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Nursing Care Plan Patient s Name: Boy Chu Lo (8 years old)

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

Medical Diagnosis: Acute Myeloid Leukemia (AML)


Rationale Evaluation Outcome Assessment Goal Met: After 24 hrs of nursing intervention Chulo was protect from infection and bleeding hazard That may contribute to patient s health condition and he demonstrate Improvement in vital signs, laboratory result, and lessen the difficulty of body function. 1. 4. When bleeding is present, even gentle brushing may cause more tissue damage. Alcohol has a drying effect and may be painful to irritated tissues. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) 5. May reduce gum irritation (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) 6. To relieved bleeding cessation. (Nanda,2008. Ineffective Protection. th Nurses Pocketbook. 11 Ed pg 547Theclient protected from Bleeding hazards and the risk for injury had been lessen. The client protected from infection.

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

5. Provide Soft Diet

2.

6. If bleeding is present do the ff.: (Apply pressure, Cold Compression, Elevation)

Nursing Care Plan Patient s Name: Boy Chu Lo (8 years old)

Medical Diagnosis: Acute Myeloid Leukemia (AML)


549) 7. Avoid use of aspirin-containing antipyretics. 7. Aspirin can cause gastric bleeding and further decrease platelet count (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)

Dependent: 1. Administer RBCs, Platelet, Clotting Factors.

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).

Collaborative: 1. Laboratory Studies (Platelet, Hbg/Hct, clotting

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,

Nursing Care Plan Patient s 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 2. Prevents crosscontamination/reduces risk for infection. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)

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)

4. Prevent chilling. Force fluids, administer tepid sponge bath.

5. Encourage frequent turning and deep breathing.

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

Nursing Care Plan Patient s 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. 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 cleanliness, reducing risk of perianal abscess can contribute to septicemia and death in immunosupressed patients. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) 11. Conserves energy for healing, cellular regeneration. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597) 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. 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

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.

Nursing Care Plan Patient s Name: Boy Chu Lo (8 years old)

Medical Diagnosis: Acute Myeloid Leukemia (AML)


procedures and risk of infection. 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 meats. 14. Proper nutrition enhances immune system. Inimizes potential sources of bacterial contamination. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)

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,

b. Gram s stain C/S

Nursing Care Plan Patient s 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. 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 providers. (Jhonroks, Nusing Care Plan for Leukemias, Scribd, 17471597)

2. Prepare for/ assist with leukemiaspecific treatments such as chemotherapy, radiation, and/or bone marrow transplant.

Nursing Care Plan Patient s Name: Boy Chu Lo (8 years old)


Assessment Nursing Diagnosis Subjective Cue(s): Ineffective Medyo nahihirapan Tissue po akong huminga Perfusion r/t minsan as verbalized inadequate red blood by Chulo cell production Objective Cue(s): as manifested With ongoing by chemotherapy bradypnea, (Cytarabine), 5th day tachycardia, -With ongoing Nausea, 0.3%NaCl 1 bottle 25gtts/min, I.V at Left Pallor, Abdominal metacarpal pain, bruises, -V/S: Nausea, RR: 18cpm Abdominal (bradypnea) Pain, PR: 120bpm Capillary (Tachycardia) refill >3sec., Weakness, CBC Easy Hgb is low: 84% Fatigability, Hct is low : 25% Headache and dizziness. Bruises Nausea Abdominal pain Pallor Weakness Easy Fatigability Capillary Refill >3sec. Headache and dizziness Cues Situational Analysis Decreased in oxygen resulting in the failure to nourish the tissues at the capillary level. Expected Outcome After 24 hrs, of Nursing Intervention, Chu Lo will demonstrate increased tissue perfusion as individually appropriate. Objectives: a) To identify causative/ contributing factors. b) To assisst client to correct/ minimize impairment and to promote healing. c) To promote wellness. b. To assisst client to correct/ minimize impairment and to promote healing. Independent: 1. Monitor V/S and Monitor I and O 2. Elevate HOB (10 degrees) and maintain head/neck in midline Planning Nursing Intervention a. To identify causative/ contributing factors.

Medical Diagnosis: Acute Myeloid Leukemia (AML)


Rationale Evaluation Outcome Assessment Goal Met: After 24 hrs, of Nursing Intervention, Chu Lo demonstrate increased tissue perfusion as individually appropriate. 1. Causative contributors had been identified. Correct/Minimize impairment and to promote client s healing had been assisted Wellness had been promoted.

