Nursing Care Plan Patients Name: Boy Chu Lo (8 years old)
Medical Diagnosis: Acute Myeloid Leukemia (AML) 549)
7. Avoid use of aspirin-containing antipyretics.
Dependent: 1. Administer RBCs, Platelet, Clotting Factors.
2. Maintain External Central Vascular access Device (subclavian or tunneled catheter or implanted port).
Collaborative: 1. Laboratory Studies (Platelet, Hbg/Hct, clotting
7. Aspirin can cause gastric bleeding and further decrease platelet count (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
1. Restores/ Normalize RBC count and carry oxygen carrying capacity to correct anemia. Used to prevent/ treat hemorrhage. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) 2. Eliminate peripheral venipuncture as source of bleeding. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) 1. When the platelet is less than 20,000.mm (because of proliferation of WBCs and/or bone marrow suppression secondary to antinoplastic drugs), patient is prone to spontaneous life-threatening bleeding. Decreasing Hb/Hct is indicative of bleeding (may be occult). (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
b. To protect client from infection. Independent: 1. Isolation Precaution (Restrict Isolation): Place in private room. Screen/Limit visitors as i ndicated. Prohibit use of live plants/ cut flowers. Restrict fresh fruits and vegetables or make sure they are washed or peeled.
1. Protect patient from potential sources of pathogens/ infection Note: Profound bone marrow, suppression, neutropenia, and chemotherapy place patient at great risk for infection (Jhonroks, Nusing Care Plan for Leukemias, Scribd,
Nursing Care Plan Patients Name: Boy Chu Lo (8 years old)
Medical Diagnosis: Acute Myeloid Leukemia (AML) 17471597)
2. Require good hand washing protocol for all personnel and visitors
3. Monitor Temperature. Note correlation between temperature elevations and chemotherapy treatments. Observe for fever associated with tachycardia, hypotension, subtle mental changes.
2. P revents crosscontamination/reduces risk for infection. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
3. Although fever may accompany some forms of chemotherapy, progressive hyperthermia occurs in some types of infections, and fever (unrelated to drugs or blood products) occurs in most leukemia patients. Note: Septiceia may occur without fever. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
4. Prevent chilling. Force fluids, administer tepid sponge bath.
4. Helps reduce fever, w/c contributes to fluid imbalance, discomfort, and CNS complication. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
5. Encourage frequent turning and deep breathing.
5. Prevent stasis of r espiratory secretions, reducing risk of atelectasis/pneumonia. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
6. Auscultate breath sounds, noting crackles, ronchi, inspect secretions for changes in characteristic, .g., increased sputum production or change in sputum color. Observe urine for sign of infection, e.g cloudy, foul smelling, or presence of urgency or burning with voids.)
6. Early intervention is essential to prevent sepsis/septicemia in immunosuppressed person. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
7. Handle patient gently. Keep linens dry/ wrinkle-free
7. Prevents sheet burn/ skin excoriation(Nanda,2008. Ineffective th Protection. Nurses Pocketbook. 11
Nursing Care Plan Patients Name: Boy Chu Lo (8 years old)
Medical Diagnosis: Acute Myeloid Leukemia (AML) Ed pg 547-549)
8. inspect skin for tender, erythematous areas; open wounds cleanse skin with antibacterial solution.
8. May indicate local infection Note; Open wounds may not produce pus because of insufficient number of granulocyte. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
9. Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care.
9. The oral cavity is an excellence medium for growth of organisms and is susceptible to ulceration and bleeding. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
10. Promote good perianal hygiene. Examine perianal area at least daily during acute illness. Provide sitz baths, using betadine or hibiclens if indicated. Avoid rectal temperatures, use of suppositories.
10. Promote cleanliness, reducing risk of perianal abscess can contribute to septicemia and death in immunosupressed patients. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
11. Coordinate Procedures and test to allow for interrupted rest periods.
11. Conserves energy for healing, cellular regeneration. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
12. Encourage increased intake of foods high in protein and fluids with adequate fiber.
12. promotes healing and prevents dehydration. Note: Constipation potentiates retention of toxins and risk of rectal irritation/ tissue injury. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
13. Avoid/ limit invasive procedures (e.g., venipuncture and injections) as possible.
13. Break in skin could provide an entry for pathogenic/ potentially lethal organisms. Use of central venous lines (e.g., tunneled catheter or implanted port) can effectively reduce need for frequent invasive
Nursing Care Plan Patients Name: Boy Chu Lo (8 years old)
Medical Diagnosis: Acute Myeloid Leukemia (AML) procedures and risk of i nfection. Note: Myelosuppression may be cumulative in nature, especially when multiple drug therapy (including steroids) is prescribed. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) 14. Provide nutritious diet, high in protein and calories, avoiding raw fruit, vegetables, or uncooked me ats.
