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Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nursin
TRAMADOL 50mg
1cap q8
ANALGESIC,
centrally acting
Binds to mu-opoid
receptors & inhibits thereuptake of
norepinephrine &serotonin; causes many
effects similar to theopoidsdizziness,
somnolence, nausea,constipationbut does
not have the respiratorydepressant effects.
CNS: sedation,dizziness orvertigo,
headache,confusion,
dreaming,sweating,
anxiety,seizures
CV:hypotension,
tachycardia,bradycardia
DERMATOLOGIC:
sweating,pruritus, rash,pallor, urticaria
GI: nausea,vomiting, dry
mouth,constipation,
flatulence OTHER:potential forabuse,
anaphtylactoidreactions,
Relief of moderate to
moderately severepain.
Contraindicated with allergyto tramadol or
opiods or acuteintoxication
with alcohol,opiods or
psychoactivedrugs.
Use cautiouslyin pregnancy,
lactation,seizures,
concomitantdysfunction or
hepaticimpairment.
BEFORE
Assessm
y Hh
ta
a
poa
su
dM
hp
o
y Pt
ob
a
Bnr
DURING
y C(
se
8/8/2019 Anaplastic Lymphoma
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W
p
pad
AFTER:
y Yt
da
ot
na
em
y Rdc
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Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nursin
Prednisone 15mg/
5ml 3-5ml TID aftermeals and afternoon
snacks
Corticosteroid Enters target cells and
binds to intracellularcorticosteroid receptors,
thereby initiating manycomplex reactions that
are responsible for itsanti-inflammatory and
immunosuppressiveeffects.
yCNS: Vertigo,headache,
paresthesias,insomnia, seizures,
psychosis, cataracts,increased IOP,
glaucoma (long-term
therapy)yCV: Hypotension,shock, hypertensionand CHF secondary
to fluid retention,thromboembolism,
thrombophlebitis, fatembolism, cardiac
arrhythmiasyElectrolyte
imbalance:Na+ andfluid retention,
hypokalemia,hypocalcemia
yEndocrine: Growthretardation,decreased
carbohydratetolerance, diabetes
mellitus, cushingoidstate (long-term
effect), increasedblood sugar,
yReplacementtherapy in adrenal
corticalinsufficiency
yHypercalcemiaassociated withcancer
yShort-termmanagement ofvariousinflammatory and
allergic disorders,such as rheumatoid
arthritis, collagendiseases (eg, SLE),
dermatologicdiseases (eg,
pemphigus), statusasthmaticus, and
autoimmunedisorders
yHematologicdisorders:thrombocytopenia
purpura,erythroblastopenia
yUlcerative colitis,acute exacerbationsof multiple sclerosis
and palliation in
yContraindicatedwithinfections,
especiallytuberculosis, fungal
infections,amebiasis, vaccinia
and varicella, and
antibiotic-resistantinfections; lactation.
yUse cautiously withkidney or liver
disease,hypothyroidism,
ulcerative colitiswith impending
perforation,diverticulitis, active
or latent pepticulcer, inflammatory
bowel disease,CHF, hypertension,
thromboembolicdisorders,
osteoporosis,seizure disorders,
diabetes mellitus;hepatic disease;
pregnancy (monitorinfants for adrenal
insufficiency).
yDo nowithou
health
yAvoidinfecti
yReporswelli
muscltarry s
prolonor oth
worsefor wh
taken.
yInstrudrug w
yThe ordilutedflavor
solid f
yMonitpressu
potassyWeigh
report
to pre
8/8/2019 Anaplastic Lymphoma
4/27
increased serum
cholesterol,
decreased T3 and T4levels, HPAsuppression with
systemic therapylonger than 5 days
yGI: Peptic oresophageal ulcer,pancreatitis,
abdominaldistention, nausea,
vomiting, increasedappetite, weight gain
(long-term therapy)
yHypersensitivity:Hypersensitivity or
anaphylactoidreactions
yMusculoskeletal:Muscle weakness,steroid myopathy,
loss of muscle mass,osteoporosis,
spontaneous
fractures (long-termtherapy)
yOther:Immunosuppression,
aggravation ormasking of
infections; impairedwound healing; thin,
some leukemias and
lymphomas
yTrichinosis withneurologic ormyocardialinvolvement
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fragile skin;
petechiae,
ecchymoses,purpura, striae;subcutaneous fat
atrophy.
