POTENTIAL NURSING DIAGNOSIS

Sittie Norjannah P. Santos

Potential for infection r/t chronic disease process

Nursing intervention:• Emphasize personal hygiene.

Rationale: Limits potential sources of infection.

• Monitor temperature. Rationale: Temperature elevation may occur, if not masked by corticosteroids or anti-inflammatory drugs, because of various factors including chemotherapy side effects, disease process, or infection. Early identification of infectious process enables appropriate therapy to be started promptly.

• Encourage fluids. Rationale: Adequate fluid intake enhances immune system and aids natural defense mechanisms.

• Assess all systems (e.g., skin, respiratory, genitourinary) for signs and symptoms of infection on a continual basis. Rationale: Early recognition and intervention may prevent progression to more serious situation such as sepsis.

Ineffective coping r/t personal vulnerability secondary to

mastectomyNursing Intervention:• Provide an atmosphere of acceptance.Rationale: Establishing rapport is essential to a therapeutic relationship and supports the

client in self-reflection. Recognizing problems and sharing feelings is best brought about in an atmosphere of warmth and trust.

• Provide factual information concerning the diagnosis, treatment, and prognosis.Rationale: Factual information serves as a foundation for the patient to explore feelings

and alternative coping strategies. Stressed clients often misunderstand facts and require frequent clarification so that appropriate conclusions can be drawn. Having valid information helps relieve stress.

• Appraise patient’s adjustment to changes in body image.Rationale: Alteration in body image may be a major issue for the patient and should be

explored to facilitate therapeutic intervention. Coping strategies often change with a reappraisal of the situation.

• Arrange situations that encourage her autonomy. Give her as many opportunities as possible to make decisions/choices for herself.

Rationale: Enhances a sense of control, personal achievement, and self-esteem.

• Explore with her previous methods of dealing with life problems.Rationale: Present and past coping status assists both Ruby and her husband

in capitalizing on successful methods, identifying ineffective strategies, and developing new skills more appropriate to the present situation. Also determines risk for inflicting self-harm.

• Encourage verbalization of feelings, perceptions, and fears.Rationale: Open, nonthreatening discussions facilitate the identification of

causative and contributing factors.

Acute pain r/t physical and surgical procedure

Intervention:• Establish rapport on the client.Rationale: To establish trust and cooperation on the client.

• Monitor the vital signs.Rationale: To obtain baseline data.

• Perform a comprehensive assessment of pain to include location, severity of pain and precipitating factor.

Rationale: To have necessary information about the case of the client.

• Provide pharmacologic agents to reduce or eliminate pain as prescribed by the physician.

Rationale: To help in reduction of pain.

Risk for Ineffective Sexual Patterns r/t knowledge or skill deficit

Nursing intervention :1. Discuss with client and SO the nature of sexuality and reactions when it is altered or threatened. Provide information about normality of these problems and that many people find it helpful to seek assistance with adaptation process.Rationale: Acknowledges legitimacy of the problem. Sexuality encompasses the way men and women view themselves as individuals and how they relate between and among themselves in every area of life.

2. Advise client of side effects of prescribed cancer treatment that are known to affect sexuality.Rationale: Anticipatory guidance can help client and SO begin the process of adaptation to new state.

3. Provide private time for hospitalized client. Knock on door and receive permission from client and SO before entering.Rationale: Sexual needs do not end because the client is hospitalized. Intimacy needs continue and an open and accepting attiude for the expression of those needs is essential.

4. Refer to sex therapist, as indicated.Rationale: May require additional assistance in dealing with situation.

Powerlessness r/t acute or chronic illness

Intervention:

• Encourage verbalization of feelings, perceptions, and fears about making decisions.

Rationale: This creates a supportive climate and sends message of caring.

• Enhance the patient’s sense of autonomy. Do this by involving the patient in decision making, by giving information, and by enabling thepatient to control the environment as appropriate.

Rationale: Patients become very dependent in the high-tech,medical environment and may relegate decision making to the health care providers. This may be especially evident in patients of cultures or ethnicheritages different from the dominant health care providers.

• Encourage patient to identify strengths.Rationale: Review of past coping experiences and prior decision-

making skills may assist the patient to recognize inner strengths. Self-confidence and security come with a sense of control.

• Encourage increased responsibility for self.Rationale: The perception of powerlessness may negate

patient’s attention to areas where self-care isattainable; however, patient may requiresignificant support systems and resources toaccomplish goals.

Hopelessness r/t Increased tension, restlessness

• Nursing intervention with rationale:1. Review client’s and significant other’s (SO’s) previous experience with cancer. Determine what the doctor has told client and what conclusion client has reached.Rationale: Clarifies client’s perceptions; assists in identification of fear(s) and misconceptions based on diagnosis and experience with cancer.

2. Encourage client to share thoughts and feelings.Rationale: Provides opportunity to examine realistic fears and misconceptions about diagnosis.

3. Provide open environment in which client feels safe to discuss feelings or to refrain from talking.Rationale: Helps client feel accepted in present condition without feeling judged and promotes sense of dignity and control.

4. Maintain frequent contact with client. Talk with and touch client, as appropriate.Rationale: Provides assurance that the client is not alone or rejected; conveys respect for and acceptance of the person, fostering trust.

5. Be aware of effects of isolation on client when required by immunosuppression or radiation implant. Limit use of isolation clothing, as possible.Rationale: Sensory deprivation may result when sufficient stimulation is not available and may intensify feelings of anxiety, fear, and alienation.

6. Assist client and SO in recognizing and clarifying fears to begin developing coping strategies for dealing with these fears.Rationale: Coping skills are often stressed after diagnosis and during different phases of treatment. Support and counseling are often necessary to enable individual to recognize and deal with fear and to realize that control and coping strategies are available.

7. Explain the recommended treatment, its purpose, and potential side effects. Help client prepare for treatments.Rationale: The goal of cancer treatment is to destroy malignant cells while minimizing damage to normal ones. Treatment may include curative, preventive, or palliative surgery as well as chemotherapy, internal or external radiation, or newer, organ-specific treatments such as whole-body hyperthermia or biotherapy. Bone marrow or peripheral progenitor cell transplant may be recommended for some types of cancer.