Symptom | Form of evaluation | Possible Nursing interventions, | Evaluation of achieving the objective of the intervention, |
Pain | Conduct a physical exam and complete medical history, taking into consideration vital signs, bearing and attitude, pain assessment scales and verbal or gesture expressions of the patient | Analgesia as needed; taking vital signs; reassess the pain scale and implement alternative treatments, taking into account the culture and beliefs of the family and the patient; The use of the analgesic ladder of the World Health Organization is recognized as a tool for pain control | Assessment and anamnesis, taking vital signs, bearing and attitude (mental assessment); The group points out the need to involve the family throughout the entirety of the care process for the effective control of this symptom |
Anorexia | Personal history, in depth interview that evaluates psycho-social-nutritional aspects, physical evaluation, body mass index, taking anthropometric measurements, assessment of alimentary and nutritional habits that allow to determine if the anorexia is voluntary or secondary to a pathological starvation disorder | Introduce probe of enteral nutrition or parenteral nutrition, remission to a nutritionist or a psychiatrist | Improved nutritional status, recovery of the nutritional appetite |
Cachexia | Muscle evaluation (tone, strength and size), body mass index, skin folds, cutaneous turgor, anamnesis, physical musculoskeletal and integumentary assessment | Nutritional assessment to start the required replacement, avoid pressure areas by making changes in position, make curves of mass and weight gain, promote protein and calorie intake (depending on the clinical condition), promote physical activities according to the condition (passive exercises) to avoid further muscle deterioration or preservation | Assess muscle mass and if necessary paraclinical to assess micronutrient levels; assess pressure zones; curve analysis to identify if the person is making an adequate contribution; assessing muscle tone and strength in order to identify muscular atrophies |
Fatigue | Perform anamnesis in relation to activities the person has discontinued, either for their physical and psychological condition | It is not presented | It is not presented |
Diarrhea | Frequency, fever, presence of blood, texture, food, smell, color, gastrointestinal habits, grade of dehydration, oral tolerance of pain; Evaluate the use of home remedies and its relationship with the appearance of the symptom | Control of vital signs, fluid control, anti-diarrheal management, changes in nutrition, administration of liquids and electrolytes and weight control | Decreased diarrhea and dehydration improvement |
Nausea | Specific anamnesis of the symptom, oral tolerance and identify drugs that could cause side effects and/or foods that can cause this symptom; It is important to assess environment and food preparation as trigger factors of the symptom | Recommend replacing the foods that cause the nausea and administer antiemetic | Decreased nausea and restarting the digestion |
Vomit | Frequency, color, texture, causes that generate it, investigate treatment received (pharmacological and non-pharmacological), food preparation and food triggers | Administer antiemetic, modify diet, fluid control, administer fluids, weight control | Decreased vomiting and improved hydration |