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Saint Louis University School of Nursing Graduate School Program Submitted to: Ms. Florence Pulido, RMT,RN,MN Professor Submitted by: BANIQUED, Charmaine Acosta Submitted on: March 15, 2012

CASE ANALYSIS BANIQUED, Charmaine Acosta

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A. Identify all the Nursing Diagnoses for M.C. 1. Chemotherapy- Related Nursing Diagnoses a. Anxiety related to prescribed chemotherapy, insufficient knowledge of chemotherapy, and self-care measures b. Knowledge deficit c. Altered comfort related to gastrointestinal cell damage, stimulation of vomiting center, fear, and anxiety d. Altered nutrition: less than body requirements related to anorexia, taste changes, persistent nausea/vomiting, and increased intestinal mobility e. Altered oral mucous membrane related to dryness and epithelial cell damage secondary to chemotherapy f. Fatigue related to effects of anemia, malnutrition, persistent vomiting, and sleep pattern disturbance g. Activity intolerance related to imbalance between oxygen supply and demand h. High risk for colonic constipation related to autonomic nerve dysfunction secondary to Vinca alkaloid administration and inactivity i. Fluid volume deficient related to intestinal cell damage, inflammation, and increased intestinal mobility secondary to diarrhea j. High risk for impaired skin integrity related to persistent diarrhea, malnutrition, prolonged sedation, and fatigue k. Self-concept disturbance related to change in lifestyle, role, alopecia, and weight loss l. Grieving related to changes in life style, role, finances, functional capacity, body image, and health losses

2. Radiation Therapy- Related Nursing Diagnoses a. Anxiety related to prescribed radiation therapy and insufficient knowledge of treatments and self-care measures b. Knowledge deficit c. High risk of altered oral mucous membrane related to dry mouth or inadequate oral hygiene d. Impaired skin integrity related to effects of radiation on epithelial and basal cells and effects of diarrhea on perineal area e. altered comfort related to stimulation of the vomiting center and damage to the gastrointestinal mucosa cells secondary to radiation f. Fatigue related to systemic effects of radiation therapy g. Activity intolerance related to imbalance between oxygen supply and demand h. Altered comfort related to damage to sebaceous and sweat glands secondary to radiation i. Self-concept disturbance related to alopecia, skin changes, weight loss, and changes in role relationships and life styles j. Grieving related to changes in life style, role, finances, functional capacity, body image, and health losses k. Altered family processes related to imposed changes in family roles, relationships, and responsibilities

CASE ANALYSIS BANIQUED, Charmaine Acosta

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3. Surgery- Related Nursing Diagnoses PREOPERATIVE PERIOD

Anxiety/fear related to surgical experience, loss of control, unpredictable outcome, and insufficient knowledge of preoperative exercises and activities, and postoperative changes and sensations, b. Anxiety related to impending surgery and insufficient knowledge of preoperative routines, intra-operative activities, and postoperative self-care activities c. Knowledge deficit
a.

POSTOPERATIVE PERIOD
a. b. c. d. e. f. g.

h. i. j.

Disturbed body image related to surgery Risk for altered respiratory function related to immobility secondary to post-anesthesia state and pain Impaired skin integrity related to mechanical trauma secondary to surgery Tissue trauma related to surgical incision Risk for infection related to increased susceptibility to bacteria secondary to wound Pain related to surgical interruption of body structure, flatus, and immobility Risk for altered nutrition: less than body requirements related to increased protein and vitamin requirements for wound healing and decreased intake secondary to pin, nausea, vomiting, and diet restrictions Risk for colonic constipation related to decreased peristalsis secondary to immobility and effects of anesthesia and narcotics Activity intolerance related to pain and weakness secondary to anesthesia, tissue hypoxia, and insufficient fluid and nutrient intake Risk for ineffective management of therapeutic regimen related to insufficient knowledge of care of operative site, restrictions (diet, activity), medications, signs an symptoms of complications, and follow-up care

