Cancer Nursing Care Plans

Anticipatory Grieving
Grieving: A normal complex process that includes emotional, physical, spiritual, social, and intellectual responses and behaviors by which
individuals, families, and communities incorporate an actual, anticipated, or perceived loss into their daily lives.
May be related to
 Anticipated loss of physiological well-being (e.g., loss of body part; change in body function); change in lifestyle
 Perceived potential death of patient
Possibly evidenced by
 Changes in eating habits, alterations in sleep patterns, activity levels, libido, and communication patterns
 Denial of potential loss, choked feelings, anger
Desired Outcomes
 Identify and express feelings appropriately.
 Continue normal life activities, looking toward/planning for the future, one day at a time.
 Verbalize understanding of the dying process and feelings of being supported in grief work.

Nursing Interventions Rationale

Expect initial shock and disbelief following diagnosis of

Few patients are fully prepared for the reality of the changes
cancer and traumatizing procedures (disfiguring surgery,
that can occur.
colostomy, amputation).
Knowledge about the grieving process reinforces the
Assess patient and SO for stage of grief currently being
normality of feelings and reactions being experienced and can
experienced. Explain process as appropriate.
help patient deal more effectively with them.
Provide open, nonjudgmental environment.
Promotes and encourages realistic dialogue about feelings
Use therapeutic communication skills of Active-Listening,
and concerns.
acknowledgment, and so on.
Encourage verbalization of thoughts or concerns and Patient may feel supported in expression of feelings by the
accept expressions of sadness, anger, rejection. understanding that deep and often conflicting emotions are
Acknowledge normality of these feelings. normal and experienced by others in this difficult situation.
Be aware of mood swings, hostility, and other acting-out Indicators of ineffective coping and need for additional
behavior. Set limits on inappropriate behavior, redirect interventions. Preventing destructive actions enables patient
 Nursing Interventions Rationale

negative thinking. to maintain control and sense of self-esteem.

Studies show that many cancer patients are at high risk
Be aware of debilitating depression. Ask patient direct
for suicide. They are especially vulnerable when recently
questions about state of mind.
diagnosed and discharged from hospital.
Visit frequently and provide physical contact as
appropriate, or provide frequent phone support as
Helps reduce feelings of isolation and abandonment.
appropriate for setting. Arrange for care provider and
support person to stay with patient as needed.
Reinforce teaching regarding disease process and Patient and SO benefit from factual information. Individuals
treatments and provide information as appropriate about may ask direct questions about death, and honest answers
dying. Be honest; do not give false hope while providing promote trust and provide reassurance that correct
emotional support. information will be given.
Review past life experiences, role changes, and coping Opportunity to identify skills that may help individuals cope
skills. Talk about things that interest the patient. with grief of current situation more effectively.
Note evidence of conflict; expressions of anger; and Interpersonal conflicts or angry behavior may be patient’s way
statements of despair, guilt, hopelessness, “nothing to live of expressing and dealing with feelings of despair or spiritual
for.” distress and could be indicative of suicidal ideation.
Determine way that patient and SO understand and
respond to death such as cultural expectations, learned These factors affect how each individual deals with the
behaviors, experience with death (close family members, possibility of death and influences how they may respond and
friends), beliefs about life after death, faith in Higher Power interact.
(God).
Possibility of remission and slow progression of disease and
Identify positive aspects of the situation.
new therapies can offer hope for the future.
Discuss ways patient and SO can plan together for the Having a part in problem solving and planning can provide a
future. Encourage setting of realistic goals. sense of control over anticipated events.
 Nursing Interventions Rationale

Provides support in meeting physical and emotional needs of

Refer to visiting nurse, home health agency as needed, or
patient and SO, and can supplement the care family and
hospice program, if appropriate.
friends are able to give.

Situational Low Self-Esteem: Development of a negative perception of self-worth in response to current situation.

May be related to
 Biophysical: disfiguring surgery, chemotherapy or radiotherapy side effects, e.g., loss of hair, nausea/vomiting, weight loss,
anorexia, impotence, sterility, overwhelming fatigue, uncontrolled pain
 Psychosocial: threat of death; feelings of lack of control and doubt regarding acceptance by others; fear and anxiety
Possibly evidenced by
 Verbalization of change in lifestyle; fear of rejection/reaction of others; negative feelings about body; feelings of helplessness,
hopelessness, powerlessness
 Preoccupation with change or loss
 Not taking responsibility for self-care, lack of follow-through
 Change in self-perception/other’s perception of role
Desired Outcomes
 Verbalize understanding of body changes, acceptance of self in situation.
 Begin to develop coping mechanisms to deal effectively with problems.
 Demonstrate adaptation to changes/events that have occurred as evidenced by setting of realistic goals and active
participation in work/play/personal relationships as appropriate.
Nursing Interventions Rationale

