NURSING DIAGNOSIS #1

Imbalanced Nutrition: Less than body requirements related to decrease intake of nutrients

as manifested by decrease appetite, weight loss of 22 kilograms and body mass index of 16.01

NURSING INFERENCE:

Nutritional status can be affected by the enlargement of tumor that compresses esophagus

which leads to difficulty of swallowing where it decreases the intake of nutrients thus imbalance

nutrition less than body requirements.

NURSING GOAL:

After 2 -3 days of nursing intervention, the patient will be able to demonstrate behaviors,

lifestyle changes to regain appropriate weight as will be manifested by increase food intake, weight

gain and enhance body mass index

NURSING RESPONSIBILITIES RATIONALE

Assist in demonstrating behavior, lifestyle For appropriate recovery from nutritional
changes to regain appropriate weight imbalance
Ascertain understanding of individual needs Determines informational needs
Emphasize importance of well balanced and Teaching the client on the importance of well
nutritious intake balance and nutritious intake can gain
cooperation
Develop consistent and realistic weight goal Weight at regular intervals and document
results to monitor effectiveness of dietary plan
Encourage to drink Ensure as prescribed diet To give nutrients
Advise to take the Multivitamins + Buclizine To enhance the appetite
as ordered
Discuss eating habits including food Appeals to client tasks, and enhances intake
preferences, intolerance and aversion
Encourage client or family member to choose Stimulates the appetite
food or to bring food that seems appealing
Weight at regular intervals and document Monitors effectiveness of dietary plan
results
Consult and refer with dietician and nutritional To have an accurate dietary intake for longer
support team as necessary needs and for nutrition therapy
NURSING EVALUATION:

After 2- 3 days of nursing intervention, the patient was able to demonstrate behaviors,

lifestyle changes that regain appropriate weight as manifested by increase food intake, weight gain

and enhanced body mass index.

NURSING DIAGNOSIS #2

Altered electrolyte balance related to excessive loss of potassium secondary to vomiting as

manifested by decrease serum potassium of 3.22 mmol/ L and body malaise.

NURSING INFERENCE:

Potassium is an electrolyte needed primarily for muscle and nerve tissue function. Fluid

loss from the body such as vomiting causes depletion of electrolyte potassium because potassium

is actually lost with gastric fluid. Depletion of potassium occurs thus altered electrolyte balance.

NURSING GOAL:

After 1-2 days of rendering nursing intervention, the client will be able to maintain serum

potassium within normal range and no complain of body malaise

NURSING RESPONSIBILITIES RATIONALE

Advise patient to increase intake of foods
rich in Potassium such as bananas, oranges,
potatoes and cucumbers
Administer Potassium Chloride as ordered
Advice patient to rest
Monitor ECG continuously
Strict monitoring of intake and output
To potentiate the action of the drug.
To normalize the level of the serum potassium
To address body malaise
To check for any changes in the ECG
Monitoring of I&O is necessary because
40mEq of potassium is lost for every liter of
urine
NURSING EVALUATION:

After 1-2 days of rendering nursing intervention, the client was be able to maintain serum

potassium within normal range and no complain of body malaise

NURSING DIAGNOSIS #3

Impaired comfort related to cervical lymphadenopathy as manifested by frequently

touching of the neck

NURSING INFERENCE:

Proliferation of cancer cells upregulates transcription of VEGF that increases the

production of angiogenic inhibitors angiostatin and endostatin, where angiogenic will switch,

which is now the start of vascularization of the tumor cells and increases the nutrient supply for

tumor cells where cells go to the lymphatic vessels, where cervical lymphadenopathy occurs thus

altered level of comfort

NURSING GOAL:

After 1-2 days of rendering nursing interventions, the patient’s perception of altered

comfort will be decreased and diminished nonverbal indicators

 NURSING RESPONSIBILITIES RATIONALE
Use of therapeutic touch when communicating Therapeutic touch can uplift patient’s feelings
with the patient and provides assurance of comfort
Encourage to do diversional activities like Diverting the attention can lessen patient’s
listening to music and read books touching of the neck and can focus on other
activities
Place patient in a comfortable position Comfortable position helps in alleviating
discomfort
Maintain a calm and quite environment To minimize stimulus that could aggravate the
condition
Offer back rubs, slow rhythmic breathing and They serve as non-pharmacologic methods for
repositioning promoting comfort

