orange peel)
Rare form of breast cancer - Paget’s disease
• Cancer collects in or around the nipple, then spreads to nipple surface and areola
• Nipple and areola become scaly, red, itchy and irritated
• Symptoms are important, because 97% will have DCIS or invasive cancer
*31 - Treatment Apply knowledge of client pathophysiology to illness management
Treatments
• Surgical interventions – lumpectomy, partial mastectomy, total mastectomy, modified radical mastectomy (take lymph
nodes, radical mastectomy (take lymph nodes and muscle)
• Chemotherapy and or radiation
• Following surgery to reduce risk of reoccurrence – selective estrogen receptor modulators – tamoxifen
• Considered Highly effective protective measure
*32 - Screening – Patient Education Educate client on actions to promote/maintain health and prevent disease
Mammography
• Use of x-ray images of the breast
• Every year after age 40
• Breast cancer
BSE (Breast Self-Examination)
• >20 years of age
• Perform monthly after menstruation
TABLE 58-3 Risk Factors for Breast Cancer
Risk Factor
Female gender
Increasing age
Personal history of breast cancer
Family history of breast cancer
Genetic mutation
Hormonal Factors
• Early menarche
• Late menopause
• Nulliparity
• Late age at first full-term
pregnancy
• Hormone therapy (formerly
referred to as hormone
replacement therapy)
Exposure to ionizing radiation during
adolescence and early adulthood
History of benign proliferative
breast disease
Obesity
High-fat diet
Comments
99% of cases occur in women.
Increasing age is associated with an increased risk.
Once treated for breast cancer, the risk of developing breast cancer in same or opposite
breast is significantly increased.
Having first-degree relative with breast cancer (mother, sister, daughter) increases the risk
twofold; having two first-degree relatives increases the risk fivefold. The risk is higher if
the relative was premenopausal at the time of diagnosis.
The risk is increased if a father or brother had breast cancer (exact risk is unknown).
BRCA1 and BRCA2 mutations account for majority of inherited cases of breast cancer (see
additional information in text).
Before 12 years of age
After 55 years of age
No full-term pregnancies
After 30 years of age
Current or recent use of combined postmenopausal hormone therapy (estrogen and
progesterone)
Long-term use (several years or more)
The risk is highest if breast tissue was exposed while still developing (during adolescence),
such as women who received mantle radiation (to the chest area) for treatment of
Hodgkin lymphoma in their younger years.
Having had atypical ductal or lobular hyperplasia or lobular carcinoma in situ increases the
risk.
Obesity and weight gain during adulthood increases the risk of postmenopausal breast
cancer.
During menopause, estrogen is primarily produced in fat tissue. More fat tissue can increase
estrogen levels, thereby increasing breast cancer risk.
More research is needed.
Alcohol intake (beer, wine, or liquor) Two to five drinks daily increases the risk about one and a half times.
Prostate Cancer
*33 - Assessment / Clinical Manifestations Identify pathophysiology related to an acute or chronic condition
Risk Factors
• African American race
• History of vasectomy
• >65 years of age, family history
• Positive brca 2 mutation
Symptoms
• Urinary – hesitancy, weak stream, urgency, frequency, nocturia
• Recurrent bladder infections
• Urinary retention
• Blood in urine and semen (late manifestations)
• Painful ejaculation
• Pain in bone (pelvis, spine, hips, ribs)
• Unexplained weight loss
• Loss of sexual desire or function
• Penile discharge or scrotal swelling
• Significant residual urine after voiding small amounts of urine
• Swollen lymph nodes, especially at groin
*34 - Brachytherapy Treatment Safety Educate client about treatments and procedures
INTERNAL RADIATION THERAPY - BRACHYTHERAPY
• Radiation that is placed close to the tumor , provides radiation to the tumor and a limited amount to surrounding tissues
• Can Be temporary or Permanent Implant
• Seeds, beads, and ribbons Can be implanted by needles or rods, or catheters. placed into body cavities, lumens within
organs or interstitial tissue compartments.
• Radiation exposure must be limited to those in proximity to the patient.
• Place the patient in Private room, far from others.
• Place sign on door warning of radiation source.
• Wear a dosimeter film badge, wear a lead apron while providing care.
• Limit visitors to 30 min visits, keep 6 foot distance from patients.
• No Children or Pregnant women in the room.
• All waste products are radioactive until isotope has been completely eliminated from the body.
*35 - Priority Action Provide Postoperative Care - Recognize signs/symptoms of client complications and intervene
Hinkle 1771
Postoperative complications depend on the type of prostatectomy performed and may include:
• Hemorrhage
• clot formation
• catheter obstruction
• sexual dysfunction.
• Transurethral Resection Syndrome
o Transurethral resection syndrome is a rare but potentially serious complication of transurethral prostatectomy
(TURP). Signs and symptoms are caused by neurologic, cardiovascular, and electrolyte imbalances associated with
absorption of the solution used to irrigate the surgical site during the surgical procedure. Hyponatremia,
hypovolemia, and occasionally hyperammonemia may occur.
▪ Signs and Symptoms
• Collapse
• Headache
• Hypotension
• Lethargy and confusion
• Muscle spasms
• Nausea and vomiting
• Seizures
• Tachycardia
▪ Interventions
• Discontinue irrigation.
• Administer diuretic agents as prescribed.
• Replace bladder irrigation with normal saline.
• Monitor intake and output.
• Monitor the patient’s vital signs and level of consciousness.
• Differentiate lethargy and confusion of TURP syndrome from postoperative disorientation and
hyponatremia.
• Maintain patient safety during times of confusion.
• Assess lung and heart sounds for indications of pulmonary edema, heart failure, or both as fluid
moves back into the intravascular space.
• All prostatectomies carry a risk of impotence because of potential damage to the pudendal nerves. In most instances,
sexual activity may be resumed in 6 to 8 weeks, which is the time required for the prostatic fossa to heal.
• The anatomic changes in the posterior urethra can lead to retrograde ejaculation. During ejaculation, the seminal fluid goes
into the bladder and is excreted with the urine.
• A vasectomy may be performed during surgery to prevent infection from spreading from the prostatic urethra through the
vas and into the epididymis.
• After total prostatectomy (usually for cancer), the risk of impotence is high. If this is unacceptable to the patient, options
are available to produce erections sufficient for sexual intercourse: prosthetic penile implants, negative-pressure (vacuum)
devices, and pharmacologic interventions
See next 2 pages for Prostate Surgeries, Complications, and Interventions
TABLE 59-4 Surgical Approaches for Treatment of Prostate Disorders
The surgical approach of choice depends on (1) the size of the gland, (2) the severity of the obstruction, (3) the age of the patient, (4) the condition
of the patient, and (5) the presence of associated diseases.
Surgical Approach
Advantages
Disadvantages
Nursing Implications
Transurethral Resection (TURP)
Avoids abdominal incision
Requires highly skilled
Monitor for hemorrhage.
Removal of prostatic tissue by
Safer for surgical-risk patient
surgeon.
Observe for symptoms of urethral
optical instrument introduced Shorter length of hospital stay
Recurrent obstruction,
stricture (dysuria, straining, weak
through urethra; used for
and recovery periods
urethral trauma, and
urinary stream).
glands of varying size. Ideal
Lower morbidity rate
stricture may develop.
for patients who are poor
Causes less pain
Delayed bleeding may occur.
surgical risks.
Can be used as a palliative
approach with history of
radiation therapy
Open Surgical Removal
Suprapubic approach
Removal of prostatic tissue
through abdominal incision;
can be used for gland of any
size
Perineal approach
Removal of gland through an
incision in the perineum;
preferred approach for
patients who are obese
Retropubic approach
Low abdominal incision; bladder
is not entered.
Transurethral Incision (TUIP)
Urethral approach; 1–2 cuts are
made in the prostate and
prostate capsule to reduce
pressure on the urethra and
to reduce urethral
constriction.
Laparoscopic Radical
Prostatectomy
In this approach, 4–6 small (1 cm
[0.5 inch]) incisions are made
in the abdomen; laparoscopic
instruments inserted through
the incisions are used to
dissect the prostate.
Technically simple
Offers wide area of exploration
Permits exploration for
cancerous lymph nodes
Allows more complete removal
of obstructing gland
Permits treatment of associated
bladder lesions
Requires surgical approach
through the bladder
Control of hemorrhage is
difficult
Urine may leak around the
suprapubic tube
Recovery may be prolonged
and uncomfortable
Monitor for indications of hemorrhage
and shock.
Provide meticulous aseptic care to the
area around suprapubic tube.
