Post on 29-May-2018
8/8/2019 ncp for prostatic cancer
1/5
8/8/2019 ncp for prostatic cancer
2/5
VII. NURSING CARE PLAN
A c a s e s t u d y o n P r o s t a t i c C a n c e r w i t h B o n e M e t a s t a s i s ( T h o r a x ) Page 28
of retained secretions. obstructive airway diseases in
patients who require more than single bronchodilator.
y Administered low flow oxygentherapy (2L/min) via nasal cannulaas ordered.R: to decrease hypoxemia
POTENTIAL INTERVENTIONS
Dependent
y
Suction secretionsR: to clear airway when excessive
secretions are blocking airway.
8/8/2019 ncp for prostatic cancer
3/5
VII. NURSING CARE PLAN
A c a s e s t u d y o n P r o s t a t i c C a n c e r w i t h B o n e M e t a s t a s i s ( T h o r a x ) Page 28
ASSESSMENT DATA
(Subjective & Objective Cues)
NURSING DIAGNOSIS(Problem and Etiology)
GOALS ANDOBJECTIVES
NURSING INTERVENTIONS ANDRATIONALE
Subjective:
dili kayo ko kalihok.. asverbalized by the patient.
Objective:
- Abnormal decrease ofRBC 3.96
- Abnormal decrease ofhemoglobin 11.3
- Abnormal decrease ofhematocrit 34.0
-pale skin
- Heart Rate: 105 bpm
Activity Intolerance (Level
3) related to imbalance
between oxygen supply
and demand
Short term Goals:
After 2hours of thoroughnursing intervention, theclient will be able to:
a. Improve heartrate from 105bpm- 100bpm
b. Use identifiedtechniques toenhance assistivemobility.
INDEPENDENT:
1. Assisted patient in bed to chaiand/or wheelchair mobility.R: To prevent injuries
2. Assisted patient in passive ROMexercises.R: to promote venous return
3. Positioned client in Semi-fowlersposition.R: to promote proper lung
expansion. To maximize oxygenation focellular uptake
4. Encouraged rest periods for clienand avoid exertion on unnecessaryactivities.R: to conserve energyconsumption.
8/8/2019 ncp for prostatic cancer
4/5
VII. NURSING CARE PLAN
A c a s e s t u d y o n P r o s t a t i c C a n c e r w i t h B o n e M e t a s t a s i s ( T h o r a x ) Page 28
ASSESSMENT DATA
(Subjective & Objective Cues)
NURSING DIAGNOSIS(Problem and Etiology)
GOALS ANDOBJECTIVES
NURSING INTERVENTIONS ANDRATIONALE
Subjective:
galisod ko ug libang asverbalized by the patient.
Objective:
> Absent bowel sounds
> Melena
> Altered blood pressure -70/40mmHg
Ineffective tissue perfusion(GI) related to interruptionof arterial blood flow
Short Term:
At the end of 3 hours ofnursing interventions,the patient will be ableto:
a. Improve bloodpressure from70/40 mmHg to130/70mm Hg
b. Demonstratevarious strategiesto improve tissueperfusion going tothe GI.
Long Term:
At the end of 24 hours of
nursing interventions,the patient will be ableto:
a. maintain normalblood pressurewithin the normalrange
ACTUAL INTERVENTIONS
INDEPENDENT:
1. Assisted client in performing range omotion.
R to promote venous return
2. Provide small/easily digested food andfluids as tolerated.R not to overwhelm the integrity of theGI with the presence of food and toallow blood flow.
3. Encourage rest after mealsR: To maximize blood flow to stomachenhancing digestion.
4. Elevate the extremities of the patienwithin the cardiac reserveR to allow venous return
DEPENDENT:
1. Administer dopamine via IV 14cc/hr.R to improve tissue perfusion throughcorrecting hypotension.
POTENTIAL INTERVENTIONS:
8/8/2019 ncp for prostatic cancer
5/5
VII. NURSING CARE PLAN
A c a s e s t u d y o n P r o s t a t i c C a n c e r w i t h B o n e M e t a s t a s i s ( T h o r a x ) Page 28
b. Establish bowelsounds. 1. Prepare Client for Nasogastric insertion
R for decompression of the GI.
COLLABORATIVE:
1. Refer to nutritionist: ImbalancedNutrition, less than body requirements.