NCP for Malignant Lymphoma - Assessment, 10 Nursing Diagnosis and Interventions

Nursing Care Plan for Malignant Lymphoma

Nursing Assessment

In the assessment, the data can be found in patients with lymphoma, among others:
1. Subjective data:

• Prolonged fever with a temperature over 38 ° C
• Frequent night sweats.
• Feel tired.
• Weakness.
• Complained of pain in the lump.
• Decreased appetite.
• Eat and drink intake decreased, nausea, vomiting.

2. Objective data :

• Chewy lumps arise, easily moved on the neck, armpit or groin.
• Pale face.

Nursing Diagnosis for Malignant Lymphoma

1. Risk for infection related to immunosuppression and malnutrition.
2. Hyperthermia related to ineffectiveness of thermoregulation, secondary to inflammation.
3. Chronic pain related to interruption of nerve cells.
4. Altered peripheral tissue perfusion related to disruption oxygen transport system to hemorrhage.
5. Impaired skin integrity / tissue related to tumor mass pushes out.
6. Activity intolerance related to weakness, the exchange of oxygen, malnutrition, exhaustion.
7. Imbalanced Nutrition: less than body requirements related to the intake is less, the increased metabolic needs, and reduced absorption of nutrients.
8. Fluid Volume Deficit related to vomiting and intake less.
9. Anxiety related to knowledge about the disease, prognosis, treatment and care.
10. Knowledge Deficit related to lack of exposure / recall, misinterpretation, did not know the sources.

Nursing Interventions

1. Hyperthermia related to ineffectiveness of thermoregulation, secondary to inflammation.

Purpose: body temperature within normal limits (36 - 37,5ºC)

Interventions:
a. Observation of the patient's body temperature.
Rationale: To know the state, so that it can take appropriate action.

b. Encourage and give drink plenty (according to the needs of children fluids, according to age).
Rationale: Expected to help maintain fluid balance in the body.

c. Give a warm compress on the forehead, axilla, abdomen and groin.
Rational: Compress can help lower the patient's body temperature by conduction.

d. Advise to use thin clothes, loose and easy to absorb sweat.
Rational: Expected to prevent evaporation so that the body fluid balance.

e. Collaboration in giving antipyretics.
Rational: Antipyretics will hinder the release of heat by the hypothalamus.


2. Chronic pain related to interruption of nerve cells.

Purpose: pain is reduced.

Interventions:
a. Determine the characteristics and location of pain, pay attention to verbal and non-verbal cues every 6 hours.
Rational: Determining follow-up interventions.

b. Monitor blood pressure, pulse and breathing every 6 hours.
Rational: Pain can lead to restlessness and increased blood pressure, pulse, respiration increases.

c. Apply distraction techniques (talk).
Rational: Diverting attention away from pain.

d. Teach relaxation techniques (deep breathing) and suggest to repeat when feeling pain.
Rational: Relaxation reduces muscle tension, thereby reducing pressure and pain.

e. Give and let the patient choose a comfortable position.
Rational: Reducing tensions painful area.

d. Collaboration in the delivery of analgesics.
Rational: analgesics will reach the center of the pain and cause pain relief.


3. Imbalanced Nutrition: less than body requirements related to the intake is less, the increased metabolic needs, and reduced absorption of nutrients.

Purpose: The nutritional requirements are met.

Interventions:
a. Feed in small portions but frequently.
Rational: provides an opportunity to increase the total caloric intake.

b. Measure the weight as indicated.
Rational: Useful for determining calorie needs, evaluation of adequacy of nutrition plan.

c. Serve food in warm and varied.
Rational: Improve the patient's desire to eat, so the calorie needs are met.

d. Create a comfortable environment while eating.
Rational: A comfortable environment helps the patient to increase the desire to eat.

e. Give health education on the benefits of nutrition.
Rational: Food supply needs calories to the body and can help the healing process and increase endurance.


4. Activity intolerance related to weakness, the exchange of oxygen, malnutrition, exhaustion.

Purpose: Activities can be improved.

Interventions:
a. Evaluation of patient response to activity, increased weakness / fatigue and changes in vital signs during and after the activity.
Rational: Establish the ability / needs of the patient and facilitate the choice of intervention.

b. Help the patient in meeting the needs of ADL.
Rational: Minimizing fatigue and help balance supply and oxygen demand.

c. Involve the family in patient care.
Rational: Helping and meet ADL patients.

d. Give activities in accordance with the ability of the patient.
Rational: Minimizing fatigue and help balance supply and oxygen demand).


5. Anxiety related to knowledge about the disease, prognosis, treatment and care.

Purpose: Patients do not worry / reduced.

Interventions:
a. Assess and monitor for signs of anxiety that occurs.
Rational: Fear can occur due to lack of information on the procedure to be done, do not know about the disease and condition.

b. Explain procedure in a simple action, according to the level of understanding of the patient.
Rational: Provide information to patients about action procedures will improve patient understanding of the actions taken to address the problem.

c. Discuss tensions and expectations of patients.
Rational: To reduce the anxiety felt by the patient.

d. Strengthen supporting factors to reduce ansietes.
Rational: To reduce the anxiety felt by the patient.