Discuss with patient and SO how the diagnosis and

treatment are affecting the patient’s personal life, home Aids in defining concerns to begin problem-solving process.
and work activities.
Review anticipated side effects associated with a particular Anticipatory guidance can help patient and SO begin the
treatment, including possible effects on sexual activity and process of adaptation to new state and to prepare for some
sense of attractiveness and desirability (alopecia, side effects (buy a wig before radiation, schedule time off
 Nursing Interventions Rationale

disfiguring surgery). Tell patient that not all side effects

from work as indicated).
occur, and others may be minimized or controlled.
Encourage discussion of concerns about effects of cancer
May help reduce problems that interfere with acceptance of
and treatments on role as homemaker, wage earner,
treatment or stimulate progression of disease.
parent, and so forth.
Acknowledge difficulties patient may be experiencing. Give Validates reality of patient’s feelings and gives permission to
information that counseling is often necessary and take whatever measures are necessary to cope with what is
important in the adaptation process. happening.
Evaluate support structures available to and used by Helps with planning for care while hospitalized and after
patient and SO. discharge.
Although some patients adapt or adjust to cancer effects or
Provide emotional support for patient and SO during
side effects of therapy, many need additional support during
diagnostic tests and treatment phase.
this period.
Use touch during interactions, if acceptable to patient, and Affirmation of individuality and acceptance is important in
maintain eyecontact. reducing patient’s feelings of insecurity and self-doubt.
May be necessary to regain and maintain a positive
Refer for professional counseling as indicated. psychosocial structure if patient and SO support systems are
deteriorating.

Acute Pain
Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such
damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.
May be related to
  Disease process (compression/destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve
pathway, inflammation)
 Side effects of various cancer therapy agents
Possibly evidenced by
 Reports of pain
 Self-focusing/narrowed focus
 Alteration in muscle tone; facial mask of pain
 Distraction/guarding behaviors
 Autonomic responses, restlessness (acute pain)
Desired Outcomes
 Report maximal pain relief/control with minimal interference with ADLs.
 Follow prescribed pharmacological regimen.
 Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing Interventions Rationale

Information provides baseline data to evaluate effectiveness

of interventions. Pain of more than 6 mo duration
Determine pain history (location of pain, frequency,
constitutes chronic pain, which may affect therapeutic
duration, and intensity using numeric rating scale (0–10
choices. Recurrent episodes of acute pain can occur within
scale), or verbal rating scale (“no pain” to “excruciating
chronic pain, requiring increased level of intervention. Note:
pain”) and relief measures used. Believe patient’s report.
The pain experience is an individualized one composed of
both physical and emotional responses.
Pain may occur near the end of the dose interval, indicating
Determine timing or precipitants of “breakthrough” pain need for higher dose or shorter dose interval. Pain may be
when using around-the-clock agents, whether oral, IV, or precipitated by identifiable triggers, or occur spontaneously,
patch medications. requiring use of short half-life agents for rescue or
supplemental doses.
Evaluate and be aware of painful effects of particular A wide range of discomforts are common (incisional pain,
therapies (surgery, radiation, chemotherapy, biotherapy). burning skin, low back pain, headaches), depending on the
Provide information to patient and SO about what to procedure and agent being used. Pain is also associated with
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expect. invasive procedures to diagnose or treat cancer.

Provide nonpharmacological comfort measures (massage,
repositioning, backrub) and diversional activities (music, Promotes relaxation and helps refocus attention.
television)
Enables patient to participate actively in nondrug treatment of
Encourage use of stress management skills or
pain and enhances sense of control. Pain produces stressand,
complementary therapies (relaxation techniques,
in conjunction with muscle tension and internal stressors,
visualization, guided imagery, biofeedback, laughter, music,
increases patient’s focus on self, which in turn increases the
aromatherapy, and therapeutic touch).
level of pain.
May decrease inflammation, muscle spasms, reducing
associated pain. Note: Heat may increase bleeding and edema
Provide cutaneous stimulation (heat or cold, massage).
following acute injury, whereas cold may further reduce
perfusion to ischemic tissues.
Patients may be reluctant to report pain for reasons such as
fear that disease is worse; worry about unmanageable side
effects of pain medications; beliefs that pain has meaning,
such as “God wills it,” they should overcome it, or that pain is
Be aware of barriers to cancer pain management related to
merited or deserved for some reason. Healthcare system
patient, as well as the healthcare system.
problems include factors such as inadequate assessment of
pain, concern about controlled substances or patient
addiction, inadequate reimbursement or cost of treatment
modalities.
Evaluate pain relief and control at regular intervals. Goal is maximum pain control with minimum interference
Adjust medication regimen as necessary. with ADLs.
Inform patient and SO of the expected therapeutic effects This information helps establish realistic expectations,
and discuss management of side effects confidence in own ability to handle what happens.
Discuss use of additional alternative or complementary May provide reduction or relief of pain without drug-related
 Nursing Interventions Rationale

therapies (acupuncture and acupressure). side effects.

Administer analgesics as indicated:
 Opioids: codeine, morphine (MS Contin),
oxycodone (oxycontin) hydrocodone (Vicodin), A wide range of analgesics and associated agents may be
hydromorphone (Dilaudid), methadone employed around the clock to manage pain. Note: Addiction
(Dolophine), fentanyl (Duragesic); oxymorphone to or dependency on drug is not a concern.
(Numorphan);
 Acetaminophen (Tylenol); and nonsteroidal
Effective for localized and generalized moderate to severe
anti-inflammatory drugs (NSAIDs),
pain, with long-acting and controlled-release forms available.
including aspirin, ibuprofen (Motrin, Advil)
Routes of administration include oral, transmucosal,
transdermal, nasal, rectal, and infusions (subcutaneous, IV,
intraventricular), which may be delivered via PCA. IM use is
not recommended because absorption is not reliable, in
 piroxicam (Feldene)
addition to being painful and inconvenient. Note: Research is
in process for oral transmucosal agent (fentanyl citrate
[oralet]) to control breakthrough pain in patients using
fentanyl patch.
Adjuvant drugs are useful for mild to moderate pain and can
 indomethacin (Indocin)
be combined with opioids and other modalities.
May be effective in controlling pain associated with
 Corticosteroids:
inflammatory process (metastatic bone pain, acute spinal
dexamethasone (Decadron)
cordcompression and neuropathic pain).

Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic needs.
May be related to
 Hypermetabolic state associated with cancer
  Consequences of chemotherapy, radiation, surgery, e.g., anorexia, gastric irritation, taste distortions, nausea
 Emotional distress, fatigue, poorly controlled pain
Possibly evidenced by
 Reported inadequate food intake, altered taste sensation, loss of interest in food, perceived/actual inability to ingest food
 Body weight 20% or more under ideal for height and frame, decreased subcutaneous fat/muscle mass
 Sore, inflamed buccal cavity
 Diarrhea and/or constipation, abdominal cramping
Desired Outcomes
 Demonstrate stable weight/progressive weight gain toward goal with normalization of laboratory values and be free of signs of
malnutrition.
 Verbalize understanding of individual interferences to adequate intake.
 Participate in specific interventions to stimulate appetite/increase dietary intake.

Nursing Interventions Rationale

Monitor daily food intake; have patient keep food diary as

Identifies nutritional strengths and deficiencies.
indicated.
Measure height, weight, and tricep skinfold thickness (or
other anthropometric measurements as appropriate). If these measurements fall below minimum standards,
Ascertain amount of recent weight loss. Weigh daily or as patient’s chief source of stored energy (fat tissue) is depleted.
indicated.
Helps in identification of protein-calorie malnutrition,
Assess skin and mucous membranes for pallor, delayed
especially when weight and anthropometric measurements
wound healing, enlarged parotid glands.
are less than normal.
Metabolic tissue needs are increased as well as fluids (to
Encourage patient to eat high-calorie, nutrient-rich diet,
eliminate waste products). Supplements can play an
with adequate fluid intake. Encourage use of supplements
important role in maintaining adequate caloric and protein
and frequent or smaller meals spaced throughout the day.
intake.
Create pleasant dining atmosphere; encourage patient to
Makes mealtime more enjoyable, which may enhance intake.
share meals with family and friends.
 Nursing Interventions Rationale

Often a source of emotional distress, especially for SO who

Encourage open communication regarding anorexia. wants to feed patient frequently. When patient refuses, SO
may feel rejected or frustrated.
Adjust diet before and immediately after treatment (clear, The effectiveness of diet adjustment is very individualized in
cool liquids, light or bland foods, candied ginger, dry relief of posttherapy nausea. Patients must experiment to find
crackers, toast, carbonated drinks). Give liquids 1 hr before best solution or combination. Avoiding fluids during meals
or 1 hr after meals. minimizes becoming “full” too quickly.
Control environmental factors (strong or noxious odors or
Can trigger nausea and vomiting response.
noise). Avoid overly sweet, fatty, or spicy foods.
Encourage use of relaxation techniques, visualization, May prevent onset or reduce severity of nausea, decrease
guided imagery, moderate exercise before meals. anorexia, and enable patient to increase oral intake.
Psychogenic nausea and vomiting occurring before
Identify the patient who experiences anticipatory nausea chemotherapy generally does not respond to antiemetic
and vomiting and take appropriate measures. drugs. Change of treatment environment or patient routine
on treatment day may be effective.
Administer antiemetic on a regular schedule before or
Nausea and vomiting are frequently the most disabling and
during and after administration of antineoplastic agent as
psychologically stressful side effects of chemotherapy.
appropriate.
Individuals respond differently to all medications. First-line
Evaluate effectiveness of antiemetic. antiemetics may not work, requiring alteration in or use of
combination drug therapy.
Certain therapies (antimetabolites) inhibit renewal of
epithelial cells lining the GI tract, which may cause changes
Hematest stools, gastric secretions.
ranging from mild erythema to severe ulceration
with bleeding.
Review laboratory studies as indicated (total lymphocyte Helps identify the degree of biochemical imbalance,
 Nursing Interventions Rationale

malnutrition and influences choice of dietary interventions.

Note: Anticancer treatments can also alter nutrition studies,
count, serum transferrin, and albumin or prealbumin).
so all results must be correlated with the patient’s clinical
status.
Provides for specific dietary plan to meet individual needs and
Refer to dietitian or nutritional support team. reduce problems associated with protein, calorie malnutrition
and micronutrient deficiencies.
In the presence of severe malnutrition (loss of 25%–30% body
Insert and maintain NG or feeding tube for enteric
weight in 2 mo) or if patient has been NPO for 5 days and is
feedings, or central line for total parenteral nutrition (TPN)
unlikely to be able to eat for another week, tube feeding or
if indicated.
TPN may be necessary to meet nutritional needs.

