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Nursing Care Plan
Lymphoma Nursing Care Plan
May be related to
- Altered body structure or function (drugs, surgery, disease process, radiation [loss of sexual desire, disruption of sexual response pattern])
Possibly evidenced by
- Verbalization of problem
- Actual or perceived limitation imposed by disease and/or therapy
- Alteration in relationship with SO
- Verbalize understanding of individual reasons for sexual problems.
- Identify stressors in lifestyle that may contribute to the dysfunction.
- Discuss concerns about body image, sex role, desirability as a sexual partner with partner/SO.
- Let the patient describe problem in own words.
- Rationale: Provides more accurate picture of patient experience with which to develop plan of care.
- Know the importance of sex to individual, partner and patient’s motivation for change.
- Rationale: Because lymphomas often affect the relatively young who are in their productive years, these people may be affected more by these problems and may be less knowledgeable about the possibilities of change.
- Weigh knowledge of patient and SO regarding sexual function and effects of current situation and condition.
- Rationale: Helps analyze areas of concern, misconception, and actual problems related to therapy side effects.
- Identify preexisting and current stress factors that may be affecting the relationship.
- Rationale: Patient may be concerned about other issues, such as job, financial, and illness-related problems.
- Determine specific pathophysiology, illness, surgery or trauma involved and impact on (perception of) individual.
- Rationale: Patient’s perception of the individual effects of this illness is crucial to planning interventions that will be appropriate to those affected (patient and family).
- Assist with treatment of underlying condition.
- Rationale: As illness is treated and patient can see improvement, hope is restored and patient can begin to look to the future.
- Provide factual information.
- Rationale: Promotes trust in caregivers.
- Encourage and accept expressions of concern, anger, grief, fear.
- Rationale: Helps patient identify feelings and begin to deal with them.
- Encourage patient to share thoughts and concerns with partner and to clarify values and impact of condition on relationship.
- Rationale: Helps couple begin to deal with issues that can strengthen or weaken relationship.
- Refer to appropriate community resources and support groups (CanSurmount).
- Rationale: Provides information about resources that are available to help with individual needs. Meeting with others who are dealing with the effects of devastating illness can help patient and family.
- Provide written material and bibliotherapy Internet sites, other resources appropriate to age and situation.
- Rationale: Reinforces information patient has received.
- Refer to psychiatric clinical nurse specialist and professional sexual therapist as indicated.
- Rationale: May need additional in-depth assistance to resolve existing problems.
- Risk for Ineffective Airway Clearance
- Risk for Ineffective Breathing Pattern
Risk factors may include
- Tracheobronchial obstruction: enlarged mediastinal nodes and/or airway edema (Hodgkin’s and non-Hodgkin’s); superior vena cava syndrome (non-Hodgkin’s)
Possibly evidenced by
- Not applicable. Existence of signs and symptoms establishes an actual nursing diagnosis.
- Maintain a normal/effective respiratory pattern, free of dyspnea, cyanosis, or other signs of respiratory distress.
- Assess and monitor respiratory rate, depth, rhythm. Note reports of dyspnea and use of accessory muscles, nasal flaring, altered chest excursion.
- Rationale: Changes (such as tachypnea, dyspnea, use of accessory muscles) may indicate progression of respiratory involvement and compromise requiring prompt intervention.
- Place patient in position of comfort, usually with head of bed elevated or sitting upright leaning forward (weight supported on arms), feet dangling.
- Rationale: Maximizes lung expansion, decreases work of breathing, and reduces risk of aspiration.
- Reposition and assist with turning periodically.
- Rationale: Promotes aeration of all lung segments and mobilizes secretions.
- Instruct and assist with deep-breathing techniques, pursed-lip or abdominal diaphragmatic breathing if indicated.
- Rationale: Helps promote gas diffusion and expansion of small airways. Provides patient with some control over respiration, helping to reduce anxiety.
- Monitor and evaluate skin color, noting pallor, development of cyanosis (particularly in nailbeds, ear lobes, and lips).
- Rationale: Proliferation of WBCs can reduce oxygen-carrying capacity of the blood, leading to hypoxemia.
- Assess respiratory response to activity. Note reports of dyspnea or ”air hunger,” increased fatigue. Schedule rest periods between activities.
- Rationale: Decreased cellular oxygenation reduces activity tolerance. Rest reduces oxygen demands and minimizes fatigue and dyspnea.
- Identify and encourage energy-saving techniques (rest periods before and after meals, use of shower chair, sitting for care).
- Rationale: Aids in reducing fatigue and dyspnea, and conserves energy for cellular regeneration and respiratory function.
