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  • Nursing Care Plans for Lung Cancer – Best Nursing Care Plans(2022)

    This article discusses Nursing Care Plans for Lung Cancer plus its causes, symptoms, preventions, treatments, and interventions.

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    Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

    Introduction

    Lung cancer is a type of cancer that starts in the lungs. Lung cancer occurs when cells divide in the lungs uncontrollably. This causes tumors to grow. These can reduce a person’s ability to breathe and spread to other parts of the body.

    Normal structure and function of the lungs

    Lungs are 2 sponge-like organs in the chest. The right lung has 3 sections, called lobes. The left lung has 2 lobes. The left lung is smaller because the heart takes up more room on that side of the body.

    Air enters through the mouth or nose and goes into the lungs through the trachea (windpipe) when a person breathes in. The trachea divides into tubes called bronchi, which enter the lungs and divide into smaller bronchi. These divide to form smaller branches called bronchioles. At the end of the bronchioles are tiny air sacs known as alveoli.

    The alveoli absorb oxygen into your blood from the inhaled air and remove carbon dioxide from the blood when you exhale. Taking in oxygen and getting rid of carbon dioxide are your lungs’ main functions.

    Lung cancers typically start in the cells lining the bronchi and parts of the lung, such as the bronchioles or alveoli.

    A thin lining layer called the pleura surrounds the lungs. The pleura protects the lungs and helps them slide back and forth against the chest wall as they expand and contract during breathing.

    Below the lungs, a thin, dome-shaped muscle called the diaphragm separates the chest from the abdomen. When you breathe, the diaphragm moves up and down, forcing air in and out of the lungs.

    Types of lung cancer

    There are 2 main types of lung cancer, and they are treated very differently.

    Non-small cell lung cancer (NSCLC)

    About 80% to 85% of lung cancers are NSCLC. The main subtypes of NSCLC are adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. These subtypes, which start from different types of lung cells, are grouped together as NSCLC because their treatment and prognoses (outlook) are often similar.

    Adenocarcinoma: Adenocarcinomas start in the cells that would normally secrete substances such as mucus.

    This type of lung cancer occurs mainly in people who currently smoke or formerly smoked, but it is also the most common type of lung cancer seen in people who don’t smoke. It is more common in women than in men, and it is more likely to occur in younger people than other types of lung cancer.

    Adenocarcinoma is usually found in the outer parts of the lung and is more likely to be found before it has spread.

    People with a type of adenocarcinoma called adenocarcinoma in situ (previously called bronchioloalveolar carcinoma) tend to have a better outlook than those with other types of lung cancer.

    Squamous cell carcinoma: Squamous cell carcinomas start in squamous cells, which are flat cells that line the inside of the airways in the lungs. They are often linked to a history of smoking and tend to be found in the central part of the lungs, near the main airway (bronchus).

    Large cell (undifferentiated) carcinoma:  Large cell carcinoma can appear in any part of the lung. It tends to grow and spread quickly, which can make it harder to treat. A subtype of large cell carcinoma, known as large cell neuroendocrine carcinoma, is fast-growing cancer that is very similar to small cell lung cancer.

    Other subtypes: A few other subtypes of NSCLC, such as adenosquamous carcinoma and sarcomatoid carcinoma, are much less common.

    Small cell lung cancer (SCLC)

    About 10% to 15% of all lung cancers are SCLC, and it is sometimes called oat cell cancer.

    This type of lung cancer tends to grow and spread faster than NSCLC. About 70% of people with SCLC will have cancer that has already spread at the time they are diagnosed. Since this cancer grows quickly, it tends to respond well to chemotherapy and radiation therapy. Unfortunately, for most people, cancer will return at some point.

    Other types of lung tumors

    Along with the main types of lung cancer, other tumors can occur in the lungs.

    Lung carcinoid tumors: Carcinoid tumors of the lung account for fewer than 5% of lung tumors. Most of these grow slowly.

    Other lung tumors: Other types of lung cancer such as adenoid cystic carcinomas, lymphomas, and sarcomas, as well as benign lung tumors such as hamartomas, are rare. These are treated differently from the more common lung cancers and are not discussed here.

    Cancers that spread to the lungs: Cancers that start in other organs (such as the breast, pancreas, kidney, or skin) can sometimes spread (metastasize) to the lungs, but these are not lung cancers. For example, cancer that starts in the breast and spreads to the lungs is still breast cancer, not lung cancer. Treatment for metastatic cancer to the lungs is based on where it started (the primary cancer site).

    Symptoms and Signs of Lung Cancer

    People with lung cancer may not have any symptoms until a later stage. If symptoms do appear, they can resemble those of a respiratory infection.

    Some possible symptoms include:

    • Changes to a person’s voice, such as hoarseness
    • Frequent chest infections, such as bronchitis or pneumonia
    • Swelling in the lymph nodes in the middle of the chest
    • A lingering cough that may start to get worse
    • Chest pain
    • Shortness of breath and wheezing

    In time, a person may also experience more severe symptoms, such as:

    • Severe chest pain
    • Bone pain and bone fractures
    • Headaches
    • Coughing up blood
    • Blood clots
    • Appetite loss and weight loss
    • Fatigue

    Causes of Lung Cancer

    Smoking causes the majority of lung cancers — both in smokers and in people exposed to secondhand smoke. But lung cancer also occurs in people who never smoked and in those who never had prolonged exposure to secondhand smoke. In these cases, there may be no clear cause of lung cancer.

    How smoking causes lung cancer

    Doctors believe smoking causes lung cancer by damaging the lungs’ cells. When a person inhales cigarette smoke, which is full of cancer-causing substances (carcinogens), changes in the lung tissue begin almost immediately.

    At first, the body may be able to repair this damage. But with each repeated exposure, normal cells that line the lungs are increasingly damaged. Over time, the damage causes cells to act abnormally, and eventually, cancer may develop.

    Stages of Lung Cancer

    The staging of cancer describes how far it has spread through the body and how severe it is. Staging helps healthcare professionals and individuals decide on a suitable course of treatment.

    The most basic form of staging is as follows:

    • Localized, wherein the cancer is within a limited area
    • Regional, wherein cancer has spread to nearby tissues or lymph nodes
    • Distant, wherein cancer has spread to other parts of the body

    Similar to this is the TNM staging system. Healthcare professionals assess the tumor for size and spread, whether or not it affects the lymph nodes, and whether or not it has spread elsewhere.

    There are also specific ways of staging non-small cell and small cell lung cancer.

    Stages of Non-Small Cell Lung Cancer

    Healthcare professionals typically use tumor size and spread to describe the stages of non-small cell lung cancer, as follows:

    Occult or hidden: Cancer does not show up on imaging scans, but cancerous cells might appear in the phlegm or mucus.

    Stage 0: There are abnormal cells only in the top layers of cells lining the airways.

    Stage 1: A tumor is present in the lung, but it is 4 centimeters (cm) or under and has not spread to other parts of the body.

    Stage 2: The tumor is 7 cm or under and might have spread to nearby tissues and lymph nodes.

    Stage 3: Cancer has spread to lymph nodes and reached other parts of the lung and surrounding area.

    Stage 4: Cancer has spread to distant body parts, such as the bones or brain.

    Stages of Small Cell Lung Cancer

    Small cell lung cancer has its own categories. The stages are known as limited and extensive, and they refer to whether cancer has spread within or outside the lungs.

    Cancer affects only one side of the chest in the limited stage, though it might already be present in some surrounding lymph nodes.

    Around one-third of people with this type find out that they have cancer when it is in the limited stage. Healthcare professionals can treat it with radiation therapy as a single area.

    In the extensive stage, cancer has spread beyond the one side of the chest. It may affect the other lung or other parts of the body.

    Around two-thirds of people with small cell lung cancer find out that they have it when it is already in the extensive stage.

    Risk factors for Lung Cancer

    A number of factors may increase the risk of lung cancer. Some risk factors can be controlled, for instance, by quitting smoking. And other factors can’t be controlled, such as family history.

    Risk factors for lung cancer include:

    Smoking. Your risk of lung cancer increases with the number of cigarettes you smoke each day and the number of years you have smoked. Quitting at any age can significantly lower your risk of developing lung cancer.

    Exposure to secondhand smoke. Even if you don’t smoke, your risk of lung cancer increases if you’re exposed to secondhand smoke.

    Previous radiation therapy. If you’ve undergone radiation therapy to the chest for another type of cancer, you may have an increased risk of developing lung cancer.

    Exposure to radon gas. Radon is produced by the natural breakdown of uranium in soil, rock, and water that eventually becomes part of the air you breathe. Unsafe levels of radon can accumulate in any building, including homes.

    Exposure to asbestos and other carcinogens. Workplace exposure to asbestos and other substances are known to cause cancer — such as arsenic, chromium, and nickel — can increase your risk of developing lung cancer, especially if you’re a smoker.

    Family history of lung cancer. People with a parent, sibling, or child with lung cancer have an increased risk of the disease.

    Complications of Lung Cancer

    Lung cancer can cause complications, such as:

    Shortness of breath. People with lung cancer can experience shortness of breath if cancer grows to block the major airways. Lung cancer can also cause fluid to accumulate around the lungs, making it harder for the affected lung to expand fully when you inhale.

    Coughing up blood. Lung cancer can cause bleeding in the airway, which can cause you to cough up blood (hemoptysis). Sometimes bleeding can become severe. Treatments are available to control bleeding.

    Pain. Advanced lung cancer that spreads to the lining of a lung or to another area of the body, such as a bone, can cause pain. Tell your doctor if you experience pain, as many treatments are available to control pain.

    Fluid in the chest (pleural effusion). Lung cancer can cause fluid to accumulate in the space that surrounds the affected lung in the chest cavity (pleural space).

    Fluid accumulating in the chest can cause shortness of breath. Treatments are available to drain the fluid from your chest and reduce the risk that pleural effusion will occur again.

    Cancer that spreads to other parts of the body (metastasis). Lung cancer often spreads (metastasizes) to other parts of the body, such as the brain and the bones.

    Cancer that spreads can cause pain, nausea, headaches, or other signs and symptoms depending on what organ is affected. It’s generally not curable once lung cancer has spread beyond the lungs. Treatments are available to decrease signs and symptoms and to help you live longer.

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    Nursing Care Plans for Lung Cancer
    Nursing Care Plans for Lung Cancer

    Prevention of Lung Cancer

    There’s no sure way to prevent lung cancer, but you can reduce your risk if you:

    Don’t smoke. If you’ve never smoked, don’t start. Talk to your children about not smoking so that they can understand how to avoid this major risk factor for lung cancer. Begin conversations about the dangers of smoking with your children early so that they know how to react to peer pressure.

    Stop smoking. Stop smoking now. Quitting reduces your risk of lung cancer, even if you’ve smoked for years. Talk to your doctor about strategies and stop-smoking aids that can help you quit. Options include nicotine replacement products, medications, and support groups.

    Avoid secondhand smoke. If you live or work with a smoker, urge him or her to quit. At the very least, ask him or her to smoke outside. Avoid areas where people smoke, such as bars and restaurants, and seek out smoke-free options.

    Test your home for radon. High radon levels can be remedied to make your home safer. For information on radon testing, contact your local department of public health or a local chapter of the American Lung Association.

    Avoid carcinogens at work. Take precautions to protect yourself from exposure to toxic chemicals at work. Follow your employer’s precautions. For instance, if you’re given a face mask for protection, always wear it. Ask your doctor what more you can do to protect yourself at work. Your risk of lung damage from workplace carcinogens increases if you smoke.

    Eat a diet full of fruits and vegetables. Choose a healthy diet with a variety of fruits and vegetables. Food sources of vitamins and nutrients are best. Avoid taking large doses of vitamins in pill form, as they may be harmful. For instance, researchers hoping to reduce the risk of lung cancer in heavy smokers gave them beta carotene supplements. Results showed the supplements actually increased the risk of cancer in smokers.

    Exercise most days of the week. If you don’t exercise regularly, start out slowly. Try to exercise most days of the week.

    Diagnosis of Lung Cancer

    1. Chest X-ray may be suspicious for mass; CT or position emission tomography scan will be better visualize the tumor.
    2. Sputum and pleural fluid samples for cytologic examination may show malignant cells.
    3. Fiberoptic bronchoscopy determines the location and extent of the tumor and may be used to obtain a biopsy specimen.
    4. Lymph node biopsy and mediastinoscopy may be ordered to establish lymphatic spread and help plan treatment.
    5. A pulmonary function test, which may be combined with a split-function perfusion scan, determines if the patient will have an adequate pulmonary reserve to withstand surgical procedures.