Risk for  Fluid Volume Deficit: At risk for experiencing vascular, cellular, or intracellular dehydration.
Risk factors may include
 Excessive losses through normal routes (e.g., vomiting, diarrhea) and/or abnormal routes (e.g., indwelling tubes, wounds)
 Hypermetabolic state
 Impaired intake of fluids
Desired Outcomes
 Display adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor, prompt
capillary refill, and individually adequate urinary output.
Nursing Interventions Rationale

Monitor I&O and specific gravity; include all output sources, Continued negative fluid balance, decreasing renal output and
(emesis, diarrhea, draining wounds. Calculate 24-hr concentration of urine suggest developing dehydration and
balance). need for increased fluid replacement.
Weigh as indicated. Sensitive measurement of fluctuations in fluid balance.
Monitor vital signs. Evaluate peripheral pulses, capillary Reflects adequacy of circulating volume.
 Nursing Interventions Rationale

refill.
Assess skin turgor and moisture of mucous membranes.
Indirect indicators of hydration status and degree of deficit.
Note reports of thirst.
Assists in maintenance of fluid requirements and reduces risk
Encourage increased fluid intake to 3000 mL per day as
of harmful side effects  such as hemorrhagic cystitis in patient
individually appropriate or tolerated.
receiving cyclophosphamide (Cytoxan).
Observe for bleeding tendencies (oozing from mucous
Early identification of problems (which may occur as a result
membranes, puncture sites); presence of ecchymosis or
of cancer or therapies) allows for prompt intervention.
petechiae.
Minimize venipunctures (combine IV starts
Reduces potential for hemorrhage and infection associated
with blood draws). Encourage patient to consider central
with repeated venous puncture.
venous catheter placement.
Avoid trauma and apply pressure to puncture sites. Reduces potential for bleeding and hematoma formation.
Given for general hydration and to dilute antineoplastic drugs
Provide IV fluids as indicated. and reduce adverse side effects (nausea and vomiting, or
nephrotoxicity).
Monitor laboratory studies (CBC, electrolytes, serum Provides information about level of hydration and
albumin). corresponding deficits.

Fatigue:  An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.
May be related to
 Decreased metabolic energy production, increased energy requirements (hypermetabolic state and effects of treatment)
 Overwhelming psychological/emotional demands
 Altered body chemistry: side effects of pain and other medications, chemotherapy
Possibly evidenced by
  Unremitting/overwhelming lack of energy, inability to maintain usual routines, decreased performance, impaired ability to
concentrate, lethargy/listlessness
 Disinterest in surroundings
Desired Outcomes
 Report improved sense of energy.
 Perform ADLs and participate in desired activities at level of ability.

Nursing Interventions Rationale

Have patient rate fatigue, using a numeric scale, if possible,

Helps in developing a plan for managing fatigue.
and the time of day when it is most severe.
Frequent rest periods and naps are needed to restore and
Plan care to allow for rest periods. Schedule activities for
conserve energy. Planning will allow patient to be active
periods when patient has most energy. Involve patient and
during times when energy level is higher, which may restore a
SO in schedule planning.
feeling of well-being and a sense of control.
Provides for a sense of control and feelings of
Establish realistic activity goals with patient.
accomplishment.
Assist with self-care needs when indicated; keep bed in low
Weakness may make ADLs difficult to complete or place the
position, pathways clear of furniture; assist with
patient at risk for injury during activities.
ambulation.
Encourage patient to do whatever possible (self-bathing,
Enhances strength and stamina and enables patient to
sitting up in chair, walking). Increase activity level as
become more active without undue fatigue.
individual is able.
Tolerance varies greatly depending on the stage of the
Monitor physiological response to activity (changes in BP,
disease process, nutrition state, fluid balance, and reaction to
heart and respiratory rate).
therapeutic regimen.
Perform pain assessment and provide pain management. Poorly managed cancer pain can contribute to fatigue.
Presence of anemia and hypoxemia reduces O2available for
Provide supplemental oxygen as indicated.
cellular uptake and contributes to fatigue.
 Nursing Interventions Rationale

Programmed daily exercises and activities help patient

maintain and increase strength and muscle tone, enhance
Refer to physical or occupational therapy.
sense of well-being. Use of adaptive devices may help
conserve energy.

Risk for Infection:  At increased risk for being invaded by pathogenic organisms.
Risk factors may include
ADVERTISEMENT
 Inadequate secondary defenses and immunosuppression, e.g., bone marrow suppression (dose-limiting side effect of both
chemotherapy and radiation).
 Malnutrition, chronic disease process
 Invasive procedures
Desired Outcomes
 Remain afebrile and achieve timely healing as appropriate.
 Identify and participate in interventions to prevent/reduce risk of infection.

Nursing Interventions Rationale

Promote good handwashing procedures by staff and

Protects patient from sources of infection, such as visitors and
visitors. Screen and limit visitors who may have infections.
staff who may have an upper respiratory infection (URI).
Place in reverse isolation as indicated.
Limits potential sources of infection and secondary
Emphasize personal hygiene.
overgrowth.
Monitor temperature. Temperature elevation may occur (if not masked by
corticosteroids or anti-inflammatory drugs) because of
various factors (chemotherapy side effects, disease process,
or infection). Early identification of infectious process enables
 Nursing Interventions Rationale

appropriate therapy to be started promptly.

