Cues/

Evidences
Subjective:
wala lagi lami
ikaun dai as
verbalized by
the patient.
Objective:
-weight loss
-weakness
-fatigue
-poor skin
turgor
-documented
inadequate
caloric intake

Nursing
Diagnosis
Imbalanced
Nutrition: Less
than body
requirements
related to the
effects of
chemotherapy

Scientific Basis
Patients having
leukemia
undergone
therapeutic
management may
consist of
combined
chemotherapeutic
agents.
Chemotherapy
treatment consists
of several stages;
induction therapy,
intensification,
consolidation and
maintenance
therapy. In which
side effects such
as inability to
taste and smells
foods, loss of
appetite, nausea
and vomiting, dry
mouth, diarrhea
occurs.

Gulanick/ Myers.
Nursing Care
Plans 8th Edition

Goals/ Outcome
Criteria
After 8 hours of
nursing intervention
the patient will be
able to maintain
optimal nutrition, as
evidenced by caloric
intake are adequate to
meet body
requirement, balance
intake and output,
absence of nausea
and vomiting and
good skin turgor.

Nursing Intervention

Rationale

Independent:
Obtain history of
previous patterns of
nausea and vomiting.

-nausea and
vomiting are most
distressing side
effects for
patients and
families.

Assess patients
description of nausea
and vomiting pattern.

-patient responses
are
individualized,
depending on
type and dosage
of chemotherapy.
Nausea and
vomiting may be
Weight patient daily at acute or delayed.
the same time with the
same scale.
-consistent
weighing is
important to
ensure accuracy
without
monitoring the pt.
may be unaware
Provide small frequent of small changes
nutritious feeding.
in weight.

-prevents gastric

Evaluation
After 8 hours
of nursing
intervention
the goal was
met the
patient was
able to
maintain
optimal
nutrition, as
evidenced by
caloric intake
are adequate
to meet body
requirement,
balance intake
and output,
absence of
nausea and
vomiting and
good skin
turgor.

Avoid spicy foods,

gravy, greasy and
foods with strong
odors.
Encourage patient to
suck on hard candies
during chemotherapy.

distention.

Position patient in a
Fowlers or sidelying
position during
vomiting episode.

-hard candies can

reduce metallic or
bitter taste.

Serve foods cold if

odors cause aversion.

Collaborative:
- Monitor
appropriate
lab. Values
-

Goals/ Outcome
Criteria

Scientific Basis
Cues/

Nursing

Administer
antiemetics.

Gulanick/
Myers.
Nursing Care
Plans 8th
Edition

-these foods can

stimulate gastric
motility

-this reduces
aspiration risk

-the smell of
cooking foods
may aggravate
feelings of nausea

These reflect
nutrition and fluid
electrolyte status.
Newer agents are
much effective in
reducing the
incidence and
severity of
emesis.

Evidences

Diagnosis
Nursing Intervention
Evaluation

Rationale
Subjective:
nagundergo
lage tawn ko ug
chemotherapy
dai, as
verbalized by
the patient.
Objective:
-altered clotting
as shown in
clients chart
-signs for
potential
bleeding are
present.

Ineffective
protection
related to bone
marrow
depression
secondary to
chemotherapy.

Patient undergoes
chemotherapy
especially in
leukemic patient
and the commonly
affected area is in
the bone marrow
in which causes
depression, it
attacks both
normal and
abnormal cell
growth.

Gulanick/ Myers.
Nursing Care
Plans 8th Edition

After 8 hours of
nursing intervention
the patient will be
able to reduce the
risk of bleeding as
evidenced by platelet
count within
acceptable limits,
compliance and with
preventive measures
and prompt reporting
of early signs and
symptoms.

Independent:
Assess for signs and
-these may
symptoms of bleeding. include petechiae,
bruising,
hemoptysis.
Note bleeding from
any recent puncture
-prolonged oozing
site.
of blood from
puncture site may
be the first signs
of a coagulation
Encouraged to use soft problem.
toothbrush and
nonabrasive
-this reduces risk
toothpaste.
of bleeding.
Avoid aspirin or
aspirin-containing
products, NSAIDs and
anticoagulant.

-these interfere
with platelet
function.

Avoid sharps objects.

-not only can
cause bleeding
but also became

After 8 hours
of nursing
intervention
the goal was
met the
patient was
able to reduce
the risk of
bleeding as
evidenced by
platelet count
within
acceptable
limits,
compliance
and with
preventive
measures and
prompt
reporting of
early signs
and
symptoms

Collaborative:
Monitor platelet count

Apply ice or topical

thrombin promptly as
prescribed for
bleeding mucous
membranes.
Ensure availability
and readiness of
platelet for
transfusion.

Gulanick/ Myers.
Nursing Care Plans 8th
Edition

the portal of entry

for
microorganisms.

-determine the
risk for bleeding.

-this promotes
clot formation.

-this prevents
spontaneous or
excessive
bleeding.

Cues/Evidences
Subjective
Cues:
Nalipong og
nagluya gyud
ko, as
verbalized by
the patient.
Objective
Cues:
*BP: 130/80
RR: 21cpm
PR: 75bpm
*Hgb: 97L
*Conscious and
coherent
*with presence
of body
weakness and
fatigue
*Restlessness
*Poor appetite
*Limited ROM

Nursing
Diagnosis
Fatigue related
to decreased
hemoglobin
count
secondary to
anemia

Scientific Basis

Goals/Outcome
Criteria
Hemoglobin is
After 8 hours of
responsible for the
nursing intervention,
cells ability to
the patient will be
transport oxygen
able to:
and carbon
- Report
dioxide.
improved
Anemia is
sense of
a condition
energy
marked by a
- Perform
reduction in the
ADLs
hematocrit and/or
hemoglobin
- Participate in
content of the blood.
desired
activities at
level of
ability

Interventions
1. Teach energy
conservation
principles.

Evaluation

Patients and
caregivers may
need to learn
skills for
delegating tasks
to others, setting
priorities and
clustering care to
use available
energy to
complete desired
activities.

Goal is met.
After 8 hours
of nursing
intervention
the patient
was able to:

2. Stress the
Energy reserves
importance of frequent may be depleted
rest periods.
unless the patient
respects the
bodys need for
increased rest.
3. Observe the
patients usual level of
exercise and physical
activity.

Gulanick/ Myers.
Nursing Care
Plans 8th Edition

Rationale

Gulanick/ Myers.
Nursing Care Plans 8th
Edition

To assess the
improvement of
the patients level
of physical
activity.

Report
improved
sense of
energy.
Perform
ADLs.
Participate in
desired
activities at
level of
ability.