Acute Pain of Leukemia

Nursing Diagnosis for Leukemia - Acute pain 

related to an agent of physical injury

Purpose: pain is resolved

Expected outcomes:

• The patient stated the pain disappeared or controlled
• Shows the behavior of pain management
• Looks relaxed and able to rest, sleep

Nursing Intervention for Leukemia :

• Assess complaints of pain, notice changes in the degree of pain (using a scale of 0-10)
• Monitor vital signs, note the non-verbal clues such as muscle tension, anxiety
• Provide quiet environment and reduce stressful stimuli.
• Place the client in a comfortable position and prop joints, extremities with pillows.
• Change the position of periodic and soft assistive range of motion exercises.
• Provide comfort measures (massage, cold compresses and psychological support)
• The review / enhance client comfort interventions
• Evaluate and support the client's coping mechanisms
• Encourage the use of pain management techniques. Example: relaxation exercises / breathing in, touch.
• Auxiliary therapeutic activity, relaxation techniques.
• Collaboration: Monitor levels of uric acid, give the medication as indicated.

Source : http://nursing-care-plan.blogspot.com/2011/12/2-nanda-nursing-diagnosis-and.html

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