You are on page 1of 2

Patient Name: A.M.V. Assessment Subjective: “Mejo okay na, pero ayan nanghihina parin” as verbalized by clients wife.

Risk for bleeding related to decreased platelet count Nursing Diagnosis

CHINESE GENERAL HOSPITAL COLLEGE OF NURSING AND LIBERAL ARTS NURSING CARE PLAN Age:53 Diagnosis: Acute Lymphoblastic Leukemia Inference Leukemia is cancer of the white blood cells. White blood cells help your body fight infection. Your blood cells form in your bone marrow. In leukemia, however, the bone marrow produces abnormal white blood cells. These cells crowd out the healthy blood cells, making it hard for blood to do its work. In acute lymphoblastic leukemia (ALL), there are too many of specific types of white blood cells called lymphocytes or lymphoblast. These leukemic cells are not able to fight infection very well. Also, as the number of leukemic cells increases in the blood and bone Goal Short Term: After 6 hours of nursing interventions Nursing Intervention  Rationale Early detection of bleeding helps prevent significant blood loss and potential shock. Occult blood shows internal hemorrhage Intracranial bleeding affects mental status and LOC. Evaluation Short Term: After 3 hours of nursing interventions  Skin is intact with no sign of bleeding  Mucous membrane is intact Long Term: After 4 days of nursing interventions, the client will:  Urine and stool are free from blood  Normalized RBC count

Objective: -Weak-looking -Ecchymoses over anterior lower extremities -Pale palpebral conjunctiva -Blood count shows reduced  HGB- 88  Platelet59  HCT0.246

Independent  Assess vital signs every 4 hours and body systems every shift for bleeding:  Skin will remain  Skin, mucous intact with no signs membranes for of bleeding petechiae, ecchymoses, and hematoma  Mucous membrane formation. will remain intact  Gums and nasal membranes for bleeding Long Term:  Vomitus, stool and urine After 4 days of for visible occult blood nursing interventions,  Neurologic changes the client will: (e.g., headache, visual changes, decreased  Urine and stool will LOC seizure) be free from blood.  Encourage use of softbristle toothbrush,  Restores/normalizes sponge or mild RBC count mouthwash to clean teeth and gums.  Instruct client to avoid forceful blowing, coughing, sneezing and straining to have a bowel movement.  Apply pressure to

Fragile tissues and altered clotting mechanisms increase the risk of hemorrhage following even minor trauma. These activities can damage mucous membrane increasing the risk of bleeding.

Pressure prevents

Decreasing Hb/Hct is indicative of bleeding (may be occult). Restores/normalizes RBC count and oxygencarrying capacity to correct anemia. Hb/Hct.. stool softeners)  Kris Charmaine E. rectal temperature and suppositories. clotting factors.g.   May help reduce gum irritation. and arterial punctures for 15 to 20 min. platelets.5 min. Used to prevent/treat hemorrhage. This may cause infection.. platelets. Source: www..  prolonged bleeding prompting hemostasis and clot formation motility.  Administer RBCs. there is less room for healthy white blood cells. and easy bleeding. Ignacio 3A Group 2 .  Avoid invasive procedures as possible (e. parenteral injection)  Provide soft diet Collaborative  Monitor laboratory studies. and platelets. clotting.g.gov (Adult Acute Lymphoblastic Leukemia) injection sites for 3 . To prevent tissue trauma and bleeding. anemia.marrow. e.cancer.g. Helpful in reducing straining at stool which can cause trauma to rectal tissues.  Dependent  Prescribe medication (e. red blood cells.