NCP Leukemia

Cues Nursing Expected Nursing Intervention Rationale Outcome Assessment
Diagnosis Outcome
Subjective Cues(s): Ineffective After 24 hrs of a. To protect client from Goal Met:
protection nursing Bleeding hazards and lessen After 24 hrs of nursing
“Nanghihina po r/t abnormal interventions, the risk for injury. interventions patient was
ako” as verbalized blood profile patient will be 1. As baseline data protected from
by patient XY and drug protected from 1. Monitor v/s infection and bleeding
requirement infection and 2. Suppression of bone marrow hazard
Objective Cue (s): (anti- bleeding hazard 2. Inspect skin/mucous and platelet production. Places that may contribute to
neoplastic). that may membrane for petechiae, patient at risk for spontaneous/ patient’s health condition
-With ongoing contribute to ecchymotic areas, note uncontrolled bleeding and demonstrated
chemotherapy patient’s health bleeding gums, frank or occult Improvement in vital signs,
(Cytarabine) condition and blood in stools and urine, laboratory result, and
may oozing from invasive-line site 3. Fragile tissues and altered lessen the difficulty of
V/S demonstrate clotting mechanisms. Increase body function.
Temp: 37.1oC Improvement in 3. Implement measure to the risk of hemorrhage following
RR: 24pm vital signs, prevent tissue injury/ bleeding even minor trauma.
HR: 120bpm laboratory (Avoid Sharp Object, Minimize
(+) Pallor result, and invading procedure,
(+) Weakness lessen the Avoid Contact Sport)
(+) Easy fatigue difficulty of body (e.g. gentle brushing of teeth
function. or gums with soft toothbrush,
cotton swab, or sponged tipped
applicator, avoiding
needlesticks when possible,
using sustained pressure on 4. When bleeding is present,
oozing puncture/IV sites. even gentle brushing may cause
more tissue damage. Alcohol has
4. Limit Oral Care to a drying effect and may be
mouthwash if indicated (a painful to irritated tissues.
mixture of 1/4tsp. baking soda
or salt in 4-8 oz water or
hydrogen peroxide in water).
Avoid mouthwashes with 5. May reduce gum irritation
alcohol
6. To relieved bleeding cessation.
5. Provide Soft Diet

7. Aspirin can cause gastric
6. If bleeding is present do the bleeding and further decrease
ff.: (Apply pressure, Cold platelet count
Compression, Elevation)
7. Avoid use of aspirin-

containing antipyretics.
1. Protect patient from potential

sources of pathogens/ infection
b. To protect client from Note: Profound bone marrow,
infection. suppression, neutropenia, and
1. Isolation Precaution (Restrict chemotherapy place patient at
Isolation): Place in private great risk for infection
room. Screen/Limit visitors as
indicated. Prohibit use of live
plants/ cut flowers. Restrict 2. Prevents cross-
fresh fruits and vegetables or contamination/reduces risk for
make sure they are washed or infection.
peeled.
2. Require good hand washing 3. Although fever may

protocol for all personnel and accompany some forms of
visitors chemotherapy, progressive
hyperthermia occurs in some
types of infections, and fever
3. Monitor Temperature. Note (unrelated to drugs or blood
correlation between products) occurs in most
temperature elevations and leukemia patients. Note:
chemotherapy treatments. Septicemia may occur without
Observe for fever associated fever.
with tachycardia, hypotension,
subtle mental changes.
4. Helps reduce fever, w/c

contributes to fluid imbalance,
discomfort, and CNS
complication.
4. Prevent chilling. Force fluids,
administer tepid sponge bath.
5. Prevent stasis of respiratory

secretions, reducing risk of
atelectasis/pneumonia.
5. Encourage frequent turning
and deep breathing.
6. Early intervention is essential

to prevent sepsis/septicemia in
immunosuppressed person.
6. Auscultate breath sounds,
noting crackles, ronchi, inspect
secretions for changes in
characteristic, .g., increased
sputum production or change
in sputum color. Observe urine 7. Prevents sheet burn/ skin
for sign of infection, e.g cloudy, excoriation
foul smelling, or presence of
urgency or burning with voids.)
8. May indicate local infection
7. Handle patient gently. Keep Note; Open wounds may not
linens dry/ wrinkle-free produce pus because of
insufficient number of
granulocyte
8. inspect skin for tender,
erythematous areas; open
wounds cleanse skin with
antibacterial solution. 9. The oral cavity is an excellence
medium for growth of organisms
and is susceptible to ulceration
and bleeding.
9. Inspect oral mucous
membranes. Provide good oral
hygiene. Use a soft toothbrush, 10. Promote cleanliness,
sponge, or swabs for frequent reducing risk of perianal abscess
mouth care. can contribute to septicemia and
death in immunosupressed
10. Promote good perianal patients.
hygiene. Examine perianal area
at least daily during acute 11. Conserves energy for healing,
illness. Provide sitz baths, using cellular regeneration.
betadine, if indicated. Avoid
rectal temperatures, use of
suppositories.
11. Coordinate Procedures and 12. promotes healing and

test to allow for interrupted prevents dehydration. Note:
rest periods. Constipation potentiates
retention of toxins and risk of
rectal irritation/ tissue injury.
12. Encourage increased intake

of foods high in protein and
fluids with adequate fiber.

NCP Leukemia

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Cues Nursing Expected Nursing Intervention Rationale Outcome Assessment

5. Provide Soft Diet

7. Avoid use of aspirin-

1. Protect patient from potential

2. Require good hand washing 3. Although fever may

4. Helps reduce fever, w/c

5. Prevent stasis of respiratory

6. Early intervention is essential

11. Coordinate Procedures and 12. promotes healing and

12. Encourage increased intake

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