    Nursing Care Plans for Lung Cancer Based on Nursing Diagnosis

    Nursing Care Plan 1: Diagnosis – Impaired Gas Exchange

    May be related to:

    • Removal of lung tissue
    • Altered oxygen supply (hypoventilation)
    • Decreased oxygen-carrying capacity of blood (blood loss)

    Possibly evidenced by:

    • Dyspnea
    • Restlessness/changes in mentation
    • Hypoxemia and hypercapnia
    • Cyanosis

    Desired Outcomes

    Patient will:

    • Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within the patient’s normal range.
    • Be free of symptoms of respiratory distress.

    Nursing Interventions

    Note respiratory rate, depth, and ease of respirations. Observe for the use of accessory muscles, pursed-lip breathing, changes in skin or mucous membrane color, pallor, cyanosis.

    Rationale: Respirations may be increased as a result of pain or as an initial compensatory mechanism to accommodate for the loss of lung tissue; however, increased work of breathing and cyanosis may indicate increasing oxygen consumption and energy expenditures and/or reduced respiratory reserve.

    Auscultate lungs for air movement and abnormal breath sounds.

    Rationale: Consolidation and lack of air movement on the operative side are normal in the pneumonectomy patient; however, the lobectomy patient should demonstrate normal airflow in the remaining lobes.

    Investigate restlessness and changes in mentation or level of consciousness.

    Rationale: May indicate increased hypoxia or complications such as a mediastinal shift in pneumonectomy a patient when accompanied by tachypnea, tachycardia, and tracheal deviation.

    Assess patient response to activity. Encourage rest periods and limit activities to patient tolerance.

    Rationale: Increased oxygen consumption demand and stress of surgery can result in increased dyspnea and changes in vital signs with activity; however, early mobilization is desired to help prevent pulmonary complications and to obtain and maintain respiratory and circulatory efficiency. Adequate rest balanced with activity can prevent respiratory compromise.

    Note development of fever.

    Rationale: Fever within the first 24 hr after surgery is frequently due to atelectasis. Temperature elevation within the 5th to 10th postoperative day usually indicates a wound or systemic.

    Maintain patent airway by positioning, suctioning, use of airway adjuncts.

    Rationale: Airway obstruction impedes ventilation, impairing gas exchange.

    Reposition frequently, placing a patient in sitting positions and supine to side positions.

    Rationale: Maximizes lung expansion and drainage of secretions.

    Avoid positioning a patient with a pneumonectomy on the operative side; instead, favor the “good lung down” position.

    Rationale: Research shows that positioning patients following lung surgery with their “good lung down” maximizes oxygenation by using gravity to enhance blood flow to the healthy lung, thus creating the best possible match between ventilation and perfusion.

    Encourage and assist with deep-breathing exercises and pursed-lip breathing as appropriate.

    Rationale: Promotes maximal ventilation and oxygenation and reduces or prevents atelectasis.

    Maintain patency of chest drainage system for lobectomy, segmental, or wedge resection patient.

    Rationale: Drains fluid from the pleural cavity to promote re-expansion of remaining lung segments.

    Note changes in amount or type of chest tube drainage.

    Rationale: Bloody drainage should decrease in amount and change to a more serious composition as recovery progresses. A sudden increase in the amount of bloody drainage or return to frank bleeding suggests thoracic bleeding or hemothorax; sudden cessation suggests tube blockage, requiring further evaluation and intervention.

    Observe the presence or degree of bubbling in the water-seal chamber.

    Rationale: Air leaks immediately postoperative are not uncommon, especially following lobectomy or segmental resection; however, this should diminish as healing progresses. Prolonged or new leaks require evaluation to identify problems inpatient versus the drainage system.

    As indicated, administer supplemental oxygen via nasal cannula, partial rebreathing mask, or high-humidity face mask.

    Rationale: Maximizes available oxygen, especially while ventilation is reduced because of anesthetic, depression, or pain, and during a period of a compensatory physiological shift of circulation to remaining functional alveolar units.

    Assist with and encourage the use of an incentive spirometer.

    Rationale: Prevents or reduces atelectasis and promotes re-expansion of small airways.

    Monitor and graph ABGs, pulse oximetry readings. Note hemoglobin (Hb) levels.

    Rationale: Decreasing Pao2 or increasing Paco2 may indicate a need for ventilatory support. Significant blood loss can result in decreased oxygen-carrying capacity, reducing Pao2.

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    Nursing Care Plans for Lung Cancer
    Nursing Care Plans for Lung Cancer

    Nursing Care Plan 2: Diagnosis – Ineffective Airway Clearance

    May be related to:

    • Increased amount/viscosity of secretions
    • Restricted chest movement/pain
    • Fatigue/weakness

    Possibly evidenced by:

    • Changes in rate/depth of respiration
    • Abnormal breath sounds
    • Ineffective cough
    • Dyspnea

    Desired Outcomes

    The patient will demonstrate patent airway, with fluid secretions easily expectorated, clear breath sounds, and noiseless respirations.

    Nursing Interventions

    Auscultate chest for the character of breath sounds and presence of secretions.

    Rationale: Noisy respirations, rhonchi, and wheezes are indicative of retained secretions and/or airway obstruction.

    Assist patient and instruct in effective deep breathing and coughing with upright position (sitting) and splinting of an incision.

    Rationale: Upright position favors maximal lung expansion, and splinting improves the force of cough effort to mobilize and remove secretions. Splinting may be done by a nurse (placing hands anteriorly and posteriorly over the chest wall) and by the patient (with pillows) as strength improves.

    Observe the amount and character of sputum or aspirated secretions. Investigate changes as indicated.

    Rationale: Increased amounts of colorless, blood-streaked, or watery secretions are normal initially and should decrease as recovery progresses. The presence of thick or tenacious, bloody, or purulent sputum suggests the development of secondary problems (dehydration, pulmonary edema, local hemorrhage, or infection) that require correction and treatment.

    Suction if cough is weak or breath sounds not cleared by cough effort. Avoid deep endotracheal or nasotracheal suctioning in pneumonectomy patients if possible. Suction the patient as needed, and encourage to begin deep breathing and coughing as soon as possible.

    Rationale: “Routine” suctioning increases the risk of hypoxemia and mucosal damage. Deep tracheal suctioning is generally contraindicated following pneumonectomy to reduce the risk of rupture of the bronchial stump suture line. If suctioning is unavoidable, it should be done gently and only to induce effective coughing.

    Encourage oral fluid intake (at least 2500 mL/day) within cardiac tolerance.

    Rationale: Adequate hydration aids in keeping secretions loose or enhances expectoration.

    Assess for pain or discomfort and medicate on a routine basis and before breathing exercises.

    Rationale: Encourages patient to move, cough more effectively, and breathe more deeply to prevent respiratory insufficiency.

    Assist with an incentive spirometer, postural drainage, and percussion as indicated.

    Rationale: Improves lung expansion or ventilation and facilitates removal of secretions. Postural drainage may be contraindicated in some patients and, in any event, must be performed cautiously to prevent respiratory embarrassment and incisional discomfort.

    Use humidified oxygen and/or ultrasonic nebulizer. Provide additional fluids via IV as indicated.

    Rationale: Providing maximal hydration helps loosen or liquefy secretions to promote expectoration. Impaired oral intake necessitates IV supplementation to maintain hydration.

    Administer bronchodilators, expectorants, and/or analgesics as indicated.

    Rationale: Relieves bronchospasm to improve airflow. Expectorants increase mucus production and liquefy and reduce the viscosity of secretions, facilitating removal. Alleviation of chest discomfort promotes cooperation with breathing exercises and enhances the effectiveness of respiratory therapies.

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    Nursing Care Plans for Lung Cancer
    Nursing Care Plans for Lung Cancer

    Nursing Care Plan 3: Diagnosis – Acute Pain

    May be related to:

    • Surgical incision, tissue trauma, and disruption of intercostal nerves
    • Presence of chest tube(s)
    • Cancer invasion of pleura, chest wall

    Possibly evidenced by:

    • Verbal reports of discomfort
    • Guarding of the affected area
    • Distraction behaviors, e.g., restlessness
    • Narrowed focus (withdrawal)
    • Changes in BP, heart/respiratory rate

    Desired Outcomes

    Patient will:

    • Report pain relieved/controlled.
    • Appear relaxed and sleep/rest appropriately.
    • Participate in desired/needed activities.

    Nursing Interventions

    Ask the patient about pain. Determine pain characteristics: continuous, aching, stabbing, burning. Have the patient rate intensity on a 0–10 scale.

    Rationale: Helpful in evaluating cancer-related pain symptoms, which may involve viscera, nerve, or bone tissue. Use of a rating scale aids the patient in assessing the level of pain and provides a tool for evaluating the effectiveness of analgesics, enhancing patient control of pain.

    Assess patient’s verbal and nonverbal pain cues.

    Rationale: Discrepancy between verbal and/or nonverbal cues may provide clues to the degree of pain, need for, or effectiveness of interventions.

    Note possible pathophysiological and psychological causes of pain.

    Rationale: Fear, distress, anxiety, and grief over confirmed diagnosis of cancer can impair the ability to cope. In addition, a posterolateral incision is more uncomfortable for a patient than an anterolateral incision. The presence of chest tubes can greatly increase discomfort.

    Evaluate the effectiveness of pain control. Encourage sufficient medication to manage pain; change medication or time span as appropriate.

    Rationale: Pain perception and pain relief are subjective; thus, pain management is best left to the patient’s discretion. If the patient is unable to provide input, the nurse should observe physiological and nonverbal signs of pain and administer medications on a regular basis.

    Encourage verbalization of feelings about the pain.

    Rationale: Fears or concerns can increase muscle tension and lower the pain perception threshold.

    Provide comfort measures: frequent position changes, back rubs, support with pillows. Encourage the use of relaxation techniques, visualization, guided imagery, and appropriate diversional activities.

    Rationale: Promotes relaxation and redirects attention. Relieves discomfort and augments therapeutic effects of analgesia.

    Schedule rest periods provide a quiet environment.

    Rationale: Decreases fatigue and conserves energy, enhancing coping abilities.

    Assist with self-care activities, breathing and/or arm exercises, and ambulation.

    Rationale: Prevents undue fatigue and incisional strain. Encouragement and physical assistance and support may be needed for some time before the patient is able or confident enough to perform these activities because of pain or fear of pain.

    Assist with patient-controlled analgesia (PCA) or analgesia through the epidural catheter. Administer intermittent analgesics routinely as indicated, especially 45–60 min before respiratory treatments, deep-breathing, or coughing exercises.

    Rationale: Maintaining a constant drug level avoids cyclic periods of pain, aids in muscle healing, and improves respiratory function and emotional comfort and coping.

    Related FAQs

    1. What are the 1st signs of lung cancer?

    Signs and Symptoms of Lung Cancer

    • A cough that does not go away or gets worse.
    • Coughing up blood or rust-colored sputum (spit or phlegm)
    • Chest pain that is often worse with deep breathing, coughing, or laughing.
    • Hoarseness.
    • Loss of appetite.
    • Unexplained weight loss.
    • Shortness of breath.
    • Feeling tired or weak.

    2. What is the survival rate of lung cancer?

    The lung cancer five-year survival rate (18.6 percent) is lower than many other leading cancer sites, such as colorectal (64.5 percent), breast (89.6 percent) and prostate (98.2 percent). The five-year survival rate for lung cancer is 56 percent for cases detected when the disease is still localized (within the lungs).

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    Nursing Care Plans for Lung Cancer
    Nursing Care Plans for Lung Cancer

    3. How does lung cancer start?

    Doctors believe smoking causes lung cancer by damaging the cells that line the lungs. When you inhale cigarette smoke, which is full of cancer-causing substances (carcinogens), changes in the lung tissue begin almost immediately.

    4. Is cancer in the lungs curable?

    As with many other cancers, a key to surviving lung cancer is catching it in its earliest stages, when it is most treatable. For patients who have small, early-stage lung cancer, the cure rate can be as high as 80% to 90%.

    Read More:

    https://customnursingassignments.com/nursing-care-plans-for-liver-cirrhosis/
    https://customnursingassignments.com/nursing-care-plans-for-leukemia/

  • Nursing Care Plans for Liver Cirrhosis – Best Nursing Care Plans(2022)

    This article discusses Nursing Care Plans for Liver Cirrhosis‘ plus its causes, symptoms, preventions, treatments, and interventions.

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    customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us.(Nursing Care Plans for Liver Cirrhosis)

    Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

    Introduction

    Cirrhosis is a late stage of liver scarring (fibrosis) caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism.

    Each time the liver is injured, whether by disease, excessive alcohol consumption, or another cause, it tries to repair itself. In the process, scar tissue forms. As cirrhosis progresses, more and more scar tissue forms, making it difficult for the liver to function. Advanced cirrhosis is life-threatening.

    The liver damage done by cirrhosis generally can’t be undone. But if liver cirrhosis is diagnosed early and the cause is treated, further damage can be limited.

