Nursing Care Plan for Malignant Lymphoma
Nursing Assessment
In the assessment, the data can be found in patients with lymphoma, among others:
1. Subjective data:
Nursing Diagnosis for Malignant Lymphoma
Nursing Interventions
1. Hyperthermia related to ineffectiveness of thermoregulation, secondary to inflammation.
Purpose: body temperature within normal limits (36 - 37,5ºC)
Interventions:
a. Observation of the patient's body temperature.
Rationale: To know the state, so that it can take appropriate action.
b. Encourage and give drink plenty (according to the needs of children fluids, according to age).
Rationale: Expected to help maintain fluid balance in the body.
c. Give a warm compress on the forehead, axilla, abdomen and groin.
Rational: Compress can help lower the patient's body temperature by conduction.
d. Advise to use thin clothes, loose and easy to absorb sweat.
Rational: Expected to prevent evaporation so that the body fluid balance.
e. Collaboration in giving antipyretics.
Rational: Antipyretics will hinder the release of heat by the hypothalamus.
2. Chronic pain related to interruption of nerve cells.
Purpose: pain is reduced.
Interventions:
a. Determine the characteristics and location of pain, pay attention to verbal and non-verbal cues every 6 hours.
Rational: Determining follow-up interventions.
b. Monitor blood pressure, pulse and breathing every 6 hours.
Rational: Pain can lead to restlessness and increased blood pressure, pulse, respiration increases.
c. Apply distraction techniques (talk).
Rational: Diverting attention away from pain.
d. Teach relaxation techniques (deep breathing) and suggest to repeat when feeling pain.
Rational: Relaxation reduces muscle tension, thereby reducing pressure and pain.
e. Give and let the patient choose a comfortable position.
Rational: Reducing tensions painful area.
d. Collaboration in the delivery of analgesics.
Rational: analgesics will reach the center of the pain and cause pain relief.
3. Imbalanced Nutrition: less than body requirements related to the intake is less, the increased metabolic needs, and reduced absorption of nutrients.
Purpose: The nutritional requirements are met.
Interventions:
a. Feed in small portions but frequently.
Rational: provides an opportunity to increase the total caloric intake.
b. Measure the weight as indicated.
Rational: Useful for determining calorie needs, evaluation of adequacy of nutrition plan.
c. Serve food in warm and varied.
Rational: Improve the patient's desire to eat, so the calorie needs are met.
d. Create a comfortable environment while eating.
Rational: A comfortable environment helps the patient to increase the desire to eat.
e. Give health education on the benefits of nutrition.
Rational: Food supply needs calories to the body and can help the healing process and increase endurance.
4. Activity intolerance related to weakness, the exchange of oxygen, malnutrition, exhaustion.
Purpose: Activities can be improved.
Interventions:
a. Evaluation of patient response to activity, increased weakness / fatigue and changes in vital signs during and after the activity.
Rational: Establish the ability / needs of the patient and facilitate the choice of intervention.
b. Help the patient in meeting the needs of ADL.
Rational: Minimizing fatigue and help balance supply and oxygen demand.
c. Involve the family in patient care.
Rational: Helping and meet ADL patients.
d. Give activities in accordance with the ability of the patient.
Rational: Minimizing fatigue and help balance supply and oxygen demand).
5. Anxiety related to knowledge about the disease, prognosis, treatment and care.
Purpose: Patients do not worry / reduced.
Interventions:
a. Assess and monitor for signs of anxiety that occurs.
Rational: Fear can occur due to lack of information on the procedure to be done, do not know about the disease and condition.
b. Explain procedure in a simple action, according to the level of understanding of the patient.
Rational: Provide information to patients about action procedures will improve patient understanding of the actions taken to address the problem.
c. Discuss tensions and expectations of patients.
Rational: To reduce the anxiety felt by the patient.
d. Strengthen supporting factors to reduce ansietes.
Rational: To reduce the anxiety felt by the patient.
Nursing Assessment
In the assessment, the data can be found in patients with lymphoma, among others:
1. Subjective data:
- Prolonged fever with a temperature over 38 ° C
- Frequent night sweats.
- Feel tired.
- Weakness.
- Complained of pain in the lump.
- Decreased appetite.
- Eat and drink intake decreased, nausea, vomiting.
- Chewy lumps arise, easily moved on the neck, armpit or groin.
- Pale face.
Nursing Diagnosis for Malignant Lymphoma
- Risk for infection related to immunosuppression and malnutrition.