Assess all systems (skin, respiratory, genitourinary) for Early recognition and intervention may prevent progression to
signs and symptoms of infection on a continual basis. more serious situation or sepsis.
Reduces pressure and irritation to tissues and may prevent
Reposition frequently; keep linens dry and wrinkle-free.
skin breakdown (potential site for bacterial growth).
Limits fatigue, yet encourages sufficient movement to prevent
Promote adequate rest and exercise periods. stasis complications (pneumonia, decubitus,
and thrombus formation).
Development of stomatitis increases risk of infection and
Stress importance of good oral hygiene.
secondary overgrowth.
Avoid or limit invasive procedures. Adhere to aseptic Reduces risk of contamination, limits portal of entry for
techniques. infectious agents.
Bone marrow activity may be inhibited by effects of
chemotherapy, the disease state, or radiation therapy.
Monitor CBC with differential WBC and granulocyte count,
Monitoring status of myelosuppression is important for
and platelets as indicated.
preventing further complications (infection, anemia, or
hemorrhage) and scheduling drug delivery.
Obtain cultures as indicated. Identifies causative organism(s) and appropriate therapy.
May be used to treat identified infection or given
Administer antibiotics as indicated.
prophylactically in immuno- compromised patient.

Risk for  Impaired Oral Mucous Membrane: Disruptions of the lips and soft tissues of the oral cavity
Risk factors may include
 Side effect of some chemotherapeutic agents (e.g., antimetabolites) and radiation
 Dehydration, malnutrition, NPO restrictions for more than 24 hr
Desired Outcomes
  Display intact mucous membranes, which are pink, moist, and free of inflammation/ulcerations.
 Verbalize understanding of causative factors.
 Demonstrate techniques to maintain/restore integrity of oral mucosa.
Nursing Interventions Rationale

Identifies prophylactic treatment needs before initiation of

Assess dental health and oral hygiene periodically. chemotherapy or radiation and provides baseline data of
current oral hygiene for future comparison.
Encourage patient to assess oral cavity daily, noting
changes in mucous membrane integrity (dry, reddened).
Good care is critical during treatment to control stomatitis
Note reports of burning in the mouth, changes in voice
complications.
quality, ability to swallow, sense of taste, development of
thick or viscous saliva, blood-tinged emesis.
Discuss with patient areas needing improvement and Products containing alcohol or phenol may exacerbate
demonstrate methods for good oral care. mucous membrane dryness and irritation.
Initiate and recommend oral hygiene program to include: May be soothing to the membranes.
 Avoidance of commercial mouthwashes, lemon Rinsing before meals may improve the patient’s sense of
or glycerine swabs taste.
 Use of mouthwash made from warm saline,
Rinsing after meals and at bedtime dilutes oral acids and
dilute solution of hydrogen peroxide or baking
relieves xerostomia.
soda and water
Prevents trauma to delicate and fragile tissues. Note:
 Brush with soft toothbrush or foam swab
Toothbrush should be changed at least every 3 mo.
Removes food particles that can promote bacterial growth.
 Floss gently or use WaterPik cautiously Note: Water under pressure has the potential to injure gums
or force bacteria under gum line.
 Keep lips moist with lip gloss or balm, K-Y Jelly, Promotes comfort and prevents drying and cracking of
Chapstick tissues.
 Nursing Interventions Rationale

Stimulates secretions and provides moisture to maintain

Encourage use of mints or hard candy or artificial saliva
integrity of mucous membranes, especially in presence of
(Ora-Lube, Salivart) as indicated.
dehydration and reduced saliva production.
Severe stomatitis may interfere with nutritional and fluid
Instruct regarding dietary changes: avoid hot or spicy
intake leading to negative nitrogen balance or dehydration.
foods, acidic juices; suggest use of straw; ingest soft or
Dietary modifications may make foods easier to swallow and
blenderized foods, Popsicles, and ice cream as tolerated.
may feel soothing.
Adequate hydration helps keep mucous membranes moist,
Encourage fluid intake as individually tolerated.
preventing drying and cracking.
May cause further irritation and dryness of mucous
Discuss limitation of smoking and alcohol intake. membranes. Note: May need to compromise if these activities
are important to patient’s emotional status.
Monitor for and explain to patient signs of oral
Early recognition provides opportunity for prompt treatment.
superinfection (thrush).
Refer to dentist before initiating chemotherapy or head or Prophylactic examination and repair work before therapy
neck radiation. reduce risk of infection.
Identifies organism(s) responsible for oral infections and
Culture suspicious oral lesions.
suggests appropriate drug therapy.
Administer medications as indicated:
Aggressive analgesia program may be required to relieve
 Analgesic rinses (mixture of Koatin,
intense pain. Note: Rinse should be used as a swish-and-spit
pectin, diphenhydramine [Benadryl], and
rather than a gargle, which could anesthetize patient’s gag
topical lidocaine [Xylocaine])
reflex.
 Antifungal mouthwash preparation such as May be needed to treat or prevent secondary oral infections,
nystatin (Mycostatin), and antibacterial Biotane such as Candida, Pseudomonas, herpes simplex.
 Antinausea agents When given before beginning mouth care regimen, may
 Nursing Interventions Rationale

prevent nausea associated with oral stimulation.

 Opioid analgesics: hydromorphone (Dilaudid), May be required for acute episodes of moderate to severe
morphine. oral pain.

Risk for  Impaired Skin Integrity:  At risk for altered epidermis and/or dermis.