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)

2.

1.

3.

1.

As baseline data

2.

To promote circulation/ venous drainage.

Nursing Care Plan Patient s Name: Boy Chu Lo (8 years old)


or neutral position.

Medical Diagnosis: Acute Myeloid Leukemia (AML)


(Nanda,2008. Ineffective tissue perfussion. Nurses Pocketbook. 11th Ed pg 705714) 3. Conserves energy/ lowers tissue Oxygen Demand (Nanda,2008. Ineffective tissue perfussion. Nurses Pocketbook. 11th Ed pg 705714) To lessen the work of the heart. (Nanda,2008. Ineffective tissue perfussion. Nurses Pocketbook. 11th Ed pg 705-714) To maximize blood flow to stomach, enhancing digestion. (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714) Enhances venous return. (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714) To facilitate good blood flow. (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714)

3.

Encourage quiet, restful atmosphere.

4.

Caution patient to avoid activities that increase cardiac workload (e.g., straining at stool).

4.

5.

Provide small/ easily digested.food and fluids, when tolerated and encourage rest after meals.

5.

6.

Encouraged early ambulation, when possible.

6.

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. Provide air mattress, foam padding, bed/foot cradle.

7.

8.

8.

To protect extremities. (Nanda,2008. Ineffective tissue perfussion. Nurses

Nursing Care Plan Patient s Name: Boy Chu Lo (8 years old)

Medical Diagnosis: Acute Myeloid Leukemia (AML)


Pocketbook. 11th Ed pg 705714) 9. Encourage use of relaxation, exercises/ techniques. 9. To decrease tension level. (Nanda,2008. Ineffective tissue perfussion. Nurses Pocketbook. 11th Ed pg 705714)

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)

Dependent: 1. Oxygenation as indicated by physician.

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)

2.

Blood transfusion, Packed RBC if Indicated by physician.

2.

Collaborative: 1. Diagnostic studies (e.g., X-Ray, UTZ, CBC)

1.

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.

2.

Assess with treatment of underlying conditions (e.g., fluid replacement/ rehydration,

2.

Nursing Care Plan Patient s Name: Boy Chu Lo (8 years old)


nutrients, treatmentof sepsis, medication) as indicated c. To promote wellness.

Medical Diagnosis: Acute Myeloid Leukemia (AML)


Nurses Pocketbook. 11th Ed pg 705-714).

Independent: 1. E ncourage discussion of feelings regarding prognosis/ long term effects of condition.

1.

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). .

2.

Discuss individual risk factors (e.g family history of cancer)

2.

3.

Demonstrate/ encourage use of relaxation activities, exercises/ techniques

3.

4.

Discuss preventing exposure to cold, dressing warmlyt, and use of natural fibers.

4.

Nursing Care Plan Patient s Name: Boy Chu Lo (8 years old)


Collaborative: 1. Review medical regimen and appropriate safety measure and review specific dietaru changes/ restriction with client. 1.

Medical Diagnosis: Acute Myeloid Leukemia (AML)


To closely monitor the patient s progression. (Nanda,2008. Ineffective tissue perfussion. Nurses th Pocketbook. 11 Ed pg 705714).

Nursing Care Plan Patient s Name: Boy Chu Lo (8 years old)


Assessment Nursing Diagnosis Subjective Cue(s): Deficient Fluid Nasusuka po ako Volume r/t as verbalized by Excessive chulo Losses (chemotherapy Objective Cue (s): effect), as evidenced by -With ongoing N/V, anorexia, chemotherapy Pallor, (Cytarabine) weakness, Easy Fatigability, I and O: Decreased Skin 1227ml intake = Turgor. 905ml urine output Capillary Refill .>3secs., V/S: increased fluid o Temp: 38.5 C need, Low (Hyperthemia) hemoglobin, RR: 18cpm Low platelet, (Bradypnea) tachycardia, PR: 120bpm Wt. Loss, Dry (Tachycardia) Mucus membrane . Wt: 19kg (wt. loss) Cues Nausea and Vomiting Anorexia Grimace Pallor Weakness Easy Fatigability Decreased Skin turgor Capillary Refill >3secs. Increased fluid need Dry Cracked Lips Situational Analysis Decreased intravascular, interstitial, and/or intracellular fluid. This referes to dehydration with changes in sodium Expected Outcome After 24 hrs. of nursing intervention the Chulo will maintain fluid volume at a functional level as evidenced by individually adequate moist mucous membrane, good skin turgor, and prompt capillary refill. Objectives: a) To assess causative/ precipitating factors. b) To evaluate degree of fluid deficit. c) To correct/ replace fluid losses to reverse pathophysiolo gical mechanisms. Planning Nursing Intervention a. To assess causative/ precipitating factors.