CASE ANALYSIS BANIQUED, Charmaine Acosta

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B. Nursing Care Plan 1. After initial discussion with the physician Subjective and Objective Goals- Objectives Data S> Express concerns regarding GOALS: Demonstrate changes in life events, feelings problem-solving skills of helplessness, hopelessness, inadequacy LTO: O>Increase tension, shakiness, >Use resources/support apprehension, restlessness, systems properly. insomnia >Demonstrate use of effective >Sympathetic stimulation coping mechanisms and active (increase in vital signs), participation all throughout the somatic complaints (voice treatment regimen. quivering, shakiness) STO: >Note mild to moderate >Display appropriate range of anxiety (irritability, impaired feelings and lessened fear. attention) >Appear relaxed and report anxiety is reduced to a manageable level.

Nursing Diagnosis

Nursing intervention Dx> Determine what the doctor has told patient and what conclusion patient has reached. >Identify stage/degree of grief patient and SO are currently experiencing. >Note ineffective coping, e.g., poor social interactions, helplessness, giving up everyday functions and usual sources of gratification. >Be alert to signs of denial/depression, e.g., withdrawal, anger, inappropriate remarks. >Determine presence of suicidal ideation and assess potential on a scale of 110. Tx>Provide open environment in which patient feels safe to discuss feelings or to refrain from talking.

Expected outcome >Fully met if patient: Demonstrates problem-solving skills Displays appropriate range of feelings and lessened fear. Appears relaxed and report anxiety is reduced to a manageable level. Demonstrates use of effective coping mechanisms and active participation in treatment regimen. Uses resources/support systems properly. >Partially met if patient: Has marked difficulty imploring problem solving skills because of the overwhelming feeling of anxiety >Unmet if patient:

Fear/Anxiety related to Situational crisis (cancer)

CASE ANALYSIS BANIQUED, Charmaine Acosta

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>Maintain frequent contact with patient. Talk with and touch patient as appropriate. >Be aware of effects of isolation on patient when required by immunosuppression. >Provide accurate, consistent information regarding diagnosis and prognosis. >Permit expressions of anger, fear, despair without confrontation. >Give information that feelings are normal and are to be appropriately expressed. >Stay with patient during anxiety-producing procedures and consultations. >Promote calm, quiet environment. Edx>Encourage patient to share thoughts and feelings. >Educate patient/SO in recognizing and clarifying fears to begin developing coping strategies for dealing with these fears.

Does not demonstrate problem-solving skills and does not able to cope with the situational crisis.

CASE ANALYSIS BANIQUED, Charmaine Acosta

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>Explain the recommended treatment, its purpose, and potential side effects. Help patient prepare for treatments. >Explain procedures, providing opportunity for questions and honest answers. >Advise SO to provide primary and consistent caregivers whenever possible. >Encourage and foster patient interaction with support systems >Advocates in provision of reliable and consistent information and support for SO. >Include SO as indicated/patient desires when major decisions are to be made.

Ref: Doenges, Marilyn, Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span, 7th ed. Doenges, Marilyn, Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, 11 th ed. Videbeck, Sheila, Psychiatric Mental Health Nursing, 3 rd ed.