Offers direct anatomic approach
Permits gravity drainage
Particularly effective for radical
cancer therapy
Allows hemostasis under direct
vision
Low mortality rate
Low incidence of shock
Ideal for patients with large
prostate who are very old,
frail, and poor surgical risks
Avoids incision into the bladder
Permits surgeon to see and
control bleeding
Shorter recovery period
Less bladder sphincter damage
Suitable for removal of large
glands
Results comparable to TURP
Low incidence of erectile
dysfunction and retrograde
ejaculation
No bladder neck contracture
Higher postoperative incidence
of impotence and urinary
incontinence
Possible damage to rectum
and external sphincter
Restricted operative field
Greater potential for
contamination and
infection of incision
Avoid using rectal tubes or
thermometers and enemas after
perineal surgery.
Use drainage pads to absorb excess
urinary drainage.
Provide foam rubber ring for patient
comfort in sitting.
Anticipate urinary leakage around the
wound for several days after the
catheter is removed.
Cannot treat associated
bladder disease
Increased incidence of
hemorrhage from
prostatic venous plexus;
osteitis pubis
Monitor for hemorrhage.
Anticipate posturinary leakage for
several days after removing the
catheter.
Recurrent obstruction and
urethral trauma
Delayed bleeding
Monitor for hemorrhage.
Minimally invasive technique
Improved patient satisfaction
and quality of life
Shorter length of hospital stay
Short convalescence
More rapid return to normal
activity
Short indwelling catheter
duration
Decreased blood loss to 400 mL
Reduced infection risk
Less scarring
Better visualization of surgical
field than other approaches
Lack of tactile sensation
available with open
prostatectomy
Inability to palpably assess for
induration and palpable
nodules
Inability to delineate the
proximity of involvement
of the neurovascular
bundles due to lack of
palpation
Long surgical time (4–5 hours)
Observe for symptoms of urethral stricture
(dysuria), straining, weak urinary
stream.
Monitor for hemorrhage and shock.
Provide meticulous aseptic care to area
around suprapubic tube.
Monitor for changes in bowel function.
Avoid using rectal tubes or thermometers
and enemas after perineal surgery.
Use drainage pads to absorb excess urinary
drainage.
Provide foam rubber ring for patient
comfort in sitting.
Anticipate urinary leakage around the
wound for several days after the
catheter is removed.
TABLE 59-4 Surgical Approaches for Treatment of Prostate Disorders
Robotic-Assisted
Laparoscopic
Radical Prostatectomy
Involves using computer console
and da Vinci. In this approach,
6 small (1 cm [0.5 inch])
incisions are made in the
abdomen; laparoscopic
instruments inserted through
the incisions are used to
dissect the prostate.
Minimally invasive technique
Improved patient satisfaction and
quality of life
Shorter length of hospital stay
Short convalescence
More rapid return to normal
activity
Short indwelling catheter
duration
Decreased blood loss to 150 mL
Improved magnification of
operative field, using a 3dimensional view (includes,
magnification, high
resolution, and depth
perception)
Less postoperative pain
Reduced risk of infection
Less scarring
Laparoscopic instruments have 6
degrees of movement with
joints, allowing extensive
range of motion and
precision.
Nerve sparing with less
incontinence and sexual
dysfunction
Lack of tactile sensation
available with open
prostatectomy
Inability to palpably assess for
induration and palpable
nodules
Inability to delineate the
proximity of involvement of
the neurovascular bundles
due to lack of palpation
Observe for symptoms of urethral
stricture (dysuria), straining, weak
urinary stream.
Monitor for hemorrhage and shock.
Provide meticulous aseptic care to the
area around suprapubic tube.
Monitor for changes in bowel function.
Avoid using rectal tubes or thermometers
and enemas after perineal surgery.
Use drainage pads to absorb excess
urinary drainage.
Provide foam rubber ring for patient
comfort in sitting.
Anticipate urinary leakage around the
wound for several days after the
catheter is removed.
Colon Cancer
*36 - Education Educate client about health promotion and maintenance recommendations
Lippincott
Include the patient's family or caregiver in your teaching, when appropriate. Provide information according to their individual
communication and learning needs. Be sure to cover:
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disease process, diagnostic testing, treatment, and postoperative course, including plans for radiation therapy or
chemotherapy and possible adverse effects
pain management plan and potential adverse effects of pain management treatment
safe use, storage, and disposal of opioids, if prescribed
stoma care
incisional site care
avoidance of heavy lifting during recovery
importance of keeping follow-up appointments
risk factors and signs of recurrence
adverse effects of radiation and chemotherapy, as applicable
infection-control measures
signs and symptoms of infection to report immediately
screening tests and recommended follow-up care, including regular surveillance for at least 5 years after surgery, with
physical examinations every 3 to 6 months for the first 3 years, every 6 months during years 4 and 5, and then as
determined by the practitioner
need to have serum carcinoembryonic antigen levels checked every 3 months (for stage II and III disease) for at least 3 years
and then every 6 months in years 4 and 5
importance of having follow-up computed tomography scanning (abdomen and pelvis) annually for the first 3 years
protective factors to reduce the risk of colorectal cancer, such as a high-fiber diet, vitamin B6 intake, increased calcium
intake, and regular exercise.
Brunner 1348
The major goals for the patient may include attainment of optimal level of nutrition; prevention of infection; maintenance of fluid
balance; reduction of anxiety; learning about the diagnosis, surgical procedure, and self-care after discharge; maintenance of
optimal tissue healing; and avoidance of complications.
*37 - Health Promotion / Safety Apply knowledge of pathophysiology to health screening
Brunner p358
per felter review entire chart
Chart 15-7 PLAN OF NURSING CARE
Complete Care Plan Chart at the end of the study guide. Pg 35
powerpoint
• Colonoscopy – either CT guided or traditional
• Barium enema
• Fecal occult blood test annually >50-75, note that false positive can occur with use of anti-inflammatory medications,
vitamin C and eating red meat 48 hours to test
• Ct or Mri
• Cea – carcinoembryonic antigen – can be positive for many types of cancer but mostly used for colon cancer.
*38 - Preoperative Care / Treatment Educate client about medications
???
Antiemetics – ondansetron (Zofran)
Hydration / IV fluids
Antibiotics – administered preoperatively to reduce intestinal bacteria
Med/Surg pg#1345
Prevention:
• smoking cessation
• Physical activity, diet, and weight reduction
• take aspirin daily or alternate day aspirin (>75mg) for 5-10 years to prevent cardiovascular disease and colorectal cancer
(powerpoint)
Treatment:
• Colon resection (Colectomy); can be with a temporary or permanent colostomy or ileostomy
• Abdominal-perineal resection
• Chemotherapy
• Radiation
Skin Cancer
*44 - Skin Assessment Perform Targeted Screening Assessments
3 Types
1. Squamous Cell (epidermis)- rough, scaly lesions, crusty with a central ulceration,
usually localized, but can Metastasize
2. Basal Cell (Basal layer) – Small, waxy nodules with well-defined borders. Can have erythema and ulcerations.
3. Malignant Melanoma – Irregular shape and borders with multiple colors. New change in an existing mole. They itch, crack,
make ulcerations and bleed. Can have rapid invasion and metastasis with high morbidity and mortality
* 90% of all skin cancers, high rate of recurrence, rarely metastasize, slow growing
ABCDE RULE OF SKIN CANCER
*45 - Basal Cell Carcinoma – Risk Potential Perform a Risk Assessment
Hinkle p 1834
BCC is the most prevalent skin cancer in the United States. It is rarely associated with any morbidity and rarely causes death. It is
estimated that up to 80% of NMSCs among men and up to 90% of NMSCs among women are BCCs. Although less common than BCC,
SCC is the second most prevalent skin cancer in the United States. Although less aggressive than melanoma, SCC is believed to be
responsible for at least 4000 deaths annually
Cancer
*39 - Chemotherapy – Patient Assessment Assess the client for actual or potential side effects and adverse effects of medications
Med/Surg pg#2097 ?
Nursing Management:
• headache characteristics should be assessed
• upright positioning and pain medications may be useful in managing pain
• patient and family should be educated about the possibility of seizure and the need to adhere to prophylactic
anticonvulsants
• medications to alleviate nausea and prevent vomiting should be considered
• neurologic checks, monitor vital signs
• use of orienting devices
• supervision of and assistance with self care
• ongoing monitoring/prevention of injury
• motor function is checked at intervals because specific motor deficits may occur
• sensory disturbances are assessed and any area of numbness should be protected from injury
• speech is evaluated
• eye movement and pupillary size and reaction may be affected by cranial nerve involvement
• fatigue is common; efforts should be made to conserve energy and promote rest
• caregiving family members should be included in the plan of care
*40 - Chemotherapy – Adverse Effects Assess the client for actual or potential side effects and adverse effects of medications
(powerpoint)
Complications:
• immunosuppression: neutropenia
• nausea, vomiting, anorexia
• oral effects: mucositis (inflammation in the mucous lining of the upper GI tract from mouth to stomach)
• stomatitis (inflammation of tissue in the oral cavity, such as gums, tongue, roof and floor of the mouth and inside the lips
and cheeks
• anemia, thrombocytopenia
*41 - Nursing Care – Radiation Apply knowledge of client pathophysiology to illness management
Radiation:
• involves ionizing radiation to target tissues and destroy cells
• adverse effects of tissues within the radiations path: skin changes, hair loss, debilitating fatigue
• usually given as a series of divided small doses on a daily basis for a set period of time
• can be used to reduce size of tumor preoperatively
• can be external (teletherapy) and internal (brachytherapy)
*42 - Cancer Symptom Management Identify pathophysiology related to an acute or chronic condition
Med/Surg pg#372/ powerpoints
Pain Management:
• distraction: music, visualization
• children: play therapy
• medications: use pain scale, give early in pain cycle at regular intervals
• Premedicate before procedures
• If discomfort is from fever: acetaminophen (tylenol) is used
• gentle back and shoulder massage
• assess prior pain experiences and previous management strategies patient found successful
• address myths or misconceptions about the use of opioids analgesics.
