Nursing Care Plan

GENERAL OBJECTIVES: To promote optimal activity, exercise, rest, and sleep

Assessment Nursing Rationale Specific Nursing Intervention Rationale Evaluation

Diagnosis Objectives
Subjective Data: Fatigue related to Appendix Within 8 hours Independent Independent After 8 hours
“gapangaluya lang altered body cancer occurs of rendering Intervention: Rationale: of rendering
lawas ko.” chemistry: side when healthy nursing care, nursing care,
effects of pain cells in the the patient’s BP 1. Have patient 1. Helps in the patient
Objective Data: and other appendix will be able to rate fatigue, using a developing a plan was able to
medications, change and have adequate numeric scale, if for managing verbalized
Awake on bed with chemotherapy grow out of rest periods. reduced
5 FU 3.6 gmc in 1L possible, and the fatigue.
secondary to
D5W x 46 control. These time of day when it discomfort.
Appendiceal
21.7 gtts/min cells form a is most severe.
Cancer
Body malaise noted growth of
tissue, called a 2. Plan care to allow 2. Frequent rest
Capillary refill: 2 tumor. A for rest periods. periods and naps
seconds tumor can be Schedule activities are needed to
RR: 21 cpm cancerous or for periods when restore and
benign. A patient has most conserve energy.
PR: 72 bpm
cancerous energy. Involve Planning will allow
tumor is patient and SO in patient to be
blood pressure
malignant, schedule planning. active during times
11/22/17: 110/70
meaning it can when energy level
mmHg
grow and is higher, which
(+) chemo spread to may restore a
IV site - edema other parts of feeling of well-
the body. being and a sense
Another name of control.
for this type of
cancer is 3. Establish realistic 3. Provides for a
appendiceal activity goals with sense of control
cancer. patient. and feelings of
Fatigue is the accomplishment.
most common
R side effect of 4. Assist with self-care 4. Weakness may
cancer needs when make ADLs
treatment. indicated; keep bed difficult to
Some doctors in low position, complete or place
 estimate that pathways clear of the patient at risk
9 out of 10 furniture; assist for injury during
people with ambulation. activities.
experience
fatigue at 5. Encourage patient 5. Enhances strength
some point to do whatever and stamina and
during possible (self- enables patient to
treatment. bathing, sitting up become more
Fatigue from in chair, walking). active without
treatment can Increase activity undue fatigue.
appear level as individual is
suddenly, at able.
any time, and
can be 6. Monitor 6. Tolerance varies
overwhelming. physiological greatly depending
Rest doesn't response to activity on the stage of the
ease fatigue (changes in BP, disease process,
and it can last heart and nutrition state,
for months respiratory rate). fluid balance, and
after reaction to
treatment therapeutic
ends. regimen.

7. Provide 7. Presence
supplemental of anemia and
oxygen as indicated. hypoxemia
reduces
O2available for
cellular uptake and
contributes
to fatigue.

R
 Dependent

1. Administer 1. To manage adverse

prescribed effect of
medication by the chemotherapy
Dr.

Collaborative

2. Provide information 2. Community

regarding community resources like health
resources, and support centers programs
patients in making and check-ups are
lifestyle changes. helpful in controlling
hypertension.

3. Prepare the patient 3. Identify

for the following abnormalities of
diagnostic results and give
procedures: proper nursing
intervention.
 Hematology
 Urinalysis

Reference for the Nursing Interventions: Nursing Care Plans by Gulanick/Myers 6th edition p.144-149

Reference for the Rationale: Medical-Surgical Nursing: Clinical Management for positive Outcomes by Joyce M. Black p.649-655