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Risk for Fluid Volume Deficit of Leukemia

Nursing Diagnosis for Leukemia

Risk for Fluid Volume Deficit

related to

  • fluid intake and output,
  • excessive loss: vomiting, bleeding, diarrhea
  • decrease in fluid intake: nausea, anorexia
  • increased need for fluids: fever, hypermetabolic.

Purpose : the volume of fluid being met

Expected outcomes:
  • Adequate fluid volume
  • The mucosa moist
  • Vital signs are stable: BP 90/60 mm Hg, pulse 100x/menit, RR 20x/menit
  • Pulse palpated
  • Urine output 30 ml / hour
  • Capillaries and refill less than 2 seconds
Nursing Intervention for Leukemia :
  • Monitor fluid intake and output
  • Monitor body weight
  • Monitor BP and heart frequency
  • Evaluation of skin turgor, capillary refill and mucous membrane conditions
  • Give fluid intake 3-4 L / day
  • Inspection of skin / mucous membranes for petechiae, ecchymoses area; noticed bleeding gums, blood color of rust or vague in feces and urine, bleeding from the puncture further invasive.
  • Implement measures to prevent tissue injury / bleeding
  • Limit oral care to wash mouth when indicated
  • Give diet a smooth
  • Collaboration:
    • Give IV fluids as indicated
    • Supervise laboratory tests: platelet count, Hb / Ht, freezing
    • Provide HR, platelets, clotting factors
    • Maintain a central vascular access device external (sub-clavicle artery catheter, tunneld, implantable ports)
    Source : http://nursing-care-plan.blogspot.com/2011/12/2-nanda-nursing-diagnosis-and.html