Dependent: Administer medication as indicated by physician; 1. Penicillin G (pfizerpen) 1 mil unit , I.V q6 ANST as antibiotic
2. Colony-Stimulating factors: Doxorubicin (adriamycin) 20mg in PNSS to make 100cc/ss q4 ,I.V. Cytarabine (cytosine) 100mg in 500cc ANST q 12, I.V.
Collaborative: 1. Monitor Laboratory studies e.g.: a. CBC, noting whether WBC count falls or sudden changes occur in neutrophils
b. Grams stain C/S
14. Proper nutrition enhances immune system. Inimizes potential sources of bacterial contamination. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
1.May be given prophylactically or treat specific infection (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) 2. Restores WBCs destroyed by chemotherapy and reduces risk of severe infection and death in certain types of leukemia. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
1. a. Decreased numbers of normal/ mature WBCs can result from disease process or chemotherapy, compromising the immune response and increasing risk of infection. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) b. Verifies presence of infections; identifies specific organisms and appropriate therapy. (Jhonroks,
Nursing Care Plan Patients Name: Boy Chu Lo (8 years old)
Medical Diagnosis: Acute Myeloid Leukemia (AML) Nusing Care Plan for Leukemias, Scribd, 17471597)
c. Review serial chest x-rays.
2. Prepare for/ assist with leukemiaspecific treatments such as chemotherapy, radiation, and/or bone marrow transplant.
c. indicator of development/ resolution of resp. complications. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) 2. Leukemia is usually treated with a combination of these agents, each requiring specific safety precautions for patient and care pr oviders. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
Nursing Care Plan Patients Name: Boy Chu Lo (8 years old)
Medical Diagnosis: Acute Myeloid Leukemia (AML) or neutral position.
(Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714)
3.
Encourage quiet, restful atmosphere.
3.
Conserves energy/ lowers tissue Oxygen Demand (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714)
4.
Caution patient to avoid activities that increase cardiac workload (e.g., straining at stool).
4.
To lessen the work of the heart. (Nanda,2008. Ineffective tissue perfussion. th Nurses Pocketbook. 11 Ed pg 705-714)
5.
Provide small/ easily digested.food and fluids, when tolerated and encourage rest after meals.
5.
To maximize blood flow to stomach, enhancing digestion. (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714)
6.
Encouraged early ambulation, when possible.
6.
Enhances venous return. (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714)
7.
Discouraged sitting/standing for long periods, wearing constrictive clothing, crossing legs. Elevate the legs when sitting, avoid sharp angulation of the hips or knees.
7.
To facilitate good blood flow. (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714)
8.
Provide air mattress, foam padding, bed/foot cradle.
8.
To protect extremities. (Nanda,2008. Ineffective tissue perfussion. Nurses
Nursing Care Plan Patients Name: Boy Chu Lo (8 years old)
Medical Diagnosis: Acute Myeloid Leukemia (AML) th
Pocketbook. 11 Ed pg 705714)
9.
Encourage use of relaxation, exercises/ techniques.
10. Prevent exposure to cold, dressing warmly, and use of natural fibers.
9.
To decrease tension level. (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714)
10. To retain heat more e fficiently that may facilitate to vasodilation that allows the blood to facilitate good circulation/flow. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
Dependent: 1. Oxygenation as indicated by physician.
1.
To increased supply and prevent further. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
2.
2.
To provide client with RBC that is a mean for supplying oxygen through body tissue. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
Collaborative: 1. Diagnostic studies (e.g., X-Ray, UTZ, CBC)
1.
To determine location/ severity of condition (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714)
2.
2.
To improve tissue perfusion / organ function. (Nanda,2008. Ineffective tissue perfussion.
Blood transfusion, Packed RBC if Indicated by physician.
Assess with treatment of underlying conditions (e.g., fluid replacement/ rehydration,
Nursing Care Plan Patients Name: Boy Chu Lo (8 years old)
Medical Diagnosis: Acute Myeloid Leukemia (AML) th
nutrients, treatmentof sepsis, medication) as indicated
c.
Nurses Pocketbook. 11 Ed pg 705-714).
To promote wellness.
Independent: 1. E ncourage discussion of feelings regarding prognosis/ long term effects of condition.
2.
Discuss individual risk factors (e.g family history of cancer)
3.
Demonstrate/ encourage use of relaxation activities, exercises/ techniques
4.
Discuss preventing exposure to cold, dressing warmlyt, and use of natural fibers.
1.
2.
To address the patients problem (Nanda,2008. Ineffective tissue perfussion. th Nurses Pocketbook. 11 Ed pg 705-714).
Information necessary for client to make informed choices about remedial risk factors and commitment to lifestyle changes, as appropriate, to prevent onset of complication/ manage symptoms when condition is present (Nanda,2008. Ineffective tissue perfussion. th Nurses Pocketbook. 11 Ed pg 705-714). . 3. To decrease tension level. (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714). . 4. To retain heat more efficiently. (Nanda,2008. Ineffective tissue perfussion. th Nurses Pocketbook. 11 Ed pg 705-714). .