CASE ANALYSIS BANIQUED, Charmaine Acosta

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2. On the admission to hospital at the start of therapy Nursing Diagnosis Anxiety related to prescribed chemotherapy, insufficient knowledge of the therapy, and self-care measures Subjective and Objective Data S> Verbalization of the feeling of anxiety and the problem >Asks for information regarding the related factors stated >Statements reflecting misconceptions O>Note mild to moderate anxiety >Inaccurate follow-through of instructions and procedures to be done Goals- Objectives GOAL: Exhibit increased interest/ assume responsibility for own learning by beginning to look for information and ask questions. OBJECTIVES: >Participate in learning process >Identify interferences to learning and specific action/s to deal with them >Verbalize understanding of condition/ disease process and treatment >Identify relationship of signs/symptoms to the disease process and correlate symptoms with causative factors >Perform necessary procedures correctly and explain reasons for the actions >Initiate necessary lifestyle changes and participate in Nursing Interventions Dx>Determine clients extent of understanding of the therapy >Review disease process with and future expectations from the patient. Tx>Premedications given as prescribed >Implement dietary regimen, as individually appropriate >Active-listen concerns about therapeutic regimen/lifestyle changes. Expected Outcome Fully met if patient: >: Exhibited increased interest/ assume responsibility for own learning by beginning to look for information and ask questions. >Verbalized understanding of disease process and potential complications. >Able to correlate symptoms with causative factors. >Verbalized understanding of therapeutic needs. >Initiated necessary lifestyle changes and participate in treatment regimen. Partially met if: Patient is not able to attain the goal but can be seen initiating necessary lifestyle changes

Edx>Stress importance of increased fluid intake. >Inform patient to notice dry mouth, N/V, diarrhea, feeling of tiredness during the therapy, possible alopecia as the therapy progresses, and loss of appetite. Radiation therapy entails markings on the area to be exposed and need not to be erased afterwards. >Teach care of the radiation site (no lotions, mild soap is

CASE ANALYSIS BANIQUED, Charmaine Acosta

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treatment regimen.

advised) >Discuss medication regimen; neutropenic diet. >Identify signs/symptoms requiring further medical concerns.

and participate in treatment regimen. Unmet if: Patient not able to reached the goal and no objectives was met

Ref: books.google.com.ph/books?isbn=0798619120 Doenges, Marilyn, Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span, 7 th ed. Doenges, Marilyn, Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, 11 th ed. Videbeck, Sheila, Psychiatric Mental Health Nursing, 3rd ed.

CASE ANALYSIS BANIQUED, Charmaine Acosta

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3. While hospitalized, 2 days later Nursing Diagnosis Altered nutrition: less than body requirements related to anorexia, taste changes, persistent nausea/vomiting, and increased intestinal mobility Subjective and Objective Data S>Reported altered taste sensation >Lack of interest in food O>Loss of weight >Pale conjunctiva and mucous membranes >Poor muscle tone/ weakness >Poor skin turgor >Edema of extremities >Electrolyte imbalances Goals- Objectives GOAL: Client will exhibit no signs or symptoms of malnutrition by time of discharge from treatment (e.g., electrolytes and blood counts will be within normal limits; a steady weight gain will be demonstrated; constipation will be corrected; client will exhibit increased energy in participation in activities). >Demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight Nursing Interventions Dx> Determine number of calories required to provide adequate nutrition and realistic (according to body structure and height) weight gain. >Strict documentation of intake, output, and calorie count. This information is necessary to make an accurate nutritional assessment and maintain client safety. >Determine clients likes and dislikes, and collaborate with dietitian >Weigh client daily. Weight loss or gain is important assessment information. >Monitor laboratory values, and report significant changes to physician. Laboratory values provide objective data regarding nutritional status. Tx >Provide favorite foods. Client is more likely to eat foods that he or she particularly enjoys. Expected Outcome Fully met if: >Client will exhibit no signs or symptoms of malnutrition by time of discharge >Client has shown a slow, progressive weight gain during hospitalization. >Vital signs, blood pressure, and laboratory serum studies are within normal limits. >Client is able to verbalize importance of adequate nutrition and fluid intake. Partially met if: >Client has shown a slow, progressive weight gain during hospitalization. >Vital signs, blood pressure, and laboratory serum studies

CASE ANALYSIS BANIQUED, Charmaine Acosta

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>Ensure that client receives small, frequent feedings, including a bedtime snack, rather than three larger meals. Large amounts of food may be objectionable, or even intolerable, to the client. >Administer vitamin and mineral supplements as indicated >Stay with client during meals to assist as needed and to offer support and encouragement. Edx>>Encourage client to increase fluid consumption and physical exercise as tolerated. >Advise family members or significant others to bring in special foods that client particularly enjoys. >Explain the importance of adequate nutrition and fluid

are within normal limits. >Client is able to verbalize importance of adequate nutrition and fluid intake. >But had not yet attained normal weight at the time of discharge. Unmet if: >Patient did not attain the goal and did not manifest any weight gain

CASE ANALYSIS BANIQUED, Charmaine Acosta

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intake. Client may have inadequate or inaccurate knowledge regarding the contribution of good nutrition to overall wellness. Ref: http://www.philippinenursingdirectory.com/nursing-care-plans/imbalanced-nutrition-less-than-body-requirements/
Doenges, Marilyn, Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span, 7 th ed. Doenges, Marilyn, Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, 11 th ed.

CASE ANALYSIS BANIQUED, Charmaine Acosta

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4. At home, 2 weeks after starting therapy Nursing Diagnosis Risk for Infection related to leukopenia secondary to chemotherapy Subjective and Objective Data O> immunosuppression as seen in the laboratory results Goals- Objectives Goal: Client will remain free of infection as evidenced by temperature remaining within normal limits. STO: Client will verbalize and integrate in the lifestyle changes interventions that prevent infection. Nursing Interventions Dx>Monitor vital signs to check for infection >Monitor laboratory results, especially complete blood count, white blood cell count (WBC), differential and absolute neutrophils >Monitor respiratory, urinary, mucosal and skin systems Tx>Practice proper handwashing and use aseptic technique when providing care Edx>Instruct SO to keep neutropenic client separate from others >Instruct patient to wear mask as for self-protection >Teach manifestations of infection and those to report immediately >Teach measures for prevention of infection, such as avoiding crows and not Expected Outcome Fully Met if: The client will remain free of infection or seek treatment promptly if manifestations of infection appear. The client will verbalize methods that minimize this condition from occurring. Partially Met if: Patient remained free of infection but does not demonstrate self-care to avoid infection Unmet If: Patient developed infection.

CASE ANALYSIS BANIQUED, Charmaine Acosta

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cleaning fish tanks or litter boxes >Reinforce neutropenic diet, and no fresh flowers in the room. >Instruct to avoid uncontrolled crowds and sources of infection; balanced diet; skin care.

Ref: Doenges, Marilyn, Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span, 7 th ed.
Doenges, Marilyn, Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, 11 th ed.

CASE ANALYSIS BANIQUED, Charmaine Acosta

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5. At home, 3 weeks after the start of chemoradiotherapy Subjective and Objective Data Fatigue related to systemic S> client's perception of the effects of radiation therapy; severity of fatigue using a fatigue rating scale Fatigue related to effects of anemia, malnutrition, >verbalization of an persistent vomiting, and sleep unremitting/ overwhelming pattern disturbance lack of energy Nursing Diagnosis Secondary to: >Build up of cellular waste products associated with rapid lysis of cancerous and normal cells exposed to cytotoxic drugs; >difficulty resting and sleeping associated with fear, anxiety, and discomfort; >tissue hypoxia associated with anemia (a result of malnutrition and chemotherapy-induced bone marrow suppression); >Inability to maintain usual routines >Perceive need for additional energy to accomplish routine tasks >Increase in rest requirements >Disinterest in surroundings >Decrease performance O>lethargic >Drowsy Goals- Objectives The client will experience a reduction in fatigue as evidenced by: a.verbalization of feelings of increased energy b. ability to perform usual activities of daily living c. Identify basis of further fatigue and ways of conserving energy c.increase interest in surroundings and ability to concentrate Nursing Interventions Dx>Assess for signs and symptoms of fatigue (e.g. verbalization of lack of energy and inability to maintain usual routines, lack of interest in surroundings, decreased ability to concentrate, lethargy) >Determine the severity of fatigue Tx>Assist client to identify personal patterns of fatigue (e.g. time of day, after certain activities) and to plan activities so that times of greatest fatigue are avoided. >Implement measures to reduce fatigue: perform actions to promote rest and/or conserve energy: *schedule several short rest periods during the day Expected Outcome Fully met if: >Patient reported improved sense of energy >Able to identify basis of fatigue and individual areas of control >Performed ADLs and participate at desired activities with minimal rest periods needed Partially met if: Patient reported improved sense of energy but not yet able to performed ADLs. Not met if: Patient does not report any sense of improved energy.