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Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nursin
Dolan Syrup
(Ibuprofen)
Analgesic
NSAIDPropionic acid
derivative
Anti-inflammatory,
analgesic and antipyreticactivities larely related to
inhibition ofprostaglandin synthesis;
exact mechanisms ofaction are not known.
y CNS: headache,dizziness,
somnolence,insomnia, fatigue,
tiredness, tinnitus
y CV: hypertension,palpitations,
arrhythmia, heartfailure
y GI: nausea,dyspepsia, GI pain,diarrhea, vomiting,
constipation,flatulence, GI
bleeding
y GU: dysuria, renalimpairment,
menorrhagia
y HEMATOLOGIC:bleeding, platelet
inhibition withhigher doses,
neutropenia,eosinophilia,
leukopenia,pancytopenia,
thrombocytopenia
y RESPIRATORY:dyspnea,
hemoptysis,
yRelief of s/s ofrheumatoid
arthritis andosteoarthritis
yRelief of mild tomoderate pain
yTreatment ofprimarydysmenorrhea
yFever reductionyUnlabeled uses:prophylactic for
migraine; abortivetreatment for
migraine
y Contraindicatedwith allergy to
ibuprofen,salicylates, or
other NSAIDs
y Contraindicatedfor treatment of
perioperative painafter coronary
artery bypass graft
y Use cautiouslywith CV
dysfunction,hypertension,
peptic ulceration,GI bleeding,
pregnancy,lactation, impaired
hepatic and renalfunction.
y Asseibupr
y Assecolorophth
evaluevalu
sensaclott
y Admor afoccu
y Use suggover
y Avoidrug
y Instrany s
y Reporash,
swel
visio
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bronchospasm,
rhinitis
y OTHER:peripheral edema,anaphylactoidreactions to
anaphylactic shock
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Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nursin
Ponstan
(Mefenamic acid)8F 5ml TID in
between Dolan syrup
NSAID Anti-inflammatory,
analgesics, andantipyretic activities
related to inhibition ofprostaglandin synthesis,
exact mechanism ofaction are not known.
CNS:Headache,
dizziness, somnolence,insomnia, fatigue,
tiredness, tinnitus,ophthalmic effects.
DERMATOLOGIC:Rash, pruritus,
sweating, dry mucousmembranes, stomatitis.
GI:Nausea, dyspepsia,GI pain, diarrhea,
vomiting, constipation,flatulence.
GU: Dysuria, renalimpairment.
HEMATOLOGIC:Bleeding, platelet
inhibition with higherdoses, neutropenia,
eosinophilia,leukopenia,
pancytopenia,thrombocytopenia,
agranulocytosis,granulocytopenia,
aplastic anemia,decreased Hgb orHct,
bone marrowdepression,
menorrhagia.
Relief ofmoderate pain
when therapywill not exceed
1 week. Treatment of
primary
dysmenorrheal.
Contraindicated withhypersensitivit
y tomefenamic
acid, aspirinallergy, and as
treatment ofperioperative
pain withcoronary artery
bypassgrafting.
Use cautiouslywith asthma,
renal orhepatic
impairment,peptic ulcer
disease, GIbleeding,
hypertension,heart failure,
pregnancy,lactation.
BEFOR
1. Assesrenal, he
conditiolactation
2. Assesskin colo
orientatiophthalm
audiomeperipher
adventitievaluatio
time, LFtest; seru
guaiac.DURIN
1. Be awbe at an
events, Gaccordin
2. Give wdecrease
3. Arranophthalm
during lo4. If ove
emergensupporti
induced
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RESPIRATORY:Dyspnea, hemoptysis,
pharyngitis,bronchospasm, rhinitis.
