Patient's Initials: GF Gender: F Student Name: AaLona Robinson, SN

Date(s) Cared For (Month & Day only): May 24 Nursing Care Plan Form Instructor's Name: Pickens

Course Number: NRSG 250 Care Plan #: 1

Nursing Diagnosis ***Clinical Reasoning *** Patient Expected Nursing Interventions Rationale Evaluation of
(Actual- 3 parts; Risk For Explain your rationale for Outcomes (With sources) Expected Outcomes
2 parts: Readiness for 2 choosing this nursing (Short & long term) (Be clear: Start with (Include date/time)
parts; include secondary diagnosis. Include With Expected Outcome Nursing will)
to as appropriate.) connections/relationships Criteria
between the parts of the n. Start with Patient will
dx. EX: how the R/T
caused the problem.
Patient showcased Patient will make 1. Assess vital signs 1. Creates baseline for 1S: Patient communicated
Knowledge Deficit inability to form a valid decisions and follow including pain level q shift further assessment. ways to prevent infection
appraisal of what to expect through with appropriate 2. Determine the patients 2. Establishes a baseline by demonstrating
Related to during treatment, side actions to maintain level of understanding. for teaching. appropriate hand
effects of therapy, as well optimal health in her 3. Develop a learning plan 3. Patient input into the washing while washing
Management of as inability to solidly personal environment as with the patient. plan of care improves the with soap and water and
therapeutic chemotherapy identify available evidenced by the following 4. Explain to patient that likelihood of successful appropriate friction, and
regimen resources. indicators: his/her resistance to management. explaining that hand
Short Term: infection is reduced when 4. Emphasizes the need to washing must be done
As Evidenced By 1S: The patient will WBC counts are low. adhere closely to before any catheter or
verbalize ways to 5. Instruct patient on ways recommended techniques incision care. MET
S: Patient being newly prevent infection during to prevent infection to prevent infection.
diagnosed with Acute periods of lowered including hand washing, 5. Infection prevention is 2S: Patient explained how
Myeloid Leukemia (AML) immunity. proper skin care, avoiding a priority during she understands that she
foods with high chemotherapy regimen must use a electric razor
O: Patient states that her 2S: The patient will microorganism content 6. Decreases risk for for shaving and to ask
mother had breast cancer verbalize ways to prevent and offering information bleeding. for help when shes
but never received bleeding when platelet on smoking cessation 7. In case patient does feeling weak to prevent
chemotherapy, and never counts are low. assistance using have spontaneous falls.
had anyone close to her go educational videos and bleeding, intervention is MET
through it. 3S: The patient will instructional pamphlets. necessary to prevent
identify techniques to 6. Instruct patient in ways further injury or death. 3S: Patient stated that she
control nausea and to minimize risk of 8. Smaller, more frequent will ask her husband to
vomiting. bleeding meals prevent overtiring buy crackers for her
a. Avoid taking aspirin and during eating because hes in charge of
COMPLETE EVERY SHIFT other nonsteroidal anti- 9. Helps to control nausea the grocery shopping to
inflammatory agents (e.g. 10. Proper maintenance help manage nausea. She
Long Term: ibuprofen) on a regular of port prevents occlusion also stated that she

