University of the Philippines Manila

The Health Sciences Center

COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development

NURSING INTERVENTIONS II (N-107)

NURSING CARE PLAN
Name of Student: BUENVIAJE, Jay Lemuel J. Date of Assignment: 26-28 February 2019, 1 March 2019
Name of Client: RGD Age: 32 Sex: M Civil Status: Single
Medical Diagnosis: Penile CA
CUES NURSING BACKGROUND GOAL AND INTERVENTIONS & EVALUATION
DIAGNOSIS KNOWLEDGE OBJECTIVES RATIONALE STANDARD CRITERIA
Subjective: Ineffective Goal: The The goal was met/partially
- Verbalized protection client will be met/unmet as evidenced by:
“Bumuka po yung related to (Carpenito- free from □ Demonstrate handwashing
sugat ko mga ilang impaired Moyet, 2008). further technique
lingo pagkatapos secondary Due to lack of infection. □ Describe in his own words, how
nung biopsy.” defenses white blood cells (NOC: disease process increases
- Verbalized secondary to the body's Immune vulnerability to infections
“Parang nagsusugat chemotherap immune system Status) □ Exhibit no further signs of
po yung kung saan y treatment is compromised infection
pinutol yung ari ko, leading to the □ Describe influence of nutrition
tapos nagnanana client being on prevention of infection
po.” unable to protect □ Adheres to neutropenic diet
itself from
Objective: threats such as Objectives: NIC: Lower extremity NOC: Tissue □ Skin: (-)
- With granulating infections. It 1. The client monitoring, skin surveillance perfusion: pallor, cyanosis,
open wound, should be noted, will maintain 1. Assess the client’s skin and cellular jaundice
measuring 4 x 5 in. however, that the adequate extremities taking note of pallor or 1. Client is able □ Peripheral
@ right inguinal client’s WBC tissue cyanosis; peripheral pulses; to demonstrate pulses: equal,
area, with minimal count is already perfusion. capillary refill and edema. Active adequate tissue bounding,
active bleeding and high which may Infection increases inflammatory perfusion. regular
serous exudate be due to stress, mediators that may affect □ Capillary refill
- With lesions at inflammation or myocardial contractility and tissue time = 2 seconds
stump of penis, infection perfusion. Circulatory inadequacy
noted redness and can be present even with normal
serous exudate blood pressures due to the
inflammatory processes.
- GCS: E4V5M6 = 2. The client NIC: Skin Surveillance, Fluid NOC: Tissue □ Skin turgor:
15/15 will maintain and electrolyte monitoring Integrity: Skin good
-VS: BP: 110/70 adequate fluid 2. Assess for skin turgor and & Mucous □ Mucous
mmHG; RR: 20 volume with moisture of mucous membranes. Membranes, membrane:
breaths/min; no sudden Breaks in skin integrity may lead Fluid and moist
electrolyte
- HR at 86 beats/min changes in to an entry site for infection. □ Na: 135-145
balance
- afebrile with temp. weight, good 2. Client is able to □ Intake: .5 – 1
at 35.2 C skin turgor, Monitor electrolyte levels. maintain adequate L within shift
- skin warm to touch and moist Imbalances in fluid volume may fluid volume. □ Output: .5 – 1
- (-) signs of pallor, mucous lead to electrolyte imbalance. L within shift
jaundice, cyanosis membranes. Monitor intake and output during □ Stools: 1-
- CRT = 1 sec. shift. 2/day
- peripheral pulses:
symmetric, regular,
bounding, (-) pulse 3. The client NIC: Infection protection NOC: Immune □ No signs of
deficit will 3. Perform handwashing before status sepsis.
- soft, nontender demonstrate and after each care activity and use 3. Client is able to X Cool, pale arms
abdomen no signs of gloves when necessary. exhibit no signs and legs
- full ROM sepsis. Handwashing by the student nurse of septic shock. X High or very
- joints (-) before and after patient low temperature,
tenderness, swelling interaction reduces the risk of X Chills
- equal muscle size cross contamination. For the X Low blood
and strength prevention of introduction of pressure
- (+) Cachexia bacteria and reducing risk of X Palpitations
nosocomial infection. X Rapid heart
Latest CBC rate
(2/25/2019) Inspect site of invasive devices X Restlessness,
- ↑ WBC (15.70) such as parenteral line at right agitation,
- ↓ RBC (3.30) bsailic vein. Parenteral insertion lethargy, or
sites are viable portal of entry to confusion
infecting organisms. X Shortness of
breath
Wear appropriate personal X Skin rash or
protective equipment. Due to the discoloration
immunocompromised state of the
client, he is at greater risk of □ANC = ____
having infections. The student
nurse must wear PPE at the
appropriate times to ensure
 reduced risk of patient acquiring
infection.

