ASSESSMENT

NURSING DIAGNOSIS
Activity Intolerance: fatigue related to anemia.

PLANNING

NURSING INTERVENTIONS
1. Monitor Vital Signs. 2. Elevate head of bed as tolerated. 3. Encourage quiet, restful atmosphere.

RATIONALE

EVALUATION

Subjective: Mabilis akong mapagodas verbalized by the patient. Objective: - pale in appearance - weakness - shortness of breath - low hemoglobin count: 6.77

After nursing intervention the patient will be able to demonstrate a decrease in physiologic signs of intolerance.

1. Serves as baseline data. 2. To promote circulation/ venous drainage. 3. Conserves energy/ lowers tissue Oxygen demand. 4. To lessen the work of the heart.

After nursing intervention the patient shows a decrease signs of intolerance.

4. Instruct patient to stop activity if palpitations, chest pains, shortness of breath, weakness, dizziness occur. 5. Demonstrate/ encourage use of relaxation activities, exercises/ techniques.

5. To decrease tension level.

ASSESSMENT
Subjective: Objective: - increased WBC:174,000 - presence of immature leukocytes - compromised immunity -low platelet count: 27, 020 cu mm

NURSING DIAGNOSIS
Risk for infection related to proliferation of immature lymphocytes.

PLANNING
After nursing intervention the client will be free from acquiring infection.

NURSING INTERVENTIONS
1. Monitor Vital Signs. 2. Instruct patient to wear mask all the time. 3. Require good hand washing protocol for all personnel and visitors. 4. Monitor Temperature. Note correlation between temperature elevations and chemotherapy treatments.

RATIONALE
1. Serves as baseline data. 2. Protect patient from potential sources of pathogens/ infection. 3.Prevents crosscontamination/reduces risk for infection.

EVALUATION
After nursing intervention the client was able to be free from acquiring infection.

4. 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. 5. May indicate local infection Note; Open wounds may not

5. Inspect skin for tender, erythematous

areas; open wounds cleanse skin with antibacterial solution. 6. Coordinate Procedures and test to allow for interrupted rest periods. 7. Avoid/ limit invasive procedures (e.g., venipuncture and injections) as possible.

produce pus because of insufficient number of granulocyte. 6. Conserves energy for healing, cellular regeneration.

7. 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 procedures and risk of infection. 8. May be given prophylactically or treat specific infection.

8. Administer medication as indicated by physician.