Medical Diagnosis: Acute Myeloid Leukemia (AML)


Rationale Evaluation Outcome Assessment Goal met: After 24 hrs. of nursing intervention the Chulo maintain fluid volume at a functional level as evidenced by individually adequate moist mucous membrane, good skin turgor, and prompt capillary refill. a) Causative/ Precipitaing factors had been identified.

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.

1.

Contributors of fluid volume deficit.(Nanda,2008. Defient Fluid Volume. Nurses Pocketbook. 11th Ed pg 320327).

2.

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.

3.

b. To evaluate degree of fluid deficit. Independent: 1. Monitor v/S

b) Degree of fluid deficit had been evaluated. c) Fluid losses to reverse pathophysiolo gical mechanisms had been correct ed/ replaced.

1.

Changes may reflect effects of hypovolemia (bleeding/ dehydration). (Jhonroks, Nusing


Care Plan for Leukemias, Scribd, 17471597)

d) To promote comfort and safety.

2.

Monitor I&O. Calculate insensible losses and fluid balance. Note decreased urine output in presence of

2.

Tumor lysis syndrome occurs when destroyed cancer cells release toxic levels of potassium, phosphorus, and uric

d) Comfort and

Nursing Care Plan Patient s Name: Boy Chu Lo (8 years old)


CBC: PLT is low: 33x109/L Hgb is low: 84% e) To promote wellness. adequate intake. Measure specific gravity and urine pH

Medical Diagnosis: Acute Myeloid Leukemia (AML)


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)

safety had been promoted e) Wellness had been promoted.

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.

Evaluate skin turgor, capillary refill, and general condition of mucous membranes.

4.

Indirect indicators of fluid status/hydration. (Jhonroks,


Nusing Care Plan for Leukemias, Scribd, 17471597)

5.

Note presence of nausea, fever.

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. Promotes urine flow, prevents uric acid precipitation, and enhances clearance of antineoplastic drugs. (Jhonroks,
Nusing Care Plan for Leukemias, Scribd, 17471597)

Independent: 1. Encourage fluids of up to 3 4 L/day when oral intake is resumed.

2. 2. Establish 24hrs. replacement needs and routes to be used

Steady rehydration over time prevent peaks/ valleys in fluid level. (Jhonroks, Nusing Care
Plan for Leukemias, Scribd,

Nursing Care Plan Patient s Name: Boy Chu Lo (8 years old)


(IV/PO, enteral feedings) 3. Provide foods and beverages with high fluid content (Increased OFI), and fluids containing electrolytes (e.g., Gatorade)

Medical Diagnosis: Acute Myeloid Leukemia (AML)


17471597)

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.

Anti-emetic, relieves N/V associated with administration of chemotherapy. (Jhonroks,


Nusing Care Plan for Leukemias, Scribd, 17471597)

2.

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)

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 Patient s Name: Boy Chu Lo (8 years old)

Medical Diagnosis: Acute Myeloid Leukemia (AML)


2. 2. Laboratory Data: Hgb/Hct, electrolyte(sodium, potassium, chloride, bicarbonate); BUN, Creatinine. As baseline data, to determine fluid and electrolytes loss. .(Nanda,2008. Defient Fluid Volume. Nurses Pocketbook. 11th Ed pg 320-327).

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).

4. 4. Provide safety measure. Note: if patient is confused).

e.

To promote wellness 1. Early identification of risk

Independent:

Nursing Care Plan Patient s Name: Boy Chu Lo (8 years old)


1. Discuss factors r/t occurrence of deficoit as individually appropriate.

Medical Diagnosis: Acute Myeloid Leukemia (AML)


factors can decrease occurrence and severity of complications..(Nanda,2008. Defient Fluid Volume. Nurses Pocketbook. 11th Ed pg 320327).