Compute for the client’s Absolute

Neutrophil Count. ANC = WBC
((segs/100) + (bands/100)). ANC
is a measure of neutrophil
granulocytes in the blood which
are white blood cells that fights of
infection. A decreased ANC
indicate an increased risk for
infection.

4. The client NIC: Infection Control NOC: Immune □ Client and SO

will adhere to 4. Instruct client to wear mask at Status wears mask at
practices to all times. Wearing mask at all 4. Client all times
prevent times will greatly aid in preventing demonstrates □ Describes
infection. opportunistic infections due to practices to understanding of
prevent infection.
client’s immunocompromised PCA and how it
state. causes immuno-
compromised
Health teaching on the disease state
process of PCA and how it places □ Demonstrates
the client at risk for infections. It is appropriate
important for the client to know wound care
how his condition causes his technique
immunocompromised state, to
develop an increased sense of
importance in the client’s efforts to
decrease his risk of infection.

Ensure appropriate wound care

technique of client
Checking and supplementing the
wound care practices of the client
ensures maximal wound healing
and prevention of infection.
 NIC: Nutritional counseling NOC: □ States food to
Assess the client’s diet habits and Nutritional avoid
preferences. To assist in diet Status □ Cites
counseling. 4. Client examples of
demonstrates alternative food
understanding of
Explain the neutropenic diet to the choices that is
diet
client. The client is recommended for recommended in
immunocompromised; a patients the neutropenic
neutropenic diet helps protect undergoing diet
them from bacteria and other chemotherapy/are □ Creates
harmful organisms found in some in an sample meal
food and drinks that might become immunocomprom plan for a day.
cause for infection ised state

Emphasize importance of
avoidance of eating raw and
unwashed food. Eating
raw/unwashed food places the
client at risk for opportunistic
infections.

Supervise client in creating a

sample meal plan in accordance to
the recommended diet. Provide list
of foods to choose. Although
listing of foods to avoid is
discouraged, it is important to
include them so that the client is
aware of what he could eat if
presented a choice.
Subjective:
- “Inoperahan po
kasi ako sa may
singit para daw
matanggal yung
nana tsaka
kukunan daw po
yung bukol para
ibiopsy.”
- “Bumuka po
yung opera ko
mga dalawang
buwan
pagkatapos
noong opera.
Tapos ngayon po
parang
nagflower na
siya tapos
ganiyan na siya
ngayon.”

Objective:

Subjective: Chronic pain Chronic Pain is Goal: The The goal was met/partially
- “Masakit yung dito related to described as an client will met/unmet as evidenced by:
ko, simula pa nung penile unpleasant report gradual □ Increased participation in
napansin ko na may carcinoma sensory and reduction of activities of recovery
bukol ako last year” emotional pain, as □ Performance of non-
as verbalized by the experience evidenced by pharmacologic ways of reducing
client while pointing arising from indicators pain
to and showing actual or □ Reduction of grade in pain scale
inguinal and pubic potential tissue Objectives: NOC: Comfort □ Provocation:
area damage or 1. Client will NIC: Emotional Support Level __________
described in be able to 1. Perform a comprehensive 1. Client □ Palliation:
Objective: terms of such verbalize assessment of pain to include identifies __________
PQRST Assessment: damage feeling of any location, characteristics, onset, presence of pain □ Quality of
Provocation/ (International pain and duration, frequency, quality, pain:________
Palliation: Association for discomforts. intensity or severity, and □ Region/
- The pain is the Study of precipitating factors of pain. Pain Location:
worsened by Pain); sudden or is a subjective experience and __________
standing/putting slow onset of must be described by the client in □ Severity:
pressure on the any intensity order to plan effective treatment. Universal Pain
inguinal area from mild to Assessment
such as sitting severe, constant Encourage the client to verbalize Tool Grade:
upright or recurring feelings, perceptions and fears. ___/10
Quality: without an Expression allows the □ Timing:
anticipated or identification of pain level, as only ________
- Client describes predictable end the client can judge the level and
the pain as a and a duration of distress of pain.
stabbing greater than six
sensation in his (6) months. Acknowledge pain.
flesh (sa loob) Acknowledging the client when he
Radiation: verbalizes/shows pain validates
- Pain radiates the client and allows for trust and
from inguinal good rapport between him and the
area to right SN.
costovertebral
angle Provide psychological support and
Severity: motivation. Assuring the client
- Rated 5/10 while that support is available and help
under pain will be given if needed by the
medication client; either by the SN or his
during present S/O will allow for greater
assessment feeling of comfort by the patient.
Temporal: NOC: Pain
- The pain is 2. Client will NIC: Pain management Control Demonstration
constant; client be able to 2. Assess client’s vital signs q 2 h. 2. Client’s of the following
describes it as demonstrate Changes in vital signs may return □ Deep breathing
persisting even the indicate acute pain and demonstration exercises
with or without nonpharmacol discomfort. of non- □ Positioning
pain medication, ogic ways of pharmacologic □ Rest
just in varying reducing pain Teach the client and his S/O the ways of □ Distraction
degrees of nonpharmacologic ways that can reducing pain. □ Relaxation
severity help her in reducing experienced □ Massage (c/o
pain (relaxation, distraction, SO)
- Observed mass massage, deep breathing exercises,
in left inguinal proper positioning, rest, sleep).
area, 5 x 5 cm in Teaching the client and significant □ BP: 120/80
size, does not others maximize opportunities for □ PR: 60-80
elicit pain self-control over manifestations of beats/min
response when pain, as they themselves are the □ RR: 16-20
palpated ones implementing the method of breaths/min
pain control. The use of □ Temp:
- Observed noninvasive pain relief measures 36.537.5 C
tenderness in can increase the release of □ O2 sat >95%
pubic area, elicits endorphins and work alongside
 pain response the therapeutic relief of pain □ (-) shortness of
when palpated medications. breath
□ (-) dyspnea
- Visibly Encourage adequate periods of rest □ (-) use of
observable veins and sleep and meeting comfort accessory
from right side of needs. Rest prevents undue fatigue muscles
pelvis up to and stress which can contribute to
lateral area of the pain and increased attention to □ Provocation:__
waist pain. __
□ Palliation:
Demonstrate and assist client in _____
deep breathing exercises. DBEs □ Quality of
are easy to follow and do even in pain:________
bed and contributes to pain _
reduction via slowing the heart □ Region/Locatio
rate and distracting the patient n
from his pain. □ Severity:
Universal Pain
Position client in a comfortable Assessment
position wherein he feels the least Tool Grade:
pain (Low Fowler’s position) ___/10
To promote circulation and □ Timing:
prevent extensive tissue pressure ________
which is his reported cause of
exacerbation of pain.
□ Identifies
Provide massage to the client and nonpharmacolo
encourage the significant other to gic technique
perform massage for the client. to reduce pain
Massaging gently the areas distal that she prefers
to the site of pain induces the to utilize
release of serotonin and
endorphins which is the body’s
anti-pain mediators and can
improve client’s disposition, as
well as improving circulation.

Return demonstration of the

previously discussed non-
 pharmacological ways of reducing
pain. Return demonstration
ensures that the client and S/O
understood the discussion and that
he will be able to perform these
methods of pain management
independently; this can also be
used to evaluate the
effectiveness of teaching

Administer medications as
prescribed. Whenever applicable,
administer pain medications/direct
client in taking pain medications
that have been previously
prescribed by the physician for
pain management.

Notify physician or buddy nurse if

regimen is inadequate. If present
pain management regimen is
inadequate as stated by client,
alterations can be made to meet
the goal of alleviating or lessening
the patient’s pain.