OTHER:Peripheraledema, anaphylactoid
reactions toanaphylactic shock.
charcoal
cathartic
AFTER1. Instruwith foo
prescribthe drug
week.2. Instru
and cons
providerdigestive
8/8/2019 Anaplastic Lymphoma
10/27
Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nursin
Catapres 75mg tab
BID
Antihypertensive
A2- adrenergicagonist
Clonidine treats high
blood pressure bystimulating 2 receptors
in the brain, whichdecreases cardiac output
and peripheral vascularresistance, lowering
blood pressure. It hasspecificity towards the
presynaptic 2 receptorsin the vasomotor center
in the brainstem. Thisbinding decreases
presynaptic calciumlevels, and inhibits the
release ofnorepinephrine (NE).
The net effect is adecrease in sympathetic
tone.
Body as a Whole:Fatigue, fever,headache, pallor,
weakness, andwithdrawal syndrome.
Also reported were aweakly positive
Coombs' test andincreased sensitivity to
alcohol.
Cardiovascular:Bradycardia,congestive heart
failure,electrocardiographic
abnormalities(i.e.,sinus node arrest,
junctional bradycardia,high degree AV block
and arrhythmias),orthostatic symptoms,
palpitations, Raynaud'sphenomenon, syncope,
and tachycardia. Casesof sinus bradycardia
and atrioventricularblock have been
reported, both with andwithout the use of
concomitant digitalis.
Central Nervous
y Used to treathypertension
(high bloodpressure).
y Catapres has alsobeen used torelieve alcohol
withdrawal, as anaid in methadone
and opiatedetoxification, as
an aid in quittingsmoking, to treat
diabetic diarrhea,to treat Tourette's
Syndrome.y Catapres has also
been used toreduce
menopausalflushing, to treatpostherpetic
neuralgia, to treat
ulcerative colitis,and to diagnosepheochromocyto
ma.
yCatapres tabletsshould not be
used in patientswith known
hypersensitivityto clonidine
y Asscata
y Asshistor s
disediso
hearkidn
y Takit w
takelarg
for reco
docy Cat
in th
bedinst
y Stortemmoi
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micturition, erectile
dysfunction, loss of
libido, nocturia, andurinary retention.
Hematologic:Thrombocytopenia.
Metabolic:Gynecomastia,transient elevation of
blood glucose or serum
creatinephosphokinase, andweight gain.
Musculoskeletal: Legcramps and muscle or
joint pain.
Oro-otolaryngeal:Dryness of the nasal
mucosa.Ophthalmological:Accommodationdisorder, blurred
vision, burning of theeyes, decreased
lacrimation, anddryness of eyes.
8/8/2019 Anaplastic Lymphoma
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Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nursin
Ondansetron tab 4mg
TID
Antiemetic Blocks specific receptor
sites (5-HT3), which areassociated with nausea
and vomiting in thechemoreceptor trigger
zone, centrally and atspecific sites
peripherally. It is notknown whether its
antiemetic actions arefrom actions at the
central, peripheral,combined sites.
y CNS: headache,dizziness,
drowsiness,shivers, malaise,
fatigue, weakness,myalgia
y CV: chest pain,hypotension
y DERMATOLOGIC: pruritus
y GI: abdominalpain, constipation
y GU: urinaryretention
y Local: pain atinjection site
y Prevention of nauseaand vomitingassociated withemetogenic cancer
chemotherapy inpatients older then 6
months
y Prevention of post-operative nausea andvomiting
y Allergy toondansetron
y Use cautiouslywith pregnancyand lactation.
