Vii Nursing Management Ideal & Soapie

8/19/2019 Vii Nursing Management Ideal & Soapie

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VII. NURSING MANAGEMENT

a. Ideal Nursing Management

CARE SETTING

Acute inpatient care on medical unit for initial evaluation and treatment tpicall !"# $%& t'en at t'e

communit level.

RE(ATE) C*NCERNS

Cancer

+sc'osocial aspects of care

Transplantation, postoperative and lifelong needs

Patient Assessment Database

)ata depend on degree-duration of t'e disease and ot'er organ involvement.

ACTIVIT-REST

May report: /atigue& malaise& $ea%ness0 ina1ilit to engage in usual activities& flu2li%e

smptoms

May exhibit: Muscle $asting

Increased need for sleep& somnolence

CIRCU(ATI*N

May report: +alpitations

May exhibit: Tac'cardia& 'eart murmurs+allor of s%in& mucous mem1ranes

Cranial nerve deficits and-or signs of cere1ral 'emorr'age

EG* INTEGRIT

May report: /eelings of 'elplessness-'opelessness

May exhibit: )epression& $it'dra$al& an3iet& fear& anger& irrita1ilit

Mood c'anges& confusion

E(IMINATI*N

May report: )iarr'ea0 perianal tenderness& pain

4rig't red 1lood on tissue paper& tarr stools

4lood in urine& decreased urine output

May exhibit: +erianal a1scess0 'ematuria

/**)-/(UI)

May report: (oss of appetite& anore3ia& vomiting

C'ange in taste-taste distortions

5eig't loss

+'arngitis& dsp'agia

May exhibit: A1dominal distension& decreased 1o$el soundsSplenomegal& 'epatomegal0 6aundice

Stomatitis& oral ulcerations

Gum 'pertrop' 7gum infiltration ma 1e indicative of acute monoctic leu%emia8

NEUR*SENS*R

May report: (ac% of coordination-decreased coordination

Mood c'anges& confusion& disorientation& lac% of concentration

)i99iness0 num1ness& tingling& parest'esias

May exhibit: Muscle irrita1ilit& sei9ure activit& uncoordinated movements

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+AIN-)ISC*M/*RT

May report: A1dominal pain& 'eadac'es& 1one-6oint pain0 sternal tenderness& muscle cramping

May exhibit: Guarding-distraction 1e'aviors& restlessness0 self2focus

RES+IRATI*N

May report: S'ortness of 1reat' $it' minimal e3ertion

May exhibit: )spnea& tac'pneaCoug'

Crac%les& r'onc'i

)ecreased 1reat' sounds

SA/ET

May report: :istor of recent-recurrent infections0 falls

Visual distur1ances-impairment

Nose1leeds or ot'er 'emorr'ages& spontaneous uncontrolla1le 1leeding $it'

minimal trauma

May exhibit: /ever& infections

4ruises& purpura& retinal 'emorr'ages& gum 1leeding& or epista3is

Enlarged lmp' nodes& spleen& or liver 7due to tissue invasion8

+apilledema and e3op't'almos

(eu%emic infiltrates in t'e dermis

SE;UA(IT

May report: C'anges in li1ido

C'anges in menstrual flo$& menorr'agia

Impotence

TEAC:ING-(EARNING

May report: :istor of e3posure to c'emicals& e.g.& 1en9ene 7commerciall used to3ic li? g->?? m(.

Reticulocytes: Count is usuall lo$.

Platelet count: Ma 1e ver lo$ 7less t'an @?&???-mm8.WBC: Ma 1e more t'an @?&???-cm $it' increased immature 54Cs 7s'ift to leftB8. (eu%emic 1last cells

ma 1e present.

Prothrombin time (PT)/activated partial thromboplastin time #aPTT $: +rolonged.

L!: Ma 1e elevated.

"erum/urine uric acid: Ma 1e elevated.

"erum muramidase (a lyso#yme): Elevated in acute monoctic and melomonoctic leu%emias.

"erum copper: Elevated.

"erum #inc: )ecreased.

Bence $ones protein (urine): Increased.

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3/13

Bone marro% biopsy: A1normal 54Cs usuall ma%e up @? or more of t'e 54Cs in t'e 1one marro$.

*ften #?"D? of t'e cells are 1last cells& $it' ert'roid precursors& mature cells& and

mega%aroctes reduced.

Chest &'ray and lymph node biopsies: Ma indicate degree of involvement.

NURSING +RI*RITIES

>. +revent infection during acute p'ases of disease-treatment.

. Maintain circulating 1lood volume.F. Alleviate pain.

!. +romote optimal p'sical functioning.

@. +rovide psc'ological support.

#. +rovide information a1out disease process-prognosis and treatment needs.

)ISC:ARGE G*A(S

>. Complications prevented-minimi9ed.

. +ain relieved-controlled.

F. A)(s met 1 self or $it' assistance.

!. )ealing $it' disease realisticall.

@. )isease process-prognosis and t'erapeutic regimen understood.

#. +lan in place to meet needs after disc'arge.