NURSING EVALUATION:

After 1-2 days of rendering nursing interventions, the patient is relieved from discomfort

and lessen touching of the neck

NURSING DIAGNOSIS #4

Impaired social interaction related to enlargement of the tumor manifested by discomfort

in social situation when talking and cannot communicate with other patients and nurses

NURSING INFERENCE:

Cancer is a disease where enlargement of a tumor occurs that leads to the compression of

the cranial nerve trigeminal, this will now impair the patient’s mouth not to open properly thus

impaired social interaction

NURSING GOAL:

After 2-3 days of nursing intervention, the client will voluntarily spend time with other

clients and nurses as manifested by no discomfort in social situation when talking and

communicate with other patients and nurses

NURSING RESPONSIBILITIES RATIONALE

Develop a therapeutic nurse client relationship Therapeutic relationship promotes
through frequent, brief contacts and an understanding and can help establish a
accepting attitude. constructive relationship between nurse and
client
Offer alternative forms of communication like Different kinds of communication can enhance
pictures, drawings, word board and flash card the nurse and patient relationship and develops
that translates words and phrases a better understanding om the situation
Validate client’s message by repeating aloud To re assure the client’s needs and concerns
and promotion of a better interaction
Use short repetitive directions Brief but repetitive direction can lead the client
for a better understanding
Initiate health teaching To initiate cooperation

NURSING EVALUATION:

After 2-3 days of nursing intervention, the client voluntarily spends time with other clients

and nurses as manifested by no discomfort in social situation when talking and communicate with

other patients and nurses

NURSING DIAGNOSIS #5

Risk for Infection related to compromised immune defenses secondary to cancer

NURSING INFERENCE:

In clients with chemotherapy treatments due to destruction of rapidly dividing

hematopoietic cells, resulting in immunosuppression. (Gale, 1994) thus increasing the risk for

infection

NURSING GOAL:

After 1 – 2 days of nursing intervention, the patient will be able to identify and participate

in interventions to prevent risk of infection

NURSING RESPONSIBILITY RATIONALE

Maintain strict asepsis when performing Asepsis will prevent client from entry o
procedures to client organisms thus, protecting her from infection
Exercise meticulous handwashing before and Frequent, meticulous handwashing greatly
after handling patient. decreases the chanced of spreaing infection.
Promote frequent and adequate fluid intake To liquefy secretions and facilitate
expectorations to prevent stasis of body fluids
and promotes moist mucus membranes.
Screen and limit visitors who may have Protects patient from sources of infection, such
infections, place in reverse isolation as as visitors and staff who may have ab upper
indicated respiratory infection (URI)
Emphasize personal hygiene Limits potential sources of infection
Monitor temperature Early identification of infectious process
enables appropriate therapy to be started
promptly
Reposition frequently; keep linens dry and Reduces pressure and irritation to tissue and
wrinkle free may prevent skin breakdown that it is a
potential site for bacterial growth
Promote adequate rest and exercise periods Limits fatigue but still encourage sufficient
movement to prevent stasis complications
NURSING EVALUATION:

After 1 – 2 days of nursing intervention, the patient has identified and participated in

interventions to prevent risk of infection

NURSING DIAGNOSIS #6

Readiness for Enhanced Coping

NURSING INFERENCE:

“A pattern of cognitive and behavioral efforts to manage demands that is sufficient for

well-being and can be strengthened.” (Doenges, 2004).

NURSING GOAL:

After 1 – 3 days of nursing intervention, the patient will express feelings of optimism

NURSING RESPONSIBILITIES RATIONALE

Review extent of feelings of anxiety There is a need to know the extent of disequilibrium and
need for intervention to prevent or resolve the
crisis.

Discuss indication and method of treatment

Promotes active participation of client in therapeutic
regimen.

Assess presence of positive coping skillls/inner
strengths e.g (use of relaxation techniques,
willingness to express feelings, use of support
systems)
Encourage patient to talk about what is
happening at this time and what has occurred
to precipitate feelings of anxiety.
Evaluate ability to understand events and
correct misconceptions by providing factual
information.
Past coping skills may be reused to relieve
tension and preserve individual's sense of
control.
Provides clues to asses patient to develop
coping and regain equilibrium.
Assists in the identification and correction of
perception of reality.
NURSING EVALUATION:

After 1 – 3 days of nursing intervention, the patient has expressed feelings of optimism