yAssesondan
yAssestexturreflex
examoutpu
yEnsurdrug dthat oradiat
yAdmifollowchem
y Repeffecdizz
shivweak
yReporand vinject
palpit
8/8/2019 Anaplastic Lymphoma
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Name of Drug General Action Specific Action Adverse Effect Indication Contraindication Nurs
Doxorubicin Antibiotic
Antineoplastic
Cytotoxic: binds to DNA
and exhibits DNAsynthsis in susceptible
cells, causing cell death
y CV: cardiactoxicity, heart
failure,phlebosclerosis
y DERMATOLOGIC: complete butreversible alopecia,
hyperpigmentationof nail beds and
dermal creases,facial flushing
y GI: nausea,vomiting,
mucositis, anorexia,diarrhea
y GU: red uriney HEMATOLOGIC:
myelosuppression,hyperuricemia due
to cell lysis
y HYPERSENSITIVITY: fever, chills,
urticaria,anaphylaxis
y LOCAL: severelocal cellulitis,vesication and
tissue necrosis ifextravasation
occurs
y To produceregression on thefollowingneoplasms: acute
lymphoblasticleukemia, acute
myeloblastic
leukemia, Wilms
tumor,neuroblastoma, soft
tissue and bone
sarcoma, Hodgkinand non-Hodgkinslymphomas
y Liposomal form:treatment of AIDS-related Kaposis
sarcoma, ovarian
cancer that hasprogressed.
y Allergy todoxorubicin,
malignantmelanoma,
kidney sarcoma,large bowel
sarcoma, brain
tumors, CNSmetastases,myelosuppression
, cardiac disease
y Use cautiouslywith impaired
hepatic function,previous courses
of doxorubicin,prior mediastinal
irradiation,current
cyclophosphamide therapy
y Assdox
y Asscolnai
ausper
adv
evameuric
y Dosub
sevtiss
y Moext
burDis
ano
subLoccor
ord
nor
comulcconsur
y Mofreq
the
lev
8/8/2019 Anaplastic Lymphoma
15/27
y OTHER:carcinogenesis
for reqdos
risk
my
damrec
dos
oftedos
y Ensdurto p
y Inscalfor
y Avusin
y Arrfoll
y Repy Rep
bre
gaipaible
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DRUG STUDY
8/8/2019 Anaplastic Lymphoma
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NURSING CARE
PLANPatient: Epis, Argean MayAge: 6 years old
Diagnosis: Anaplastic large cell lymphoma
8/8/2019 Anaplastic Lymphoma
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Cues Nursing Diagnosis Rationale Goal of Care Nursing Intervention Rationale
Subjective:
pinapalimpyo kopermi amun room
didi para diri maka-impeksyon akon
anak as verbalized
by the mother
Objective:
y Dust particlessurroundingthe room
y WBC count:5.8 x 10
9/L
y Presence ofbacteria in the
urine
Vital signs: BP:110/70mmHg
P: 122bpmR: 24cpm
T: 37.4Wt: 19kgs
H: 115cm
Risk for infection
related to alteredimmune response
because of lymphomaand leukopenia caused
by chemotherapy
Infection and bleeding,
often the result ofdiminished production
ofWBCs and platelets,secondary to treatment
are common cause of
death in clients withcancer. The time afterchemotherapyadministration when the
WBC or platelet count isthe lowest point is
referred to as nadir. Formost chemotherapeutic
agents, the nadir occurs7-14 days after drug
administration. Theetiology of infection
associated with cancer ismultifactorial. Some
cancers cause specificdefects in the immune
response. Side effects oftreatment can result in
myelosuppression(decreased RBCs,
WBCs, platelets). Animpaired integumentary
system increasesvulnerability to
After 1-2 days of
nursing intervention,client will be:
yRemain afebrileand achieve
timely healing asappropriate.
yIdentify andparticipate in theintervention to
prevent/ reducerisk of infection.
INDEPENDENT:
1.Monitortemperature.
2.Assess all systems(eg., skin,
respiratory,genitourinary) for s/s
of infection on acontinual basis.
3.Promote goodhandwashingprocedures by staff
and visitors. Screenor limit visitors who
may have infections.Place in reverse
isolation asindicated.
4.Emphasize personalhygiene.
INDEPENDENT:
1.Temperatureelevation may occurbecause of various
factors, eg.,
chemotherapy sideeffects, diseaseprocess or infection.
2.Early recognitionand intervention may
prevent progressionto more serious
situation/ sepsis.
