Assessment Nursing Diagnosis Subjective Cues(s): Ineffective protection Nanghihina po ako r/t abnormal as verbalized by Chulo blood profile and drug requirement Objective Cue (s): (antineoplastic) -With ongoing as chemotherapy manifested (Cytarabine) by elevated body temp., V/S bradypnea, Temp: 38.5oC tachycardia, (Hyperthemia) deficient RR: 18cpm immunity (Bradypnea) (Low HR: 120bpm matured (Tachycardia) WBC and High CBC immature WBC is elevated but immature:13.59x109/L WBC), Low platelet Neutrophil: 0.18% count and Lymp: 0.81% Hgb, Pallor, (Deficient immunity Weakness, and Maladaptive Easy Stress Response) fatigability, PLT is low: 33x109/L and Hgb is low: 84% Maladaptive Hct is low : 25% to stress response. Pallor Weakness Easy fatigability Dyspnea Cues Situational Analysis Decreased in the ability to guard self from internal or external threats such as illness or injury. Expected Outcome After 24 hrs of nursing intervention Chulo will be protect from infection and bleeding hazard That may contribute to patient s health condition and may demonstrate Improvement in vital signs, laboratory result, and lessen the difficulty of body function. Objectives: a) To protect client from Bleeding hazards and lessen the risk for injury. b) To protect client from infection. Planning Nursing Intervention a. To protect client from Bleeding hazards and lessen the risk for injury. Independent: 1. Monitor v/s 2. Inspect skin/mucous membrane for petechiae, ecchymotic areas, note bleeding gums, frank or occult blood in stools and urine, oozing from invasive-line site
1. as baseline data 2. Suppression of bone marrow and platelet production. Places patient at risk for spontaneous/ uncontrolled bleeding (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) 3. Fragile tissues and altered clotting mechanisms. Increase the risk of hemorrhage following even minor trauma. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
3. Implement measure to prevent tissue injury/ bleeding (Avoid Sharp Object, Minimize invading procedure, Avoid Contact Sport) (e.g. gentle brushing of teeth or gums with soft toothbrush, cotton swab, or sponged tipped applicator, avoiding needlesticks when possible, using sustained pressure on oozing puncture/IV sites. 4. Limit Oral Care to mouthwash if indicated (a mixture of 1/4tsp. baking soda or salt in 4-8 oz water or hydrogen peroxide in water). Avoid mouthwashes with alcohol
2.
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)
2. Maintain External Central Vascular access Device (subclavian or tunneled catheter or implanted port).
b. To protect client from infection. Independent: 1. Isolation Precaution (Restrict Isolation): Place in private room. Screen/Limit visitors as indicated. 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,
3. Monitor Temperature. Note correlation between temperature elevations and chemotherapy treatments. Observe for fever associated with tachycardia, hypotension, subtle mental changes.
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. Helps reduce fever, w/c contributes to fluid imbalance, discomfort, and CNS complication. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) 5. Prevent stasis of respiratory secretions, reducing risk of atelectasis/pneumonia. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) 6. Early intervention is essential to prevent sepsis/septicemia in immunosuppressed person. (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.) 7. Handle patient gently. Keep linens dry/ wrinkle-free
7. Prevents sheet burn/ skin excoriation(Nanda,2008. Ineffective Protection. Nurses Pocketbook. 11th
9. Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care.
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. 11. Coordinate Procedures and test to allow for interrupted rest periods.
12. Encourage increased intake of foods high in protein and fluids with adequate fiber.
13. Avoid/ limit invasive procedures (e.g., venipuncture and injections) as possible.
Dependent: Administer medication as indicated by physician; 1. Penicillin G (pfizerpen) 1 mil unit , I.V q6 ANST as antibiotic
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)
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
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,
2. Prepare for/ assist with leukemiaspecific treatments such as chemotherapy, radiation, and/or bone marrow transplant.
Independent: 1. Note reports of increasing fatigue, weakness. Observe for tachycardia, pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient activities to avoid fatigue. Note poor hygiene/ health practices(e.g., lack of cleanliness, poor dental care.) 1. May reflect effects of anemia and cardiac response. To let the patient rest. (Nanda,2008. Ineffective tissue perfussion. th Nurses Pocketbook. 11 Ed pg 705-714)
2.
2.
Collaborative: 1. Assess blood supply and sensation (nerve damage) of affected area. Evaluates pulses/ calculate ankle- brachial index
May impacting tissue health. (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714) To evaluate actual/potential for impairment of circulation to lower extremities. Result less than 0.9 indicates need for close monitoring/ more aggressive intervention. (Nanda,2008. Ineffective tissue perfussion. Nurses Pocketbook. 11th Ed pg 705714)
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As baseline data
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Caution patient to avoid activities that increase cardiac workload (e.g., straining at stool).