    Symptoms of Liver Cirrhosis

    1. Fatigue and weakness
    2. Lack of appetite and weight loss
    3. Nausea
    4. Bleed or bruise easily and have swelling legs or belly.
    5. Changes in your skin, such as:
    6. Jaundice (when your skin and eyes turn yellow)
    7. Intense itching
    8. Spider web-like blood vessels in your skin
    9. Redness in the palms of your hands or whitening of your nails

    Some other symptoms might include:

    • Vomiting blood
    • Severe muscle cramps
    • Brownish urine
    • Fever
    • Enlarged spleen
    • Bone disease, causing bones to break more easily

    Causes of Liver Cirrhosis

    Cirrhosis always develops because of another liver problem or disease. If the cause of liver cirrhosis is not treated, it’ll worsen, and the healthy liver cells won’t be able to keep up over time. A patient might start to get tired, feel like they don’t want to eat, and lose weight without trying. After a while, the liver may not be able to work well or at all.

    It’s important to know the cause of liver cirrhosis so it can get the right treatment and keep it from getting worse. The most common causes are:

    1. Alcohol abuse
    2. Nonalcoholic fatty liver disease – Obesity raises the chances of this condition. If this disease causes liver cirrhosis, liver health can be improved by losing weight and controlling blood sugar levels, preventing further damage.
    3. Hepatitis B or hepatitis C – Medicines for these diseases can stop more damage from happening to the liver.
    4. Other conditions that can lead to cirrhosis include:
    5. Cystic fibrosis
    6. Diseases that make it hard for the body to process sugars
    7. Too much iron buildup in the body
    8. Wilson’s disease, where too much copper is stored in the liver
    9. Autoimmune diseases that cause the body to attack liver cells
    10. Blockage of the bile duct, which carries digestive enzymes from the liver into the intestines
    11. Certain genetic digestive disorders
    12. Some infections, including syphilis and brucellosis
    13. Bad reactions to certain medications

    Diagnosis of Liver Cirrhosis

    A doctor will examine the patient and feel around the liver area to determine whether it is enlarged. The patient will be asked about their medical history and lifestyle, including drinking.

    The following tests may also be ordered:

    Blood tests – These measures how well the liver is functioning. If levels of alanine transaminase (ALT) and aspartate transaminase (AST) are high, the patient may have hepatitis.

    Imaging tests – Ultrasound, CT, or MRI scans can be used to see whether the liver is enlarged and detect any scarring or nodules.

    Biopsy – A small sample of liver cells is extracted and examined under a microscope. The biopsy can confirm cirrhosis and its cause.

    Endoscopy – The doctor inserts a long, thin tube with a light and video camera at the end that goes through the esophagus and into the stomach. The doctor looks out for swollen blood vessels called varices that can signify cirrhosis.

    Complications of Liver Cirrhosis

    High blood pressure in the veins that supply the liver (portal hypertension). Cirrhosis slows the normal flow of blood through the liver, thus increasing pressure in the vein that brings blood to the liver from the intestines and spleen.

    Swelling in the legs and abdomen. The increased pressure in the portal vein can cause fluid to accumulate in the legs (edema) and in the abdomen (ascites). Edema and ascites also may result from the inability of the liver to make enough of certain blood proteins, such as albumin.

    Enlargement of the spleen (splenomegaly). Portal hypertension can also cause changes to and swelling of the spleen and trapping of white blood cells and platelets. Decreased white blood cells and platelets in your blood can be the first sign of cirrhosis.

    Bleeding. Portal hypertension can cause blood to be redirected to smaller veins. Strained by the extra pressure, these smaller veins can burst, causing serious bleeding. Portal hypertension may cause enlarged veins (varices) in the esophagus (esophageal varices) or the stomach (gastric varices) and lead to life-threatening bleeding. If the liver can’t make enough clotting factors, this also can contribute to continued bleeding.

    Infections. If you have cirrhosis, your body may have difficulty fighting infections. Ascites can lead to bacterial peritonitis, a serious infection.

    Malnutrition. Cirrhosis may make it more difficult for your body to process nutrients, leading to weakness and weight loss.

    Buildup of toxins in the brain (hepatic encephalopathy). A liver damaged by cirrhosis isn’t able to clear toxins from the blood as well as a healthy liver can. These toxins can then build up in the brain and cause mental confusion and difficulty concentrating. With time, hepatic encephalopathy can progress to unresponsiveness or coma.

    Jaundice. Jaundice occurs when the diseased liver doesn’t remove enough bilirubin, a blood waste product, from your blood. Jaundice causes yellowing of the skin and whites of the eyes, and darkening of urine.

    Bone disease. Some people with cirrhosis lose bone strength and are at greater risk of fractures.

    Increased risk of liver cancer. A large proportion of people who develop liver cancer have pre-existing cirrhosis.

    Acute-on-chronic cirrhosis. Some people end up experiencing multiorgan failure. Researchers now believe this is a distinct complication in some people with cirrhosis, but they don’t fully understand its causes.

    Treatment of Liver Cirrhosis

    If cirrhosis is diagnosed early enough, damage can be minimized by treating the underlying cause or the various complications that arise.

    Treatment for alcohol dependency: The patient needs to stop drinking if their cirrhosis is caused by long-term, regular heavy alcohol consumption. The doctor will recommend a treatment program for treating alcohol dependency in many cases.

    Medications: The patient may be prescribed drugs to control liver cell damage caused by hepatitis B or C.

    Controlling pressure in the portal vein: Blood can “back up” in the portal vein that supplies the liver with blood, causing high blood pressure in the portal vein. Drugs are usually prescribed to control the increasing pressure in other blood vessels. The aim is to prevent severe bleeding. Signs of bleeding can be detected via an endoscopy.

    Note: If the patient vomits blood or passes bloody stools, they probably have esophageal varices. Urgent medical attention is required. The following procedures may help:

    Banding: A small band is placed around the base of the varices to control bleeding.

    Injection sclerotherapy: After an endoscopy, a substance is injected into the varices, which triggers a blood clot and scar tissue to form. This helps stem the bleeding.

    A Sengstaken-Blakemore tube with a balloon: A balloon is placed at the end of the tube. If endoscopy does not stop the bleeding, the tube goes down the patient’s throat and into their stomach. The balloon is inflated. This places pressure on the varices and stops the bleeding.

    Transjugular intrahepatic portosystemic stent shunt (TIPSS): If the therapies mentioned above do not stem the bleeding, a metal tube is passed across the liver to join the portal and hepatic veins, creating a new route for the blood to flow through. This reduces the pressure that was causing the varices.

    Other complications are handled in different ways:

    Infections: The patient will be given antibiotics for any infections that arise.

    Screening for liver cancer: Patients with cirrhosis have a much higher risk of developing liver cancer. The doctor may recommend regular blood tests and imaging scans.

    Hepatic encephalopathy, or high blood toxin levels: Drugs can help treat excessive blood toxin levels.

    In some cases, the damage caused by cirrhosis covers most of the liver and cannot be reversed. In these cases, the person may need a new, transplanted liver. It can take time to find a suitable donor, and this procedure is often advised only as a last resort.

    Prevention of Liver Cirrhosis

    Reduce the risk of cirrhosis by taking these steps to care for the liver:

    Do not drink alcohol if you have cirrhosis. If you have liver disease, you should avoid alcohol.

    Eat a healthy diet. Choose a plant-based diet that’s full of fruits and vegetables. Select whole grains and lean sources of protein. Reduce the amount of fatty and fried foods you eat.

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    Nursing Care Plans for Liver Cirrhosis
    Nursing Care Plans for Liver Cirrhosis

    Maintain a healthy weight. An excess amount of body fat can damage your liver. Talk to your doctor about a weight-loss plan if you are obese or overweight.

    Reduce your risk of hepatitis. Sharing needles and having unprotected sex can increase your risk of hepatitis B and C. Ask your doctor about hepatitis vaccinations.

    Nursing Care Plans for Liver Cirrhosis Based on Diagnosis

    Nursing Care Plans for Liver Cirrhosis – Nursing Care Plan 1: Diagnosis – Imbalanced Nutrition: Less than Body Requirements

    It is related to abnormal bowel functions secondary to cirrhosis. Evidenced by changes in bowel functions and imbalances in nutritional studies.

    Desired Outcome

    The patient will be able to regain patient-appropriate normalization of laboratory results with no further observed signs of malnutrition.

    Nursing InterventionsRationale
    Measure the patient’s daily calorie intake.Observing and recording the patient’s food intake will help the healthcare providers assess preferences, needs, deficiencies, and other nutritional patterns that are otherwise vital for proper management.
    Weigh the patient daily. Ensure recording of changes such as fluid status, weight history, and skinfold measurements.Although daily patient weighing is limited in assessing for malnutrition (due to edema or ascites), it is still necessary to allow for proper assessment. Skinfold measurement allows the healthcare provider to assess for latent fat reserves of the patient and detect muscle or fat wasting.
    Encourage the patient to eat small, frequent meals as tolerated.Because of signs of cirrhosis (e.g., nausea, malaise), eating for the patient could be difficult. Having the patient eat small, frequent meals ensures that the patient receives nutrition continuously.
    Monitor laboratory studies, especially serum glucose, albumin, total protein, and ammonia levels.Glucose levels may be depressed due to depleted stores in the liver, poor nutritional intake, or impaired gluconeogenesis (synthesis of glucose from other sources). Protein reserves in the body may also be decreased due to impaired metabolism, decreased synthesis in the liver, or wastage into the peritoneal cavity (i.e., ascites). Ammonia levels may become elevated and would cause complications if left untreated.
    Maintain nil by mouth/ nothing per orem (NBM/ NPO) status as indicated.Resting the GI tract would be beneficial to acutely ill patients to reduce metabolic demands to the liver and reduce ammonia and urea levels in the body.

    Nursing Care Plans for Liver Cirrhosis – Nursing Care Plan 2: Diagnosis – Fluid Volume Excess

    Related to compromised regulatory mechanism secondary to decreased plasma proteins in cirrhosis. Evidenced by edema, weight gain, and altered electrolyte levels.

    Desired Outcome

    The patient will be able to regain patient-appropriate normalization of laboratory results with no further observed edema and abnormal weight gain.

    Nursing InterventionsRationale
    Ensure the measurement of the patient’s daily weight, intake, and output.This is done to assess the patient’s volume status, development or resolution of third space-shifting of body fluids, and response to therapeutic management. Increases in weight and positive balances in I&O may mean abnormal fluid retention.
    Ensure daily abdominal girth measurement.Daily abdomen measurement helps assess ascites, the accumulation of unwanted fluid in the abdomen due to the loss of protein into the peritoneal space. Note that excessive accumulation reduces circulating fluid volume in the body, thereby inducing signs of dehydration.
    Monitor serum albumin and electrolytes.Depressed albumin levels result in edema formation due to plasma colloid osmotic pressure effects. Treatment regimens such as the use of diuretics to reduce latent edema may cause significant electrolyte changes.
    Administer albumin (salt-free) or plasma expanders as indicated.Albumin and/or plasma expanders are beneficial in pulling out unwanted fluid by increasing osmotic pressure, thereby increasing circulating volume and reducing ascites.
    Administer medications as ordered, including loop-diuretics and aldosterone receptor antagonists.         Potassium       Positive inotropic drugs and arterial vasodilatorsThis is indicated to control edema and ascites formation and increase elimination of water while sparing potassium. Given when conservative management (e.g., sodium restriction) does not address the condition.   Potassium replacement is always given due to them being depleted in instances of liver disease and urinary elimination.   Administered to support cardiac function and blood flow, consequently decreasing excess fluid accumulation.

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    Nursing Care Plans for Liver Cirrhosis
    Nursing Care Plans for Liver Cirrhosis

    Nursing Care Plans for Liver Cirrhosis – Nursing Care Plan 3: Diagnosis – Ineffective Breathing Pattern

    Related to the accumulation of intra-abdominal fluid. Evidenced by increasing abdominal girth, presence of edema, and adventitious breath sounds.

    Desired Outcome

    The patient will be able to maintain an effective respiratory pattern, normal arterial blood gasses (ABGs), and vital signs within acceptable normal limits.

    Nursing InterventionsRationale
    Monitor respirations, taking note of the patient’s rate, depth, and effort.Irregularities in respirations such as dyspnea or shallow patterns may appear due to the accumulation of fluid in the abdomen, thereby reducing effective lung expansion.
    Auscultate breath sounds, taking note of the presence of adventitious sounds such as crackles, rhonchi, wheezes.The occurrence of adventitious breath sounds usually indicates developing complications. Diminished, even absent, breath sounds may indicate lung atelectasis.
    Maintain the head of the bed elevated at least 30 degrees.This facilitates adequate breathing through the reduction of pressure in the diaphragm and aspiration risks of the patient.
    Allow for frequent changes in position, deep breathing, and coughing exercises.This method aids the patient in proper and adequate lung expansion and the mobilization of secretions to allow expectoration.
    Monitor arterial blood gas vital signs, including oxygen saturation.This allows for monitoring of patient status and addressing complications as soon as it happens.
    Provide supplemental oxygen as ordered.Oxygen supplementation addresses or prevents hypoxia.
    Assist for procedures necessary to alleviate edema such as: Paracentesis     Peritoneovenous shunt         Paracentesis is done to remove ascites and thereby relieve abdominal pressure once other interventions are unsuccessful.   Peritoneovenous shunt involves a surgically implanted catheter made to drain accumulated fluid in the abdomen back to the vena cava for elimination. This provides long-term relief of ascites of the patient.