Refer to C+, Cancer& for furt'er discussion-e3pansion of interventions related to

cancer care and for patient teac'ing.

%&R'(%G D(AG%)'(': (nfection* ris+ for

Ris+ factors may incl,de

Inade


4/13

ACTI*NS-INTERVENTI*NS

(nfection Protection #%(0$

(ndependent

+lace in private room. Screen-limit visitors as

indicated. +ro'i1it use of live plants-cut flo$ers.

Restrict fres' fruits and vegeta1les or ma%e sure

t'e are $as'ed or peeled.

Re


5/13


(nfection Protection #%(0$

(ndependent

Avoid-limit invasive procedures 7e.g.& venipuncture

and in6ections8 as possi1le.

0ollaborati-e

Monitor la1orator studies& e.g.,

C4C& noting $'et'er 54C count falls or sudden

c'anges occur in neutrop'ils0

Gram=s stain cultures-sensitivit.

Revie$ serial c'est 32ras.

+repare for-assist $it' leu%emia2specific treatments

suc' as c'emot'erap& radiation& and-or 1one

marro$ transplant.

Administer medications as indicated& e.g.,

anti1iotics0

Colon2stimulating factors, sargramostim

7(eu%ine8.

Avoid use of aspirin2containing antipretics.

+rovide nutritious diet& 'ig' in protein and calories&

avoiding ra$ fruits& vegeta1les& or uncoo%ed meats.

RATI*NA(E

4rea% in s%in could provide an entr for

pat'ogenic-potentiall let'al organisms. Use of

central venous lines 7e.g.& tunneled cat'eter or

implanted port8 can effectivel reduce need for

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%&R'(%G D(AG%)'(': 8l,id 2ol,me* ris+ for deficient

Ris+ factors may incl,de

E3cessive losses& e.g.& vomiting& 'emorr'age& diarr'ea

)ecreased fluid inta%e& e.g.& nausea& anore3ia

Increased fluid need& e.g.& 'permeta1olic state& fever0 predisposition for %idne stone formation-tumor

lsis sndrome

Possibly e-idenced byNot applica1le0 presence of signs and smptoms esta1lis'es an actual diagnosis.H

D'(RD )&/0)M'12A3&A/()% 0R(/R(APA/(%/ 5(33:

9ydration #%)0$

)emonstrate ade


7/13


leeding Preca,tions #%(0$

(ndependent

Inspect s%in-mucous mem1ranes for petec'iae&

ecc'motic areas0 note 1leeding gums& fran% or

occult 1lood in stools and urine0 oo9ing from

invasive2line sites.

Implement measures to prevent tissue

in6ur-1leeding& e.g.& gentle 1rus'ing of teet' or

gums $it' soft toot'1rus'& cotton s$a1& or sponge2

tipped applicator0 using electric ra9or and avoiding

s'arp ra9ors $'en s'aving0 avoiding forceful nose

1lo$ing and needlestic%s $'en possi1le0 using

sustained pressure 7sand1ags or pressure

dressings8 on oo9ing puncture-IV sites.

(imit oral care to mout'$as' if indicated 7a mi3ture

of >-! tsp 1a%ing soda or salt in !"K o9 $ater or

'drogen pero3ide in $ater8. Avoid mout'$as'es

$it' alco'ol.

+rovide soft diet.

8l,id Management #%(0$

0ollaborati-e

Administer IV fluids as indicated.

Administer medications as indicated& e.g.,

Antiemetics, @2:TF receptor antagonist drugs

suc' as ondansetron 7Lofran8 or granisetron

7tril80

Allopurinol 7Lloprim80

+otassium acetate or citrate& sodium

1icar1onate0

Stool softeners.


Monitor la1orator studies& e.g.& platelets& :1-:ct&

clotting.

RATI*NA(E

Suppression of 1one marro$ and platelet production

places patient at ris% for spontaneous-uncontrolled

1leeding.

/ragile tissues and altered clotting mec'anisms

increase t'e ris% of 'emorr'age follo$ing even

minor trauma.

5'en 1leeding is present& even gentle 1rus'ing ma

cause more tissue damage. Alco'ol 'as a dring

effect and ma 1e painful to irritated tissues.

Ma 'elp reduce gum irritation.

Maintains fluid-electrolte 1alance in t'e a1sence of

oral inta%e0 prevents or minimi9es tumor lsis

sndrome& reduces ris% of renal complications.

Relieves nausea-vomiting associated $it'

administration of c'emot'erap agents.

Improves renal e3cretion of to3ic 1products from

1rea%do$n of leu%emia cells. Reduces t'e c'ances

of nep'ropat' as a result of uric acid production.

Ma 1e used to al%alini9e t'e urine& preventing or

minimi9ing tumor lsis sndrome-%idne stones.

:elpful in reducing straining at stool $it' trauma to

rectal tissues.

5'en t'e platelet count is less t'an ?&???-mm

71ecause of proliferation of 54Cs and-or 1one

marro$ suppression secondar to antineoplastic

drugs8& patient is prone to spontaneous life2

t'reatening 1leeding. )ecreasing :1-:ct is

indicative of 1leeding 7ma 1e occult8.