- Hyperthermia related to ineffectiveness of thermoregulation, secondary to inflammation.
- Chronic pain related to interruption of nerve cells.
- Altered peripheral tissue perfusion related to disruption oxygen transport system to hemorrhage.
- Impaired skin integrity / tissue related to tumor mass pushes out.
- Activity intolerance related to weakness, the exchange of oxygen, malnutrition, exhaustion.
- Imbalanced Nutrition: less than body requirements related to the intake is less, the increased metabolic needs, and reduced absorption of nutrients.
- Fluid Volume Deficit related to vomiting and intake less.
- Anxiety related to knowledge about the disease, prognosis, treatment and care.
- Knowledge Deficit related to lack of exposure / recall, misinterpretation, did not know the sources.
Nursing Interventions
1. Hyperthermia related to ineffectiveness of thermoregulation, secondary to inflammation.
Purpose: body temperature within normal limits (36 - 37,5ºC)
Interventions:
a. Observation of the patient's body temperature.
Rationale: To know the state, so that it can take appropriate action.
b. Encourage and give drink plenty (according to the needs of children fluids, according to age).
Rationale: Expected to help maintain fluid balance in the body.
c. Give a warm compress on the forehead, axilla, abdomen and groin.
Rational: Compress can help lower the patient's body temperature by conduction.
d. Advise to use thin clothes, loose and easy to absorb sweat.
Rational: Expected to prevent evaporation so that the body fluid balance.
e. Collaboration in giving antipyretics.
Rational: Antipyretics will hinder the release of heat by the hypothalamus.
2. Chronic pain related to interruption of nerve cells.
Purpose: pain is reduced.
Interventions:
a. Determine the characteristics and location of pain, pay attention to verbal and non-verbal cues every 6 hours.
Rational: Determining follow-up interventions.
b. Monitor blood pressure, pulse and breathing every 6 hours.
Rational: Pain can lead to restlessness and increased blood pressure, pulse, respiration increases.
c. Apply distraction techniques (talk).
Rational: Diverting attention away from pain.
d. Teach relaxation techniques (deep breathing) and suggest to repeat when feeling pain.
Rational: Relaxation reduces muscle tension, thereby reducing pressure and pain.
e. Give and let the patient choose a comfortable position.
Rational: Reducing tensions painful area.
d. Collaboration in the delivery of analgesics.
Rational: analgesics will reach the center of the pain and cause pain relief.
3. Imbalanced Nutrition: less than body requirements related to the intake is less, the increased metabolic needs, and reduced absorption of nutrients.
Purpose: The nutritional requirements are met.
Interventions:
a. Feed in small portions but frequently.
Rational: provides an opportunity to increase the total caloric intake.
b. Measure the weight as indicated.
Rational: Useful for determining calorie needs, evaluation of adequacy of nutrition plan.
c. Serve food in warm and varied.
Rational: Improve the patient's desire to eat, so the calorie needs are met.
d. Create a comfortable environment while eating.
Rational: A comfortable environment helps the patient to increase the desire to eat.
e. Give health education on the benefits of nutrition.
Rational: Food supply needs calories to the body and can help the healing process and increase endurance.
4. Activity intolerance related to weakness, the exchange of oxygen, malnutrition, exhaustion.
Purpose: Activities can be improved.
Interventions:
a. Evaluation of patient response to activity, increased weakness / fatigue and changes in vital signs during and after the activity.
Rational: Establish the ability / needs of the patient and facilitate the choice of intervention.
b. Help the patient in meeting the needs of ADL.
Rational: Minimizing fatigue and help balance supply and oxygen demand.
c. Involve the family in patient care.
Rational: Helping and meet ADL patients.
d. Give activities in accordance with the ability of the patient.
Rational: Minimizing fatigue and help balance supply and oxygen demand).
5. Anxiety related to knowledge about the disease, prognosis, treatment and care.
Purpose: Patients do not worry / reduced.
Interventions:
a. Assess and monitor for signs of anxiety that occurs.
Rational: Fear can occur due to lack of information on the procedure to be done, do not know about the disease and condition.
b. Explain procedure in a simple action, according to the level of understanding of the patient.
Rational: Provide information to patients about action procedures will improve patient understanding of the actions taken to address the problem.
c. Discuss tensions and expectations of patients.
Rational: To reduce the anxiety felt by the patient.
d. Strengthen supporting factors to reduce ansietes.
Rational: To reduce the anxiety felt by the patient.
