Student Nurses’ Community
NURSING CARE PLAN – Leukemia ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION INDEPENDENT: • Place the patient in • private room. Limit visitors as indicated. Prohibit use of live plants or cut flowers. Restrict fresh fruits and vegetables or make sure they are washed or peeled. • • Require good handwashing protocol for all personnel and visitors. • • Encourage frequent turning and deep breathing. RATIONALE EVALUATION After 8 hours of nursing interventions the patient was able to identify actions to prevent or reduce the risk for infection.
SUBJECTIVE: “Napansin ko na madalas ako mgkaroon ng pasa at palagi nalang akong pagod at nanghihina” (I’ve
noticed that I bruise easily and also I feel weak and tired all the time.) as
Risk for infection related to inadequate primary defenses.
Leukemias are cancers of the blood-forming tissues. White blood cells may be produced in excessive amounts and are unable to work properly which weakens the immune system.
After 8 hours of nursing interventions the patient will identify actions to prevent or reduce the risk for infection.
Protect patient from potential sources of pathogens or infection.
verbalized by the patient. OBJECTIVE: • • • Irritability Pallor of skin and mucous membranes V/S taken as follows T: 37.1 P: 80 R: 19 BP: 100/80
Prevents crosscontamination or reduce risk for infection. Prevents stasis of respiratory secretions, reducing risk of atelectasis or pneumonia. Prevents sheet burn or skin excoriation. May indicate local infection.
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Handle patient gently. Keep linens dry or wrinkle free. Inspect skin for tender, erythematous areas, open wounds. Cleanse skin with antibacterial solutions.
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Student Nurses’ Community •
Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care. Promote good perineal hygiene. Examine perianal area at least daily during acute illness and provide sitz baths. Coordinate procedures and tests to allow for uninterrupted rest periods. • The oral cavity is an excellent medium for growth of organism and is susceptible to ulceration and bleeding. Promotes cleanliness, reducing risk of perianal abscess; enhances circulation and healing. Conserves energy for healing, cellular regeneration.
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COLLABORATIVE: • Prepare for or assist patient with leukemia treatments such as chemotherapy, radiation, and bone marrow transplantation. • Administer antibiotics as indicated.
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Leukemia is usually treated with a combination of these agents, each requiring specific safety precautions for patient and care providers. May be given prophylactically or to treat specific infection.