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0ollaborati-e

Administer R4Cs& platelets& clotting factors.

Maintain e3ternal central vascular access device

7su1clavian or tunneled cat'eter or implanted port8.

Administer medications& e.g.& oral contraceptives

RATI*NA(E

Restores-normali9es R4C count and o3gen2

carring capacit to correct anemia. Used to

prevent-treat 'emorr'age.

Eliminate perip'eral venipuncture as source of

1leeding.

Minimi9es 1lood loss 1 stopping or slo$ing

menstrual flo$.

%&R'(%G D(AG%)'(': Pain* ac,te

May be related to

+'sical agents& e.g.& enlarged organs-lmp' nodes& 1one marro$ pac%ed $it' leu%emic cells

C'emical agents& e.g.& antileu%emic treatments

+sc'ological manifestations& e.g.& an3iet& fear

Possibly e-idenced by

Reports of pain 71one& nerve& 'eadac'es& and so fort'8

Guarding-distraction 1e'aviors& facial grimacing& alteration in muscle tone

Autonomic responses

D'(RD )&/0)M'12A3&A/()% 0R(/R(APA/(%/ 5(33:

Pain 3e-el #%)0$

Report pain is relieved-controlled.

Appear rela3ed and a1le to sleep-rest appropriatel.Pain 0ontrol #%)0$

)emonstrate 1e'aviors to manage pain.


Pain Management #%(0$

(ndependent

Investigate reports of pain. Note c'anges in degree

7use scale of ?">?8 and site.

Monitor vital signs& note nonver1al cues& e.g.&

muscle tension& restlessness.

+rovide


9/13


Pain Management #%(0$

(ndependent

+lace in position of comfort and support 6oints&

e3tremities $it' pillo$s-padding.

Reposition periodicall and provide-assist $it'

gentle R*M e3ercises.

+rovide comfort measures 7e.g.& massage& cool

pac%s8 and psc'ological support 7e.g.&

encouragement& presence8.

Revie$-promote patient=s o$n comfort interventions&

e.g.& position& p'sical activit-nonactivit& and so

fort'.

Evaluate and support patient=s coping mec'anisms.

Encourage use of stress management tec'ni


10/13

%&R'(%G D(AG%)'(': Acti-ity intolerance

May be related to

Generali9ed $ea%ness0 reduced energ stores& increased meta1olic rate from massive production of

leu%octes

Im1alance 1et$een o3gen suppl and demand 7anemia-'po3ia8

T'erapeutic restrictions 7isolation-1edrest80 effect of drug t'erap

Possibly e-idenced byVer1al report of fatigue or $ea%ness

E3ertional discomfort or dspnea

A1normal :R or 4+ response

D'(RD )&/0)M'12A3&A/()% 0R(/R(APA/(%/ 5(33:

nd,rance #%)0$

Report a measura1le increase in activit tolerance.

+articipate in A)(s to level of a1ilit.

)emonstrate a decrease in p'siological signs of intolerance0 e.g.& pulse& respiration& and 4+ remain

$it'in patient=s normal range.


nergy Management #%(0$

(ndependent

Evaluate reports of fatigue& noting ina1ilit to

participate in activities or A)(s.

Encourage patient to %eep a diar of dail routines

and energ levels& noting activities t'at increase

fatigue.

+rovide


11/13

%&R'(%G D(AG%)'(': 6noledge* deficient ;3earning %eed< regarding disease* prognosis*

treatment* self=care* and discharge needs

May be related to

(ac% of e3posure to resources

Information misinterpretation-lac% of recall

Possibly e-idenced by

Ver1ali9ation of pro1lem-reation #dependent on patient?s age* physical

condition1presence of complications* personal reso,rces* and life responsibilities$

Infection& ris% forinade


12/13

1. Actual Nursing Management 7S*A+IE8

S Ma'adlo% lagi %o masamad sa og mag 1leedingB& as ver1ali9ed 1 t'e mot'er

*

> Increased $'ite 1lood cells, >@??u(

> Compromised immunit> 5ears mas%> (o$ eosinop'il, ?.#> (o$ lmp'octe, >@.!

A Ris% for infection related to proliferation of immature lmp'octes

+ At t'e end of Eig't 'ours of Nursing Interventions& t'e patient $ill 1e a1leto Identif actions to prevent-reduce ris% of infection.

I

• Vital signs ta%en and recorded " monitored temperature

• +rovided safet and comfort measures

• Re


13/13

*

/atigue

+ale and $ea% in appearance

/acial grimace

(et'argic

Unstead

A Activit Intolerance, fatigue related to anemia

+ At t'e end of Eig't 'ours of Nursing Interventions& t'e patient $ill 1e a1le todemonstrate a decrease in p'siologic signs of intolerance

I

• Vital signs ta%en and recorded " monitored temperature

• +rovided safet and comfort measures

• Encouraged fre

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Vii Nursing Management Ideal & Soapie