3.Protects patient fromsources of infection,such as visitors and
staff who may havean upper respiratory
infection.
4.Limits potentialsource of infection/secondary
8/8/2019 Anaplastic Lymphoma
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infection. Neutropenia
predisposes the client to
infection, especiallyinfection byopportunistic
endogenous organisms.More than half of the
infections in clients withneutropenia are
associated with
organisms from the localenvironment.
Source: Medical-Surgical Nursing by
Black and Hawks Vol. 1page 290
5.P
romote adequaterest/ exerciseperiods.
6.Stress importance ofgood oral hygiene.
DEPENDENT:
1.Administerantibiotics as
indicated.
(Doxorubicin)
COLLABORATIVE:
1.Minor CBC withdifferentialWBC
and granulocytecount, and platelet as
indicated.
overgrowth.
5.Limits fatigue, yetencourages sufficientmovement to prevent
stasis ofcomplications.
6.Development ofstomatitis increases
the risk of infection.Secondary growth.
DEPENDENT:
1. May be used to treatidentified infection
or given
prophylactically inimmunocompromis
ed patient.
COLLABORATIVE:
1. Bone marrowactivity may be
inhibited by theeffects of
chemotherapy, thedisease state or
radiation therapy.
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Cues Nursing Diagnosis Rationale Goal of Care Nursing Intervention Rationale
Subjective: masakit akon tiyan!
Objective:
y Headachey Hypogastric
pain
y Guardingbehavior
y Protectivegestures
y Positioning toavoid pain
y Expressivebehavior (irritable,moaning in
pain)
y Diaphoresisy Pain
assessment
scale:
Vital signs:BP: 110/70mmHg
P: 122bpmR: 24cpm
T: 37.4Wt: 19kgs
Height: 115cm
Acute pain related tocompression of nerve
tissue/ body organs
Although pain does notusually arise suddenly
or unexpectedly, it isoften regarded as an
oncologic emergencybecause it is such a
pervasive problem. As
many as one thirdclients in an activetreatment and 60% to
90% clients withadvanced cancer have
pain. Pain interfereswith the ability to enjoy
activities and
relationships that aremeaningful. Whencancer causes pain,
some probable causesinclude the pressure of
a tumor on one of thebody's organs or on
bone or nerves.Sometimes cancer can
cause pain when bloodvessels become
obstructed by thetumor. There are a
variety of treatmentsfor cancer and some of
After 30 minutes ofnursing intervention,
client will:
y Report maximalpain control
with minimalinterference
with ADLs.y Follow
prescribed
pharmacological regimen
y Demonstrateuse of
relaxation skillsand diversional
activities asindicated for
individualsituation.
INDEPENDENT:
1.Assess pain history,location of pain,
frequency, durationand intensity.
2.Evaluate or be awareof painful effects of
particular therapies(eg., surgery,
radiation,chemotherapy,
biotherapy.
3.Provide non-pharmacological
comfort measures(eg., massage,
respositioning, backrub) and diversional
activities (eg. Music,television)
4.Provide cutaneousstimulation (eg. Heator cold compress)
INDEPENDENT:
Information providesbaseline data to
evaluate need foreffectiveness of
interventions.
A wide range ofdiscomforts are
common depending onthe procedure/ agent
being used.
Promotes relaxationand helps refocus
attention.
May decreaseinflammation and
muscle spasms,reducing associated
GP
P
a
pr
dd
a
8/8/2019 Anaplastic Lymphoma
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them are less than
pleasant. However,
please remember thatnot all people beingtreated for cancer
experience all of thearray of side effects of
these treatments. A sideeffect one person feels
may never happen to
another. It is also veryimportant to rememberthat many treatment-
related side effects canbe successfully
prevented in somecases, and treated if
they occur.
Source: Medical-
Surgical Nursing byBlack and Hawks Vol.
1 page 295-296
5.Inform patient/ SOof the expected
therapeutic effectsand discussmanagement of side
effects.
DEPENDENT:
6. Administermedications asindicated (
Ponstan, Dolansyrup, tramadol)
pain.