    Nursing Care Plans for Liver Cirrhosis – Nursing Care Plan 4: Diagnosis – Disturbed Body Image 

    Related to biophysical changes. Evidenced by verbalization of changes in lifestyle and negative feelings about the body.

    Desired Outcome

    The patient will verbalize understanding and acceptance of biophysical changes and address these changes through acceptable coping mechanisms.

    Nursing InterventionsRationale
    Discuss with the patient his current situation and encourage verbalization of issues regarding current health status. Explain the symptoms of the disease with its etiology.The patient would be sensitive regarding body issues and may oftentimes have guilt feelings, especially if alcoholism or drug use is the cause of his condition.
    Encourage the patient. Provide professional and emotional support as needed. Adopt a friendly and positive attitude when caring for the patient.The caregiver should focus mainly on the patient’s needs so as to allow the patient to feel valued. Avoid judgmental statements because the patient is very sensitive to these issues.
    Encourage the family or significant others in active participation in the patient’s care.The family may sometimes have the guilt of the current condition and fear of the patient’s eventual death. Because of this, the family would need continuous access to the patient as much as necessary. Participation of relatives in the patient’s care allows for feelings of usefulness and therefore promotes trust between the staff, patient, and family.
    Assist the patient and his family on how to cope with biophysical changes. Suggest clothing choices that do not focus on the current altered appearance.The patient may have feelings of dissatisfaction brought about by signs of cirrhosis, such as jaundice, ascites, etc. Providing psychological support can allow the patient to regain his self-esteem and self-respect despite the limitations of the disease.
    Refer to appropriate support services such as counselors, psychiatric agencies, social services, among others.The patient is already in a vulnerable state because of the condition. Because of this, the patient would need further professional services in order for him to adapt to the condition.

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    Nursing Care Plans for Liver Cirrhosis
    Nursing Care Plans for Liver Cirrhosis

    Nursing Care Plans for Liver Cirrhosis – Nursing Care Plan 5: Diagnosis –Risk for Impaired Skin Integrity

    Related to altered metabolic state. Evidenced by poor skin turgor, presence of edema, and ascites.

    Desired Outcome

    The patient will be able to maintain his skin free from breakdown and demonstrate techniques to maintain epidermal integrity.

    Nursing InterventionsRationale
    Inspect the patient’s skin thoroughly, taking note of pressure points. Use emollient lotions to massage bony prominences as gently as possible. Avoid the use of soap when cleansing the skin.Fluid-filled tissues are more prone to skin breakdown and consequently wounds. Ascites may stretch the skin excessively, therefore losing skin integrity. The use of soap removes latent skin moisturizer and can cause skin drying.
    Assist the patient with frequent repositioning, typically following a turning schedule as needed. Assist with a range of motion exercises, either in the passive or active form.Frequent repositioning allows for the relief of the pressure points and thereby improving skin circulation. Exercises promote circulation and retention of musculoskeletal function and range of motion.
    Recommend elevation of lower extremities as indicated.This position promotes venous blood flow return and the reduction of edema of the lower extremities.
    Utilize alternating mattresses, waterbed, egg-crate mattresses, as ordered.The use of these devices helps in reducing stress to the skin, especially the bony prominences; Further, this increases proper circulation and decreases tissue injury.
    Utilize calamine lotion and baking soda baths. Administer medications such as antihistamines as needed.Calamine lotion and baking soda baths may be soothing for patients with cirrhosis. Antihistamines help control itchiness brought about by jaundice and the presence of bile salts in the skin.
    Encourage the patient to keep his or her fingernails short. Suggest the use of mittens or gloves as indicated.Short nails prevent skin breakdown and injury from inadvertent scratching of the skin due to the presence of bile salts in the skin.

    Related FAQs

    1. What is the main nursing diagnosis for patient with liver cirrhosis?

    Based on the assessment data, the major nursing diagnosis for the patient are: Activity intolerance related to fatigue, lethargy, and malaise. Imbalanced nutrition: less than body requirements related to abdominal distention and discomfort and anorexia.

    2. How do you care for someone with cirrhosis of the liver?

    If you have cirrhosis, be careful to limit additional liver damage:

    1. Don’t drink alcohol. Whether your cirrhosis was caused by chronic alcohol use or another disease, avoid alcohol.
    2. Eat a low-sodium diet.
    3. Eat a healthy diet.
    4. Avoid infections.
    5. Use over-the-counter medications carefully.

    3. What is the principal goal of cirrhosis therapy?

    Doctors have two main goals in treating this disease: Stop the damage to your liver, and prevent complications. Alcohol abuse, hepatitis, and fatty liver disease are some of the main causes. Your doctor will personalize your treatment based on what caused your cirrhosis, and the amount of liver damage you have.

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    Nursing Care Plans for Liver Cirrhosis
    Nursing Care Plans for Liver Cirrhosis

    4. What does a liver nurse do?

    The nurse specialist in liver diseases provides coordination of care, support, and guidance to the patient not only during the initial phase of addiction treatment but also during follow-up, so that sustained sobriety can be achieved.

    Read More:

    https://customnursingassignments.com/nursing-care-plans-for-leukemia/
    https://customnursingassignments.com/nursing-care-plans-for-kidney-stones/

  • Nursing Care Plans for Leukemia – Best Nursing Care Plans(2022)

    This article discusses Nursing Care Plans for Leukemia plus its causes, symptoms, preventions, treatments, and interventions.

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    Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

    Introduction

    Leukemia is a cancer of the blood-forming tissues, including the bone marrow and the lymphatic system.

    Many types of leukemia exist. Some forms of leukemia are more common in children. Other forms of leukemia occur mostly in adults.

    Leukemia usually involves white blood cells. The WBC are potent infection fighters – they normally grow and divide in an orderly way, as the body needs them. But in people with leukemia, the bone marrow produces an excessive amount of abnormal WBC, which don’t function properly.

    Treatment for leukemia can be complex — depending on the type of leukemia and other factors. But there are strategies and resources that can help make your treatment successful.

    Some types of leukemia are more commonly found in children, while other forms are usually seen in adults. Currently, there is no absolute cure for leukemia.

    However, the treatment plans for leukemia have been rapidly developed in the past few decades. These have shown promising results in terms of the overall increase in survivorship and improvement of the quality of life for patients.

    Signs and Symptoms of Leukemia

    Each type of leukemia may have varying signs and symptoms. Generally, leukemia patients have the following clinical manifestations:

    1. Fever or chills
    2. Bone pain or tenderness
    3. Swollen lymph nodes, enlarged liver or spleen
    4. Persistent fatigue
    5. Myalgia
    6. Malaise or generalized body weakness
    7. Moderate to severe infections, which may be recurrent
    8. Unexplained or unintentional weight loss
    9. Recurrent nosebleeds
    10. Tendency to bleed or bruise easily
    11. Petechiae – tiny red spots on the skin
    12. Excessive sweating, especially at night (nocturnal hyperhidrosis)

    Types of Leukemia

    Based on Progression:

    Acute leukemia – this condition occurs when the young and immature white blood cells called blasts rapidly multiply and are unable to perform according to their normal functions. The symptoms worsen quickly, requiring the patient to commence an aggressive treatment as early as possible.

    Chronic leukemia – this condition happens when more mature blood cells either slowly replicate or accumulate. It may involve either an increased or decreased production of these abnormal blood cells. They may also be able to function normally in the beginning. Thus the symptoms may not appear until years later.

    Based on the Affected White Blood Cell Type:

    1. Lymphocytic leukemia – this condition involves the lymphocytes, which are the immune cells formed in the lymphatic tissue.
    2. Acute lymphocytic leukemia (ALL) – is common in children but can also be found in some adults.
    3. Chronic lymphocytic leukemia (CLL) – common in adults who may be well and asymptomatic for years
    4. Myelogenous leukemia – this condition affects the myeloid cells, which are the precursors of leukocytes (white blood cells), erythrocytes (red blood cells), and thrombocytes (platelets)
    5. Acute myelogenous leukemia (AML) – occurs more commonly in adults but can also be diagnosed in children.
    6. Chronic myelogenous leukemia (CML) – occurs more commonly in adults who may be well and asymptomatic for years but will experience rapid growth and replication of leukemia cells.

    Rare Types:

    There are several rare types of leukemia which include:

    Hairy cell leukemia – slow progressive cancer that involves the excessive production of B cells / B lymphocytes

    Myelodysplastic syndromes (MDS) – a group of leukemia disorders wherein the blood-forming cells produced in the bone marrow undergo dysplastic change accompanied by ineffective hematopoiesis (the process of forming blood cellular components)

    Myeloproliferative disorders (MPD) – a group of leukemia disorders that involve the abnormal growth or proliferation of the blood cells in the bone marrow accompanied by effective hematopoiesis

    Causes and Risk Factors of Leukemia

    Currently, the exact cause of leukemia is unknown. As with other types of cancer, leukemia is believed to develop from various factors in both a person’s genetic makeup and his or her environment.

    The combination of these factors causes changes called mutations in the genetic material (DNA) of the blood cells, causing them to grow and divide immaturely and rapidly.

    These abnormal blood cells crown the bone marrow, which leads to the decreased production of healthy blood cells.

    Risk Factors for Leukemia

    • Family history of leukemia
    • Previous cancer treatment such as chemotherapy or radiotherapy
    • Genetic disorders such as Down syndrome
    • Smoking
    • Chemical exposure – this may include chemicals like benzene in gasoline.

    Complications of Leukemia

    Leukemia may cause several complications, which may include:

    Recurrent infections due to low levels of immunity

    Unintentional weight loss

    Anemia

    Bleeding problems

    Metabolic abnormalities – may lead to organ failure, particularly in the kidneys.

    Central nervous system impairment

    Cataracts

    Infertility

    Increased risk of other types of cancer

    Mental health problems

    Poor quality of life

    Diagnosis of Leukemia

    History taking – to check for family history of leukemia and cancers, smoking history, and other risk factors.

    Physical exam – to assess the body for the clinical manifestations of leukemia, especially swollen lymph nodes, enlargement of liver and spleen, and presence of fever and chills

    Blood tests – include complete and differential blood counts

    Bone marrow biopsy – to look for leukemia cells by means of taking a sample of bone marrow from the patient’s hipbone using a long, thin needle; also called bone marrow aspiration

    Lumbar puncture – to check for the presence of leukemia cells in the cerebrospinal fluid if the bone marrow biopsy is positive for leukemia; also called spinal tap

    Treatment for Leukemia

    1. Medications. Several pharmacologic therapies have been used to treat leukemia, such as:
    2. Chemotherapy – uses drugs to kill cancer cells. The most common chemotherapy protocols for leukemia may include combinations of anti-tumor antibiotics, vinca alkaloids, and other systemic anti-cancer therapy (SACT) medications.
    3. Targeted Therapy – uses drugs that attack specific abnormalities in the cancer cell.
    4. Immunotherapy – utilizes the immune system to attack the leukemia cells; examples include immune system modulators and checkpoint inhibitors.

    2. Radiotherapy. Radiotherapy uses radiation or high-powered energy beams such as protons and X-rays to kill cancer cells. This can last from 3 days to 6 weeks.

    1. External beam radiation – aims the energy beams at the affected body area
    2. Brachytherapy – places radioactive material inside the body in order to perform radiation therapy

    3. Chimeric antigen receptor (CAR)-T Cell Therapy. This is a specialized treatment that involves the harvesting of the patient’s T-cells, engineering them to fight the leukemia cells, and infusing them back into the patient’s body.

    4. Bone Marrow Transplant. BMT is a procedure wherein the unhealthy bone marrow of the leukemia patient is removed and replaced by healthy stem cells, which will cause regeneration of healthy bone marrow to produce normal blood cells. It is also known as stem cell transplant.

    Nursing Care Plans for Leukemia Based on Diagnosis

    Nursing Care Plan 1: Diagnosis – Risk for Infection

    Risk factors may include:

    • Inadequate secondary defenses: alterations in mature WBCs (low granulocyte and abnormal lymphocyte count), increased number of immature lymphocytes; immunosuppression, bone marrow suppression (effects of therapy/transplant)
    • Inadequate primary defenses (stasis of body fluids, traumatized tissue)
    • Invasive procedures
    • Malnutrition; chronic disease

    Desired Outcome

    Patient will:

    • Identify actions to prevent/reduce the risk of infection.
    • Demonstrate techniques lifestyle changes to promote a safe environment achieve timely healing.

