General Care Plans
PART I: Medical-Surgical Nursing
ASSESSMENT/INTERVENTIONS RATIONALES
Teach importance of being alert to the side effects of interferon. Fever, chills, and flulike symptoms are expected side effects of interferon.
Suggest that the patient take acetaminophen, with health care provider’s approval, to manage these symptoms, but avoid aspirin and NSAIDs.
Aspirin and NSAIDs may interrupt the action of interferon.
Assess I&O and weight closely for hospitalized patients and teach these assessments to patients.
Fluid shifts may occur with IL-2 treatment.
Teach the patient to monitor and record temperature twice daily and to drink 2000-3000 mL fluid/day.
These actions enable detection of fever, an expected interferon side effect, and replace fluid losses that can occur as a result.
Provide information regarding nutritional supplementation. Dose-related anorexia and weight loss are other common side effects of interferon.
See also: Chapter 74, “Providing Nutritional Support,” p. 539.
Nursing Diagnosis:
Disturbed Body Image
related to alopecia occurring with radiation therapy to the head and neck or administration of certain chemotherapeutic agents
Desired Outcome:
The patient discusses the effects alopecia may have on self-concept, body image, and social interaction and identifies measures to cope satisfactorily with alopecia.
ASSESSMENT/INTERVENTIONS RATIONALES
Discuss potential for hair loss before treatment. Patients need to be informed about expected hair loss, depending on type of therapy, to develop strategies for coping and adaptation.
- Radiation therapy of 1500-3500 cGy to the head and neck will produce either partial or complete hair loss.
Hair loss is usually temporary and loss onset usually occurs 14-21 days from initiation of treatment. Regrowth begins as early as 2-3 months after final treatment but in some cases may take longer. This knowledge is likely to be reassuring to the patient.
- Radiation therapy of more than 4000 cGy usually results in permanent hair loss.
Patients may need to develop strategies for permanent hair loss.
- Hair loss associated with chemotherapy is temporary and related to specific agent, dose, and duration of administration.
Regrowth usually begins 1-2 mo after last treatment and hair often temporarily grows back a different texture. Common chemotherapeutic agents that cause alopecia include actinomycin D, amsacrine, bleomycin, cyclophosphamide, daunomycin, docetaxel, doxorubicin, epirubicin, etoposide (VP-16), topotecan (Hycamtin), idarubicin, ifosfamide, irinotecan (CPT-11), paclitaxel, teniposide, vinblastine, and vincristine.
Assess the impact hair loss has on the patient’s self-concept, body image, and social interaction.
Alopecia is an extremely stressful side effect for most people. For some men, beard loss is disturbing as well.
Caution about the inadvisability of scalp hypothermia and tourniquet applications during IV chemotherapy.
These measures have not proved to be effective in minimizing hair loss and are contraindicated with some malignancies.
Suggest measures for women, such as cutting their hair short before treatment and selecting a wig before hair loss occurs that matches color and style of their own hair. Suggest wearing a hair net or turban during hair loss to help collect hair as it falls out.
These measures may help minimize the psychological impact of hair loss.
Being prepared by having head coverings available when hair loss actually occurs may reduce anxiety surrounding the event. Wearing scarves, hats, caps, turbans, makeup, and accessories may enhance self-concept. Note: Wigs are tax deductible and often are reimbursed by insurance with appropriate prescriptions. Some centers and communities have wig banks that provide used and reconditioned wigs at no cost.
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PART I: Medical-Surgical Nursing
Inform the patient that hair loss may occur on body parts other than the head.
Areas such as the axillae, groin, legs, eyes (eyelashes and eyebrows), and face also may lose hair. Loss of facial hair makes it difficult for makeup to stay on.
Instruct the patient to keep the head covered during summer and winter.
Covering the head minimizes sunburn during summer and prevents heat loss during winter. Certain chemotherapy agents and radiation therapy may sensitize skin to sun exposure.
Suggest resources that promote adaptation to alopecia. For example, ACS hosts the “Look Good Feel Better” program, which provides women with encouragement and tips for managing body image changes during treatment.
Nursing Diagnosis:
Risk for Injury
related to changes in sensory perception (auditory, tactile, kinesthetic) and neuropathies associated with certain chemotherapeutic drugs
Desired Outcome:
The patient reports early signs and symptoms of ototoxicity and peripheral neuropathy (functional disturbance of the peripheral nervous system), and measures are implemented promptly to minimize these side effects.
