Nursing Care PlanAssessment Diagnosis Planning Implementation Evaluation

Ineffective airway clearance related to increased amount or viscosity of secretionsas evidenced byChanges in rate and depth of respirationAbnormal breath soundsIneffective coughDyspnea

At the end of 8 hours, the patient WillDemonstrate patent airway, with fluid secretions easily expectorated

Intervention Rationale

1. Auscultated chest for character of breath sounds and presence of secretions.

2. Assist client with and provide instruction in effective deep breathing, coughing in upright position (sitting), and splinting of incision.

3. Observe amount and character of sputum and aspirated secretions. Investigate changes, as indicated.

Noisy respirations, rhonchi, and wheezes are indicative of retained secretions or airway obstruction.

Upright position favors maximal lung expansion, and splinting improves force of cough effort to mobilize and remove secretions. Splinting may be done by nurse placing hands anteriorly and posteriorly over chest wall and by client, with pillows, as strength improves

Increased amounts of colorless (or blood-streaked) or watery secretions are normal initially and should decrease as recovery progresses.

Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

acute/chronic Pain related to disease process—compression or destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation, metastasis to

INTERVENTION

1. Determine pain history, for example, location of

pain, frequency, duration, and intensity using a

rating scale (scale of 0–10), or verbal rating scale

—“no pain” to “excruciating pain”; and

relief measures used. Believe client’s report. 

RATIONALE

Information provides

baseline data to evaluate

need for, and effectiveness

of, interventions. Pain of more

than 6 months’ duration

constitutes chronic pain,

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bones; side effects of various cancer therapy agents Possibly evidenced by Reports of pain Self-focusing, narrowed focus Alteration in muscle tone; facial mask of pain Distraction/guarding behaviors Autonomic responses, restlessnes

2. Determine timing and precipitants of “breakthrough” pain when using around-the-clock agents, whether oral, intravenous (IV), topical, transmucosal, epidural, or patch medications. 

2. Evaluate painful effects of particular therapies, such as surgery, radiation, chemotherapy, or biotherapy. Provide information to client and SO about what to expect. 

which may affect

Pain may occur near the end of

the dose interval,

indicating need for higher dose or shorter dose interval. Pain

may be precipitated by

identifiable triggers, or

occur spontaneously, requiring use of short half-life agents for

rescue or supplemental

doses. 

A wide range of discomforts are common such as incisional pain,

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3. Provide nonpharmacological comfort measures such as massage, repositioning, and back rub; as well as diversional activities, such as music, reading, and TV.. 5. Encourage use of stress management skills and complementary therapies such as relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and Therapeutic Touch. Enables client to participate actively in nondrug treatment of pain and enhances sense

burning skin, low back pain, mouth sores, or headaches, depending on the procedure or agent being used. Pain is also associated with invasive procedures to diagnose or treat cancer. 

Promotes relaxation and helps refocus attention

Enables client to participate actively in nondrug treatment of pain and enhances sense of control. Pain produces

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of control. Pain produces stress and, in conjunction with muscle tension and internal stressors, increases client’s focus on self, which in turn increases the level of pain. 

6. Provide cutaneous stimulation, such as heat and cold packs, or massage. 

7.Administer analgesics, as indicated, for example: Opioids such as codeine, morphine (MSContin, Kadian), oxycodone (oxycontin), hydrocodone (Vicodin), hydromorphone

stress and, in conjunction with muscle tension and internal stressors, increases client’s focus on self, which in turn increases the level of pain. 

May decrease inflammation, muscle spasms, reducing associated pain

unmanageable side effects of pain medications that

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(Dilaudid), methadone (Dolophine), fentanyl (Duragesic, Actiq, Fentora), or oxymorphone (Numorphan, Opana 

Encourage verbalization of feelings

Effective for localized and generalized moderate to severe pain, with long-acting or controlled-release forms available

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Nursing Care PlanASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

imbalanced Nutrition: Less than

Body Requirements related to

hypermetabolic state associated with

cancer; consequences of chemotherapy,

radiation, surgery—anorexia, gastric irritation, taste

distortions, nausea; emotional distress,

fatigue, poorly controlled pain 

Possibly evidenced by Reported

inadequate food intake, altered taste

sensation, loss of interest in food,

perceived or actual inability to ingest

food, vomiting 

Body weight 20% or more under ideal for

height and frame, decreased

subcutaneous fat and muscle mass 

Sore, inflamed buccal cavity 

Diarrhea and/or constipation,

abdominal cramping 

INTERVENTION RATIONALE

1. Monitor daily food intake and have client keep food diary, as indicated. .

2. Measure height, weight, and skinfold thickness, or other anthropometric measurements, as appropriate. Ascertain amount of recent weight loss. Weigh daily or as indicated. 

3. Assess skin and mucous membranes for pallor, delayed wound healing, and enlarged parotid glands. 

4. Encourage client to eat high-calorie, nutrient-rich diet, with adequate fluid intake. Encourage

Identifies nutritional strengths and deficiencies. 

If these measurements fall below minimum standards, client’s chief source of stored energy, fat tissue, is depleted

Helps in identification of protein-calorie malnutrition, especially when weight

Metabolic tissue and needs are increased as to eliminate waste products. Supplements can play an important role in maintaining adequate caloric and protein intake. 

Nursing Care Plan