    Nursing Interventions

    Infection Protection

    Independent

    Place in a private room. Screen/limit visitors as indicated. Prohibit the use of live plants/cut flowers. Restrict fresh fruits and vegetables or make sure they are washed or peeled.

    Rationale: Protect the patient from potential sources of pathogens/infection. Note: Profound bone marrow suppression, neutropenia, and chemotherapy place patient at great risk for infection.

    Require good handwashing protocol for all personnel and visitors.

    Rationale: Prevents cross-contamination/reduces the risk of infection.

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    Nursing Care Plans for Leukemia
    Nursing Care Plans for Leukemia

    Monitor temperature. Note the correlation between temperature elevations and chemotherapy treatments. Observe for fever associated with tachycardia, hypotension, subtle mental changes.

    Rationale: Although fever may accompany some forms of chemotherapy, progressive hyperthermia occurs in some types of infections, and fever (unrelated to drugs or blood products) occurs in most leukemia patients. Note: Septicemia may occur without fever.

    Prevent chilling. Force fluids, administer tepid sponge bath.

    Rationale: Helps reduce fever, which contributes to fluid imbalance, discomfort, and CNS complications.

    Encourage frequent turning and deep breathing.

    Rationale: Prevents stasis of respiratory secretions, reducing the risk of atelectasis/pneumonia.

    Auscultate breath sounds, noting crackles rhonchi; inspect secretions for changes in characteristics, e.g., increased sputum production or change in sputum color. Observe urine for signs of infection, e.g., cloudy, foul-smelling, presence of urgency, or burning with voids.

    Rationale: Early intervention is essential to prevent sepsis/septicemia in an immunosuppressed person.

    Handle the patient gently. Keep linens dry/wrinkle-free.

    Rationale: Prevents sheet burn/skin excoriation.

    Inspect the skin for tender, erythematous areas; open wounds. Cleanse skin with antibacterial solutions.

    Rationale: May indicate local infection. Note: Open wounds may not produce pus because of an insufficient number of granulocytes.

    Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care.

    Rationale: The oral cavity is an excellent medium for the growth of organisms and is susceptible to ulceration and bleeding.

    Promote good perianal hygiene. Examine the perianal area at least daily during acute illness. Provide sitz baths, using Betadine or Hibiclens if indicated. Avoid rectal temperatures using suppositories.

    Rationale: Promotes cleanliness, reducing the risk of perianal abscess; enhances circulation and healing. Note: Perianal abscess can contribute to septicemia and death in immunosuppressed patients.

    Coordinate procedures and tests to allow for uninterrupted rest periods.

    Rationale: Conserves energy for healing cellular regeneration.

    Encourage increased intake of foods high in protein and fluids with adequate fiber.

    Rationale: Promotes healing and prevents dehydration. Note: Constipation potentiates retention of toxins and the risk of rectal irritation/tissue injury.

    Avoid/limit invasive procedures (e.g., venipuncture and injections) as possible.

    Rationale: Break in the skin could provide an entry for pathogenic/potentially lethal organisms. The use of central venous lines (e.g., tunneled catheter or implanted port) can effectively reduce the need for frequent invasive procedures and the risk of infection. Note: Myelosuppression may be cumulative in nature, especially when multiple drug therapy (including steroids) is prescribed.

    Collaborative

    Monitor laboratory studies, e.g., CBC, noting whether WBC count falls or sudden changes occur in neutrophils.

    Rationale: Decreased numbers of normal/mature WBCs can result from the disease process or chemotherapy, compromising the immune response and increased risk of infection.

    Gram’s stain cultures/sensitivity.

    Rationale: Verifies presence of infections; identifies specific organisms and appropriate therapy.

    Review serial chest x-rays.

    Rationale: Indicator of development/resolution of respiratory complications.

    Prepare for/assist with leukemia-specific treatments such as chemotherapy, radiation, and/or bone marrow transplant.

    Rationale: Leukemia is usually treated with a combination of these agents, each requiring specific safety precautions for patients and care providers.

    Administer medications as indicated, e.g., antibiotics.

    Rationale: May be given prophylactically or to treat a specific infection.

    Colony-stimulating factors: sargramostim (Leukine).

    Rationale: Restores WBCs destroyed by chemotherapy and reduces the risk of severe infection and death in certain types of leukemia.

    Avoid use of aspirin-containing antipyretics.

    Rationale: Aspirin can cause gastric bleeding and further decrease platelet count.

    Provide a nutritious diet high in protein and calories, avoiding raw fruits, vegetables, or uncooked meats.

    Rationale: Proper nutrition enhances the immune system. Minimizes potential sources of bacterial contamination.

    Nursing Care Plan 2: Diagnosis – Fluid Volume and Risk for Deficient

    Risk factors may include:

    • Excessive losses, e.g., vomiting, hemorrhage, diarrhea
    • Decreased fluid intake, e.g., nausea, anorexia
    • Increased fluid need, e.g., hypermetabolic state, fever; predisposition for kidney stone formation/tumor lysis syndrome

    Desired outcomes

    Patient will:

    • Demonstrate adequate fluid volume, as evidenced by stable vital signs, palpable pulses, urine output, specific gravity, and pH within normal limits.
    • Identify individual risk factors and appropriate interventions.
    • Initiate behaviors/lifestyle changes to prevent the development of dehydration.

    Nursing Intervention

    Fluid Management

    Independent

    Monitor I&O. Calculate insensible losses and fluid balance. Note decreased urine output in the presence of adequate intake. Measure specific gravity and urine pH.

    Rationale: Tumor lysis syndrome occurs when destroyed cancer cells release toxic levels of potassium, phosphorus, and uric acid. Elevated phosphorus and uric acid levels can cause crystal formation in the renal tubules, impairing filtration and leading to renal failure.

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    Nursing Care Plans for Leukemia
    Nursing Care Plans for Leukemia

    Weigh daily.

    Rationale: Measure of the adequacy of fluid replacement and kidney function. Continued intake greater than output may indicate renal insult/obstruction.

    Monitor BP and HR.

    Rationale: Changes may reflect the effects of hypovolemia (bleeding/dehydration).

    Evaluate skin turgor, capillary refill, and general condition of mucous membranes.

    Rationale: Indirect indicators of fluid status/hydration.

     Note the presence of nausea fever.

    Rationale: Affects intake, fluid needs, and route of replacement.

    Encourage fluids of up to 3–4 L/day when oral intake is resumed.

    Rationale: Promotes urine flow, prevents uric acid precipitation and enhances clearance of antineoplastic drugs.

    Bleeding Precautions

    Independent

    Inspect skin/mucous membranes for petechiae ecchymotic areas; note bleeding gums, frank or occult blood in stools and urine; oozing from invasive-line sites.

    Rationale: Suppression of bone marrow and platelet production places the patient at risk for spontaneous/uncontrolled bleeding.

    Implement measures to prevent tissue injury/bleeding, e.g., gentle brushing of teeth or gums with a soft toothbrush, cotton swab, or sponge-tipped applicator; using an electric razor and avoiding sharp razors when shaving; avoiding forceful nose blowing and needlesticks when possible; using sustained pressure (sandbags or pressure dressings) on oozing puncture/IV sites.

    Rationale: Fragile tissues and altered clotting mechanisms increase the risk of hemorrhage following even minor trauma.

    Limit oral care to mouthwash if indicated (a mixture of 1/4 tsp baking soda or salt in 4–8 oz water or hydrogen peroxide in water). Avoid mouthwashes with alcohol.

    Rationale: When bleeding is present, even gentle brushing may cause more tissue damage. Alcohol has a drying effect and may be painful to irritated tissues.

    Provide a soft diet.

    Rationale: May help reduce gum irritation.

    Fluid Management

    Collaborative

    Administer IV fluids as indicated.

    Rationale: Maintains fluid/electrolyte balance in the absence of oral intake; prevents or minimizes tumor lysis syndrome; reduces the risk of renal complications.

    Administer medications as indicated, e.g., Antiemetics: 5-HT3 receptor antagonist drugs such as ondansetron (Zofran) or granisetron (Kytril)

    Rationale: Relieves nausea/vomiting associated with administration of chemotherapy agents.

    Allopurinol (Zyloprim)

    Rationale: Improves renal excretion of toxic byproducts from the breakdown of leukemia cells. Reduces the chances of nephropathy as a result of uric acid production.

    Potassium acetate or citrate, sodium bicarbonate

    Rationale: May be used to alkalinizing the urine, preventing or minimizing tumor lysis syndrome/kidney stones.

    Stool softeners.

    Rationale: Helpful in reducing straining at stool with trauma to rectal tissues.

    Bleeding Precautions

    Monitor laboratory studies, e.g., platelets, Hb/Hct, clotting.

    Rationale: When the platelet count is less than 20,000/mm (because of the proliferation of WBCs and/or bone marrow suppression secondary to antineoplastic drugs), the patient is prone to spontaneous life-threatening bleeding. Decreasing Hb/Hct is indicative of bleeding (maybe occult).

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    Nursing Care Plans for Leukemia
    Nursing Care Plans for Leukemia

    Collaborative

    Administer RBCs, platelets, clotting factors.

    Rationale: Restores/normalizes RBC count and oxygen-carrying capacity to correct anemia. Used to prevent/treat hemorrhage.

    Maintain external central vascular access device (subclavian or tunneled catheter or implanted port).

    Rationale: Eliminate peripheral venipuncture as a source of bleeding.

    Administer medications, e.g., oral contraceptives

    Rationale: Minimizes blood loss by stopping or slowing the menstrual flow.

    Nursing Care Plan 3: Diagnosis – Pain, acute

    May be related to:

    • Physical agents, e.g., enlarged organs/lymph nodes, bone marrow packed with leukemic cells
    • Chemical agents, e.g., antileukemic treatments
    • Psychological manifestations, e.g., anxiety, fear.

    Possibly evidenced by:

    • Reports of pain (bone, nerve, headaches, and so forth)
    • Guarding/distraction behaviors, facial grimacing, alteration in muscle tone
    • Autonomic responses

    Desired outcomes

    Patient will:

    Pain Level (NOC)

    • Report pain is relieved/controlled.
    • Appear relaxed and able to sleep/rest appropriately.

    Pain Control (NOC)

    • Demonstrate behaviors to manage pain.

    Nursing Intervention

    Pain Management

    Independent

    Investigate reports of pain. Note changes in degree (use scale of 0–10) and site.

    Rationale: Helpful in assessing the need for intervention; may indicate developing complications.

    Monitor vital signs note nonverbal cues, e.g., muscle tension, restlessness.

    Rationale: May be useful in evaluating verbal comments and the effectiveness of interventions.

    Provide a quiet environment and reduce stressful stimuli, e.g., noise, lighting, constant interruptions.

    Rationale: Promotes rest and enhances coping abilities.

    Place in a position of comfort and support joints, extremities with pillows/padding.

    Rationale: May decrease associated bone/joint discomfort.

    Reposition periodically and provide/assist with gentle ROM exercises.

    Rationale: Improves tissue circulation and joint mobility.

    Provide comfort measures (e.g., massage, cool packs) and psychological support (e.g., encouragement, presence).

    Rationale: Minimizes need for/enhances effects of medication.

    Review/promote patient’s own comfort interventions, e.g., position, physical activity/nonactivity, and so forth.

    Rationale: Successful management of pain requires patient involvement. The use of effective techniques provides positive reinforcement, promotes a sense of control, and prepares patients for interventions to be used after discharge.

    Evaluate and support the patient’s coping mechanisms.

    Rationale: Using own learned perceptions/behaviors to manage pain can help the patient cope more effectively.

    Encourage use of stress management techniques, e.g., relaxation/deep-breathing exercises, guided imagery, visualization, Therapeutic Touch.

    Rationale: Facilitates relaxation, augments pharmacological therapy, and enhances coping abilities.

    Assist with/provide diversional activities relaxation techniques.

    Rationale: Helps with pain management by redirecting attention.

    Collaborative

    Monitor uric acid level as appropriate.

    Rationale: Rapid turnover and destruction of leukemic cells during chemotherapy can elevate uric acid, causing swollen, painful joints in some patients. Note: Massive infiltration of WBCs into joints can also result in intense pain.

    Administer medications as indicated: Analgesics, e.g., acetaminophen (Tylenol)

    Rationale: Given for mild pain not relieved by comfort measures.Note: Avoid aspirin-containing products because they may potentiate hemorrhage.

    Opioids, e.g., codeine, morphine, hydromorphone (Dilaudid).

    Rationale: Used around-the-clock, rather than prn, when pain is severe. Note: The use of patient-controlled analgesia (PCA) is beneficial in preventing peaks and valleys associated with intermittent drug administration and increases the patient’s sense of control.

