Cancer Nursing Care Plan(NCP) -Risk for Infection

Cancer Cells Cancer Nursing Care Plan(NCP)  Risk for InfectionCancer is a potentially fatal disease caused mainly by environmental factors that mutate genes encoding critical cell-regulatory proteins. The resultant aberrant cell behavior leads to expansive masses of abnormal cells that destroy surrounding normal tissue
and can spread to vital organs resulting in disseminated disease, commonly a harbinger of Imminent patient death.

Most types of a cancer cell’s clumps together to form a mass or tumor. When a cell breaks away from tumor, it can be swept into the lymph system or bloodstream and carried to other parts of the body where new tumors can be formed.

Classifications of cancer

  • Lymphomas -cancers originating in infection-fighting organs
  • Leukemia’s -cancers originating in blood-forming organs
  • Sarcomas -cancers originating in bones, muscle, or connective tissue
  • Carcinomas-cancers originating in epithelial cells

Common Signs of Cancer

  • A lump or thickening in the breast or testicles are indicative signs for further investigation.
  • A change in a wart or mole may be reflective of melanoma or squamous carcinoma.
  • A persistent skin sore that does not heal may be indicative of melanoma.
  • A change in bowel or bladder habits, such as constipation, chronic
  • diarrhea, abdominal pain, rectal or urinary bleeding indicating gastrointestinal cancer.
  • A persistent cough or coughing up blood, indicating bronchial tree damage.
  • Constant indigestion or trouble swallowing, are common signs of colon, stomach, or esophagus cancer.
  • Unexplained weight loss, as cancer cells use up patient energy source without him/her knowing it.
  • Unusual bleeding or vaginal discharge may be signs of uterine, endometrial or cervical cancer.
  • Chronic fatigue, a symptom often accompanied by rapidly progressing cancers.

Nursing Diagnosis:Risk for Infection

Risk factors may include

  • Inadequate secondary defenses and immunosuppression, e.g., bone marrow suppression (dose-limiting side effect of both chemotherapy and radiation)
  • Malnutrition, chronic disease process
  • Invasive procedures

Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis]

Desired Outcomes

  • Remain afebrile and achieve timely healing as appropriate.
  • Identify and participate in interventions to prevent/reduce risk of infection.

Cancer Nursing Care Plan(NCP) -Risk for Infection

Nursing actions Rationale
Promote good handwashing procedures by staff and visitors. Screen/limit visitors who may have infections. Place in reverse isolation as indicated. Protects patient from sources of infection, such as visitors and staff who may have an upper respiratory infection (URI).
 Emphasize personal hygiene. Limits potential sources of infection and/or secondary overgrowth
Monitor temperature.  Temperature elevation may occur (if not masked by corticosteroids or anti-inflammatory drugs) because of various factors, e.g., chemotherapy side effects, disease process, or infection. Early identification of infectious process enables appropriate therapy to be started promptly.
Assess all systems (e.g., skin, respiratory, genitourinary) for signs/symptoms of infection on a continual basis Early recognition and intervention may prevent progression to more serious situation/sepsis.
Reposition frequently; keep linens dry and wrinkle-free. Reduces pressure and irritation to tissues and may prevent skin breakdown (potential site for bacterial growth)
Promote adequate rest/exercise periods. Limits fatigue, yet encourages sufficient movement to prevent stasis complications, e.g., pneumonia, decubitus, and thrombus formation.
Stress importance of good oral hygiene. Development of stomatitis increases risk of infection/
secondary overgrowth.
Avoid/limit invasive procedures. Adhere to aseptic techniques. Reduces risk of contamination, limits portal of entry for infectious agent.
Monitor CBC with differential WBC and granulocyte count, and platelets as indicated. Bone marrow activity may be inhibited by effects of chemotherapy, the disease state, or radiation therapy. Monitoring status of myelosuppression is important for preventing further complications (e.g., infection, anemia, or hemorrhage) and scheduling drug delivery. Note: The nadir (point of lowest drop in blood count) is usually seen 7–10 days after administration of chemotherapy.
Obtain cultures as indicated. Identifies causative organism(s) and appropriate therapy.
Administer antibiotics as indicated. May be used to treat identified infection or given prophylactically in immunocompromised patient.

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