Francisco, Krisianne Mae L.

BSN III B (group B3)

Acute Myeloid Leukemia

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective
“Nanghihina po siya at Risk for Infection After 6 hours of Dependent   Prevents stasis of After 6 hours of nursing
nag karoon din po siya related to nursing  Encourage and demonstrate respiratory secretions, intervention, the client
ng mga pula pula” as suppressed intervention, the frequent turning and deep breathing. reducing risk of and relatives were able to
verbalized by his immune response client and relatives atelectasis demonstrate interventions
daughter. will be able to or pneumonia. and lifestyle changes to
Objective demonstrate reduce or prevent risk for
 Weakness interventions and  Auscultate breath sounds, noting  Early intervention is infection as evidenced by
 Fatigue lifestyle changes to crackles, rhonchi. Inspect secretions essential to proper and regular hand
 Dyspnea reduce or prevent for changes in characteristics: prevent sepsis in hygiene, proper oral are
 Skin pallor  risk for infection. increased sputum production or immunosuppressed using soft brittle
 Petechial rash on both change in sputum color. Observe person. toothbrush, proper
lower extremities   urine for signs of infection: cloudy, handling of foods and
foul-smelling, or presence of increased nutritional food
Vital signs: urgency or burning with voids. intake as recommended.
 BP: 90/80mmHg
(hypotensive)
 PR: 80 bpm  Handle patient gently. Keep linens  Prevents skin
(bradycardic) dry and wrinkle-free. excoriation.
 RR: 10 bpm
(bradypneic)
 Temperature: 37.8 ⁰C  Inspect oral mucous membranes.  Use soft brittle
Laboratory result Provide good oral hygiene. Use a toothbrush to prevent
 Increased WBC ( 18 × soft toothbrush, sponge, or swabs bleeding.
109/L)Hematocrit: for frequent mouth care.
 30%
 Decreased hemoglobin  Provide thorough skin care by  Additional measures to
(6.7 g/dL) keeping the patient’s skin and avoid infection.
 Low platelet count of perianal area clean; apply mild
20 × 109/L lotion or creams to keep the skin
 bone marrow biopsy from drying or cracking.
reveals a hypercellular Thoroughly clean skin before all
marrow with 22 invasive skin procedures.
percent blasts  IV sites can harbor
 Use strict sterile technique in infection. Additional
changing IV tubing according to measure to avoid
your facility’s policy. infection.

 Monitor vital signs especially body  Hyperthermia is an

temperature. early indication for
infection.
Independent
 Administer medication as  For medical
prescribed. management

 Place in a private room. Limit  To protect the patient

visitors as indicated.  from potential sources
of pathogens or
infection. 
Collaborative
 Demonstrate and require good hand  Prevents cross-
washing protocol for all personnel contamination and
and visitors. reduces risk of
infection.

 Coordinate procedures and tests to  Conserves energy for

allow for uninterrupted rest periods. healing, cellular
regeneration.
 Educated the relatives to keep sharp
objects away from the patient to
prevent wound and bleeding. And
promoted use of soft brittle
toothbrush.
 Educate the relatives to avoid use
of aspirin-containing antipyretics.
 Encourage increased intake of foods
high in protein and fluids with
adequate fiber.
 Recommend nutritious diet, high in
protein and calories, avoiding raw
fruits, vegetables, or uncooked
meats.
 To prevent bleeding.
 Aspirin can cause
gastric bleeding and
further decrease platelet
count.
 Promotes healing and
prevents dehydration. C
onstipation potentiates
retention of toxins and
risk of rectal irritation
or tissue injury.
 Proper nutrition
enhances immune
system. Minimizes
potential sources of
bacterial contamination.