    Antianxiety agents, e.g., diazepam (Valium), lorazepam (Ativan).

    Rationale: May be given to enhance the action of analgesics/opioids.

    Nursing Care Plan 4: Diagnosis – Activity intolerance

    May be related to:

    • Generalized weakness; reduced energy stores, increased metabolic rate from massive production of leukocytes
    • Imbalance between oxygen supply and demand (anemia/hypoxia)
    • Therapeutic restrictions (isolation/bedrest); effect of drug therapy

    Possibly evidenced by:

    • Verbal report of fatigue or weakness
    • Exertional discomfort or dyspnea
    • Abnormal HR or BP response

    Desired outcomes

    Patient will:

    • Report a measurable increase in activity tolerance.
    • Participate in ADLs to a level of ability.
    • Demonstrate a decrease in physiological signs of intolerance; e.g., pulse, respiration, and BP remain within the patient’s normal range.

    Nursing Intervention

    Energy Management

    Independent

    Evaluate reports of fatigue, noting inability to participate in activities or ADLs.

    Rationale: Effects of leukemia, anemia, and chemotherapy may be cumulative (especially during acute and active treatment phase), necessitating assistance.

    Encourage the patient to keep a diary of daily routines and energy levels, noting activities that increase fatigue.

    Rationale: Helps patient prioritize activities and arrange them around fatigue patterns.

    Provide a quiet environment and uninterrupted rest periods. Encourage rest periods before meals.

    Rationale: Restores energy needed for activity and cellular regeneration/tissue healing.

    Implement energy-saving techniques, e.g., sitting, rather than standing, use of shower chair. Assist with ambulation/other activities as indicated.

    Rationale: Maximizes available energy for self-care tasks.

    Schedule meals around chemotherapy. Give oral hygiene before meals and administer antiemetics as indicated.

    Rationale: May enhance intake by reducing nausea.

    Recommend small, nutritious, high-protein meals and snacks throughout the day.

    Rationale: Smaller meals require less energy for digestion than larger meals. Increased intake provides fuel for energy.

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    Nursing Care Plans for Leukemia
    Nursing Care Plans for Leukemia

    Collaborative

    Provide supplemental oxygen.

    Rationale: Maximizes oxygen available for cellular uptake, improving tolerance of activity.

    Related FAQs

    1. What are the nursing interventions for leukemia?

    Nursing Management

    • Check labs for coagulation parameters.
    • Check vitals.
    • Provide skin protection.
    • Monitor for infection and sepsis.
    • Promote normothermia.
    • Educate the patient and family.
    • Monitor ins and outs.
    • Check if nutrition is sufficient.

    2. What is nursing care plan for cancer?

    Nursing care plans for cancer involves assessment, support for therapies (e.g., chemotherapy, radiation, etc.), pain control, promoting nutrition, and emotional support.

    3. How do you care for someone with leukemia?

    How to Care for a Loved One With Leukemia

    1. Be a champion for your loved one.
    2. Learn about infection risk.
    3. Monitor the PICC line.
    4. Help manage chemotherapy side effects.
    5. Be understanding.
    6. Encourage physical activity.
    7. Plan ahead for hospital stays.

    4. What kind of treatments are there for leukemia?

    Common treatments used to fight leukemia include:

    • Chemotherapy. Chemotherapy is the major form of treatment for leukemia.
    • Targeted therapy.
    • Radiation therapy.
    • Bone marrow transplant.
    • Immunotherapy.
    • Engineering immune cells to fight leukemia.
    • Clinical trials.

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  • Nursing Care Plans for Kidney Stones – Best Nursing Care Plans(2022)

    This article discusses Nursing Care Plans for Kidney Stones plus its causes, symptoms, preventions, treatments, and interventions.

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    Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

    Introduction

    Kidney stones (also called renal calculi, nephrolithiasis, or urolithiasis) are hard deposits made of minerals and salts that form inside your kidneys.

    Diet, excess body weight, some medical conditions, and certain supplements and medications are among the many causes of kidney stones. Kidney stones can affect any part of your urinary tract — from your kidneys to your bladder. Often, stones form when the urine becomes concentrated, allowing minerals to crystallize and stick together.

    Passing kidney stones can be quite painful, but the stones usually cause no permanent damage if they’re recognized in a timely fashion. Depending on your situation, you may need nothing more than taking pain medication and drinking lots of water to pass a kidney stone. In other instances — for example, if stones become lodged in the urinary tract, are associated with a urinary infection, or cause complications — surgery may be needed.

    Symptoms of Kidney stones

    A kidney stone usually will not cause symptoms until it moves around within your kidney or passes into your ureters — the tubes connecting the kidneys and the bladder. If it becomes lodged in the ureters, it may block the flow of urine and cause the kidney to swell and the ureter to spasm, which can be very painful. At that point, you may experience these signs and symptoms:

    1. Severe, sharp pain in the side and back, below the ribs
    2. Pain that radiates to the lower abdomen and groin
    3. Pain that comes in waves and fluctuates in intensity
    4. Pain or burning sensation while urinating

    Other signs and symptoms may include:

    Pink, red, or brown urine

    Cloudy or foul-smelling urine

    A persistent need to urinate, urinating more often than usual or urinating in small amounts

    Nausea and vomiting

    Fever and chills if an infection is present

    Pain caused by a kidney stone may change — for instance, shifting to a different location or increasing in intensity — as the stone moves through your urinary tract.

    Causes of Kidney stones

    Kidney stones often have no definite, single cause, although several factors may increase your risk.

    Kidney stones form when your urine contains more crystal-forming substances — such as calcium, oxalate, and uric acid — than the fluid in your urine can dilute. At the same time, your urine may lack substances that prevent crystals from sticking together, creating an ideal environment for kidney stones to form.

    Types of kidney stones

    Knowing the type of kidney stone you have helps determine its cause and may give clues on how to reduce your risk of getting more kidney stones. If possible, try to save your kidney stone if you pass one so that you can bring it to your doctor for analysis.

    Types of kidney stones include:

    Calcium stones.

    Most kidney stones are calcium stones, usually in the form of calcium oxalate. Oxalate is a substance made daily by your liver or absorbed from your diet. Certain fruits and vegetables, as well as nuts and chocolate, have high oxalate content.

    Dietary factors, high doses of vitamin D, intestinal bypass surgery, and several metabolic disorders can increase the concentration of calcium or oxalate in urine.

    Calcium stones may also occur in the form of calcium phosphate. This type of stone is more common in metabolic conditions, such as renal tubular acidosis. It may also be associated with certain medications used to treat migraines or seizures, such as topiramate (Topamax, Trokendi XR, Qudexy XR).

    Struvite stones

    Struvite stones form in response to a urinary tract infection. These stones can grow quickly and become quite large, sometimes with few symptoms or little warning.

    Uric acid stones

    Uric acid stones can form in people who lose too much fluid because of chronic diarrhea or malabsorption, those who eat a high-protein diet, and those with diabetes or metabolic syndrome. Certain genetic factors also may increase your risk of uric acid stones.

    Cystine stones

    These stones form in people with a hereditary disorder called cystinuria that causes the kidneys to excrete too much of specific amino acid.

    Risk factors of kidney stones

    Factors that increase your risk of developing kidney stones include:

    Family or personal history. If someone in your family has had kidney stones, you’re more likely to develop stones, too. If you’ve already had one or more kidney stones, you’re at increased risk of developing another.

    Dehydration. Not drinking enough water each day can increase your risk of kidney stones. People who live in warm, dry climates and those who sweat a lot may be at higher risk than others.

    Certain diets. Eating a diet that’s high in protein, sodium (salt), and sugar may increase your risk of some types of kidney stones. This is especially true with a high-sodium diet. Too much salt in your diet increases the amount of calcium your kidneys must filter and significantly increases your risk of kidney stones.

    Obesity. High body mass index (BMI), large waist size, and weight gain have been linked to an increased risk of kidney stones.

    Digestive diseases and surgery. Gastric bypass surgery, inflammatory bowel disease, or chronic diarrhea can cause changes in the digestive process that affect your absorption of calcium and water, increasing the amounts of stone-forming substances in your urine.

    Other medical conditions such as renal tubular acidosis, cystinuria, hyperparathyroidism, and repeated urinary tract infections also can increase your risk of kidney stones.

    Certain supplements and medications, such as vitamin C, dietary supplements, laxatives (when used excessively), calcium-based antacids, and certain medications used to treat migraines or depression, can increase your risk of kidney stones.

    Diagnosis of Kidney Stone

    Blood tests: Doctors can diagnose if a patient has too much calcium or uric acid in the blood by doing a blood test. Blood tests can also tell the doctor a lot about how healthy the kidneys are.

    Urine test: Shows if there are too many stone-forming minerals in your urine or not enough other compounds that stop stones from forming.

    Imaging tests: Doctors use these to check for stones in the urinary tract. A patient might get an X-ray of the belly or a computerized tomography (CT) scan, which combines a series of X-rays to make a picture of the body. An X-ray can show larger stones, but the CT scan helps doctors find small ones.

    Analysis of passed stones: The doctor will get a patient to pee through a strainer to catch any stones that might pass. They’ll send them to a lab to see what they’re made of. This can tell them what’s causing the stones and how to treat them.

    Pregnant women should get an ultrasound rather than a CT scan in the first trimester when babies are most at risk of a radiation injury. A low-dose CT scan is less dangerous in the second and third trimesters.

    Nursing Care Plans for Kidney Stones Based on Diagnosis

    Nursing Care Plan 1: Diagnosis – Acute Pain

    It may be related to:

    • Increased frequency/force of ureteral contractions
    • Tissue trauma, edema formation; cellular ischemia

    Possibly evidenced by:

    • Reports of colicky pain
    • Guarding/distraction behaviors, restlessness, moaning, self-focusing, a facial mask of pain, muscle tension
    • Autonomic responses

    Desired outcomes

    Patient will:

    • Report pain is relieved with spasms controlled.
    • Appear relaxed able to sleep/rest appropriately.

    Nursing Interventions

    Pain Management

    Independent

    Document location, duration, intensity (0–10 scale), and radiation. Note nonverbal signs, e.g., elevated BP and pulse, restlessness, moaning, thrashing about.

    Rationale: Helps evaluate the site of obstruction and progress of calculi movement. Flank pain suggests that stones are in the kidney area, upper ureter. Flank pain radiates to the back, abdomen, groin, genitalia because of the proximity of nerve plexus and blood vessels supplying other areas. Sudden, severe pain may precipitate apprehension, restlessness, severe anxiety.

    Explain the cause of pain and the importance of notifying caregivers of changes in pain occurrence/characteristics.

    Rationale: Provides an opportunity for timely administration of analgesia (helpful in enhancing patient’s coping ability and may reduce anxiety) and alerts caregivers to the possibility of passing of stone/developing complications. Sudden cessation of pain usually indicates stone passage.

    Provide comfort measures, e.g., back rub, restful environment.

    Rationale: Promotes relaxation, reduces muscle tension, and enhances coping.

    Assist with/encourage the use of focused breathing, guided imagery, diversional activities.

    Rationale: Redirects attention and aids in muscle relaxation.

    Encourage/assist with frequent ambulation as indicated and increased fluid intake of at least 3–4 L/day within cardiac tolerance.

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    Nursing Care Plans for Kidney Stones
    Nursing Care Plans for Kidney Stones

    Rationale: Renal colic can be worse in the supine position. Vigorous hydration promotes the passing of stone, prevents urinary stasis, and aids in the prevention of further stone formation.

    Note reports of increased/persistent abdominal pain.

    Rationale: Complete obstruction of the ureter can cause perforation and extravasation of urine into perirenal space. This represents an acute surgical emergency.

    Administer medications as indicated: Narcotics, e.g., meperidine (Demerol), morphine;

    Rationale: Usually given during acute episodes to decrease ureteral colic and promote muscle/mental relaxation.

    Antispasmodics, e.g., flavoxate (Urispas) oxybutynin (Ditropan)

    Rationale: Decreasing reflex spasms may decrease colic and pain.

    Collaborative

    Apply warm compresses to the back.

    Rationale: Relieves muscle tension and may reduce reflex spasms.

    Maintain patency of catheters when used.

    Rationale: Prevents urinary stasis/retention reduces the risk of increased renal pressure and infection.

    Nursing Care Plan 2: Diagnosis – Impaired Urinary Elimination

    It may be related to:

    • Stimulation of the bladder by calculi, renal or ureteral irritation
    • Mechanical obstruction, inflammation

    Possibly evidenced by:

    • Urgency and frequency; oliguria (retention)
    • Hematuria

    Desired outcomes

    Patient will:

    • Urinary Elimination
    • Void in normal amounts and usual pattern.
    • Experience no signs of obstruction.

    Nursing Interventions

    Urinary Elimination Enhancement

    Independent

    Monitor input and output characteristics of urine.

