Nursing Care Plan

Assessment
Actual/ Abnormal data Activity/Rest: Fatigue General malaise Night sweats Fever/ chills Circulation: Chest pain Palpitations Tachycardia Cyanosis and edema of the face or right arm (superior vena cava syndromeobstruction of venous drainage from enlarged lymph nodesis a rare occurrence) Scleral icterus and a generalized jaundice related to liver damage and consequent obstruction of bile ducts by enlarge lymph noses Definition Unpleasant and experience from potential in terms of sudden actual sensory emotional arising or tissue such or Malignant lymphocytes travels all over the body (lungs, liver, gastrointestinal tract, meninges, skin, and bones 3. Provide nonpharmacological comfort measures (massage, repositioning, back rub) and diversional Form masses in lymph tissues such as lymph nodes, spleen and other organs

Diagnosis
Acute pain related to disease process (enlargement/compres sion/destruction of nerve tissue/body organs, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation) as evidenced by reports of pain, facial grimace guarding behaviors.

Rationale
Risk Factors (Increased age, Immune deficiencyHIV/AIDS, VirusesHTLV-1/Epstein-Barr virus, Exposure to chemicals, Organ transplant, Gene mutation)

Desired Outcome
After days of nursing

Intervention

Justification
Independent

care, the client will Independent be able to: 1. Report with ADLs. maximal 1. minimal with pain relief/control interference

Mutation in B and T lymphocytes

2. Follow prescribed pharmacologic regimen. 3. Demonstrate and use

Determine pain 1. Information history (location of provides baseline data pain, frequency, to evaluate need duration, and intensity for/effectiveness of using rating scale (0interventions. 10 scale); verbal ratings (no pain to excruciating pain), and relief measures used. Evaluate/be 2. A wide range of aware of painful discomforts are effects of particular common (incisional therapies (surgery, pain, burning skin, radiation, headaches), depending chemotherapy, on the procedure/agent biotherapy); provide being used. Pain is information to also associated with patient/SO about what invasive procedures to to expect. diagnose/treat cancer. 3. Promotes relaxation and helps refocus attention.

Proliferation of abnormal B and T lymphocytes in lymphatic system

2.

of relaxation skills diversional as activities indicated

damage or described damage;

 Pallor/diaphoresis Elimination: Abdomen: RUQ tenderness and enlargement on palpation (hepatomegaly); LUQ tenderness and enlargement on palpation (splenomegaly) Decreased urine output/anuria (renal failure) Bowel/bladder dysfunction (spinal cord compression) Food/Fluid: Dysphagia (pressure on the esophagus) Edema of the lower extremities (inferior vena cava obstruction from intra-abdominal lymph node enlargement associated with nonHodgkins lymphoma)

slow onset of any intensity from mild to severe anticipated with an or Rapid growing of malignant cells/masses in an affected organ

activities (music television). 4.

or 4. Enables patient to participate actively in nondrug treatment of pain and enhances sense of control. Pain produces stress and, in conjunction with muscle tension and internal stressors, increases patients focus on self, which in turn increases the level of pain. May decrease inflammation, muscle spasms, reducing associated pain. Goal is maximum pain control with minimum interference with ADLs.

predictable end and duration of less than 6 months. Compression/destructi on of nerve tissue/body organs, infiltration of nerves or the vascular supply, obstruction of a nerve pathway, inflammation

Encourage use of stress management skills/complementary therapies (relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and therapeutic touch).

Pain

5. 5. Provide cutaneous stimulation (heat/cold, massage). 6. 6. Evaluate pain relief/control at regular intervals. Adjust medication regimen as necessary. 7. 7. Inform patient/SO of the expected therapeutic effects and discuss management of side effects.

This information helps establish realistic expectations, confidence in own ability to handle what happens.

Collaborative Collaborative 1. Mayprovide reduction/

Neurosensory: Nerve pain (neuralgia) compression of nerve roots by enlarged lymph noses in the brachial, lumbar, and sacral plexus Muscle weakness/ paresthesia Pain/Discomfort: Tenderness/pain over involved lymph nodes Chest pain, back pain (vertebral compression) Generalized bone pain (lymphomatous bone involvement) Guarding behavior Respiration: Dyspnea on exertion, Tachypnea Hoarseness/laryngeal paralysis (pressure from enlarged nodes on the laryngeal

1. Discuss use of / refer for additional alternative/ complementary therapies (acupuncture/ acupressure). 2. An organized plan beginning with the 2. Develop individualized simplest dosage pain management plan schedules and least with patient and invasive modalities physician. Provide improves chance for written copy of plan to pain control. patient, family/SO, and care providers. 3. A wide range of analgesics and 3. Administer medication associated agents may as indicated for pain be used around the relief. clock to manage pain.

relief of pain without drug-related side effects.

nerve)