CASE ANALYSIS BANIQUED, Charmaine Acosta

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>overwhelming emotional demands associated with the diagnosis of cancer and treatment with chemoradiotherapy; >increased energy expenditure associated with an increase in the metabolic rate resulting from continuous, active tumor growth and increased levels of certain cytokines (e.g. tumor necrosis factor, interleukin-1); >malnutrition; >effects of medications used for control of pain, nausea, and anxiety.

*minimize environmental activity and noise *limit the number of visitors and their length of stay *assist client with self-care activities as needed *keep supplies and personal articles within easy reach *implement measures to reduce fear and anxiety *implement measures to promote sleep (e.g. encourage relaxing diversional activities in the evening, allow client to continue usual sleep practices unless contraindicated, reduce environmental stimuli, administer prescribed sedative-hypnotics) *implement measures to reduce discomfort >Promote an adequate nutritional status encourage

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client to maintain a fluid intake of at least 2500 ml/day to promote elimination of the by-products of cellular breakdown >Administer the following if ordered for treatment of anemia: *folate, iron, epoetin alfa (EPO), blood transfusions (e.g. packed red blood cells), peripheral blood stem cell transplantation >Facilitate client's psychological adjustment to the diagnosis of cancer and the treatment regimen and its effects. Edx>>Advise to increase activity gradually as tolerated >Advise to consult appropriate health care provider (e.g. oncology nurse specialist, physician) if signs and

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symptoms of fatigue worsen. >Inform client that a feeling of persistent fatigue is not unusual and is a result of the disease itself as well as a side effect of chemoradiotherapy. >Instruct client in energysaving techniques (e.g. using shower chair when taking a bath, sitting to brush teeth or comb hair, prioritizing activities and eliminating those that are optional) >Encourage to take rest periods in between activities

Ref: http://books.google.com.ph/books?id=dZe4ZSVDdBsC&pg=PA306&lpg=PA306&dq=nursing+care+plan-fatigue+related+to+chemotherapy&source=bl&ots=yICZkuX_WC&sig=4QIFCCrmTdhwAQqmzk7pppXk0w&hl=tl&sa=X&ei=AydeT4m4MuHGmQXjzsihDw&ved=0CGsQ6AEwCQ#v=onepage&q=nursing%20care%20plan-fatigue%20related%20to%20chemotherapy&f=false th : Doenges, Marilyn, Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span, 7 ed. th Doenges, Marilyn, Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, 11 ed

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C. Schematic Pathophysiology of Lung Cancer


Modifiable Risk Factors Tobacco smoke Second hand (passive) smoke Environmental and occupational Exposures Dietary deficits Respiratory diseases

Non modifiable Risk Factors Gender Genetics Genetics predisposition

Carcinogenics agent will enter the respiratory tract LEGEND: Diagnostic Test Nursing Diagnosis Signs and symptoms Transformation of a single epithelial cell in the tracheobronchial always It will attack the epithelial cells/ Lining of the lungs

Attachment of a carcinogen into cells DNA causing damage

Cellular changes, abnormal cell growth, and eventually a malignant cell

Mutations in the K RAS proto oncogenes will develop cancer cells

Proto oncogenes will turn into oncogenes

Chromosomal damage can lead to heterozygosity

Can cause inactivation of tumor suppressor genes

CASE ANALYSIS BANIQUED, Charmaine Acosta


Passing of damaged DNA to daughter cells causing further changes and becomes unstable.