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 1L: The patient will basis
demonstrate the ability b. Use an electric rather
to care for a central than a straight-edge razor
venous catheter, a c. Floss and brush teeth
peritoneal catheter, or an gently
implanted infusion d. Use caution when
device once placed. ambulating to prevent
2L: The patient will state falls or bumps and do not
signs and symptoms to walk barefoot
report to the health care 7. Instruct patient to
provider. control any bleeding by
3L: The patient will applying firm, prolonged
identify community pressure to the area if
resources that can assist possible. Demonstrate on
with home management peripheral extremity and
and adjustment to the request a return
diagnosis of cancer and demonstration.
chemotherapy and its 8. Eat several small meals
effects. per day instead of 3 large
4L: The patient will ones
verbalize an 9. Encourage patient to eat
understanding of and a dry foods, such as toast
plan for adhering to and crackers) or sip cold
recommended follow-up carbonated beverages if
care including nausea is present. Take
medications prescribed deep, slow breaths when
and schedule for nauseated.
chemotherapy, laboratory 10. Provide instructions
studies, and future related to care of a central
appointments with health venous catheter
care provider. (Groshong):
a. Change dressing if
COMPLETE BEFORE present according to
DISCHARGE protocol using aseptic
technique
b. Observe exit site for
changes in appearance,
redness, swelling, and
unusual drainage
c. Flush catheter according
to protocol to maintain
patency
d. Replace injection cap as
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11. Identifying side effects
and alerting appropriate
medical professionals
could prevent infection
12. These services can
assist patient and
significant others with
home management and
adjustment to diagnosis of
cancer and chemotherapy
and its effects as well as
provide support for coping
and care.
13. Active listening
provides the patient
and/or family a
nonjudgmental person to
listen to them and relieve
their guilt feelings
(Hopkins, 1994).
Acknowledgment of
feelings communicates
support and conveys that
they are understood
(Leske, 1998).
14. Reinforce importance
of keeping appointments
for chemotherapy and
laboratory studies.
15. Patient input into the
plan of care improves the
likelihood of successful
management.
16. Reinforce importance
of keeping follow-up
appointments with health
care provider
prefers to eat smaller
meals throughout the
day already so it will not
be a huge change.
MET
Short Term Goals Met by
end of shift
05/24/2017 3pm
1L: Patient port is not
implanted. Unable to
demonstrate proper care
based on uncertainty of
specific port.
UNMET (continue POC)
as of end of shift
05/24/2017 3pm
2L: Patient identifies some
side effects of
medications and signs
and symptoms of
infection to report to the
physician.
MET (reinforcement
recommended)
3L: Patient reported that
she looked at the
websites of the Genesys
Hurley Cancer Institute
and the schedule for
support groups.
MET
4L: Patient is determined
to fight her diagnosis
and is determined to
cooperate 100% with
adhering to all
treatments for optimal
outcomes.
 directed MET
e. Tape catheter securely
to the chest wall to Long Term Goals Met by
prevent accidental end of shift
dislodgment 05/24/2017 3pm
f. Notify physician if (Excluding 1L)
unable to flush catheter, if
signs and symptoms of
infection occur at exit site,
or if catheter appears to
be leaking. Observe return
demonstration on mock
catheter model
11. Observe for and notify
physician if any of the
following occur:
Redness, swelling, or
change in appearance of
insertion site
Unusual drainage from
exit site
Increasing abdominal pain
Chills or fever
Increased abdominal
distention between
treatments
Persistent nausea or
vomiting
Dyspnea
Allow time for questions,
clarification, and return
demonstration of
procedures.
12. Provide information
about and encourage use
of community resources
that can assist patient and
significant others with
home management and
adjustment to diagnosis of
cancer and chemotherapy
and its effects
(Genesys/Hurley Cancer
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 Institute, American Cancer
Society, counselors, social
service agencies, Meals on
Wheels, Make Today
Count, Look Good-Feel
Better Program, hospice,
local community support
groups). Initiate a referral
if indicated.
13. Use active listening
and acceptance to help
patient express emotions
such as crying, guilt, and
anger (within appropriate
limits).
14. Thoroughly explain
rationale for, side effects
of, and importance of
taking medications
prescribed. Inform patient
of pertinent food and drug
interactions. Reinforce
physician's explanation of
planned chemotherapy
schedule.
15. Discuss with patient
any difficulties he/she
might have adhering to
the schedule and assist in
planning ways to
overcome these.
16. Implement measures
to improve patient
compliance
a. Include significant
others in teaching
sessions
b. Encourage questions
and allow time for
reinforcement and
clarification of
information provided
c. Provide written
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 instructions regarding
ways to maintain
nutritional status, future
appointments with health
care provider and
laboratory, medications
prescribed, and signs and
symptoms to report.

These interventions are to

be reinforced Q Shift.

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