Need Help With Nursing Interventions

Coffee Nurse, BSN, RN · Apr 12, 2009

Why don't you take a stab first at coming up with a list, and then ask here if they'd be appropriate? You already have some good diagnoses (although I might might address his nutritional needs rather than mucous membranes specifically -- that way you can include his nausea as well as his MM in your care plan); let them guide you to what kind of steps you would take to remedy them.

OT -- Does BC in your username stand for Boston College, or something else?

Reno1978, BSN, RN · Apr 12, 2009

Risk for infection is a big one. Think about, or look up, what kind of precautions are taken for neutropenic patients and you should receive many ideas.

Jules A, MSN · Apr 12, 2009

Doesn't your text book include interventions? Mine did and our professors said just pick appropriate ones right from there rather than "reinventing the wheel". Good luck.

HonestRN · Apr 12, 2009

Possible Body Image Disturbance, Lack of Knowledge, Impaired Coping?

Daytonite, BSN, RN · Apr 12, 2009

the problem i have with the question you are asking is that you ask for help with interventions, but you don't seem to know what it is that he needs help with! i disagree with your diagnosing and since you haven't explained how you came to your diagnostic conclusions i'll have to explain mine. what was he admitted for? surgery? or the nausea and not eating? this was not made clear. interventions specifically target signs and symptoms of the patient's response to their illness. the stems of your nursing diagnoses are of no help because it is the abnormal data that supports the nursing diagnoses that is the focus of the nursing interventions. if i were to care plan this patient using the nursing process this is what i would determine his nursing problems to be. . .

step 1 assessment - assessment consists of:

a health history (review of systems) - 16yr old patient with osteosarcoma of his (l) leg who is receiving chemotherapy prior to having surgery to remove the osteosarcoma. labs: wcc/wbc- 1.23, platelet 102, hb 13.2.
performing a physical exam - p-98. sore lips and mouth, nausea, won't eat or drink much over the past few days and worries about the surgery since he may loose his leg and need a prosthesis
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - look up the pathophysiology, signs and symptoms of osteosarcoma and age 16 growth milestones.
- http://kidshealth.org/parent/_cancer_center/cancer_basics/cancer_osteosarcoma.html - osteosarcoma
- http://www.merck.com/mmpe/sec04/ch044/ch044c.html#sec04-ch044-ch044c-1169 - primary malignant bone tumors
- from the national cancer institute: http://www.cancer.gov/cancertopics/pdq/treatment/osteosarcoma/patient - osteosarcoma and malignant fibrous histiocytoma of bone treatment
- http://www.kidsgrowth.com/resources/articledetail.cfm?id=1138 - age 16 growth milestones
[*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking - the chemotherapy agents weren't mentioned

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

p-98
nausea
won't eat or drink much over the past few days, but not dehydrated
sore lips and mouth
worries about the surgery since he may loose his leg and need a prosthesis
wcc/wbc- 1.23

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use. in order of priority. . .

imbalanced nutrition: less than body requirements r/t side effects of chemotherapy aeb report by patient of not eating or drinking much over the past few days
nausea r/t gastric irritation secondary to chemotherapy aeb patient report of nausea
impaired oral mucous membranes r/t side effects of chemotherapy aeb sore lips and mouth
this may be going on although not actually mentioned, bone cancer is painful: acute pain r/t inflammatory processes in leg aeb tachycardia and decreased appetite
ineffective protection r/t chemotherapy aeb wcc/wbc of 1.23
grieving r/t anticipated loss of leg aeb worry about the outcome of surgery and the possible need for a prosthesis [a prosthesis means the leg would have to be amputated]
risk for delayed development r/t chemotherapy and surgery

step #3 planning (write measurable goals/outcomes and nursing interventions) - now i know what direction i can take with nursing interventions because i know exactly what data i am developing interventions for--all the aeb stuff.

imbalanced nutrition: less than body requirements r/t side effects of chemotherapy aeb report by patient of not eating or drinking much over the past few days
- interventions (for not eating or drinking much over the past few days) - there are 4 types of nursing interventions (1) assess/monitor/evaluate/observe (to evaluate the patient's condition), (2) care/perform/provide/assist (performing actual patient care), (3) teach/educate/instruct/supervise (educating patient or caregiver), and (4) manage/refer/contact/notify (managing the care on behalf of the patient or caregiver):
  - monitor the amount of food served at eaten at meals being served using a consistent scale
  - observe what is difficult for the patient to eat from what they dislike eating
  - evaluate their intake against rda daily requirements
  - make sure dietary has been notified of patient preferences and is served food that he will eat
  - check to be sure patient is served a tray at each meal
  - arrange for between meal high protein snacks
  - teach patient the importance of maintaining nutrition
  - consult with the dietician for other strategies to maximize nutritional intake particular as patient is going to have surgery and healing is anticipated

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risk for infection...

while it is true that he is at a risk for infection i think he already has a problem of being unprotected because his wbc count is already low, and if i am not mistaken, that is what you are basing the risk for infection upon.

anxiety...

is true, but

anxiety

is more physiologically based and he is really already starting to

think

about the potential loss of his leg and that is grieving. once the leg is gone it is gone forever; anxiety is temporary and can be corrected. i looked at what you posted and the only symptoms of anxiety that are there are worry which i feel are due to the grieving and nausea which is really a side effect of the chemo.