Fatigue:
• encourage rest periods before and after activities
• avoid prolonged periods of inactivity
• encourage light exercise
• organize activities to conserve energy
• eat good nutritious meals
• encourage the use of relaxation techniques and guided imagery
• participation in planned exercise programs based on individual limitations and safety measures
• collaborate with OT,PT, certified cancer exercise trainer, or sports medicine to ID safe and appropriate activities
• provide for uninterrupted sleep periods
Leukemia
*43 - Intervention after Patient Assessment Recognize trends and changes in client condition and intervene as needed
Treatment: goal is complete remission by:
• Induction therapy: aggressive administration of chemotherapy
• If patient to old: supportive care and light chemo
• HSCT: Hematopoietic stem cell transplant
• Blood products
See Nursing Care on next page. Super condensed. Full Care Plan at end of study guide. Pg 35
*48 - Nursing Care / Interventions Apply knowledge of client pathophysiology to illness management
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MONITOR FOR INFECTION
Check V/S, report fever or any signs of infection (chills, pain,
erythema)
Monitor CBC QD
Inspect all sites for infection – IV ports, wounds, skinfolds, oral
cavities
Obtain Cultures and sensitivities before antibiotics are started
Private room, good handwashing, limit visitors
Use electric razor
Ambulate around room
Daily care of dentures
Change water in pitcher, respiratory equipment
Wash all fruits and vegetables
No flowers
Avoid IM injections
Avoid foleys
CARE OF MUCOSITIS
Assess oral cavity daily
Id patients at risk for mucositis
Instruct to report oral burning, pain, areas of redness open
lesions in mouth, pain associated with swallowing, decreased
tolerance to temperature extremes in food.
Encourage and assist as needed with oral hygiene.
Avoid irritants – mouthwash, alcoholic beverages, tobacco
Brush with soft toothbrush
Use normal saline mouth washes every 1-4 hours
Remove dentures except for meals
Avoid foods that are spicy or hard to chew and those with
extreme temperatures
Minimize discomfort, get order for topical anesthetic.
PAIN MANAGEMENT
Distraction – music, visualization
Children – play therapy
Medications – use pain scale, give early in pain cycle at regular
intervals
Premedicate before procedures
If discomfort is from fever – Acetaminophen (Tylenol) is used.
Gentle back and shoulder massage
Assess prior pain experiences and previous management
strategies patient found successful.
Address myths or misconceptions about the use of opioids
analgesics.
EMOTIONAL SUPPORT
Emotional support to parents, and forgotten siblings
Emotional support to address body image changes and self
esteem
Support with issues related to change in appearance – loss of
hair, weight loss
Allow to participate in all decision making
Encourage to verbalize concerns.
Assist with personal hygiene as needed.
Empathetic listening
Assess spiritual and religious practices
Offer pastoral services.
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BLEEDING
Monitor labs (thrombocytopenia, elevated INR/PT/PTT,
decreased fibrinogen)
Monitor for S/S of bleeding – hypotension, tachycardia, altered
mental status
Monitor for bleeding from any orifice
Observe for alternate mental status
Change positions slowly to avoid hypotension and tachycardia
Use soft toothbrush, avoid commercial mouthwashes, avoid
foods hard to chew
Use electric razor
Keep lips moist, Increase fluids
Stool softeners
Water based lubricants for sexual intercourse
Minimize bleeding – draw all blood at one time for the day, Hold
direct pressure for at least 5 minutes
Platelet transfusions
Gently blow noise
IMPROVE NUTRITIONAL INTAKE
Provide mouth care before and after meals
Administer analgesic agents before eating, warn patient to chew
with extreme care to avoid biting the tongue or buccal mucosa.
Provide antiemetic therapy for nausea.
Small, frequent feedings of foods that are soft in texture and
moderate in temperature
Low-microbial diets may be prescribed
Nutritional supplements are frequently used.
Daily body weight, Calorie counts and formal nutritional
assessment
Intake and output measurements
Parenteral nutrition may be required to maintain adequate
nutrition.
FATIGUE
Encourage rest periods before and after activities
Avoid prolonged periods of inactivity
Encourage light exercise
Organize activities to conserve energy
Eat good nutritious meals
Encourage the use of relaxation techniques and guided imagery
Participation in planned exercise programs based on individual
limitations and safety measures.
Collaborate with OT, PT, certified cancer exercise trainer, or
Sports medicine to ID safe and appropriate activities.
Provide for uninterrupted sleep periods.
Acute Lymphocytic Leukemia
*47 - Individuals At Risk Identify risk factors for disease (e.g. age, gender, ethnicity, lifestyle)
• Arises from uncontrolled proliferation of immature lymphoid cells
• Affects – most common in children ages 2-10, peaks at age 4, greater than age 15 is uncommon, until the age of 50 when
incidence peaks again.
• Affects more males than females
• Cause – 20% Chromosomal translocation, the rest is unknown
Hodgkin’s Disease
*46 - Clinical Manifestations Identify pathophysiology related to an acute or chronic condition
Symptoms
• Usually begins as enlarged PAINLESS lymph node on side of the neck. Firm but not hard.
• Node can be more than one, most common sites are cervical, supraclavicular, mediastinal.
• Pruritus – cause unknown
• B-symptoms – fever, drenching night sweats, unintentional weight loss, fatigue even with rest
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All organs are vulnerable to invasion by tumor cells resulting in compression of organ and compromised function
o Abdomen – compression of ureters, kidneys, N&V, anorexia, early satiety, weight loss
o Lungs – cough, pulmonary effusion, respiratory distress
o Mediastinal – compression of trachea = dyspnea
o Liver – jaundice
o Spleen – abdominal pain
o Bone – bone pain
o Aggressive types will affect CNS
Grief
Stages of Grief
*49 - Nursing Interventions Evaluate the client’s coping and fears related to grief and Loss
Kubler Ross Stage of Grief (powerpoint)
• Denial (ex. dx /dz) (it ain’t just a river in Egypt HAHAHAHAHAHAHA)
• Anger (ex. why me? takes it out @ anyone & God)
• Bargaining (ex. over it & start planning)
• Depression (sad)
• Acceptance (of the issue dx or dz)
(powerpoint)
• Understand the grieving process as well as the cultural response to loss.
• Develop therapeutic communication skills
• Active listening encourages the patient to talk. -Words are not always necessary.
• Use non-judgmental statements to acknowledge the loss
• Use the love one’s name, if appropriate.
• Respect the client’s unique process of grieving.
• Respect their personal beliefs.
• Being honest, dependable, consistent and worthy of the client’s trust.
• Examine your own personal attitudes.
• Maintain an attentive presence
• Provide psychologically safe environment
Terminal Illness
*50 - Coping with Grief (Patient and Family) Provide care for a patient experiencing grief or loss
Terminal Illness:
• Those Diagnosed with a Terminal Illness have Anticipatory Grief and Mourning.
• Denial, sadness, anger, fear, and anxiety are normal grief reactions for the patient and those close to them.
• Not every patient or family member experiences every stage and many never reach acceptance.
• Both the family and patient’s emotional responses can fluctuate daily.
• The impending loss causes stress to patient and loved one, but it also provides a unique opportunity for family members to
reminisce, resolve relationships, plan, and say goodbye.
• Individual and family coping with the anticipation of death is complicated by the varied and conflicting trajectories. Each
member concerned about how roles will change. Patient concerned about inability to care for themselves, partner worried
about loss of income, children worried about who will care for them.
• Tensions can rise when one or more family members that others are less caring, to emotional or to detached.
Nursing:
• Assess the characteristics of the family dynamics.
• Intervene in a manner that supports and enhances cohesion of the family unit.
• Suggest family members talk about their feelings and understand that these feelings are normal.
• Encourage family to interact with patient in meaningful ways.
• Provide or consult with professional support, as grief counselors, Chaplin or hospice team.
• This can help patient and family sort out and acknowledge feelings and make the end of life as meaningful as possible.