Risk factors may include
 Effects of radiation and chemotherapy
 Immunologic deficit
 Altered nutritional state, anemia
Desired Outcomes
 Identify interventions appropriate for specific condition.
 Participate in techniques to prevent complications/promote healing as appropriate.
Nursing Interventions Rationale

A reddening or tanning effect (radiation reaction) may develop

within the field of radiation. Dry desquamation (dryness and
Assess skin frequently for side effects of cancer therapy; pruritus), moist desquamation (blistering), ulceration, hair
note breakdown and delayed wound healing. Emphasize loss, loss of dermis and sweat glands may also be noted. In
importance of reporting open areas to caregiver. addition, skin reactions (allergic rashes, hyperpigmentation,
pruritus, and alopecia) may occur with some chemotherapy
agents.
Bathe with lukewarm water and mild soap. Maintains cleanliness without irritating the skin.
Encourage patient to avoid vigorous rubbing and scratching
Helps prevent skin friction and trauma to sensitive tissues.
and to pat skin dry instead of rubbing.
Promotes circulation and prevents undue pressure on skin
Turn or reposition frequently.
and tissues.
Review skin care protocol for patient receiving radiation Designed to minimize trauma to area of radiation therapy.
 Nursing Interventions Rationale

Can potentiate or otherwise interfere with radiation delivery.

therapy: Avoid rubbing or use of soap, lotions, creams, May actually increase irritation and reaction. Skin is very
ointments, powders or deodorants on area; sensitive during and after treatment, and all irritation should
be avoided to prevent dermal injury.
Helps control dampness or pruritus. Maintenance care is
Avoid applying heat or attempting to wash off marks or
required until skin and tissues have regenerated and are back
tattoos placed on skin to identify area of irradiation;
to normal.
Recommend wearing soft, loose cotton clothing; have Protects skin from ultraviolet rays and reduces risk of recall
female patient avoid wearing bra if it creates pressure; reactions.
Apply cornstarch, Aquaphor, Lubriderm, Eucerin (or other
Reduces risk of tissue irritation and extravasation of agent
recommended water-soluble moisturizing gel) to area twice
into tissues.
daily as needed;
Development of irritation indicates need for alteration of rate
Encourage liberal use of sunscreen or block and
or dilution of chemotherapy and change of IV site to prevent
breathable, protective clothing.
more serious reaction.
Assess skin and IV site and vein for erythema, edema,
Presence of phlebitis, vein flare (localized reaction) or
tenderness; weltlike patches, itching and burning; or
extravasation requires immediate discontinuation of
swelling, burning, soreness; blisters progressing to
antineoplastic agent and medical intervention.
ulceration or tissue necrosis.
Wash skin immediately with soap and water if
Dilutes drug to reduce risk of skin irritation and chemical
antineoplastic agents are spilled on unprotected skin
burn.
(patient or caregiver).
Advise patients receiving 5-fluorouracil (5-FU) Sun can cause exacerbation of burn spotting (a side effect of
and methotrexate to avoid sun exposure. Withhold 5-fluorouracil) or can cause a red “flash” area with
methotrexate if sunburn present. methotrexate, which can exacerbate drug’s effect.
Review expected dermatologic side effects seen with Anticipatory guidance helps decrease concern if side effects
 Nursing Interventions Rationale

chemotherapy (rash, hyperpigmentation, and peeling of

do occur.
skin on palms).
Anticipatory guidance may help in preparation for baldness.
Inform patient that if alopecia occurs, hair could grow back
Men are often as sensitive to hair loss as women. Radiation’s
after completion of chemotherapy, but may or may not
effect on hair follicles may be permanent, depending on rad
grow back after radiation therapy.
dosage.
Controversial intervention depends on type of agent used. Ice
restricts blood flow, keeping drug localized, while heat
Apply ice pack or warm compresses per protocol
enhances dispersion of neoplastic drug or antidote,
minimizing tissue damage.
Risk for Constipation/Diarrhea
Constipation: A decrease in a person’s normal frequency of defecation, accompanied by difficult or incomplete passage of stool and/or
passage of excessively hard, dry stool.
Diarrhea: Passage of loose, unformed stools
Risk factors may include
 Irritation of the GI mucosa from either chemotherapy or radiation therapy; malabsorption of fat
 Hormone-secreting tumor, carcinoma of colon
 Poor fluid intake, low-bulk diet, lack of exercise, use of opiates/narcotics
Desired Outcomes
 Maintain usual bowel consistency/pattern.
 Verbalize understanding of factors and appropriate interventions/solutions related to individual situation.

Nursing Interventions Rationale

Data required as baseline for future evaluation of therapeutic

Ascertain usual elimination habits.
needs and effectiveness.
Assess bowel sounds and record bowel movements (BMs) Defines problem (diarrhea, constipation). Note: Constipation
including frequency, consistency (particularly during first 3– is one of the earliest manifestations of neurotoxicity.
 Nursing Interventions Rationale

5 days of Vinca alkaloid therapy).