This information helpsestablish realisticexpectations,
confidence in ownability to handle what
happens.
DEPENDENT:
A wide range ofanalgesics and
associated agents maybe used around the
clock to manage pain.
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Cues Nursing Diagnosis Rationale Goal of Care Nursing Intervention Rationale
Subjective: Kulang gud it katurog
niya, permi la hya nghihinigda.un as
verbalized by the mother.
Objective:
y Overwhelminglack of energy
y Inability tomaintain usualroutines
y Decreasedperformance
yDisinterest insurroundings
y IrritableVital signs:BP: 110/70mmHg
P: 122bpmR: 24cpm
T: 37.4Wt: 19kgs
H: 115cm
Fatigue related toaltered body chemistry:
side effects of pain andother medications,
chemotherapy
Anemia is an importantcomponent of cancer-
related fatigue, which isone of the most
common and distressingmanifestations
experienced by the
client. Fatigue is poorlyunderstood; no onedefinition describes all
experiences. Researchon cancer related
fatigue is inconclusive.It is difficult to predict
with certainty which
interventions will havetherapeutic benefit forwhich clients. Careful
evaluation ofexacerbating and
relieving factors, theeffect of daily life and
personal or culturalinfluences as well as
review of laboratorydata add depth to the
assessment of clientsfatigue and guide
interventions. Anychemotherapy drug may
After 1-2 days ofnursing intervention,
client will be ableto:
yReport improvedsense of energy
yPerform ADLsand participate indesired activities
at level of ability
INDEPENDENT:
1.Monitorphysiological
response to activity,eg., changes in BP or
heart/ respiratory
rate.
2.Performa painassessment andprovide pain
management.
3.Plan care to allow forrest periods.
Schedule activitiesfor periods when
patient has mostenergy.
4.Assist with self care
INDEPENDENT:
1.Tolerance variesgreatly depending
on the stage of thedisease process,
nutrition state, fluid
balance, andreaction totherapeutic regimen.
2.Poorly managedcancer pain maycontribute to fatigue.
3.Frequent restperiods/ naps are
needed to restore/conserve energy.
Planning will allowpatient be active at
all times whenenergy level is
higher, which mayrestore a feeling of
well-being and asense of control.
4.Weakness may
8/8/2019 Anaplastic Lymphoma
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cause fatigue, but it
may be a more common
side effect of drugssuch as vincristine,vinblastine, and
cisplatin. Fatigueusually develops after
several weeks ofchemotherapy. In some,
fatigue lasts a few days,
while others say theproblem persiststhroughout the course
of treatment and evenafter the treatment is
complete.
Source: Medical-
Surgical Nursing byBlack and Hawks Vol.
1 page 291-292
needs when
indicated; keep bed
in low position;assist withambulation.
5.Encouragenutritional intake.
make ADls difficult
to complete or place
patient at risk forinjury duringactivities.
5.Adequate intake ofnutrients isnecessary to meet
energy needs and
build energyreserves for activity.
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Cues Nursing Diagnosis Rationale Goal of Care Nursing Intervention Rationale
Subjective:tutusukon naliwat
ako!! (crys) asverbalized by the
patient.
Objective:
y Increasedtension
y Apprehensiony Irritabley Cries a loty Shaking of
head
Vital signs: BP:
110/70mmHgP: 122bpm
R: 24cpmT: 37.4
Wt: 19kgsH: 115cm
Anxiety related tosituational crisis Anxiety is a normal
reaction to cancer. Onemay experience anxiety
while undergoing acancer screening test,
waiting for test results,
receiving a diagnosis ofcancer, undergoingcancer treatment, or
anticipating a recurrenceof cancer. Anxiety
associated with cancermay increase feelings of
pain, interfere with
one's ability to sleep,cause nausea andvomiting, and interfere
with the patient's (andhis or her family's)
quality of life. If leftuntreated, severe
anxiety may evenshorten a patient's life.