Complete Cancer Care Plans (Hinkle pg 358)
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 (r/t myelosuppression 2nd to radiation or antineoplastic agents)
Nursing Interventions
Rationale
Expected Outcomes
1. Assess patient for evidence of infection.
1. Signs and symptoms of infection may be
• Demonstrates
normal
a. Check vital signs every 4 hours.
diminished in the immunocompromised
temperature and vital
b. Monitor white blood cell (WBC) count and
host. Prompt recognition of infection
signs
differential each day.
and subsequent initiation of therapy will
• Exhibits absence of signs
c. Inspect all sites that may serve as entry
reduce morbidity and mortality
of inflammation: local
ports for pathogens (IV sites, wounds, skin
associated with infection.
edema, erythema, pain,
folds, bony prominences, perineum, and
and warmth
oral cavity).
• Exhibits normal breath
sounds on auscultation
2. Report fever (≥38.3°C [101°F] or ≥38°C
2. Early detection of infection facilitates
[100.4°F] for >1 hour) (see Table 15-10), chills,
early intervention.
• Takes deep breaths and
diaphoresis, swelling, heat, pain, erythema,
coughs every 2 hours to
exudate on any body surfaces. Also report
prevent
respiratory
change in respiratory or mental status, urinary
dysfunction and infection.
frequency or burning, malaise, myalgias,
• Exhibits
absence
of
arthralgias, rash, or diarrhea.
pathogens on cultures
• Avoids contact with
3. Obtain cultures and sensitivities as indicated
3. Tests identify the organism and indicate
others with infections
before initiation of antimicrobial treatment
the most appropriate antimicrobial
• Avoids crowds
(wound exudate, sputum, urine, stool, blood).
therapy. The use of inappropriate
antibiotics enhances proliferation of
• All personnel carry out
additional flora and encourages growth
hand hygiene after each
of antibiotic-resistant organisms.
voiding
and
bowel
movement.
4. Initiate measures to minimize infection.
4. Exposure to infection is reduced.
• Excoriation and trauma of
a. Discuss with patient and family:
a. Preventing contact with pathogens
skin are avoided.
1. Placing patient in private room if
helps prevent infection.
3
• Trauma
to
mucous
absolute WBC count <1000/mm .
b. Hands are significant source of
membranes is avoided
2. Importance of patient avoiding
contamination.
(avoidance of rectal
contact with people who have known
c. Incidence of rectal and perianal
thermometers,
or recent infection or recent
abscesses and subsequent systemic
suppositories,
vaginal
vaccination.
infection is high. Manipulation may
tampons,
perianal
b. Instruct all personnel in careful hand
cause disruption of membrane
trauma).
hygiene before and after entering room.
integrity and enhance progression
c. Avoid rectal or vaginal procedures (rectal
of infection.
• Uses
evidence-based
procedures
and
temperatures,
examinations,
d. Minimizes trauma to tissues
techniques if participating
suppositories; vaginal tampons).
e. Prevents skin irritation
in
management
of
d. Use stool softeners to prevent
f. Minimizes skin trauma
constipation and straining.
g. Minimizes
chance
of
skin
invasive lines or catheters
e. Assist patient in practice of meticulous
breakdown and stasis of pulmonary
• Uses electric razor
personal hygiene.
secretions
• Is free of skin breakdown
f. Instruct patient to use electric razor.
h. No evidence supports dietary
and stasis of secretions
g. Encourage patient to ambulate in room
restrictions of avoiding raw or fresh
• Adheres to dietary and
unless contraindicated.
fruit and vegetables for patients
environmental
h. Provide patient and family education on
who are neutropenic. General
precautions
food hygiene and safe food handling.
precautions
regarding
food
• Exhibits no signs of sepsis
i. Each day, change water pitcher, denture
handling
and
storage
are
or septic shock
cleaning
fluids,
and
respiratory
recommended.
• Exhibits normal vital
equipment containing water.
i. Stagnant water is a source of
signs, cardiac output, and
infection.
5.
6.
7.
8.
9.
Assess IV sites every day for evidence of
infection.
a. Change peripheral short-term IV sites
every other day.
b. Cleanse skin with povidone–iodine before
arterial puncture or venipuncture.
c. Change central venous catheter dressings
every 48 hours.
d. Change all solutions and infusion sets
every 72–96 hours.
e. Follow Infusion Nursing Society guidelines
for care of peripheral and central venous
access devices.
5.
Avoid intramuscular injections.
Avoid insertion of urinary catheters; if
catheters are necessary, use aseptic
technique.
Educate patient or family member to
administer granulocyte (or granulocytemacrophage) colony-stimulating factor when
prescribed.
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.
6.
7.
Nosocomial staphylococcal septicemia is
closely associated with IV catheters.
a. Incidence of infection is increased
when catheter is in place >72 hours.
b. Povidone–iodine is effective against
many gram-positive and gramnegative 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.
Reduces risk for skin abscesses.
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
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arterial pressures when
monitored
Demonstrates ability to
administer
colonystimulating factor
Has bowel movements at
regular intervals without
constipation or straining
Patient
hygiene
is
maintained.
Absence of IV catheter–
related infection
Absence of skin abcesses
Absence
of
urinary
catheter–related
infection
NURSING DIAGNOSIS: Risk for impaired skin integrity: erythematous and wet desquamation reactions to radiation therapy
GOAL: Maintenance of skin integrity related to radiation therapy
Nursing Intervention
Rationale
Expected Outcomes
1. In erythematous areas:
1. Care to the affected areas must focus on
• Avoids use of soaps,
a. Avoid the use of soaps,
preventing further skin irritation, drying, and
powders,
and
other
cosmetics, perfumes, powders,
damage.
cosmetics on site of
lotions, and ointments; non–
a. These substances may cause pain and
radiation therapy
aluminum-based deodorant
additional skin irritation and damage.
• States
rationale
for
may be used on intact skin.
b. Avoiding water of extreme temperatures and
special care of skin
b. Use only lukewarm water to
soap minimizes additional skin damage,
• Exhibits minimal change
bathe the area.
irritation, and pain.
in skin
c. Avoid rubbing or scratching
c. Rubbing, scratching, or both will lead to
• Avoids trauma to affected
the area.
additional skin irritation, damage, and
skin
region
(avoids
d. Avoid shaving the area with a
increased risk of infection.
shaving, constricting and
straight-edged razor.
d. The use of razors may lead to additional
irritating
clothing,
e. Avoid applying hot-water
irritation and disruption of skin integrity and
extremes of temperature,
bottles, heating pads, ice, and
increased risk of infection.
and the use of adhesive
adhesive tape to the area.
e. Avoiding extreme temperatures minimizes
tape)
f. Avoid exposing the area to
additional skin damage, irritation, burns, and
• Reports change in skin
sunlight or cold weather.
pain.
promptly
g. Avoid tight clothing in the area.
f. Sun exposure or extreme cold weather may
• Demonstrates
proper
Use cotton clothing.
lead to additional skin damage and pain.
care of blistered or open
h. Topical agents such as
g. Allows air circulation to affected area
areas
Aquaphor, Radiacare gel, aloe
h. May aid healing; however, evidence
• Exhibits
absence
of
vera, or Biafine (Valeant may
supporting the benefits of topical agents is
infection of blistered and
be used, and low- or mediumlacking.
opened areas.
potency corticosteroid cream
• Wound is
free
of
may be given if pruritus is
development of eschar.
present.)
2. If wet desquamation occurs:
2. Open weeping areas are susceptible to bacterial
a. Do not disrupt any blisters that
infection. Care must be taken to prevent
have formed.
introduction of pathogens.
b. Avoid frequent washing of the
a. Disruption of skin blisters disrupts skin
area.
integrity and may lead to increased risk of
c. Report any blistering.
infection.
d. Use prescribed creams
or
b. Frequent washing may lead to increased
ointments;
topical
irritation and skin damage, with increased risk
antibacterial creams may help
of infection.
to dry a wet wound (e.g.,
c. Blistering of skin represents progression of skin
Silvadene cream)
damage.
e. If area weeps, apply a
d. Anecdotally believed to decrease irritation and
nonadhesive
absorbent
inflammation of the area and promote healing;
dressing.
although a variety of products are used in
f. If the area is without drainage,
many settings, there are few randomized
moisture
and
vaporcontrolled trials with evidence to support one
permeable dressings, such as
product or intervention over another.
hydrocolloids and hydrogels on
e. Easier to remove and associated with less pain
noninfected areas, have been
and trauma when drainage dries and adheres
used in many settings.
to dressing.
g. Consult with wound-ostomyf. May promote healing; however, randomized
continence nurse (WOCN) and
controlled clinical trial support is lacking in the
primary provider if eschar
setting of moist desquamation. Hydrocolloid
forms.
dressings may enhance comfort.
