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

marrow, there is less room for healthy white blood cells, red blood cells, and platelets. This may cause infection, anemia, and easy bleeding. Source: www.cancer.gov (Adult Acute Lymphoblastic Leukemia)

injection sites for 3 - 5 min. and arterial punctures for 15 to 20 min. Avoid invasive procedures as possible (e.g., rectal temperature and suppositories, parenteral injection) Provide soft diet Collaborative Monitor laboratory studies; e.g., platelets, Hb/Hct, clotting. Administer RBCs, platelets, clotting factors.

prolonged bleeding prompting hemostasis and clot formation motility. To prevent tissue trauma and bleeding.

May help reduce gum irritation. Decreasing Hb/Hct is indicative of bleeding (may be occult). Restores/normalizes RBC count and oxygencarrying capacity to correct anemia. Used to prevent/treat hemorrhage. Helpful in reducing straining at stool which can cause trauma to rectal tissues.

Dependent Prescribe medication (e.g., stool softeners)

Kris Charmaine E. Ignacio 3A Group 2