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Cancer cell proliferate due to inhibition of tumor suppressor genes

Pulmonary epithelium undergoes malignant transformation Wheezing SOB Dyspnea Lung Cancer

Formation of tissue mass Bronchoscopy FNAB PET scan CT-scan MRI

>Ineffective airway clearance >Impaired gas exchange

Cough / hemoptysis Chest pain Acute pain Fatigue

Treatment modalities
Anxiety Surgery Knowledge deficit Anxiety Chemotherapy Anemia Risk for ineffective management Altered comfort Anesthesia effects Risk for altered respiratory function Risk for colonic constipation

Knowledge deficit

Anxiety Knowledge deficit Radiation therapy Dryness of mouth Altered oral mucos membrane Radiation affect epithelial and basal cells Altered comfort N/V, DRH Alopecia, skin changes, changes in role relationships and life style

Fatigue

Deficient Fluid Volume Risk for impaired skin Taste changes, Altered integrity anorexia nutrition N / V, gastrointestinal disturbances Risk for infection Impaired skin integrity

Bone marrow suppression Dryness of the mouth

Wound Acute pain Activity intolerance Risk for altered nutrition: less than body requirements

Impaired skin integrity Tissue trauma Risk for infection

Altered oral mucos membrane

Lifestyle changes, role, alopecia, & weight loss Grieving Self-concept disturbance Altered family processes

Self-concept disturbance Grieving Altered family processes

Ref:McCance,Understanding Pathophysiology, 4th ed.

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Roles of an Oncology Nurse (Focus: Treatment modality- Standards of Care) EXPANDING THE ROLE OF THE ONCOLOGY NURSE NURSING PRACTICE The involvement of oncology nurses today evolves into practice in a variety of settings, including acute-care hospitals, outpatient clinics, private oncologists offices, radiation therapy facilities, home health care agencies and community agencies. This means that as the treatments in oncology became increasingly complex the oncology nurse needs to be more competitive in order to provide unique comprehensive patient care. Aside from the more advanced way of navigating patients who were undertreated which means earlier detection leads to earlier treatment, expanding the scope of an oncology nurse especially in the participation in treatment modalities such as chemotherapy, radiotherapy and hormone therapy also opens a window for bigger opportunities for the nurse to reach out and enhance the delivery of care to help cancer patients. This is somehow a way for the oncology nurse to practice independently from the physician in terms of giving the chemodrugs. More nurses involved in the continuity of palliative care. This study somehow provide basis for an oncology nurse on what they can do in the extent of their service. Furthermore, this study open our eyes on how diverse could be the field of oncology nursing as more and more subfields emerge. Hence, the more opportunities for the oncology nurse to upgrade their skills in delivering anti-cancer-drugs. Not only that, as they are also pivotal in the duration of treatment because they are not only capable of giving the drugs but they are also the ones staying with the patient, teaching the possible side-effects and how to prevent them. NURSING EDUCATION In the academe, clinical instructors could also update their supervisory student nurses in the area of the emerging fields in oncology nursing therefore entails expanding the responsibilities and more complex procedures that the oncology nurse could do. Though, one is not trained by those exact procedures on how they are done, as a clinical instructor, imparting knowledge for an overview or familiarity sake is a very important role of an educator. We never know, as a nurse educator, mentorship is also a part of our duty and we could touch and inspire lives of the students who could later realize a calling for this career path. Tackling on the career path development, which is a topic actually during undergrad, the emerging subfields of oncology nursing is of concern and can be discussed to help students realize their potentials. NURSING RESEARCH The reason why more and more subfields of oncology nursing emerged is the fact that this is rooted from a research. If a study conducted sees an opportunity for the need of more specialized oncology nurse on a particular care of a certain cancer, hence, an opening of a new subfield for practice. So, it is needless to say that this journal may be used as additional review of related literatures for related studies to be conducted in the future that may possibly offer more great opportunities for oncology nurses or for the whole nursing community.