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 (stomatitis)
Nursing Intervention
Rationale
Expected Outcomes
1. Assess oral cavity daily using the same
1. Provides baseline for later
• States
rationale
for
assessment criteria or rating scale.
evaluation; maintains consistency in
frequent oral assessment
assessment findings
and hygiene
•
Factors associated with the
2. Identify individuals at increased risk for
2. Patient and treatment variables are
incidence, severity, and
stomatitis and related complications.
associated with the incidence and
complications are identified
severity of stomatitis as well as
prior to initiation of cancer
related complications such as
treatment
delayed healing and infection.
• Oral mucosal assessment is
3. Instruct patient to report oral burning, pain,
3. Identification of initial stages of
conducted at baseline and
areas of redness, open lesions on oropharyngeal
stomatitis will facilitate prompt
on an ongoing basis.
mucosa and lips, pain associated with
interventions, including
•
Oral hygiene practices are
swallowing, or decreased tolerance to
modification of treatment as
initiated
prior
to
temperature extremes of food.
prescribed by primary provider.
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
4. Encourage and assist as needed in oral hygiene.
4. 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.
Nursing Intervention
Rationale
Expected Outcomes
Preventive
1. Advise patient to avoid irritants such as
1. Alcohol content of mouthwashes
• Exhibits clean, intact oral
commercial mouthwashes, alcoholic beverages,
and tobacco smoke will dry oral
mucosa
and tobacco.
tissues and potentiate breakdown.
• Exhibits no ulcerations or
infections of oral cavity
2. Brush with soft toothbrush using nonabrasive
2. Limits trauma and removes debris.
• Exhibits no evidence of
toothpaste for 90 seconds after meals and at
Patients who have not previously
bleeding
bedtime; allow toothbrush to air dry before
flossed regularly do initiate flossing
storing; floss at least once daily or as advised by
during stomatoxic treatment due to
• Reports
absent
or
the clinician; patients who have not previously
potential for injury to the oral
decreased oral pain
flossed regularly should not initiate flossing
mucosa and increased susceptibility
• Reports
no
difficulty
during stomatoxic treatment; rinse mouth four
to infection.
swallowing
times a day with a bland rinse (normal saline,
3.
sodium bicarbonate, or saline and sodium
bicarbonate); avoid irritating foods (acidic, hot,
rough, and spicy); use water-based moisturizers
to protect lips.
Consider use of oral ice chips during stomatoxic
chemotherapy infusions.
Oral cryotherapy has demonstrated
reduced oral mucositis incidence,
severity, and pain; improved quality
of life; and minimizes chances of
complications of oral mucositis
4. Consider use of low level laser therapy.
4. Low energy level laser therapy has
demonstrated decreased severity,
duration, and pain associated with
stomatitis.
5. Consider administration of Palifermin as
5. Palifermin, a recombinant
prescribed for patients receiving high-dose
keratinocyte growth factor (KGF)
chemotherapy.
that stimulates the growth of cells
lining the mouth and intestinal
tract, has been shown to decrease
the severity and duration of
stomatitis.
6. Maintain adequate hydration.
6. Maintenance of hydration prevents
mucosal drying and breakdown.
7. Provide written instruction and education to
7. Written information reinforces
patients on the above items.
patient education and provides the
patient and family with a source.
Mild stomatitis (generalized erythema, limited ulcerations, small white patches: Candida)
1. Use normal saline mouth rinses every 1–4 hours. 1. Assists in removing debris, thick
secretions, and bacteria
2. Use soft toothbrush or toothette.
2. Minimizes trauma
3. Remove dentures except for meals; be certain
3. Minimizes friction and discomfort
that dentures fit well.
4. Apply water-soluble lip lubricant.
4. Promotes comfort
•
Exhibits
healing
(reepithelialization) of oral
mucosa within 5–7 days
(mild stomatitis)
•
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
3.
•
•
•
•
5.
Avoid foods that are spicy or hard to chew and
5. Prevents local trauma
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
1. Assists in identifying need for
a. Adheres to oral care regimen
tests of areas of infection.
antimicrobial therapy
b. Exhibits healing of oral tissues
within 10–14 days (severe
2. Assess ability to chew and swallow; assess gag
2. Patient may be in danger of
stomatitis)
reflex.
aspiration
• Consumes adequate fluid
3. Use oral rinses (may combine in solution saline,
3. Facilitates cleansing and provides
and food
anti-Candida agent, such as Mycostatin, and
for safety and comfort
•
Exhibits
absence of
topical anesthetic agent [described later]) as
dehydration
and weight
prescribed, or place patient on side and irrigate
loss
mouth; have suction available.
• Exhibits no evidence of
4. Remove dentures.
4. Prevents trauma from ill-fitting
infection
dentures
• Reports absent or decreased
5. Use toothette or gauze soaked with solution for
5. Limits trauma and promotes
discomfort or pain
cleansing.
comfort
6. Use water-soluble lip lubricant.
6. Promotes comfort and minimizes
loss of skin integrity
7.
Provide liquid or pureed diet.
7.
8.
Monitor for dehydration.
8.
9.
Minimize discomfort.
a. Consult primary provider for use of topical
anesthetic, such as dyclonine and
diphenhydramine, or viscous lidocaine.
b. Administer systemic analgesics as prescribed.
c. Perform mouth care as described.
a.
b.
c.
Ensures intake of easily digestible
foods without chewing
Decreased oral intake and
ulcerations potentiate fluid deficits.
Alleviates pain and increases sense
of
well-being;
promotes
participation in oral hygiene and
nutritional intake
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.
Promotes removal of debris,
healing, and comfort
NURSING DIAGNOSIS: Impairment of skin integrity related to rash
GOALS: Maintenance of skin integrity related to rash
Nursing Intervention
Rationale
Prevention
1. Instruct patients to avoid sunlight through 1. Many agents are associated with
use of protective clothing, use of sun
photosensitivity; sunburn would
screen with SPF of 30 with physical
intensify inflammation associated
blockers (zinc oxide, titanium dioxide), or
with rash and potentiate loss of skin
avoidance of direct sun exposure.
integrity
2. Maintain adequate oral hydration.
2. Prevents skin dryness related to
dehydration
3. Avoid long hot showers or baths, harsh
3. Prevents skin irritation, dryness,
soaps and laundry detergents, perfumes,
flaking, and inflammation
and non-hypoallergenic cosmetics.
4. Apply emollients; apply hydrocortisone 1% 4. Minimizes dryness, flaking, and
cream with moisturizer at least twice
disruption of skin integrity.
daily; administer doxycycline 100 mg twice
per day or minocycline, as prescribed
Treatment
1. Apply topical treatment as prescribed:
1. Recommended as treatment to
clindamycin 1%, fluocinonide 0.05% cream
minimize skin disruption and
twice a day, or alclometasone 0.05%
prevent infection by Multinational
cream twice a day
Association of Supportive Care in
Cancer (MSACC)
2. For severe papulopustular rash:
2. Recommended as treatment to
Administer systemic treatment as
minimize skin disruption and
prescribed: doxycycline 100 mg twice per
prevent infection by Multinational
day; minocycline 100 mg daily; or
Association of Supportive Care in
isotretinion at low doses of 20–30 mg per
Cancer (MSACC)
day
3.
Assess for development of infection:
obtain cultures of pustules and administer
appropriate antibiotics as prescribed by
the physician
3.
Prompt recognition and treatment
of infection are necessary to prevent
bacteremia, sepsis, and further
patient compromise
Expected Outcomes
•
•
•
•
•
•
•
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 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
NURSING DIAGNOSIS: Impaired tissue integrity: alopecia
GOAL: Maintenance of tissue integrity; coping with hair loss (alopecia)
Nursing Intervention
Rationale
Expected Outcomes
1. Discuss potential hair loss and
1. Provides information so that patient and
• Identifies
alopecia
as
regrowth with patient and family;
family can begin to prepare cognitively and
potential side effect of
advise that hair loss may occur on
emotionally for loss
treatment
body parts other than the head.
• Identifies positive and
negative
feelings
and
2. Explore potential impact of hair loss
2. Facilitates coping and maintenance of
threats
to
self-image
on self-image, interpersonal
interpersonal relationships
• Verbalizes meaning that hair
relationships, and sexuality.
and possible hair loss have
3. Prevent or minimize hair loss through 3. Retains hair as long as possible.
for him or her
the following:
a. Decreases hair follicle uptake of
• States
rationale
for
a. Use scalp hypothermia and scalp
chemotherapy (not used for patients with
modifications in hair care
tourniquets, if appropriate.
leukemia or lymphoma because tumor
and treatment
b. Cut long hair before treatment.
cells may be present in blood vessels or
•
Uses mild shampoo and
c. Use
mild
shampoo
and
scalp tissue)
conditioner, and shampoos
conditioner, gently pat dry, and
b. Minimizes hair loss due to the weight and
hair only when necessary
avoid excessive shampooing.
manipulation of hair
• Avoids hair dryer, curlers,
d. Avoid electric curlers, curling
sprays, and other stresses
irons, dryers, clips, barrettes, hair
on hair and scalp
sprays, hair dyes, and permanent
• Wears hat or scarf over hair
waves.
when exposed to sun
e. Avoid excessive combing or
brushing; use wide-toothed
• Takes steps to deal with
comb.
possible hair loss before it
occurs; purchases wig or
4. Prevent trauma to scalp.
4. Preserves tissue integrity
hairpiece if desired
a. Lubricate scalp with vitamin A
a. Assists in maintaining skin integrity
•
Maintains hygiene and
and D ointment to decrease
b. Prevents ultraviolet light exposure
grooming
itching.