    Rationale: Provides information about kidney function and presence of complications, e.g., infection and bleeding. Bleeding may indicate increased obstruction or irritation of the ureter. Note: Hemorrhage due to ureteral ulceration is rare.

    Determine the patient’s normal voiding pattern and note variations.

    Rationale: Calculi may cause nerve excitability, which causes sensations of an urgent need to void. Usually, frequency and urgency increase as calculus nears the ureterovesical junction.

    Encourage increased fluid intake.

    Rationale: Increased hydration flushes bacteria, blood, and debris and may facilitate stone passage.

    Strain all urine. Document any stones expelled and send them to a laboratory for analysis

    Rationale: Retrieval of calculi allows identification of the type of stone and influences choice of therapy.

    Investigate reports of bladder fullness; palpate for suprapubic distension. Note decreased urine output presence of periorbital/dependent edema.

    Rationale: Urinary retention may develop, causing tissue distension (bladder/kidney) and potentiating infection renal failure risk.

    Observe for changes in mental status, behavior, or level of consciousness.

    Rationale: Accumulation of uremic wastes and electrolyte imbalances can be toxic to the CNS.

    Collaborative

    Monitor laboratory studies, e.g., electrolytes, BUN, Cr.

    Rationale: Elevated BUN, Cr, and certain electrolytes indicate the presence/degree of kidney dysfunction.

    Obtain urine for culture and sensitivities.

    Rationale: Determines presence of UTI, which may be causing/complicating symptoms.

    Administer medications as indicated, e.g.: Acetazolamide (Diamox), allopurinol (Zyloprim)

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    Nursing Care Plans for Kidney Stones
    Nursing Care Plans for Kidney Stones

    Rationale: Increases urine pH (alkalinity) to reduce the formation of acid stones. Antigout agents such as allopurinol (Zyloprim) also lower uric acid production and the potential of stone formation.

    Hydrochlorothiazide (Esidrix, HydroDIURIL), chlorthalidone (Hygroton)

    Rationale: May be used to prevent urinary stasis and decrease calcium stone formation if not caused by an underlying disease process such as primary hyperthyroidism or vitamin D abnormalities.

    Ammonium chloride; potassium or sodium phosphate

    Rationale: Reduces phosphate stone formation.

    Antibiotics

    Rationale: The presence of UTI/alkaline urine potentiates stone formation.

    Sodium bicarbonate

    Rationale: Replaces losses incurred during bicarbonate wasting and alkalinization of urine; may reduce/prevent the formation of some calculi.

    Ascorbic acid.

    Rationale: Acidifies urine to prevent recurrence of alkaline stone formation.

    Nursing Care Plan 3: Diagnoses – Fluid Volume and Risk for deficient

    Risk factors may include:

    • Nausea/vomiting (generalized abdominal and pelvic nerve irritation from renal or ureteral colic)
    • Postobstructive diuresis

    Desired outcomes

    Patient will:

    • Hydration
    • Maintain adequate fluid balance as evidenced by vital signs and weight within the patient’s normal range, palpable peripheral pulses, moist mucous membranes, good skin turgor.

    Nursing Interventions

    Fluid/Electrolyte Management

    Independent

    Monitor input and output.

    Rationale: Comparing actual and anticipated output may aid in evaluating the presence/degree of renal stasis/impairment. Note: Impaired kidney functioning and decreased urinary output can result in higher circulating volumes with signs/symptoms of HF.

    Document incidence and note characteristics and frequency of vomiting and diarrhea and accompanying or precipitating events.

    Rationale: Nausea/vomiting and diarrhea are commonly associated with renal colic because celiac ganglion serves both kidneys and stomach. Documentation may help rule out other abdominal occurrences as a cause for pain or pinpoint calculi.

    Increase fluid intake to 3–4 L/day within cardiac tolerance.

    Rationale: Maintains fluid balance for homeostasis and “washing” action that may flush the stone(s) out. Dehydration and electrolyte imbalance may occur secondary to excessive fluid loss (vomiting and diarrhea).

    Monitor vital signs. Evaluate pulses, capillary refill, skin turgor, and mucous membranes.

    Rationale: Indicators of hydration/circulating volume and need for intervention. Note: Decreased GFR stimulates the production of renin, which acts to raise BP in an effort to increase renal blood flow.

    Weigh daily.

    Rationale: Rapid weight gain may be related to water retention.

    Collaborative

    Monitor Hb/Hct, electrolytes.

    Rationale: Assesses hydration and effectiveness of/need for interventions.

    Administer IV fluids.

    Rationale: Maintains circulating volume (if oral intake is insufficient), promoting renal function.

    Provide appropriate diet, clear liquids, bland foods as tolerated.

    Rationale: Easily digested foods decrease GI activity/irritation and help maintain fluid and nutritional balance.

    Administer medications as indicated: antiemetics, e.g., prochlorperazine (Compazine).

    Rationale: Reduces nausea/vomiting.

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    Nursing Care Plans for Kidney Stones
    Nursing Care Plans for Kidney Stones

    Nursing Care Plan 4: Diagnosis- Deficient Knowledge

    It may be related to:

    • Lack of exposure/recall; information misinterpretation
    • Unfamiliarity with information resources

    Possibly evidenced by

    • Questions; request for information; statement of misconception
    • Inaccurate follow-through of instructions, development of preventable complications

    Desired outcomes

    Patient will:

    • Verbalize understanding of disease process and potential complications.
    • Correlate symptoms with causative factors.
    • Verbalize understanding of therapeutic needs.
    • Initiate necessary lifestyle changes and participate in treatment regimen.

    Nursing Interventions

    Teaching: Disease Process

    Independent

    Review disease process and future expectations.

    Rationale: Provides knowledge base from which patient can make informed choices.

    Stress importance of increased fluid intake, e.g., 3–4L/day or as much as 6–8 L/day. Encourage the patient to notice dry mouth and excessive diuresis/diaphoresis and to increase fluid intake whether or not feeling thirsty.

    Rationale: Flushes renal system, decreasing the opportunity for urinary stasis and stone formation. Increased fluid losses/dehydration require additional intake beyond usual daily needs.

    Review dietary regimen, as individually appropriate:

    Rationale: Diet depends on the type of stone. Understanding the reason for restrictions provides an opportunity for the patient to make informed choices, increases cooperation with regimen, and may prevent a recurrence.

    Low-purine diet, e.g., limited lean meat, turkey, legumes, whole grains, alcohol

    Rationale: Decreases oral intake of uric acid precursors.

    Low-calcium diet, e.g., limited milk, cheese, green leafy vegetables, yogurt

    Rationale: Reduces risk of calcium stone formation. Note: Research suggests that restricting dietary calcium is not helpful in reducing calcium-stone formation, and researchers, although not advocating high-calcium diets, are urging that calcium limitation be reexamined.

    Low-oxalate diet, e.g., restrict chocolate, caffeine-containing beverages, beets, spinach.

    Rationale: Reduces calcium oxalate stone formation.

    Short regimen: low-calcium/phosphorus diet with aluminum carbonate gel 30–40 mL, 30 min pc/hs.

    Rationale: Prevents phosphatic calculi by forming an insoluble precipitate in the GI tract, reducing the load to the kidney nephron. Also effective against other forms of calcium calculi. Note: May cause constipation.

    Discuss medication regimen, avoidance of OTC drugs, and reading all product/food ingredient labels.

    Rationale: Drugs will be given to acidify or alkalize urine, depending on the underlying cause of stone formation. Ingestion of products containing individually contraindicated ingredients (e.g., calcium, phosphorus) potentiates the recurrence of stones.

    Encourage regular activity/exercise program.

    Rationale: Inactivity contributes to the stone formation through calcium shifts and urinary stasis.

    Active-listen concerns about therapeutic regimen/lifestyle changes.

    Rationale: Helps patient work through feelings and gain a sense of control over what is happening.

    Identify signs/symptoms requiring medical evaluation, e.g., recurrent pain, hematuria, oliguria.

    Rationale: With an increased probability of recurrence of stones, prompt interventions may prevent serious complications.

    Demonstrate proper care of incisions/catheters if present.

    Rationale: Promotes competent self-care and independence.

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    Nursing Care Plans for Kidney Stones
    Nursing Care Plans for Kidney Stones

    Related FAQs

    1. What are some nursing interventions for kidney stones?

    Nursing Interventions

    • Administer opioid analgesics (IV or intramuscular) with IV NSAID as prescribed.
    • Encourage and assist patient to assume a position of comfort.
    • Assist patient to ambulate to obtain some pain relief.
    • Monitor pain closely and report promptly increases in severity.

    2. What is the most important teaching for a patient with renal calculi?

    Consuming the recommended daily allowance of calcium is important for patients with calcium oxalate stones since calcium binds up oxalate in the gut, decreasing available urinary oxalate. Uric acid: To reduce uric acid stones, cut down on high-purine foods such as red meat, organ meats, and shellfish.

    3. What is nursing care of patient having surgery of kidney due to renal stone?

    Encourage use of focused breathing, guided imagery, diversional activities. Redirects attention and helps in muscle relaxation. Assist with frequent ambulation as indicated and increased fluid intake of at least 3–4 L a day within cardiac tolerance. Renal colic can be worse in the supine position.

    4. Which nursing intervention can help the client prevent urinary incontinence?

    Nurses play an important role in educating patients about bladder control training to prevent incontinence. Bladder control training includes several these techniques: Pelvic muscle exercises (also known as Kegel exercises) work the muscles used to stop urination, which can help prevent stress incontinence.

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  • Nursing Care Plans for Jaundice – Best Nursing Care Plans(2022)

    This article discusses Nursing Care Plans for Jaundice plus its causes, symptoms, preventions, treatments, and interventions.

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    Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

    Introduction

    Jaundice is a term used to describe a yellowish tinge to the skin and the whites of the eye. Body fluids may also be yellow. It is also known as icterus.

    The color of the skin and whites of the eyes will vary depending on bilirubin levels. Bilirubin is a waste material found in the blood. Moderate levels lead to a yellow color, while very high levels will appear brown.

    Jaundice can happen to people of all ages and is normally the result of an underlying condition. Jaundice normally indicates a problem with the liver or bile duct.

    Nursing Care Plans for Jaundice – Causes of Jaundice

    A problem in the liver may cause jaundice.

    Jaundice is a yellowing of the skin and the whites of the eyes that happens when the body does not process bilirubin properly. This may be due to a problem in the liver.

    Bilirubin is a yellow-colored waste material that remains in the bloodstream after iron is removed from the blood.

    The liver filters waste out from the blood. When bilirubin reaches the liver, other chemicals attach to it. A substance called conjugated bilirubin results.

    The liver produces bile, a digestive juice. Conjugated bilirubin enters the bile, then it leaves the body. It is this type of bilirubin that gives feces its brown color.

    Too much bilirubin can leak into the surrounding tissues. This is known as hyperbilirubinemia, and it causes a yellow color in the skin and eyes.

    Nursing Care Plans for Jaundice – Risk Factors of Jaundice

    Jaundice most often happens due to an underlying disorder that either causes the production of too much bilirubin or prevents the liver from getting rid of it. Both of these result in bilirubin being deposited in tissues.

    Underlying conditions that may cause jaundice include:

    Acute inflammation of the liver: This may impair the ability of the liver to conjugate and secrete bilirubin, resulting in a buildup.

    Inflammation of the bile duct: This can prevent bile secretion and removal of bilirubin, causing jaundice.

    Obstruction of the bile duct: This prevents the liver from disposing of bilirubin.

    Hemolytic anemia: Bilirubin production increases when large quantities of red blood cells are broken down.

    Gilbert’s syndrome: This is an inherited condition that impairs the ability of enzymes to process the excretion of bile.

    Cholestasis: This interrupts the flow of bile from the liver. The bile containing conjugated bilirubin remains in the liver instead of being excreted.

    Rarer conditions that may cause jaundice include:

    Crigler-Najjar syndrome: This inherited condition impairs the specific enzyme responsible for processing bilirubin.

    Dubin-Johnson syndrome: This is an inherited form of chronic jaundice that prevents conjugated bilirubin from being secreted from the liver cells.

    Pseudojaundice: This is a harmless form of jaundice. The yellowing of the skin results from an excess of beta-carotene, not from an excess of bilirubin. Pseudojaundice usually arises from eating large quantities of carrot, pumpkin, or melon.

    Nursing Care Plans for Jaundice – Symptoms of Jaundice

    An excess of bilirubin can cause a yellow tinge in the eyes and skin.

    Common symptoms of jaundice include:

    1. A yellow tinge to the skin and the whites of the eyes, normally starting at the head and spreading down the body
    2. Pale stools
    3. Dark urine
    4. Itchiness

    Accompanying symptoms of jaundice resulting from low bilirubin levels include:

    1. Fatigue
    2. Abdominal pain
    3. Weight loss
    4. Vomiting
    5. Fever
    6. Pale stools
    7. Dark urine

    Nursing Care Plans for Jaundice – Treatment of Jaundice

    Medication or supplements can help jaundice depending on the cause.

