Student Nurses Community

NURSING CARE PLAN Leukemia

ASSESSMENT DIAGNOSIS INERENCE PLANNING INTER!ENTION RATIONALE E!ALUATION
SUBJECTIVE:
Napansin ko na
madalas ako
mgkaroon ng
pasa at palagi
nalang akong
pagod at
nanghihina (Ive
noticed that I bruise
easily and also I feel
weak and tired all
the time.) as
!r"ali#!d "$ th!
pati!nt.
%BJECTIVE:
Irrita"ilit$
&allor o' skin
and m()o(s
m!m"ran!s
V*S tak!n as
'ollo+s
T: ,-..
&: /0
1: .2
B&: .00*/0
1isk 'or
in'!)tion r!lat!d
to inad!3(at!
primar$
d!'!ns!s.
Leukemias ar!
)an)!rs o' th!
"lood4'orming
tiss(!s. 5hit!
"lood )!lls ma$
"! prod()!d in
!6)!ssi!
amo(nts and ar!
(na"l! to +ork
prop!rl$ +hi)h
+!ak!ns th!
imm(n! s$st!m.
7't!r / ho(rs o'
n(rsing
int!r!ntions th!
pati!nt +ill
id!nti'$ a)tions to
pr!!nt or r!d()!
th! risk 'or
in'!)tion.
IN8E&EN8ENT:
&la)! th! pati!nt in
priat! room. 9imit
isitors as
indi)at!d. &rohi"it
(s! o' li! plants or
)(t 'lo+!rs.
1!stri)t 'r!sh 'r(its
and !g!ta"l!s or
mak! s(r! th!$ ar!
+ash!d or p!!l!d.
1!3(ir! good
hand+ashing
proto)ol 'or all
p!rsonn!l and
isitors.
En)o(rag!
'r!3(!nt t(rning
and d!!p
"r!athing.
:andl! pati!nt
g!ntl$. ;!!p lin!ns
dr$ or +rinkl! 'r!!.
Insp!)t skin 'or
t!nd!r<
!r$th!mato(s
ar!as< op!n
+o(nds. Cl!ans!
skin +ith
anti"a)t!rial
sol(tions.
&rot!)t pati!nt
'rom pot!ntial
so(r)!s o'
pathog!ns or
in'!)tion.
&r!!nts )ross4
)ontamination or
r!d()! risk 'or
in'!)tion.
&r!!nts stasis o'
r!spirator$
s!)r!tions<
r!d()ing risk o'
at!l!)tasis or
pn!(monia.
&r!!nts sh!!t
"(rn or skin
!6)oriation.
=a$ indi)at! lo)al
in'!)tion.
7't!r / ho(rs o'
n(rsing
int!r!ntions th!
pati!nt +as a"l!
to id!nti'$ a)tions
to pr!!nt or
r!d()! th! risk 'or
in'!)tion.
Student Nurses Community
Insp!)t oral
m()o(s
m!m"ran!s.
&roid! good oral
h$gi!n!. Us! a so't
tooth"r(sh<
spong!< or s+a"s
'or 'r!3(!nt mo(th
)ar!.
&romot! good
p!rin!al h$gi!n!.
E6amin! p!rianal
ar!a at l!ast dail$
d(ring a)(t! illn!ss
and proid! sit#
"aths.
Coordinat!
pro)!d(r!s and
t!sts to allo+ 'or
(nint!rr(pt!d r!st
p!riods.
C%997B%17TIVE:
&r!par! 'or or
assist pati!nt +ith
l!(k!mia
tr!atm!nts s()h as
)h!moth!rap$<
radiation< and "on!
marro+
transplantation.
7dminist!r
anti"ioti)s as
indi)at!d.
Th! oral )ait$ is
an !6)!ll!nt
m!di(m 'or
gro+th o'
organism and is
s(s)!pti"l! to
(l)!ration and
"l!!ding.
&romot!s
)l!anlin!ss<
r!d()ing risk o'
p!rianal a"s)!ss>
!nhan)!s
)ir)(lation and
h!aling.
Cons!r!s !n!rg$
'or h!aling<
)!ll(lar
r!g!n!ration.
9!(k!mia is
(s(all$ tr!at!d
+ith a
)om"ination o'
th!s! ag!nts<
!a)h r!3(iring
sp!)i'i) sa'!t$
pr!)a(tions 'or
pati!nt and )ar!
proid!rs.
=a$ "! gi!n
proph$la)ti)all$ or
to tr!at sp!)i'i)
in'!)tion.