Dehydration, weight loss, and electrolyte imbalance are
Monitor I&O and weight. complications of diarrhea. Inadequate fluid intake may
potentiate constipation.
May reduce potential for constipation by improving stool
Encourage adequate fluid intake (2000 mL per 24 hr),
consistency and stimulating peristalsis; can prevent
increased fiber in diet; regular exercise.
dehydration associated with diarrhea.
Provide small, frequent meals of foods low in residue (if not
contraindicated), maintaining needed protein and Reduces gastric irritation. Use of low-fiber foods can decrease
carbohydrates (eggs., cooked cereal, bland cooked irritability and provide bowel rest when diarrhea present.
vegetables).
Adjust diet as appropriate: avoid foods high in fat (butter,
fried foods, nuts); foods with high-fiber content; those
GI stimulants that may increase gastric motility frequency of
known to cause diarrhea or gas (cabbage, baked beans,
stools.
chili); food and fluids high in caffeine; or extremely hot or
cold food and fluids.
Check for impaction if patient has not had BM in 3 days or Further interventions and alternative bowel care may be
if abdominal distension, cramping, headache are present. needed.
Monitor laboratory studies as indicated:
 Electrolytes Electrolyte imbalances may contribute to altered GI function.
Prevents dehydration, dilutes chemotherapy agents to
 Administer IV fluids
diminish side effects.
 Antidiarrheal agents May be indicated to control severe diarrhea.
 Stool softeners, laxatives, enemas as indicated Prophylactic use may prevent further complications in some
patients (those who will receive Vinca alkaloid, have poor
bowel pattern before treatment, or have decreased motility).
Risk for Altered Sexuality Patterns
Ineffective Sexuality Pattern: Expressions of concern regarding own sexuality.
Risk factors may include
 Knowledge/skill deficit about alternative responses to health-related transitions, altered body function/
 structure, illness, and medical treatment
 Overwhelming fatigue
 Fear and anxiety
 Lack of privacy/SO
Desired Outcomes
 Verbalize understanding of effects of cancer and therapeutic regimen on sexuality and measures to correct/
 deal with problems.
 Maintain sexual activity at a desired level as possible.

Nursing Interventions Rationale

Discuss with patient and SO the nature of sexuality and

Acknowledges legitimacy of the problem. Sexuality
reactions when it is altered or threatened. Provide
encompasses the way men and women view themselves as
information about normality of these problems and that
individuals and how they relate between and among
many people find it helpful to seek assistance with
themselves in every area of life.
adaptation process.
Advise patient of side effects of prescribed cancer Anticipatory guidance can help patient and SO begin the
treatment that are known to affect sexuality. process of adaptation to new state.
Provide private time for hospitalized patient. Knock on door Sexual needs do not end because the patient is hospitalized.
and receive permission from patient and SO before Intimacy needs continue and an open and accepting attitude
entering. for the expression of those needs is essential.
Refer to sex therapist as indicated. May require additional assistance in dealing with situation.

Risk for Altered Family Processes/Role Performance: At risk for a change in family relationships and/or functioning.
Risk factors may include
 Situational/transitional crises: long-term illness, change in roles/economic status
 Developmental: anticipated loss of a family member
Desired Outcomes
 Express feelings freely.
 Demonstrate individual involvement in problem-solving process directed at appropriate solutions for the situation.
 Encourage and allow member who is ill to handle situation in own way.

Nursing Interventions Rationale

Note components of family, presence of extended family Helps patient and caregiver know who is available to assist
and others (friends and neighbors). with care or provide respite and support.
Provides information about effectiveness of communication
Identify patterns of communication in family and patterns and identifies problems that may interfere with family’s ability
of interaction between family members. to assist patient and adjust positively to diagnosis and
treatment of cancer.
Each person may see the situation in own individual manner,
Assess role expectations of family members and encourage
and clear identification and sharing of these expectations
discussion about them.
promote understanding.
Provides clues about interventions that may be appropriate to
Assess energy direction (are efforts at resolution and
assist patient and family in directing energies in a more
problem solving purposeful or scattered?).
effective manner.
Affects patient and SO reaction and adjustment to diagnosis,
Note cultural and religious beliefs.
treatment, and outcome of cancer.
Helpless feelings may contribute to difficulty adjusting to
Listen for expressions of helplessness.
diagnosis of cancer and cooperating with treatment regimen.
Deal with family members in a warm, caring, respectful Provides feelings of empathy and promotes individual’s sense
way. Provide information (verbal and written), and of worth and competence in ability to handle current
reinforce as necessary. situation.
Encourage appropriate expressions of anger without Feelings of anger are to be expected when individuals are
reacting negatively to them. dealing with the difficult and potentially fatal illness of cancer.
 Nursing Interventions Rationale

Appropriate expression enables progress toward resolution of

the stages of the grieving process.
Acknowledge difficulties of the situation (diagnosis and Communicates acceptance of the reality the patient and
treatment of cancer, possibility of death). family are facing.
Identify and encourage use of previous successful coping Most people have developed effective coping skills that can be
behaviors. useful in dealing with current situation.
Promotes understanding and assists family members to
Stress importance of continuous open dialogue between
maintain clear communication and resolve problems
family members.
effectively.
May need additional assistance to resolve problems of
Refer to support groups, clergy, family therapy as indicated. disorganization that may accompany diagnosis of potentially
terminal illness (cancer).
Fear/Anxiety
Fear: Response to perceived threat that is consciously recognized as a danger.
Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.
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May be related to:
 Situational crisis (cancer)
 Threat to/change in health/socioeconomic status, role functioning, interaction patterns
 Threat of death
 Separation from family (hospitalization, treatments), interpersonal transmission/contagion of feelings
Possibly evidenced by:
 Increased tension, shakiness, apprehension, restlessness, insomnia
 Expressed concerns regarding changes in life events
 Feelings of helplessness, hopelessness, inadequacy
 Sympathetic stimulation, somatic complaints