• Interacts and socializes with
b. Use sunscreen or wear hat when
others
in the sun.
5. Suggest ways to assist in coping with
5. Minimizes change in appearance
hair loss.
a. Wig that closely resembles hair color and
a. Purchase wig or hairpiece before
style is more easily selected if hair loss has
hair loss.
not begun.
b. If hair loss has occurred, take
b. Facilitates adjustment
photograph to wig shop to assist
c. Enables patient to be prepared for loss
in selection.
and facilitates adjustment
c. Begin to wear wig before hair
d. Provides options to patient and assists
loss.
with financial burden if necessary
d. Contact the American Cancer
e. Conceals loss and protects scalp
Society for dona ted wigs or a
store that specializes in this
product.
e. Wear hat, scarf, or turban.
6. Encourage patient to wear own
6. Assists in maintaining personal identity
clothes and retain social contacts.
7. Explain that hair growth usually
7. Reassures patient that hair loss is usually
begins again once therapy is
temporary
completed.
NURSING DIAGNOSIS: Imbalanced nutrition: less than body requirements, related to nausea and vomiting
GOAL: Patient experiences less nausea and vomiting associated with chemotherapy; weight loss is minimized
(r/t Nausea and Vomiting)
Nursing Intervention
1. Assess the patient’s previous experiences
and expectations of nausea and vomiting,
including causes and interventions used.
Rationale
1. Identifies patient concerns, misinformation,
and potential strategies for intervention;
also gives patient sense of empowerment
and control
2. Adjust diet before and after drug
2. Each patient responds differently to food
administration according to patient
after chemotherapy. A diet containing foods
preference and tolerance.
that relieve or prevent nausea or vomiting is
most helpful.
3. Prevent unpleasant sights, odors, and sounds 3. Unpleasant sensations can stimulate the
in the environment.
nausea and vomiting center.
4. Use distraction, music therapy, biofeedback,
4. Decreases anxiety, which can contribute to
self-hypnosis, relaxation techniques, and
nausea and vomiting. Psychological
guided imagery before, during, and after
conditioning may also be decreased.
chemotherapy.
5. Administer prescribed antiemetics, sedatives, 5. Administration of antiemetic regimen before
and corticosteroids before chemotherapy
onset of nausea and vomiting limits the
and afterward as needed.
adverse experience and facilitates control.
Combination drug therapy reduces nausea
and vomiting through various triggering
mechanisms.
6. Ensure adequate fluid hydration before,
6. Adequate fluid volume dilutes drug levels,
during, and after drug administration; assess
decreasing stimulation of vomiting
intake and output.
receptors.
7. Encourage frequent oral hygiene.
7. Reduces unpleasant taste sensations
8. Provide pain-relief measures, if necessary.
8. Increased comfort increases physical
tolerance of symptoms.
9. Consult with dietician as needed.
9. Interdisciplinary collaboration is essential in
addressing complex patient needs.
10. Assess and address other contributing factors 10. Multiple factors may contribute to nausea
to nausea and vomiting, such as other
and vomiting.
symptoms, constipation, gastrointestinal
irritation, electrolyte imbalance, radiation
therapy, medications, and central nervous
system metastasis.
Expected Outcomes
• Identifies
previous
triggers of nausea and
vomiting
• Exhibits
decreased
apprehension
and
anxiety
• Identifies previously
used
successful
interventions
for
nausea and vomiting
• Reports decrease in
nausea
• Reports decrease in
incidence of vomiting
• Consumes adequate
fluid and food when
nausea subsides
• Demonstrates use of
distraction, relaxation,
and imagery when
indicated
• Exhibits normal skin
turgor and moist
mucous membranes
• No additional weight
loss
NURSING DIAGNOSIS: Imbalanced nutrition: less than body requirements, related to anorexia, cachexia, or malabsorption
GOAL: Maintenance of nutritional status and of weight within 10% of pretreatment weight (r/t Anorexia,
Cachexia, or Malabsorption)
Nursing Intervention
Rationale
Expected Outcomes
1. Assess and address factors
1. Multiple patient or treatment-related factors
• Factors associated with increased
that interfere with oral intake
are associated with increased risk of impaired
risk for impaired nutritional intake
or are associated with
nutritional intake, such as radiation to the
are identified.
increased risk of decreased
head, neck, and thorax; stomatoxic or
• Factors associated with increased
nutritional status.
emetogenic chemotherapy; prior oral, head,
risk of impaired nutritional intake
and neck surgery; mucositis; impaired
are identified and addressed,
swallowing or dysphagia; poor dentition; cough
whenever
possible,
through
or shortness of breath.
interdisciplinary collaboration.
• Patient and family identify minimal
2. Initiate appropriate referrals
2. Other disciplines may be more appropriate for
nutritional requirements
for interdisciplinary
assessment and management of issues such as
collaboration to manage
swallowing impairments (speech therapy),
• Maintains or increases weight and
factors that interfere with
fatigue and decreased physical ability (physical
body cell mass as per goals identified
oral intake.
and occupational therapy), nutritional
by nutritionist
assessment and determination of patient
• Reports decreasing anorexia and
needs (nutritionist), cough and shortness of
increased interest in eating
breath (respiratory therapy), poor dentition
• Demonstrates normal skin turgor
(dental medicine), depression/anxiety (social
• Identifies rationale for dietary
worker, psychologist, or psychiatrist).
modifications; patient and family
verbalize strategies to minimize
3. Educate patient to avoid
3. Anorexia can be stimulated or increased with
nutritional deficits
unpleasant sights, odors, and
noxious stimuli.
sounds in the environment
• Participates in calorie counts and
during mealtime.
diet histories
• Uses relaxation techniques and
4. Suggest foods that are
4. Foods preferred, well tolerated, and high in
guided imagery before meals
preferred and well tolerated
calories and protein maintain nutritional status
• Exhibits laboratory and clinical
by the patient, preferably
during periods of increased metabolic demand.
findings indicative of adequate
high-calorie and high-protein
nutritional intake: normal serum
foods. Respect ethnic and
levels
of
protein,
albumin,
cultural food preferences.
transferrin,
iron,
blood
urea
5. Encourage adequate fluid
5. Fluids are necessary to eliminate wastes and
nitrogen
(BUN),
creatinine,
vitamin
intake, but limit fluids at
prevent dehydration. Increased fluids with
D,
electrolytes,
hemoglobin,
mealtime.
meals can lead to early satiety.
hematocrit,
and
lymphocytes;
6. Suggest smaller, more
6. Smaller, more frequent meals are better
normal urinary creatinine levels
frequent meals.
tolerated because early satiety is less likely to
•
Consumes diet containing required
occur.
nutrients
7. Promote relaxed, quiet
7. A quiet environment promotes relaxation.
• Carries out oral hygiene before
environment during
Social interaction at mealtime may foster
meals
mealtime with increased
appetite, divert focus on food, and promote
•
Reports decreased pain and/or
social interaction as desired.
enjoyment of eating.
other symptoms; symptoms do not
8. If patient desires, serve wine
8. Wine may stimulate appetite and add calories.
interfere with oral intake
at mealtime with foods.
• Reports decreasing episodes of
9. Consider cold foods, if
9. Cold, high-protein foods are often more
nausea and vomiting
desired.
tolerable and less odorous than hot foods.
• Participates in increasing levels of
10. Encourage nutritional
10. Supplements and snacks add protein and
activity as measured by assessment
supplements and highcalories to meet nutritional requirements.
of performance status
protein foods between
• Family and friends do not focus
meals.
efforts on encouraging food intake
11. Encourage frequent oral
11. Oral hygiene may stimulate appetite and
• States rationale for use of tube
hygiene, particularly prior to
increase saliva production.
feedings or parenteral nutrition
meals.
• Demonstrates ability to manage
enteral feedings or parenteral
12. Address pain and other
12. Pain and other symptoms impair appetite and
nutrition, if prescribed
symptom management
nutritional intake.
needs.
13. Increase activity level as
tolerated.
14. Decrease anxiety by
encouraging verbalization of
fears and concerns; use
relaxation techniques and
guided imagery at mealtime.
15. Instruct patient and family
about body alignment and
proper positioning at
mealtime.
16. Collaborate with dietician to
provide nutritional
counseling; instruct patient
and family regarding enteral
tube feedings of commercial
liquid diets, elemental diets,
or other foods as prescribed.
