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Student Nurses’ Community

NURSING CARE PLAN – Leukemia


ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

INDEPENDENT: After 8 hours of


SUBJECTIVE: Risk for Leukemias are After 8 hours of • Place the patient in • Protect patient nursing
infection related cancers of the nursing private room. Limit from potential interventions the
“Napansin ko na to inadequate blood-forming interventions the visitors as sources of patient was able to
madalas ako primary tissues. White patient will indicated. Prohibit pathogens or identify actions to
mgkaroon ng defenses. blood cells may identify actions to use of live plants or infection. prevent or reduce
pasa at palagi be produced in prevent or reduce cut flowers. the risk for
nalang akong excessive the risk for Restrict fresh fruits infection.
pagod at amounts and are infection. and vegetables or
nanghihina” (I’ve unable to work make sure they are
noticed that I bruise properly which washed or peeled.
easily and also I feel
weak and tired all
weakens the • Require good • Prevents cross-
the time.) as immune system. handwashing contamination or
verbalized by the protocol for all reduce risk for
patient. personnel and infection.
visitors.
OBJECTIVE: • Encourage • Prevents stasis of
frequent turning respiratory
• Irritability and deep secretions,
• Pallor of skin breathing. reducing risk of
and mucous atelectasis or
membranes pneumonia.
• V/S taken as
follows • Handle patient • Prevents sheet
gently. Keep linens burn or skin
T: 37.1 dry or wrinkle free. excoriation.
P: 80
R: 19 • Inspect skin for • May indicate local
BP: 100/80 tender, infection.
erythematous
areas, open
wounds. Cleanse
skin with
antibacterial
solutions.
Student Nurses’ Community

• Inspect oral • The oral cavity is


mucous an excellent
membranes. medium for
Provide good oral growth of
hygiene. Use a soft organism and is
toothbrush, susceptible to
sponge, or swabs ulceration and
for frequent mouth bleeding.
care.
• Promote good • Promotes
perineal hygiene. cleanliness,
Examine perianal reducing risk of
area at least daily perianal abscess;
during acute illness enhances
and provide sitz circulation and
baths. healing.
• Coordinate • Conserves energy
procedures and for healing,
tests to allow for cellular
uninterrupted rest regeneration.
periods.

COLLABORATIVE:
• Prepare for or • Leukemia is
assist patient with usually treated
leukemia with a
treatments such as combination of
chemotherapy, these agents,
radiation, and bone each requiring
marrow specific safety
transplantation. precautions for
patient and care
providers.
• Administer • May be given
antibiotics as prophylactically or
indicated. to treat specific
infection.