Desired Outcomes: 
  Display appropriate range of feelings and lessened fear.
 Appear relaxed and report anxiety is reduced to a manageable level.
 Demonstrate use of effective coping mechanisms and active participation in treatment regimen.
Nursing Interventions Rationale

Review patient’s and SO’s previous experience with cancer. Clarifies patient’s perceptions; assists in identification of
Determine what the doctor has told patient and what fear(s) and misconceptions based on diagnosis and
conclusion patient has reached. experience with cancer.
Provides opportunity to examine realistic fears and
Encourage patient to share thoughts and feelings.
misconceptions about diagnosis.
Provide open environment in which patient feels safe to Helps patient feel accepted in present condition without
discuss feelings or to refrain from talking. feeling judged, and promotes sense of dignity and control.
Provides assurance that patient is not alone or rejected;
Maintain frequent contact with patient. Talk with and touch
conveys respect for and acceptance of the person, fostering
patient as appropriate.
trust.
Be aware of effects of isolation on patient when required Sensory deprivation may result when sufficient stimulation is
by immunosuppression or radiation implant. Limit use of not available and may intensify feelings of anxiety, fear and
isolation clothing and masks as possible. alienation.
Coping skills are often stressed after diagnosis and during
Assist patient and SO in recognizing and clarifying fears to different phases of treatment. Support and counseling are
begin developing coping strategies for dealing with these often necessary to enable individual to recognize and deal
fears. with fear and to realize that control and coping strategies are
available.
Provide accurate, consistent information regarding
Can reduce anxiety and enable patient to make decisions and
diagnosis and prognosis. Avoid arguing about patient’s
choices based on realities.
perceptions of situation.
Permit expressions of anger, fear, despair without
Acceptance of feelings allows patient to begin to deal with
confrontation. Give information that feelings are normal
situation.
and are to be appropriately expressed.
 Nursing Interventions Rationale

The goal of cancer treatment is to destroy malignant cells

while minimizing damage to normal ones. Treatment may
include surgery (curative, preventive, palliative), as well as
Explain the recommended treatment, its purpose, and
chemotherapy, radiation (internal, external), or organ-specific
potential side effects. Help patient prepare for treatments.
treatments such as whole-body hyperthermia or biotherapy.
Bone marrow or peripheral progenitor cell (stem cell)
transplant may be recommended for some types of cancer.
Explain procedures, providing opportunity for questions Accurate information allows patient to deal more effectively
and honest answers. Stay with patient during anxiety- with reality of situation, thereby reducing anxiety and fear of
producing procedures and consultations. the unknown.
Provide primary and consistent caregivers whenever May help reduce anxiety by fostering therapeutic
possible. relationship and facilitating continuity of care.
Facilitates rest, conserves energy, and may enhance coping
Promote calm, quiet environment.
abilities.
Identify stage and degree of grief patient and SO are Choice of interventions is dictated by stage of grief, coping
currently experiencing. behaviors (anger, withdrawal, denial).
Note ineffective coping (poor social interactions,
Identifies individual problems and provides support for
helplessness, giving up everyday functions and usual
patient and SO in using effective coping skills.
sources of gratification).
Patient may use defense mechanism of denial and express
Be alert to signs of denial and depression (withdrawal, hope that diagnosis is inaccurate. Feelings of guilt, spiritual
anger, inappropriate remarks). Determine presence of distress, physical symptoms, or lack of cure may cause patient
suicidal ideation and assess potential on a scale of 1–10. to become withdrawn and believe that suicide is a viable
alternative.
Reduces feelings of isolation. If family support systems are not
Encourage and foster patient interaction with
available, outside sources may be needed immediately, (local
support systems
cancer support groups).
 Nursing Interventions Rationale

Provide reliable and consistent information and support for Allows for better interpersonal interaction and reduction of
SO. anxiety and fear.
Include SO as indicated or patient desires when Provides a support system for patient and allows SO to
major decisions are to be made. be involved appropriately.

Other Possible Nursing Care Plans

Here are other possible nursing diagnoses for cancer:
 Fear and Anxiety—may be related to situational crises, threaten to/change in health/socioeconomic status, role functioning,
interaction, patterns, threat of death, separation from family, interpersonal transmission of feelings, possibly evidenced by
expressed concerns, feelings of inadequacy/helplessness, insomnia, increased tension, restlessness, focus on self, sympathetic
stimulation.
 Impaired home maintenance—may be related to debilitation, lack of resources, and/or inadequate support systems, possibly
evidenced by verbalization of problems, request for assistance, and lack of necessary equipments of aids.
 Compromised family coping—may be related to chronic nature of disease and disability, ongoing treatment needs, parental
supervision, and lifestyle restrictions, possibly evidenced by expression of denial/despair, depression, and protective behavior
of disproportionate to client’s abilities or need for autonomy.
 Readiness for enhanced family coping—may be related to the fact that the individual’s needs are being sufficiently gratified
and adaptive tasks effectively addressed, enabling goals of self-actualization to surface, possibly evidenced by verbalization of
impact of crisis on own values, priorities, goals and relationships.