    Treatment will depend on the underlying cause. Jaundice treatment targets the cause rather than the jaundice symptoms.

    The following treatments are used:

    1. Anemia-induced jaundice may be treated by boosting the amount of iron in the blood by either taking iron supplements or eating more iron-rich foods. Iron supplements are available for purchase online.
    2. Hepatitis-induced jaundice requires antiviral or steroid medications.
    3. Doctors can treat obstruction-induced jaundice by surgically removing the obstruction.
    4. If using medication has caused jaundice, treatment  involves changing to an alternative medication.

    Nursing Care Plans for Jaundice – Prevention of Jaundice

    Jaundice is related to liver function. People must maintain the health of this vital organ by eating a balanced diet, exercising regularly, and not consuming more than the recommended amounts of alcohol.

    Nursing Care Plans for Jaundice – Complications of Jaundice

    The itching that accompanies jaundice can sometimes be so intense that patients have been known to scratch their skin raw, experience insomnia, or, in extreme cases, even have thoughts of suicide.

    When complications happen, this is usually because of the underlying problem, not jaundice itself.

    For example, uncontrolled bleeding may result if an obstructed bile duct leads to jaundice. This is because the blockage leads to a shortage of vitamins needed for clotting.

    Nursing Care Plans for Jaundice – Types of Jaundice

    There are three main types of jaundice:

    Hepatocellular jaundice occurs as a result of liver disease or injury.

    Hemolytic jaundice occurs due to hemolysis, or an accelerated breakdown of red blood cells, leading to an increase in the production of bilirubin.

    Obstructive jaundice occurs as a result of an obstruction in the bile duct. This prevents bilirubin from leaving the liver.

    Nursing Care Plans for Jaundice – Diagnosis of Jaundice

    Doctors will most likely use the history of the patient and a physical exam to diagnose jaundice and confirm bilirubin levels. They will pay close attention to the abdomen, feel for tumors, and check the firmness of the liver.

    A firm liver indicates cirrhosis or scarring of the liver. A rock-hard liver suggests cancer.

    Several tests can confirm jaundice. The first is a liver function test to determine whether the liver is functioning properly.

    If a doctor cannot find the cause, a doctor may request blood tests to check bilirubin levels and blood composition. These include:

    Bilirubin tests: A high level of unconjugated bilirubin compared to levels of conjugated bilirubin suggest hemolytic jaundice.

    Full blood count (FBC) or complete blood count (CBC): This measures levels of red blood cells, white blood cells, and platelets.

    Hepatitis A, B, and C tests: This tests for a range of liver infections.

    The doctor will examine the structure of the liver if they suspect an obstruction. They will use imaging tests in these cases, including MRI, CT, and ultrasound scans.

    They may also carry out an endoscopic retrograde cholangiopancreatography (ERCP). This is a procedure combining endoscopy and X-ray imaging.

    A liver biopsy can check for inflammation, cirrhosis, cancer, and fatty liver. This test involves inserting a needle into the liver to obtain a tissue sample. The sample is then examined under a microscope.

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    Nursing Care Plans for Jaundice
    Nursing Care Plans for Jaundice

    Nursing Care Plans for Jaundice Based on Diagnosis

    Nursing Care Plans for Jaundice: Care Plan 1- Diagnosis: Hyperthermia related to infection and excessive bile in the blood secondary to adult jaundice

    Evidenced by a temperature of 39 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.

    Desired Outcome

    Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.

    InterventionsRationales
    Assess the patient’s vital signs at least every 4 hours.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs administered.
    Remove excessive clothing, blankets, and linens. Adjust the room temperature.To regulate the environment’s temperature and make it more comfortable for the patient.
    Administer the prescribed antibiotic and anti-pyretic medications.Use the antibiotic to treat a bacterial infection, which is the underlying cause of the patient’s jaundice and hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.
    Offer a tepid sponge bath.To facilitate the body in cooling down and to provide comfort.
    Elevate the head of the bed.Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.

    Nursing Care Plans for Jaundice: Care Plan 2 – Diagnosis: Fatigue related to elevated serum bilirubin levels resulting in adult jaundice

    Evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion

    Desired Outcome

    The adult patient will demonstrate active participation in necessary and desired activities and demonstrate an increase in activity levels.

    InterventionsRationales
    Assess the patient’s degree of fatigability by asking to rate his/her fatigue level (mild, moderate, or severe). Explore activities of daily living and actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance.
    Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media for long periods. Alternate periods of physical activity with rest and sleep.To gradually increase the patient’s tolerance to physical activity.
    Teach deep breathing exercises and relaxation techniques.   Provide adequate ventilation in the room.To allow the patient to relax while at rest. To allow enough oxygenation in the room.
    Refer the patient to the physiotherapy / occupational therapy team as required.To provide more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity.

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    Nursing Care Plans for Jaundice
    Nursing Care Plans for Jaundice

    Nursing Care Plans for Jaundice: Care Plans 3 – Diagnosis: Deficient Knowledge related to infant jaundice

    Evidenced by the patient’s mother’s verbalization of “I want to know more about how I can take care of my baby.”

    Desired Outcome

    At the end of the health teaching session, the patient’s mother will be able to demonstrate sufficient knowledge of infant jaundice and its management.

    InterventionsRationales
    Assess the patient’s readiness to learn, misconceptions, and blocks to learning.To address the patient’s cognition and mental status towards the new diagnosis and to help the patient overcome blocks to learning.
    Explain what jaundice is, the two main types/ causes of infant jaundice (physiologic and pathologic), and how it affects the vital organs such as the liver. Avoid using medical jargon and explain in layman’s terms.To provide information on infant jaundice and its pathophysiology in the simplest way possible.
    Inform the caregiver of the details about the prescribed medications (e.g., drug class, use, benefits, side effects, and risks) to treat jaundice.To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and administration details.
    Explain to the newborn’s mother what phototherapy is.Phototherapy is a treatment wherein a baby is placed under a special blue spectrum light to reduce the bilirubin levels while keeping the eyes protected. The nursing team may use a fiber-optic blanket and place it under the baby if advised by the physician.
    Educate the mother about the need for exchange transfusion for the baby before getting her consent.Exchange transfusion may also be prescribed in babies with extremely high bilirubin levels.
    Explain the reason behind the need for IV Ig administration if this is prescribed.In instances of ABO and Rh incompatibility, administration of IV Ig is beneficial to reduce the serum levels of the antibodies in the infant’s blood.

    Nursing Care Plans for Jaundice: Care Plan 4 – Risk for Injury (Infant)

    Risk factors

    • Complications of exchange transfusions
    • An invasive procedure, abnormal blood profile, chemical imbalances.

    Desired Outcomes

    Neonate will complete exchange transfusion without complications.

    Neonate will display decreasing serum bilirubin levels.

    InterventionsRationale
    Note the condition of the infant’s cord prior to transfusion if the umbilical vein is to be used. If the cord is dry, administer saline soaks for 30–60 min prior to the procedure.Soaks may be necessary to soften the cord and umbilical vein prior to transfusion for IV access and ease the umbilical catheter’s passage.
    Verify infant’s and mother’s blood type and Rh factor. Note blood type and Rh factor of blood to be exchanged. (Exchanged blood will be the same type as the baby’s but will be Rh-negative or type O–negative blood that has been cross-matched with mother’s blood beforehand.)Exchange transfusions are most often associated with Rh incompatibility problems. Using Rho(D)-positive blood would only increase hemolysis and bilirubin levels because antibodies in infants’ circulation would destroy new RBCs.
    Assess the infant for weight changes.Weight change reveals weight gain related to fluid overload. Fluid overload can cause respiratory and cardiac complications.
    Assess the infant for neurologic changes.Irritability, twitching, convulsions, or seizures are a sign of hyperkalemia, hypocalcemia, or neurotoxicity as a result of jaundice.
    Maintain infant’s temperature prior to, during, and after the procedure. Place infant under radiant warmer with servomechanism. Warmblood prior to infusion by placing in an incubator, warm basin of water, or blood warmer.Helps prevent hypothermia and vasospasm, reduces the risk of ventricular fibrillation, and decreases blood viscosity.
    Ensure freshness of blood (not more than 2 days old), with heparinized blood preferred.Older blood is more likely to hemolyze, thereby increasing bilirubin levels. Heparinized blood is always fresh but must be discarded if not used within 24 hr.
    Avoid overheating of blood prior to transfusion.Too much heat on the blood promotes hemolysis and release of potassium, causing hyperkalemia.
    Ensure availability of resuscitative equipment.To provide immediate support if necessary.
    Maintain NPO status for 4 hr prior to the procedure, or aspirate gastric contents.Reduces risk of possible regurgitation and aspiration during procedure.
    Assess infant for excessive bleeding from IV site following the transfusion.Infusion of heparinized blood (or citrated blood without calcium replacement) alters coagulation for 4–6 hr following the exchange transfusion and may result in bleeding.
    Monitor venous pressure, pulse, color, and respiratory rate/ease before, during, and after transfusion. Suction as needed.Establishes baseline values, identifies potentially unstable conditions (e.g., apnea or cardiac dysrhythmia/arrest), and maintains airway. Note: Bradycardia may occur if calcium is injected too rapidly.
    Monitor for signs of electrolyte imbalance (e.g., lethargy, seizure activity, and apnea;  hyperreflexia, bradycardia, or diarrhea).Hypocalcemia and hyperkalemia may develop during and following exchange transfusion.
    Carefully document events during transfusion, recording the amount of blood withdrawn and injected (usually 7–20 ml at a time).Helps prevent errors in fluid replacement. The amount of blood exchanged is approximately 170 ml/kg of body weight. A double-volume exchange transfusion ensures that between 75% and 90% of circulating RBCs are replaced.
    Monitor laboratory studies, as indicated:
    Hb/Hct levels prior to and the following transfusionIf Hct is 40% prior to transfusion, a partial exchange with packed RBCs may precede full exchange. Dropping levels following the transfusion suggest the need for a second transfusion.
    Serum bilirubin levels immediately following the procedure, then every 4–8 hr.Bilirubin levels may decrease by half immediately following the procedure but may rise shortly thereafter, necessitating a repeat transfusion. Multiplying level by 3.7 determines the degree of elevation of bilirubin necessitating exchange transfusion.
    Serum calcium and potassiumDonor blood containing citrate as an anticoagulant binds calcium, thereby decreasing serum calcium levels. In addition, if blood is more than 2 days old, RBC destruction releases potassium, creating a risk of hyperkalemia and cardiac arrest.
    GlucoseLow glucose levels may be associated with continued anaerobic glycolysis within donor RBCs. Prompt treatment is necessary to prevent untoward effects/CNS damage.
    Serum pH levels.The serum pH of donor blood is typically 6.8 or less. Acidosis may result when fresh blood is not used, and the infant’s liver cannot metabolize citrate used as an anticoagulant, or when donor blood continues anaerobic glycolysis, with the production of acid metabolites.
    Administer albumin prior to transfusion if indicated.Although somewhat controversial, administration of albumin may increase the albumin available for binding of bilirubin, thereby reducing levels of freely circulating serum bilirubin. Synthetic albumin is not thought to increase available binding sites.
    Administer medications, as indicated:
    5% calcium gluconateFrom 2–4 ml of calcium, gluconate may be administered after every 100 ml of blood infusion to correct hypocalcemia and minimize possible cardiac irritability. Note: Some controversy exists as to the purpose and effectiveness of this practice.
    Sodium bicarbonateCorrects acidosis.
    Protamine sulfateCounteracts anticoagulant effects of heparinized blood.
    Administer antibiotics as indicated.Antibiotics prevent and/or treat infections.

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    Nursing Care Plans for Jaundice
    Nursing Care Plans for Jaundice

    Related FAQs

    1. What is a nursing diagnosis for hyperbilirubinemia?

    Nursing Diagnosis: Hyperthermia related to elevated serum bilirubin levels as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.

    2. Can neonatal jaundice be a nursing diagnosis?

    A nursing diagnosis of neonatal jaundice (00194) was included in the 2008 NANDA-I taxonomy and revised in 2010 and 2013.

    3. What are the nursing intervention for neonatal jaundice?

    Treatments to lower the level of bilirubin in your baby’s blood may include: Enhanced nutrition. To prevent weight loss, your doctor may recommend more-frequent feeding or supplementation to ensure that your baby receives adequate nutrition. Light therapy (phototherapy).

    4. What are the nursing intervention for neonatal jaundice?

    What nursing interventions are required during phototherapy?During phototherapy neonates require ongoing monitoring of:

    • adequacy of hydration (urine output) and nutrition(weight gain)
    • temperature.
    • clinical improvement in jaundice.
    • TSB or SBR levels.
    • potential signs of bilirubin encephalopathy.

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