17. Collaborate with dietician or
nutrition support team to
instruct patient and family
regarding home parenteral
nutrition with lipid
supplements as prescribed.
18. Administer appetite
stimulants as prescribed by
primary provider.
19. Encourage family and friends
not to nag or cajole patient
about eating.
20. Assess and address other
contributing factors to
nausea, vomiting, and
anorexia such as electrolyte
imbalance, radiation therapy,
medications, and central
nervous system metastasis.
13. Increased activity promotes appetite.
14. Relief of anxiety may increase appetite.
15. Proper body position and alignment are
necessary to aid chewing and swallowing.
16. Nutritional counseling may improve outcomes.
Tube feedings may be necessary in the
severely debilitated patient who has a
functioning gastrointestinal system but is
unable to maintain adequate oral intake.
17. Parenteral nutrition with supplemental fats
supplies needed calories and proteins to meet
nutritional demands, especially in the
nonfunctional gastrointestinal system.
18. Although the mechanism is unclear,
medications such as megestrol acetate
(Megace) have been noted to improve appetite
in patients with cancer and human
immunodeficiency virus infection.
19. Pressuring patient to eat may cause conflict
and unnecessary stress.
20. Multiple factors contribute to anorexia and
nausea.
•
Maintains body position and
alignment needed to facilitate
chewing and swallowing
NURSING DIAGNOSIS: Fatigue
GOAL: Decreased fatigue level
Nursing Intervention
1. Assess patient and treatment factors that are
associated with or increase fatigue (e.g.,
anemia, fluid and electrolyte imbalances, pain,
anxiety, etc.)
2.
3.
4.
5.
6.
7.
8.
Rationale
Expected Outcomes
1. Multiple factors are associated with or
• Factors contributing
contribute to cancer-related fatigue.
to
fatigue
are
Although fatigue is common in patients
assessed
and
receiving chemotherapy or radiation
managed whenever
therapy, there are several factors that can be
possible.
modified or addressed, such as dehydration,
• Exhibits acceptable
electrolye abnormalities, organ impairment,
serum value levels
anemia, impaired nutrition, pain and other
for
nutritional
symptoms, depression, anxiety, impaired
indices
(See
mobility, and shortness of breath.
Imbalanced
Nutrition)
Institute interventions to address factors
2. Addressing factors contributing to fatigue
• Reports decreased
contributing to fatigue (e.g., correct electrolyte
assists in managing fatigue (i.e., lowered
pain and/or other
imbalance, manage pain, collaborative
hemoglobin and hematocrit predispose
symptoms
management of anemia, administer prescribed
patient to fatigue due to decreased oxygen
antidepressants, anxiolytics, hypnotics, or
availability especially in a setting of impaired
• Consumes diet with
psychostimulants, as indicated)
mobility that requires increased energy
recommended
expenditure).
nutritional intake
• Achieves
or
Encourage balance of rest and exercise;
3. Sleep helps to restore energy levels.
maintains
avoiding extended periods of inactivity. At
Prolonged napping during the day may
appropriate weight
minimum, promote patient’s normal sleep
interfere with sleep habits.
and body mass
habits.
•
Maintains adequate
During active treatment, rearrange daily
4. Reorganization of activities can reduce
hydration
schedule and organize activities to conserve
energy losses and stressors.
•
Reports decreasing
energy expenditure; encourage patient to ask
levels of fatigue
for others’ assistance with necessary chores,
•
Adopts
healthy
such as housework, child care, shopping, and
lifestyle
practices
cooking. During periods of profound fatigue,
• Rests when fatigued
consider reduced job workload, if necessary
• Reports adequate
and possible, by reducing number of hours
sleep
worked per week.
•
Requests assistance
Encourage protein, fat, and calorie intake at
5. Protein and calorie depletion decreases
with
activities
least equal to that recommended for the
activity tolerance; preventing malnutrition,
appropriately
general public.
achieving and maintaining recommended
• Uses
relaxation
weight and body mass assist in management
exercises
and
of fatigue
imagery
to
decrease
Encourage the use of relaxation techniques
6. Promotion of relaxation and psychological
anxiety and promote
and guided imagery.
rest limits contribution to physical fatigue.
rest
Encourage participation in planned exercise
7. Various approaches to exercise programs
• Reports
no
programs involving aerobic, resistance, and
have demonstrated increases in endurance
breathlessness
flexibility training based on individual
and stamina and lower fatigue.
during activities
limitations and safety measures.
•
Reports improved
a. Minimum
exercise
for
survivors
ability to relax and
depending on individual capabilities
rest
ranges from 10 minutes of light exercise,
•
Exhibits improved
yoga, or stretching daily to 30 minutes of
mobility
and
moderate to vigorous of activity
decreased fatigue
Collaborate with other cancer providers to
8. Many providers fail to discuss the role of
Fatigue does not interfere
encourage them to give patients a prescription
exercise and healthy lifestyle practices for
with ability to participate
to exercise and explain role of exercise in
patients during and after cancer treatment.
in activities of daily living
cancer treatment.
Patients maybe more likely to utilize the
or pleasure
benefits of exercise in addressing fatigue if
they receive a formal prescription.
9.
Partner with community organizations (i.e.,
YMCA) to develop and offer cancer survivor
specific rehab/exercise programs.
10. Collaborate with physical and occupational
therapy and/or refer to American College of
Sports Medicine (ACSM) Certified Cancer
Exercise Trainer (CET) to identify safe and
appropriate activities.
9.
Creates community partnerships, a nonclinical environment of support, fosters
increased awareness of survivorship needs,
and provides referral sources that can reach
more survivors.
10. A CET designs and administers fitness
assessments and exercise programs specific
to an individual’s cancer diagnosis,
treatment, current recovery status;
possesses basic understanding of cancer
diagnoses, treatments, and potential adverse
effects.
NURSING DIAGNOSIS: Chronic pain
GOAL: Relief of pain and discomfort
Nursing Intervention
Rationale
1. Use pain scale to assess pain and 1. Provides baseline for assessing changes in pain level
discomfort characteristics:
and evaluation of interventions
location, quality, frequency,
duration, etc., at baseline and on
an ongoing basis.
2. Assure patient that you know
2. Fear that pain will not be considered real increases
the pain is real and will assist
anxiety and reduces pain tolerance.
him or her in reducing it.
3. Assess prior pain experiences
3. Helps to individualize pain management approaches
and previous management
and identify potential challenges or approaches that
strategies the patient found
should not be utilized because of safety or other
successful.
issues
4. Assess other factors contributing 4. Provides data about factors that decrease the
to patient’s pain: fear, fatigue,
patient’s ability to tolerate pain and increase pain
other symptoms, psychosocial
level
distress, etc.
5. Provide education to patient and 5. Analgesics tend to be more effective
family about prescribed
when given early in pain cycle, around the clock at
analgesic regimen.
regular intervals, or when given in long-acting forms;
breaks the pain cycle; premedication with analgesics
is used for activities that cause increased pain or
breakthrough pain.
6. Address myths or
6. Barriers to adequate pain management involve
misconceptions and lack of
patients’ fear of side effects, fatalism about the
knowledge about the use of
possibility of achieving pain control, fear of
opioid analgesics.
distracting providers from treating the cancer, belief
that pain is indicative of progressive disease, and
fears about addiction. Professional health providers
also have demonstrated limited knowledge about
evidence-based approaches to pain.
7. Collaborate with patient,
7. New methods of administering analgesia must be
primary provider, and other
acceptable to patient, primary provider, and health
health care team members
care team to be effective; patient’s participation
when changes in pain
decreases the sense of powerlessness.
management are necessary.
8. Consult with palliative care
8. Palliative care specialists provide expertise and
providers or team throughout
contribute to symptom management regardless of
the cancer continuum.
stage of disease or treatment within the cancer
continuum, not only during end-stage disease.
Palliative care can improve quality of life, length of
survival, symptom burden, mood, and efficient
utilization of health services.
9. Explore nonpharmacologic and
9. Increases the number of options and strategies
complementary strategies to
available to patient that serve as adjuncts to
relieve pain and discomfort:
pharmacologic interventions.
distraction, imagery, relaxation,
cutaneous stimulation,
acupuncture, etc.
Expected Outcomes
• Reports decreased level of
pain and discomfort on
pain scale
• Reports less disruption in
activity and quality of life
from pain and discomfort
• Reports decrease in other
symptoms
and
psychosocial distress
• Adheres
to
analgesic
regimen as prescribed
• Barriers to adequately
addressing pain do not
interfere with strategies for
managing pain.
• Takes an active role in
administration of analgesia
• Identifies
additional
effective
pain-relief
strategies
• Uses previously employed
successful
pain-relief
strategies appropriately
• Identifies and/or utilizes
nonpharmacologic painrelief
strategies
and
reports
successful
decrease in pain
• Reports that decreased
level of pain permits
participation in other
activities and events and
quality of life
NURSING DIAGNOSIS: Grieving related to loss; altered role functioning
GOAL: Appropriate progression through grieving process
Nursing Intervention
Rationale
1. Encourage verbalization of
1. An increased and accurate knowledge base
fears, concerns, and questions
decreases anxiety and dispels misconceptions.
regarding disease, treatment,
and future implications.