Nursing Care Plan Patients Name: Boy Chu Lo (8 years old)
Medical Diagnosis: Acute Myeloid Leukemia (AML) Collaborative: 1. Review medical regimen and appropriate safety measure and review specific dietaru changes/ restriction with client.
1.
To closely monitor the patients progression. (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714).
Nursing Care Plan Patients Name: Boy Chu Lo (8 years old)
Medical Diagnosis: Acute Myeloid Leukemia (AML) e)
CBC: 9 PLT is low: 33x10 /L Hgb is low: 84%
To promote wellness.
adequate intake. Measure specific gravity and urine pH
acid. Elevated phosphorus and uric acid levels can cause crystal formation in the renal tubules, impairing filtration and leading to renal failure. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
3.
Weigh daily.
3.
Measure of adequacy of fluid replacement and kidney function. Continued intake greater than output may indicate renal insult/obstruction. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
4.
5.
Evaluate skin turgor, capillary refill, and general condition of mucous membranes.
Note presence of nausea, fever.
4.
Indirect indicators of fluid status/hydration. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
5.
Affects intake, fluid needs, and route of replacement. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
c.
To correct/ replace fluid losses to reverse pathophysiological mechanisms. 1.
Independent: 1. Encourage fluids of up to 34 L/day when oral intake is resumed.
Nusing Care Plan for Leukemias, Scribd, 17471597)
2. 2.
Establish 24hrs. replacement needs and routes to be used
Promotes urine flow, prevents uric acid precipitation, and enhances clearance of antineoplastic drugs. (Jhonroks,
Steady rehydration over time prevent peaks/ valleys in fluid level. (Jhonroks, Nusing Care Plan for Leukemias, Scribd,
safety had been promoted e)
Wellness had been promoted.
Nursing Care Plan Patients Name: Boy Chu Lo (8 years old)
Medical Diagnosis: Acute Myeloid Leukemia (AML) 17471597)
(IV/PO, enteral feedings) 3.
Provide foods and beverages with high fluid content (Increased OFI), and fluids containing electrolytes (e.g., Gatorade)
Dependent: 1. Ondansetron Hydrochloride (Zofran) 2mg SIVP q 12h RTC as administered by physician
2.
Allopurinol (Zyloprim) 300mg P.O daily or divided t.i.d after meal. As administered by physician
3.
To promote rehydration (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
1.
Anti-emetic, relieves N/V associated with administration of chemotherapy. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
2.
Improves Renal excretion of toxic by products from breakdown of leukemia cells. Reduces the chances of nephropathy as a result of uric acid production. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
3.
Sodium Bicarbonate (NaHCO3) 50 meq plus D5 0.3% NaCl as administered by physician.
3.
May be used to alkalinize the urine, preventing or minimizing tumor lysis syndrome/ kidney stones. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
Collaborative: 1. Administer IV fluids as indicated
1.
Maintain fluid/electrolyte balance in the absence of oral intake; prevents or minimizes tumor lysis syndrome, reduces risk of renal complication. (Nanda,2008. Defient Fluid Volume. Nurses th Pocketbook. 11 Ed pg 320327).
Nursing Care Plan Patients Name: Boy Chu Lo (8 years old)
Medical Diagnosis: Acute Myeloid Leukemia (AML)
2.
d.
2.
3.
As baseline data, to determine fluid and electrolytes loss. .(Nanda,2008. Defient Fluid Volume. Nurses Pocketbook. th 11 Ed pg 320-327).
1.
To maintain skin integrity and pevent excessive dryness. Skin Barrier. .(Nanda,2008. Defient Fluid Volume. Nurses th Pocketbook. 11 Ed pg 320327).
2.
Prevent injury from dryness. .(Nanda,2008. Defient Fluid Volume. Nurses Pocketbook. th 11 Ed pg 320-327).
3.
To prevent decubitus ulcer and facilitate body fluid flow. .(Nanda,2008. Defient Fluid Volume. Nurses Pocketbook. th 11 Ed pg 320-327).
4.
To promote safety and security. .(Nanda,2008. Defient Fluid Volume. Nurses th Pocketbook. 11 Ed pg 320327).
To promote safety and comfort
Independent: 1.
2. Laboratory Data: Hgb/Hct, electrolyte(sodium, potassium, chloride, bicarbonate); BUN, Creatinine.
Bathe less frequently using mild cleanser soap and provide ptimal skin care with suitable emollients. Apply lotion / skin care if indicated.
Provide frequent oral and eye care.
Change position frequently,
4.
Provide safety measure. Note: if patient is confused).
e.
To promote wellness
Independent:
1.
Early identification of risk
Nursing Care Plan Patients Name: Boy Chu Lo (8 years old)
Medical Diagnosis: Acute Myeloid Leukemia (AML) 1.
Discuss factors r/t occurrence of deficoit as individually appropriate.
factors can decrease occurrence and severity of complications..(Nanda,2008. Defient Fluid Volume. Nurses th Pocketbook. 11 Ed pg 320327).