ASSESSMENT/INTERVENTIONS RATIONALES
Teach the patient and caregivers to report early symptoms of hearing loss the patient may experience.
Cumulative doses of cisplatin can result in irreversible loss of high- frequency range hearing or tinnitus.
Suggest that the patient face speakers and watch their lips during conversation while being aware that background noise may interfere with hearing ability.
This information promotes skills with which to cope with hearing loss.
Suggest a trial of a hearing aid before purchasing it. A hearing aid may be helpful, or it may amplify background noise and worsen speech comprehension.
In instances of cisplatin-induced hearing loss, refer the patient to community resources for hearing-impaired persons.
Hearing loss from cisplatin is usually irreversible. A baseline audiogram may be done before cisplatin administration.
Assess for development of peripheral neuropathy. Suggest consultation with PT or occupational therapist (OT) to assist with maintaining function. Explain that severity of symptoms may abate when treatment is halted; however, recovery may be slow and is usually incomplete.
Peripheral neuropathy can occur with several antineoplastic agents.
Neurotoxicity is cumulative with some chemotherapy drugs, and therefore assessment of symptoms is done before delivery of each dose.
Instruct the patient to report early signs and symptoms. Numbness and tingling (paresthesias) of fingers and toes occur initially and can progress to difficulty with fine motor skills, such as buttoning shirts or picking up objects. The most severely affected individuals may lose sensation at hip level and have difficulty with balance and ambulation.
Assess for neuropathic pain. See Chronic Pain, p. 6, for desired outcomes and assessment/interventions.
Patients with neuropathies may experience neuropathic pain, which is often described and treated differently than nociceptive pain.
Assess bowel elimination daily in individuals at risk for paralytic ileus associated with neuropathy.
Patients receiving vinca alkaloids are at risk for paralytic ileus and require monitoring for this problem.
Administer stool softeners, psyllium, or laxatives daily if the patient does not have bowel movements at least every other day. Instruct the patient to increase dietary fiber and fluid intake.
If constipation is a problem, patients should be placed on a bowel regimen. Prevention of constipation is easier than treating constipation.
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Pain 2
Nursing Diagnoses:
Acute Pain/
Chronic Pain/
Impaired Comfort
related to the disease process, injury, or surgical procedure
Desired Outcome:
The patient’s subjective report of pain using a pain scale, family’s report, and behavioral and/or physiologic indicators reflect that pain is either reduced or at an acceptable level within 1-2 hr.
ASSESSMENT/INTERVENTIONS RATIONALES
Obtain history about ongoing/previous pain experiences and previously used methods of pain control. Elicit what was/was not effective. Consider whether pain is acute, chronic, or acute with an underlying chronic component.
A pain history enables development of a systematic approach to pain management for each patient, using information gathered from pain history and the hierarchy of pain measurement (self-report, pathologic conditions or procedures that usually cause pain, behavioral indicators, report of family, and physiologic indicators). The Agency for Health Care Research and Quality (AHRQ, 2013) and the American Pain Society (APS, 2008) state that self-report of pain is the single most reliable indicator of pain.
Use a formal patient-specific method of assessing self-reported pain when possible, including description, location, intensity, and aggravating/alleviating factors.
The first step of effective pain management is accurate assessment of pain. Pain rating scales identify the intensity of pain over time and assist in evaluating the effectiveness of interventions. A numeric rating scale (NRS) of 0 (no pain) to 10 (worst possible pain), descriptive scales, and visual analog scale (VAS) are commonly used to assess intensity in adults who are cognitively intact. Pain intensity scales are available in many different languages when language barriers are present.
The Wong-Baker FACES scale was developed for use in children. It is used in younger children and cognitively impaired adults. The Faces Pain Scale is appropriate for cognitively intact and cognitively impaired elders and appropriate for various cultures (Pasero & McCaffery, 2011).
Use the selected scale consistently.
Note: Although pain is multidimensional in nature, it is the
subjective intensity of pain that is most often measured in clinical practice.
Assess for behavioral and physiologic indicators of pain at frequent intervals (e.g., during scheduled vital signs [VS] assessments).
Document responses.
Behavioral and physiologic responses are potential indicators of pain in patients who are unable to self-report. This assessment optimizes reassessment and treatment intervals.
Note: Not all patients demonstrate the same response to pain, nor does the lack of response negate the presence of pain.
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