- Promote bedrest and provide care as indicated during acute and prolonged exacerbation.
- Rationale: Worsening respiratory involvement and hypoxia may necessitate cessation of activity to prevent more serious respiratory compromise.
- Encourage expression of feelings. Acknowledge reality of situation and normality of feelings.
- Rationale: Anxiety increases oxygen demand, and hypoxemia potentiates respiratory distress and cardiac symptoms, which in turn escalates anxiety.
- Provide calm, quiet environment.
- Rationale: Promotes relaxation, conserving energy and reducing oxygen demand.
- Observe for neck vein distension, headache, dizziness, periorbital and facial edema, dyspnea, and stridor.
- Rationale: Non-Hodgkin’s patients are at risk for superior vena cava syndrome, which may result in tracheal deviation and airway obstruction, representing an oncologic emergency.
- Provide support to family and caregivers. Encourage open expression of feelings.
- Rationale: Development of this complication is very frightening for patient and family because it may indicate end-stage of disease process and approaching death, especially in the hospice setting. Keeping family informed may diminish their anxiety and minimize transmission to patient.
- Provide supplemental oxygen.
- Rationale: Maximizes oxygen available for circulatory uptake; aids in reducing hypoxemia.
- Monitor laboratory studies (ABGs, oximetry).
- Rationale: Measures adequacy of respiratory function and effectiveness of therapy.
- Administer analgesics and tranquilizers as indicated.
- Rationale: Reducing physiological responses to pain and anxiety decreases oxygen demands and may limit respiratory compromise.
- Assist with respiratory treatments or adjuncts, (IPPB, incentive spirometer) if appropriate.
- Rationale: Promotes maximal aeration of all lung segments, preventing atelectasis.
- Assist with intubation and mechanical ventilation.
- Rationale: May be necessary to support respiratory function until airway edema is resolved in acutely ill hospitalized patient.
- Prepare for emergency radiation therapy when indicated.
- Rationale: Treatment of choice for superior vena cava syndrome.
May be related to
- Lack of exposure/recall
- Information misinterpretation
- Unfamiliarity with information resources
- Cognitive limitations
Possibly evidenced by
- Request for information, verbalization of problem, statements reflecting misconceptions
- Inaccurate follow-through of instruction, development of preventable complications
- Verbalize understanding of condition, prognosis, and potential complications.
- Identify relationship of signs/symptoms to disease process.
- Initiate necessary lifestyle changes.
- Discuss potential complications relative to specific therapeutic regimen.
- Rationale: Possible side effects and long-term physical complications of radiation (direct or indirect) and some chemotherapy agents include pneumonitis, hypothyroidism, pericarditis, cardiomyopathy.
- Emphasize need for ongoing medical follow-up.
- Rationale: Following treatment, there is increased risk of secondary malignancies (thyroid, myeloid leukemia, non-Hodgkin’s lymphoma) in addition to other complications listed. Note: Yearly Pap smears are recommended for female patients because Hodgkin’s cells may be found on the cervix.
- Identify signs and symptoms requiring further evaluation, such as cough, fever, chills, malaise, dyspnea (pneumonitis); weight gain, slow pulse, decreased energy level, intolerance to cold (hypothyroidism); moderate fever, chest pain, dry cough, dyspnea, rapid pulse (pericarditis); dyspnea, fatigue, chest pain, dizziness/syncope (cardiomyopathy).
- Rationale: Prompt intervention can limit progression of complication, reduce debilitating effects.
- Recommend regular exercise in moderation, with adequate rest. Discuss energy conservation techniques.
- Promotes general well-being. Note: Fatigue is associated with disease process and treatment regimen, as well as developing complications. Therefore, balancing activity with rest enhances patient’s ability to perform ADLs.
- Review infection prevention measures and signs and symptoms requiring further evaluation.
- Rationale: Condition is associated with a complex deficiency in cellular immunity both before and after therapy. Note: Herpes zoster is a common occurrence.
- Determine financial needs and concerns. Identify community resources, vocational services.
- Rationale: Although survival rates are relatively good, patients often have limitations in physical activities and employment because of dyspnea, chronic fatigue, and difficulties in concentration or memory. Presence of the disease can also impact patient’s ability to work or qualify for bank loans or obtain insurance.
Other Possible Nursing Care Plans
- Fatigue—decreased metabolic energy production, overwhelming psychological or emotional demands, states of discomfort, altered body chemistry, e.g., chemotherapy.
- Family Processes, interrupted—situational crisis (illness, disabling/expensive treatments).