Diagnosed with Cancer

Care Plan for Cancer

Category / Primary Body System:

Oncology

Problem:

Diagnosed with cancer

Goal:

1. Pain will be assessed and treatment will be ordered within 24 hours of admission.
2. Pain will be monitored and effective treatment will be administered as evidenced by patient report for the next 90 days.
3. Resident will have appropriate treatment and care needs addressed, per request, for the next 90 days.

Plan/Approach:

1. Pain Assessment and Monitoring:

   • Step-by-Step Approach: Complete pain assessment on admission, quarterly, and with any changes in presenting pain issues. Ask resident if pain is present on every visit to the room (e.g., med pass, meal delivery, care needs).
   • Educational Efforts: Encourage resident to use a consistent pain assessment scale (either 0 to 4 scale or "faces" scale).

2. Pain Reporting and Management:

   • Step-by-Step Approach: Report all complaints of pain, anxiety, or mood changes to the Team Leader immediately. Administer medication for pain as ordered.
   • Monitoring Strategies: Monitor behavior for signs and symptoms indicating pain that the resident may be unable to communicate, including facial grimace, moaning, guarding, increased restlessness, increased agitation, increased anxiety, sudden mood change, or change in sleep pattern.

3. Pain Treatment Environment:

   • Step-by-Step Approach: During episodes of pain, provide a quiet and restful area. Frequently recheck on needs.
   • Monitoring Strategies: Monitor closely for any side effects that residents may experience from the pain medication (e.g., nausea, constipation, dizziness).

4. Communication with Physician:

   • Step-by-Step Approach: Notify the attending physician with any persistent pain not easily altered. Discuss with residents and family members why pain relief is important and how we ensure it occurs.

5. Cancer-Related Concerns:

   • Step-by-Step Approach: Monitor for typical areas of concern regarding cancer diagnosis, including changes in mood, anxiety, fear, abnormal labs, changes in vital signs, anorexia, insomnia, weight loss, edema, fatigue, malaise, sweating, dyspnea, and incontinence.
   • Monitoring Strategies: If new onset issues are noted, complete a full body assessment and notify MD of symptomatology. Follow up as needed.

6. Nutrition and Hydration:

   • Step-by-Step Approach: Encourage a balanced diet, adequate fluids, and plenty of rest daily. Monitor the resident’s routine and initiate changes as needed to ensure optimal health.

7. Emotional Support and Education:

   • Step-by-Step Approach: Provide emotional support for the resident and family during this stressful time. Provide teaching regarding site-specific cancer, what to expect, and where support services are available.
   • Educational Efforts: Notify MD of any additional needs regarding site-specific treatment.

8. Follow-Up and Specialist Care:

   • Step-by-Step Approach: Set up appointments with the Oncologist as ordered. Ensure recommendations are given to the MD in a timely manner.

Rationale:

• Pain Assessment and Monitoring: Ensuring regular and consistent pain assessments can help in managing pain effectively and improving the patient's quality of life.
• Pain Reporting and Management: Immediate reporting and administration of pain medication help in timely pain relief and prevent unnecessary suffering.
• Pain Treatment Environment: A quiet and restful environment can aid in pain management and provide comfort to the patient.
• Communication with Physician: Timely communication with the physician ensures that persistent pain is addressed promptly.
• Cancer-Related Concerns: Monitoring for common cancer-related issues allows for early intervention and appropriate management.
• Nutrition and Hydration: Adequate nutrition and hydration are essential for maintaining strength and health during cancer treatment.
• Emotional Support and Education: Providing support and education helps the patient and family understand the treatment process and manage expectations.
• Follow-Up and Specialist Care: Regular follow-up and specialist care ensure comprehensive management of the patient's cancer.

Actions:

1. Pain Assessment and Monitoring:

   • Staff will complete a pain assessment on admission, quarterly, and with any changes in presenting pain issues.
   • Staff will ask the resident about pain presence on every visit to the room.

2. Pain Reporting and Management:

   • Staff will report all complaints of pain, anxiety, or mood changes to the Team Leader immediately.
   • Staff will administer medication for pain as ordered.
   • Staff will monitor behavior for signs and symptoms of pain that the resident may be unable to communicate.

3. Pain Treatment Environment:

   • Staff will provide a quiet and restful area during episodes of pain.
   • Staff will frequently recheck on needs during episodes of pain.
   • Staff will monitor for side effects of pain medications.

4. Communication with Physician:

   • Staff will notify the attending physician with any persistent pain not easily altered.
   • Staff will discuss the importance of pain relief with the resident and family.

5. Cancer-Related Concerns:

   • Staff will monitor for typical areas of concern regarding cancer diagnosis.
   • Staff will complete a full body assessment and notify MD of symptomatology if new onset issues are noted.

6. Nutrition and Hydration:

   • Staff will encourage a balanced diet, adequate fluids, and plenty of rest daily.
   • Staff will monitor the resident’s routine and initiate changes as needed.

7. Emotional Support and Education:

   • Staff will provide emotional support for the resident and family.
   • Staff will provide teaching regarding site-specific cancer and support services.

8. Follow-Up and Specialist Care:

   • Staff will set up appointments with the Oncologist as ordered.
   • Staff will ensure recommendations are given to the MD in a timely manner.