Subjective: Risk for Disturbed Body Goal: The The goal was met/partially
- “Paano ko ba disturbed Image is client will met/unmet as evidenced by:
gagawin, parang body image confusion in demonstrate □ Demonstrate a willingness and
positive ba?” as mental picture of acceptance of ability to resume self-care/role
stated by the client, one’s physical appearance, as responsibilities
when asked to self. As the evidenced by □ Initiate new or reestablish
describe how he sees client is indicators. contact with existing support
himself. undergoing systems.
- “Nawalan ako ng chemotherapy
buhok tapos with multiple
namayat talaga ako chemotherapeuti
ng husto simula c
nung chemotherapy” c agents, the Objectives: Encourage the client to verbalize Verbal feedback Client verbalizes
as stated by the body’s immune The client will feelings especially his perception experiences and
client. system is implement of himself or feelings about his identifies
- “Tumigil na kami depressed. As effective appearance. Frequent verbal support system
sa pagtatalik ni the drugs target coping contact with the caregiver and S/O
misis nung napansin rapidly dividing patterns. facilitates for gradual acceptance
ko na may bukol na cancerous cells, and building of trust and rapport.
ko” as stated by the many normal
client. cells are Encourage the client to ask
- states previous use destroyed along questions about health problem
of chemotherapeutic the process. Hair treatment, progress and prognosis.
agents follicles are The client may be hesitant to
structures in the approach the staff or his attending
Objective: skin filled with physician because of negative
- (+) hair loss blood vessels selfconcept or feelings of
- (+) cachexia responsible in inferiority, therefore the SN must
- Client, when asked the production of reach out to the client and make
to describe how he hair. These cells him feel that he is allowed and
sees himself, are one of the even encouraged to know more
displayed hesitation fastest growing and be participant in directing his
and slight confusion cells in the body care.
on how to respond dividing every 1
adequately to 3 days.

Chemo agents, The client will Provide opportunity to share with Client verbalizes
targeting rapidly resume social people going through similar experiences and
dividing cells activities. experiences. Having people with identifies
↓ similar experiences to share their Verbal feedback support system
Hair follicles are thoughts and feelings assists in
subsequently accepting the different bodily
destroyed along changes and being more
with cancerous comfortable with it.

Encourage contact with peers and

family members The client is
going through a great challenge in
his life and utmost support will be
beneficial, especially from the
people that he trusts. This also
ensures the client that previous
 support system is still intact and
can be reached out to by him.

Encourage visits from peers and

significant others. Isolation can
increase feelings of guilt, fear and
embarrassment or frustration.

Promote social interaction. Social

interactions can reaffirm that the
person is acceptable and can
adapt even with alterations in
physique or other bodily changes.

The client will Discuss the hair loss and where Verbal feedback Client accepts
maintain they may occur (head, eyelashes, current hair loss
healthy levels eyebrows; axillary, pubic and leg and where it has
of self- hair). Hair is a very important part occurred.
esteem. in a person’s body image and loss
may lead to decreased levels of self-
esteem; feelings of frustration

Encourage the client to share

concerns, fears and perception of
the effects of these changes in life.
Patients undergoing chemotherapy
may have many thoughts that
require specific care and attention
of the student nurse, as well as
addressing particular
misconceptions or fears.

Explain that hair will grow back

after treatment but may change in
color and texture. To encourage
the client that bodily changes such
 as hair loss is temporary and thus
reversible after treatment.

References:
Bilo, G., Revera, M., Bussotti, M., Bonacina, D., Styczkiewicz, K., Caldara, G., . . . Parati, G. (2012). Effects of Slow Deep Breathing at High
Altitude on Oxygen Saturation, Pulmonary and Systemic Hemodynamics. PLoS ONE, 7(11). doi:10.1371/journal.pone.0049074
Carpenito-Moyet, L. (2006). Health Seeking Behaviors. In Nursing Diagnosis: Application to Clinical Practice (11th ed., pp. 458). New Jersey:
Mullica Hill.
Fundamentals of Nursing 7th ed. by Kozier, Barbara, p. 536
Medical Surgical Nursing, 7th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 440
Renwick W, Pettengell R, Green M. Use of filgrastim and pegfilgrastim to support delivery of chemotherapy. Twenty years of clinical experience.
BioDrugs 2009;23:175–86
Zuo, X.L., Meng, FJ., (2015). A care bundle for pressure ulcer treatment in intensive care units. International Journal of Nursing Sciences 2, pp. 340-
347. Doi: http://dx.doi.org/10.1016/j.ijnss.2015.10.008