About
Spread of cancer from one part of the body to another. Can include organs, lymph system, blood, skin, bone, brain, etc.
Assess
Diagnostic tests, vital signs, pain, nausea, coping mechanisms, family support systems, neurological status, orientation, lung sounds, bowel sounds, nutritional status.
Complications
Hypercalcemia, superior vena cava syndrome, Syndrome of inappropriate antidiuretic hormone, spinal cord compression, metastasis, disseminated intravascular coagulation ( DIC), bleeding, pericardial effusion, cardiac tamponade, infection, septic shock, death
Diagnosis
- Risk for infection related to immunodeficiency.
- Risk for injury related to impaired immune defenses.
- Fear related to threat of death.
- Disturbed body image related to changes in physical appearance.
- Nutrition less than body requirements related to impaired oral intake.
- Impaired mucous membranes related to stomatitis.
- Fatigue related to immune system compromise.
- Acute pain related to disease progression and infiltration of surrounding tissues and organs.
- Anticipatory grieving related to disease progression.
Goals
- The client will remain free from infection.
- The client will maintain adequate nutrition.
- The client will be able to discuss fears, concerns related to diagnosis.
- The client will maintain intact skin integrity.
- The client will be able to discuss anxiety related to body changes, hair loss.
- The client will have adequate pain relief.
- The client will have an increase in activity tolerance.
- The client will remain free from complications.
Interventions
- Monitor for signs and symptoms of infection.
- Administer anti-emetics, pain medicines as needed.
- Encourage small, frequent high caloric meals.
- Encourage client to express fears and concerns related to diagnosis.
- Encourage adequate fluid intake.
- Avoid sick personnel, visitors.
- Monitor IV sites frequently, assess for blood return prior to administering antineoplastic agents.
- Report any increase in temperature, rash, pain, achiness, diarrhea as may indicate infection.
- Monitor WBC's and neutrophils after chemotherapy and implement precautions if significant decrease in WBC < 1000/mm3 or neutropenia.
- Monitor oral cavity and treat promptly for thrush/ stomatitis.
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