CASE: Merlie, 66, years old, previously diagnosed of Acute Lymphocytic Leukemia, was brought to the ER of NVPH with

complaints of severe
nausea and vomiting. She is alarmed also of the presence of black tarry stool for the past two days. She is on chemotherapy with Adriamycin and
Cytoxan. Upon admission, she is weak, pale, with dry mucous membranes, poor skin turgor, BP: 90/70.

1. Fluid Volume Deficit

Assessment Diagnosis Scientific Planning Implementation Rationale Evaluation

explanation

Subjective: Fluid Volume Chemotherapy Short Term Goal: Independent Interventions: Independent Interventions: Short Term Goal:
Deficit r/t agents (Adriamycin
- Patient excessive and Cytoxan) After 8 hours of •Monitor vital signs •To detect early signs of After 8 hours of
complains of gastrointestinal nursing (especially BP and pulse) every hypovolemia and assess nursing
severe nausea and losses (vomiting | interventions, the 1-2 hours. effectiveness of fluid interventions, the
vomiting. and possible patient will show replacement. patient show
Causes irritation to improved hydration • Assess the frequency and improved
gastrointestinal
- presence of gastrointestinal as evidenced by BP amount of vomiting and stool. •To monitor fluid loss due to hydration as
bleeding) as
black tarry stool tract, leading to of at least 100/70 vomiting and stool for evidenced by BP of
evidenced by
for the past two nausea, vomiting, •Encourage oral fluids, if appropriate interventions.
hypotension (BP mmHg, moist 100/70 mmHg,
days noted. and potential tolerated, in small amounts
90/70), dry mucous moist mucous
bleeding and monitor for signs of • To help in rehydration
mucous membranes, and membranes, and
(evidenced by intolerance such as increased without exacerbating nausea.
membranes, poor decreased nausea. decreased nausea.
black tarry stool) nausea.
Objective: skin turgor, and •To maintains comfort and
reports of nausea •Perform oral care to manage prevents further dehydration.
|
- Signs of and vomiting dry mucous membranes.
Long Term Goal: Long Term Goal:
dehydration: dry This excessive loss •To empower patient with
mucous of fluids can result After 3 days, the •Educate patient on the knowledge in detecting After 3 days, the
membranes, poor in a fluid volume patient will importance of fluid intake and dehydration and fluid loss. patient has normal
skin turgor, deficit maintain normal early signs of dehydration. fluid balance as
hypotension fluid balance as evidenced by
| evidenced by stable stable vital signs,
- History of Dependent Interventions:
vital signs, normal normal skin turgor,
chemotherapy Leading to Dependent Interventions:
skin turgor, and •To replenish circulating and absence of
with Adriamycin hypotension, dry
absence of nausea •Administer IV fluids as volume, improving perfusion nausea and
and Cytoxan mucous and vomiting. prescribed as ordered by the and hydration. vomiting.
membranes, and doctor.
poor skin turgor. • To reduce nausea and
•Administer antiemetics as vomiting.
Vital signs: BP ordered by the doctor.
90/70 mmHg

Collaborative Interventions:
Collaborative Interventions:
•A personalized diet plan
•Collaborate with a dietitian ensures adequate nutrition
to provide a diet plan that the while reducing nausea
patient can tolerate without triggers.
exacerbating nausea or
vomiting.

2. Activity Intolerance

Assessment Diagnosis Scientific Planning Implementation Rationale Evaluation

explanation

Subjective: Activity Intolerance Insufficient Short Term Goal: Independent Interventions: Independent Interventions: Short Term Goal:
r/t weakness physiological or
- Patient reports secondary to psychological After 24 hours of •Assess patient’s activity •To help determine the After 24 hours of
feeling very weak chemotherapy energy to complete nursing tolerance by monitoring vital patient’s physical limits and nursing
(Adriamycin and tasks due to a interventions, the signs (BP, pulse) before, ensure safety. interventions, the
Cytoxan), as compromised patient will report during, and after activity. patient has
reduced fatigue as •To prevent exhaustion and reduced fatigue as
evidenced by health state
Objective: evidenced by •Encourage frequent rest allow the patient to gradually evidenced by
patient reports of
| increased tolerance periods between activities. build up strength. increased tolerance
weakness,
- Patient appears
hypotension (BP to activity such as to activity such as
weak and pale. Chemotherapy •Assist patient with daily •To conserve the energy of
90/70 mmHg), and being able to do being able to do
drugs (Adriamycin activities (ex. bathing or the patient and prevent
pale appearance light activities light activities
- History of dressing) if needed. fatigue.
and Cytoxan) cause without excessive without excessive
chemotherapy
side effects like fatigue. fatigue.
with Adriamycin • Educate the patient on •Energy-conservation
fatigue and
and Cytoxan weakness due to energy-conservation techniques can help patient in
their cytotoxic techniques such as sitting managing energy level more
effects on normal Long Term Goal: while performing tasks and effectively. Long Term Goal:
cells, including pacing activities.
Vital signs: BP After 3 days of •To help prevent muscle After 3 days of
bone marrow
90/70 mmHg nursing •Gradually increase activity deconditioning and improve nursing
suppression
interventions, the levels as tolerated, starting activity tolerance. interventions, the
| patient will with light activities such as patient has
demonstrate sitting up in bed or short improved strength
Leads to reduced improved strength walks. and energy levels,
oxygen-carrying and energy levels, with stable vital
capacity and with stable vital signs during activity
energy production. signs during activity Dependent Interventions: and is able to
and is able to Dependent Interventions: perform daily
•To help manage symptoms activities with
perform daily
•Administer prescribed of fatigue. minimal assistance.
activities with
medications for weakness.
minimal assistance.
•To help restore hydration
•Administer IV fluids as and improve energy levels.
prescribed as ordered by the
doctor.

Collaborative Interventions:

Collaborative Interventions: •To safely increase the

patient's activity tolerance
•Collaborate with a physical over time.
therapist to create a exercise
plan based on patient’s
energy levels.
•To supports energy
•Collaborate with a dietitian production and recovery,
to ensure that the patient improving overall strength
receives adequate nutrition to
improve strength.