2. Explore previous successful
2. Provides frame of reference and examples of
coping strategies.
coping.
3. Encourage active participation
3. Active participation maintains patient
of patient or family in care and
independence and control.
treatment decisions.
4. Visit family and friends to
4. Frequent contacts promote trust and security and
establish and maintain
reduce feelings of fear and isolation.
relationships and physical
closeness.
5. Encourage ventilation of
5. This allows for emotional expression without loss
negative feelings, including
of self-esteem.
projected anger and hostility,
within acceptable limits.
6. Allow for periods of crying and 6. These feelings are necessary for separation and
expression of sadness.
detachment to occur.
7. Involve spiritual advisor as
7. This facilitates the grief process and spiritual care.
desired by the patient and
family.
8. Refer patient and family to
8. Goal is to facilitate the grief process or adaptive
professional counseling as
methods of coping.
indicated to alleviate
pathologic or nonadaptive
grieving.
9. Allow for progression through
9. Grief work is variable. Not every person uses every
the grieving process at the
phase of the grief process, and the time spent in
individual pace of the patient
dealing with each phase varies with every person.
and family.
To complete grief work, this variability must be
allowed.
Expected Outcomes
The patient and family:
• Progress through the phases
of grief as evidenced by
increased verbalization and
expression of grief.
• Identify resources available to
aid coping strategies during
grieving.
• Use resources and supports
appropriately.
• Discuss the future openly with
each other.
• Discuss concerns and feelings
openly with each other.
• Use nonverbal expressions of
concern for each other.
• Develop positive or adaptive
coping
mechanisms
for
processing of grief.
NURSING DIAGNOSIS: Disturbed body image and situational low self-esteem related to changes in appearance, function, and roles
GOAL: Improved body image and self-esteem
Nursing Intervention
Rationale
Expected Outcomes
1. Assess patient’s feelings about body image
1. Provides baseline assessment for
• Identifies concerns of importance
and level of self-esteem.
evaluating changes and assessing
• Takes active role in activities
effectiveness of interventions
• Maintains
participation
in
decision making
2. Identify potential threats to patient’s self2. Anticipates changes and permits
esteem (e.g., altered appearance, decreased
patient to identify importance of
• Verbalizes feelings and reactions
sexual function, hair loss, decreased energy,
these areas to him or her
to losses or threatened losses
role changes). Validate concerns with patient.
• Participates in self-care activities
• Permits others to assist in care
3. Encourage continued participation in activities 3. Encourages and permits
when he or she is unable to be
and decision making.
continued control of events and
independent
self
•
Exhibits interest in appearance,
4. Encourage patient to verbalize concerns.
4. Identifying concerns is an
maintains grooming, and uses
important step in coping with
aids (cosmetics, scarves, etc.)
them.
appropriately if desired
5. Individualize care for the patient.
5. Prevents or reduces
•
Participates with others in
depersonalization and
conversations and social events
emphasizes patient’s self-worth
and activities
6. Assist patient in self-care when fatigue,
6. Physical well-being improves
• Verbalizes concern about sexual
lethargy, nausea, vomiting, and other
self-esteem.
partner and/or significant others
symptoms prevent independence.
• Explores alternative ways of
7. Assist patient in selecting and using
7. Promotes positive body image.
expressing concern and affection
cosmetics, scarves, hair pieces, hats, and
• The patient and significant other
clothing that increase their sense of
are able to maintain level of
attractiveness.
intimacy and express affection
8. Encourage patient and partner to share
8. Provides opportunity for
and acceptance.
concerns about altered sexuality and sexual
expressing concern, intimacy,
function and to explore alternatives to their
affection, and acceptance.
usual sexual expression.
9. Refer to collaborating specialists as needed.
9. Interdisciplinary collaboration is
essential in meeting patient
needs.
COLLABORATIVE PROBLEM: Potential complication: risk for bleeding problems
GOAL: Prevention of bleeding
Nursing Intervention
Rationale
Expected Outcomes
1. Monitor for factors increasing risk of
1. The underlying cancer, antineoplastic
• Signs and symptoms of
bleeding (thrombocytopenia, elevated
agents or other medications may interfere
bleeding are identified.
INR/PT/PTT, decreased fibrinogen or
with normal mechanisms of clotting.
• Exhibits no blood in feces,
other clotting factors, use of
urine, or emesis
medications affecting platelets or
• Exhibits no bleeding of gums or
other clotting indices)
injection/venipuncture sites
2. Assess for and instruct patient/family
2. Early detection promotes early
• Exhibits
no
ecchymosis
about signs and symptoms of bleeding:
intervention.
(bruising) or petechiae
a. DecreasPetechiae or ecchymosis
a. Petechiae and ecchymosis indicate
• Patient and family identify
(bruising)
injury to microcirculation and larger
ways to prevent bleeding.
b. Decrease in hemoglobin or
vessels.
• Uses recommended measures
hematocrit
b. Decreased hemoglobin or hematocrit
to reduce risk of bleeding (uses
c. Prolonged bleeding from invasive
may indicate blood loss.
soft toothbrush, shaves with
procedures, venipunctures, minor
c. Prolonged bleeding may indicate
electric razor only)
cuts or scratches
abnormal clotting indices.
• Exhibits normal vital signs
d. Frank or occult blood in any body
d. Occult blood in body fluids indicates
• Reports that environmental
fluids
bleeding.
hazards have been reduced or
e. Bleeding from any body orifice
e. Indicates blood loss
removed
f. Altered mental status
f. Altered mental status may indicate
• Maintains hydration
g. Hypotension; tachycardia
decreased
cerebral
tissue
• Reports
absence
of
oxygenation or bleeding.
constipation
g. Hypotension or tachycardia may
• Avoids substances interfering
indicate blood loss.
with clotting
3. Instruct patient and family about ways
3. Patient can participate in self-protection.
• Absence of tissue destruction
to minimize risk of bleeding.
a. ContaiPrevents trauma to oral tissues
• Exhibits normal mental status
a. Use soft toothbrush or toothette
b. Contain high alcohol content that will
and absence of signs of
for mouth care.
dry oral tissues
intracranial bleeding
b. Avoid commercial mouthwashes.
c. Prevents trauma to skin
• Avoids
medications
that
c. Use electric razor for shaving.
d. Reduces risk of trauma to nail beds
interfere with clotting (e.g.,
d. Use emery board for nail care.
e. Prevents oral tissue trauma
aspirin)
e. Avoid foods that are difficult to
f. Prevents skin from drying
• Absence of epistaxis and
chew.
g. Prevents skin and oral tissue
cerebral bleeding
f. Keep lips moisturized with watermembranes from drying
based lubricant
h. Prevents trauma to rectal mucosa
g. Maintain fluid intake of at least 3 L
from straining
per
24
hours
unless
i. Prevents friction and tissue trauma
contraindicated
h. Use stool softeners or increase
bulk in diet.
i. Recommend use of water-based
lubricant
before
sexual
intercourse.
4. Initiate measures to minimize
4. Measures are taken to minimize bleeding.
bleeding. Draw all blood for lab work
a. Minimizes blood loss
with one daily venipuncture for
b. Bleeding
may
occur
from
hospitalized patients.
intramuscular
injection
sites,
a. Avoid taking temperature rectally
particularly if large bore needles are
or administering suppositories
used.
and enemas.
c. Bleeding may occur if direct pressure
b. Avoid intramuscular injections;
is not applied for a long enough time
use smallest needle possible.
period.
c. Apply direct pressure to injection
d. Prevents trauma to urethra
and venipuncture sites for at least
e. Minimizes risk of bleeding
5 minutes.
f. Nursing Interventions
d.
e.
f.
g.
h.
i.
Avoid bladder catheterizations;
use
smallest
catheter
if
catheterization is necessary.
Avoid medications that will
interfere with clotting (e.g.,
aspirin).
Recommend use of water-based
lubricant
before
sexual
intercourse.
Platelet
transfusions
as
prescribed; administer prescribed
diphenhydramine hydrochloride
(Benadryl) or hydrocortisone
sodium succinate (Solu-Cortef) to
prevent reaction to platelet
transfusion.
Supervise activity when out of
bed.
Caution against forceful nose
blowing.
g.
h.
i.
j.
k.
l.
Rationale
Expected Outcomes
Helps prevent bleeding from small
skin tears.
Platelet count <20,000/mm3 (0.02 ×
1,012/L) is associated with increased
risk of spontaneus bleeding. Allergic
reactions to blood products are
associated with antigen–antibody
reaction that causes
platelet
destruction.
Reduces risk of falls
Prevents trauma to nasal mucosa and
increased intracranial pressure