5 Nursng Diagnosis Interventions for Malignant Lymphoma

Lymphomas are a group of cancers in which cells of the lymphatic system become abnormal and start to grow uncontrollably. Because there is lymph tissue in many parts of the body, lymphomas can start in almost any organ of the body.

The two main types of lymphomas:

  • Hodgkin's lymphoma (HL) — There are six types of HL, an uncommon form of lymphoma that involves the Reed–Sternberg cells.
  • Non-Hodgkin lymphoma (NHL) — There are more than 61 types of NHL, some of which are more common than others. Any lymphoma that does not involve Reed-Sternberg cells is classified as non-Hodgkin lymphoma.

The diagnosis of malignant lymphoma requires the presence of malignant lymphocytes in a biopsy of lymph node or extra-lymphatic tissue. An excisional lymph node biopsy is essential for complete diagnostic assessment. If a whole lymph node is not obtainable, sufficient incised tissue from an extra-lymphatic site can be diagnostic but is less desirable.

Treatment of malignant lymphoma is based on histologic subtype, extent of disease, and age of the patient as is shown in the following table. In the case of discordant (two separate sites of disease with differing types of lymphoma), composite (one site of disease with two discrete types of lymphoma at that site) or transformed (a second lymphoma developing out of a background of previously known lymphoma) lymphoma, treatment must be directed at the most aggressive phase of the disease.


Nursing Diagnosis for Malignant Lymphoma

1. Acute Pain related to the injury of biological agents.
2. Hyperthermia related to ineffective thermoregulation secondary to inflammation.
3. Imbalanced Nutrition Less than Body Requirements related to nausea, vomiting.
4. Knowledge Deficit related to lack of exposure to information
5. Risk for Ineffective Airway Clearance related to enlarged lymph medinal / airway edema.


Nursing Intervention for Malignant Lymphoma

1. Acute Pain related to the injury of biological agents.

Goal: Pain is reduced / lost

Expected outcomes:
  • Pain scale: 0-3
  • Clients do not face grimace
  • Clients not holding area pain

Intervention:
1. Assess pain scale with PQRST.
R /: to know the pain scale and to facilitate clients in determining interventions.

2. Teach the client relaxation and distraction techniques.
R /: relaxation and distraction techniques were taught to the client, can help in reducing the client's perception of the pain he suffered.

3. Collaboration in the delivery of analgesic drugs.
R /: analgesics may reduce or eliminate the pain suffered by the client.


2. Hyperthermia related to ineffective thermoregulation secondary to inflammation.

Goal: the client's body temperature down / within normal limits

Expected outcomes:
  • Body temperature within the normal range (35.9 to 37.5 0 Celsius)

Intervention:

1. Observation of the client's body temperature.
R /: to monitor the client's body temperature can know the state of the client and also can take the appropriate action.

2. Give a warm compress on the forehead, axilla, abdomen and groin.
R /: compress can reduce body temperature.

3. Encourage and provide drinking a lot (in accordance with the needs of the client's body fluids).
R /: by drinking lots are expected to help maintain the body's fluid balance in the client.

4. Collaboration in the provision of antipyretics.
R: antipyretics can reduce body temperature.


3. Imbalanced Nutrition Less than Body Requirements related to nausea, vomiting.

Goal: client's nutritional needs can be met

Expected outcome:
  • Showed an increase in body weight / body weight stable.
  • Clients increased appetite.
  • Clients exhibit behavioral changes in lifestyle to maintain an appropriate body weight.

Intervention:

1. Review the history of nutrition, including food preferences.
R /: to identify nutritional deficiencies and interventions.

2. Observation and record food intake.
R /: watching caloric intake.

3. Measure weight every day.
R /: oversee the effectiveness of weight loss and nutritional intervention.

4. Give eat little but often frequency.
R /: increase in total caloric intake and also to prevent gastric distention.

5. Collaboration in the provision of nutritional supplements.
R /: increase protein intake and calories.



4. Knowledge Deficit related to lack of exposure to information.

Goal: Clients and their families can learn about the disease suffered by the client

Expected outcomes:
  • Client and the client's family can understand the disease process.
  • Client and the client's family to get clear information about the disease suffered by the client.
  • Client and the client's family to comply with the therapeutic process to be carried out.

Intervention:

1. Provide therapeutic communication to clients and client families.
R/ : ease of doing terpiutuk procedures to clients.

2. Provide information about the disease process to the client and the client's family.
R/ : the client and the client's family can know the process of the disease suffered by the client.



5. Risk for Ineffective Airway Clearance related to enlarged lymph medinal / airway edema.

Goal: Effective client airway

Expected outcomes:
  • Clients can breathe normally / effective.
  • Clients are free of dyspnea, cyanosis.
  • There is no sign of respiratory distress.
Intervention:

1. Assess respiratory rate, depth, rhythm.
R /: changes may indicate the continued engagement / respiratory effects requiring intervention efforts.

2. Place the patient in a comfortable position, usually with a high headboard / or sit up straight to the feet of hanging.
R /: to maximize lung expansion, lower respiratory work, and reduce the risk of aspiration.

3. Assist with deep breathing techniques or breathing and lip / diaphragm. Abdomen when indicated.
R /: to help improve gas diffusion and expansion of small airway, give the client some control over breathing, helps reduce anxiety.

4. Assess the respiratory response to activity.
R /: decrease in cellular oxygenation lowering activity tolerance.

0 komentar:

Post a Comment