Persons with cancer willfind that their feelings
of anxiety increase ordecrease at different
times. A patient maybecome more anxious as
After 30 min. ofnursing intervention,
client will be able to:
y Displayappropriate rangeof feelings and
lessen anxiety.
y Appear relaxedand report anxietyis reduced to
manageable level.
y Demonstrate useof effective
copingmechanism and
activeparticipation intreatment
regimen.
Independent:
1. Review patients orS.Os previous
experience withcancer.
2. Encourage patientto share thoughtsand feelings.
3. Provide openenvironment inwhich patient feelssafe to discuss
feelings or torefrain from
talking.
4. Maintain frequentcontact with
patient. Talk withand touch patient as
appropriate.
5. Permit expressions
Clarifies patients perception, assist in
identification of fearsand misconceptions
based on diagnosis and
experiences.
Provides opportunity to
examine realistic fearsand misconceptions
about diagnosis.
Helps patient feel
accepted in presentcondition withoutfeeling judged and
promotes sense ofdignity and control.
Provides assurance that patient is not alone or
rejected, conveysrespect for and
acceptance of theperson, fostering trust.
Acceptance of feelings
GOPati
appfeel
App
Demcop
8/8/2019 Anaplastic Lymphoma
25/27
cancer spreads or
treatment becomes moreintense.
Source:Medicine.net.com
of anger, fear,
despair, withoutconfrontation. Give
information thatfeelings are normal
and are to beappropriately
expressed.
6. Promote calm, quietenvironment.
allows patient to begin
to deal with situation.
Facilitates rest, conserve
energy and may enhancecoping abilities.
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Cues Nursing Diagnosis Rationale Goal of Care Nursing Intervention Rationale
Subjective:Nagsuka, pero guti
la man as verbalizedby the mother.
Objective:
y Fatiguey Drowsyy Irritabley Nauseay Vomiting
Vital signs: BP:
110/70mmHgP: 122bpm
R: 24cpmT: 37.4
Wt: 19kgsH: 115cm
Risk for fluid volumedeficit related to
vomiting as an adverseeffects of
chemotherapy
Gastrointestinal effectsof chemotherapyinclude nausea and
vomiting, anorexia,alteration in taste,
weight loss, oralleukocytis, diarrhea,
and constipation. The
vomiting center in themedulla can bestimulated by any of
five different afferentpathways or by arousal
of the chemoreceptortrigger zone located in
the fourth ventricle of
the brain. The emeticpotential of a particularchemotherapeutic
regimen depends on thedrugs given, the dose,
the route ofadministration and the
clients susceptibility toemesis. Uncontrolled
nausea and vomiting,among the most feared
treatment related side reffects are experienced
by as many as 60% ofpeople receiving
After 1 to 2 days ofnursing intervention,client will be able to:
y Display adequatefluid balance as
evidenced bystable vital signs,
moist mucousmembranes, good
skin turgor,prompt capillary
refill andadequate urine
output.
Independent:1. Monitor I&O
and specific
gravity, includeall output
sources.
2. Monitor vitalsigns, evaluateperipheral
pulses andcapillary refill.
3. Assess skinturgor andmoisture of
mucousmembranes.
Note reports ofthirst.
4. Observe forbleeding
tendencies.
Continued negativefluid balance,
decreasing renaloutput and
concentration of urinesuggests developing
dehydration and need
for increased fluidreplacement.
Reflex adequacy ofcirculating volume.
Indirect indicators ofhydration status or
degree of deficit.
Early identification of
problems allows forprompt intervention.
GO
Patiade
8/8/2019 Anaplastic Lymphoma
27/27
chemotherapy and can
result in anorexia, dmalnutrition,
dehydration, metabolicimbalances,
psychologicaldepression and
decreased immunity.
Source:Medical Surgical
Nursing by Black andHawks Vol.1 page 292
Dependent:
5. Provide IV(PNSS) fluid asindicated.
6. Administeranti-emetic
therapy asindicated(Ondansetron).
Given for general
hydration and to diluteantineoplastic drugs
and reduce adverseside effects.
Alleviation of nausea
and vomiting
decreases gastriclosses and allows forincreased oral intake.