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Provide small/ easily digested.food and fluids, when tolerated and encourage rest after meals.
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Discouraged sitting/standing for long periods, wearing constrictive clothing, crossing legs. Elevate the legs when sitting, avoid sharp angulation of the hips or knees. Provide air mattress, foam padding, bed/foot cradle.
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10. Prevent exposure to cold, dressing warmly, and use of natural fibers.
10. To retain heat more efficiently that may facilitate to vasodilation that allows the blood to facilitate good circulation/flow. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
1.
To increased supply and prevent further. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) To provide client with RBC that is a mean for supplying oxygen through body tissue. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
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To determine location/ severity of condition (Nanda,2008. Ineffective tissue perfussion. Nurses Pocketbook. 11th Ed pg 705714) To improve tissue perfusion / organ function. (Nanda,2008. Ineffective tissue perfussion.
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Independent: 1. E ncourage discussion of feelings regarding prognosis/ long term effects of condition.
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To address the patient s problem (Nanda,2008. Ineffective tissue perfussion. Nurses Pocketbook. 11th 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). . To decrease tension level. (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714). . To retain heat more efficiently. (Nanda,2008. Ineffective tissue perfussion. th Nurses Pocketbook. 11 Ed pg 705-714). .
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Discuss preventing exposure to cold, dressing warmlyt, and use of natural fibers.
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Independent: 1. Note possible conditions/ processes that may lead to deficits: 1) fluid loss(e.g., diarrhea/ vomiting, excessive sweating;2) environmental factor (isolation, restraints, exposure to extreme heat) 2. Determine effect of age.
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Contributors of fluid volume deficit.(Nanda,2008. Defient Fluid Volume. Nurses Pocketbook. 11th Ed pg 320327).
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Very young are quickly affected by fluid volume deficit, and are least able to express need. .(Nanda,2008. Defient Fluid Volume. Nurses Pocketbook. 11th Ed pg 320327). Monitor precipitating factors. .(Nanda,2008. Defient Fluid Volume. Nurses Pocketbook. 11th Ed pg 320-327).
3.
Evaluate nutritional status, noting current intake, weight changes, problems with oral intake use of supplements.
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b) Degree of fluid deficit had been evaluated. c) Fluid losses to reverse pathophysiolo gical mechanisms had been correct ed/ replaced.
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2.
Monitor I&O. Calculate insensible losses and fluid balance. Note decreased urine output in presence of
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Tumor lysis syndrome occurs when destroyed cancer cells release toxic levels of potassium, phosphorus, and uric
d) Comfort and
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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)
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Evaluate skin turgor, capillary refill, and general condition of mucous membranes.
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c.
To correct/ replace fluid losses to reverse pathophysiological mechanisms. 1. Promotes urine flow, prevents uric acid precipitation, and enhances clearance of antineoplastic drugs. (Jhonroks,
Nusing Care Plan for Leukemias, Scribd, 17471597)
Steady rehydration over time prevent peaks/ valleys in fluid level. (Jhonroks, Nusing Care
Plan for Leukemias, Scribd,
3.
To promote rehydration
(Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
Dependent: 1. Ondansetron Hydrochloride (Zofran) 2mg SIVP q 12h RTC as administered by physician
1.
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Allopurinol (Zyloprim) 300mg P.O daily or divided t.i.d after meal. As administered by physician
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)
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May be used to alkalinize the urine, preventing or minimizing tumor lysis syndrome/ kidney stones.
(Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)
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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).
d. To promote safety and comfort Independent: 1. Bathe less frequently using mild cleanser soap and provide ptimal skin care with suitable emollients. Apply lotion / skin care if indicated. 2. 2. Provide frequent oral and eye care. 3. 3. Change position frequently, 1. To maintain skin integrity and pevent excessive dryness. Skin Barrier. .(Nanda,2008. Defient Fluid Volume. Nurses Pocketbook. 11th Ed pg 320327). Prevent injury from dryness. .(Nanda,2008. Defient Fluid Volume. Nurses Pocketbook. 11th Ed pg 320-327). To prevent decubitus ulcer and facilitate body fluid flow. .(Nanda,2008. Defient Fluid Volume. Nurses Pocketbook. 11th Ed pg 320-327). To promote safety and security. .(Nanda,2008. Defient Fluid Volume. Nurses th Pocketbook. 11 Ed pg 320327).
e.
Independent: