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NURSING MANAGEMENT
a. Ideal Nursing Management
CARE SETTING
Acute inpatient care on medical unit for initial evaluation and treatment typically 46 wk, then at the
community level.
RELATED CONCERNS
Cancer
Psychosocial aspects of care
Transplantation: postoperative and lifelong needs
ACTIVITY/REST
May report:
May exhibit:
CIRCULATION
May report:
May exhibit:
EGO INTEGRITY
May report:
May exhibit:
Palpitations
Tachycardia, heart murmurs
Pallor of skin, mucous membranes
Cranial nerve deficits and/or signs of cerebral hemorrhage
Feelings of helplessness/hopelessness
Depression, withdrawal, anxiety, fear, anger, irritability
Mood changes, confusion
ELIMINATION
May report:
May exhibit:
FOOD/FLUID
May report:
May exhibit:
NEUROSENSORY
May report:
May exhibit:
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PAIN/DISCOMFORT
May report:
May exhibit:
RESPIRATION
May report:
May exhibit:
SAFETY
May report:
May exhibit:
SEXUALITY
May report:
Changes in libido
Changes in menstrual flow, menorrhagia
Impotence
TEACHING/LEARNING
May report:
Discharge plan
considerations:
DIAGNOSTIC STUDIES
Carcinoembryonic antigen (CEA): May be elevated.
Cold agglutinins: May be elevated (more than 1:16) in lymphatic leukemia.
Cryoglobulins: Positive cryoglobulin findings may be present in patients with lymphocytic leukemia.
CBC: Indicates a normocytic, normochromic anemia.
Hemoglobin: May be less than 10 g/100 mL.
Reticulocytes: Count is usually low.
Platelet count: May be very low (less than 50,000/mm).
WBC: May be more than 50,000/cm with increased immature WBCs (shift to left). Leukemic blast cells
may be present.
Prothrombin time (PT)/activated partial thromboplastin time (aPTT): Prolonged.
LDH: May be elevated.
Serum/urine uric acid: May be elevated.
Serum muramidase (a lysozyme): Elevated in acute monocytic and myelomonocytic leukemias.
Serum copper: Elevated.
Serum zinc: Decreased.
Bence Jones protein (urine): Increased.
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Bone marrow biopsy: Abnormal WBCs usually make up 50% or more of the WBCs in the bone marrow.
Often 60%90% of the cells are blast cells, with erythroid precursors, mature cells, and
megakaryocytes reduced.
Chest x-ray and lymph node biopsies: May indicate degree of involvement.
NURSING PRIORITIES
1.
2.
3.
4.
5.
6.
DISCHARGE GOALS
1.
2.
3.
4.
5.
6.
Complications prevented/minimized.
Pain relieved/controlled.
ADLs met by self or with assistance.
Dealing with disease realistically.
Disease process/prognosis and therapeutic regimen understood.
Plan in place to meet needs after discharge.
Refer to CP: Cancer, for further discussion/expansion of interventions related to
cancer care and for patient teaching.
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ACTIONS/INTERVENTIONS
RATIONALE
Independent
Place in private room. Screen/limit visitors as
indicated. Prohibit use of live plants/cut flowers.
Restrict fresh fruits and vegetables or make sure
they are washed or peeled.
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ACTIONS/INTERVENTIONS
RATIONALE
Independent
Avoid/limit invasive procedures (e.g., venipuncture
and injections) as possible.
Collaborative
Monitor laboratory studies, e.g.:
CBC, noting whether WBC count falls or sudden
changes occur in neutrophils;
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ACTIONS/INTERVENTIONS
RATIONALE
Independent
Monitor I&O. Calculate insensible losses and fluid
balance. Note decreased urine output in presence of
adequate intake. Measure specific gravity and urine
pH.
Weigh daily.
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ACTIONS/INTERVENTIONS
RATIONALE
Independent
Inspect skin/mucous membranes for petechiae,
ecchymotic areas; note bleeding gums, frank or
occult blood in stools and urine; oozing from
invasive-line sites.
Implement measures to prevent tissue
injury/bleeding, e.g., gentle brushing of teeth or
gums with soft toothbrush, cotton swab, or spongetipped applicator; using electric razor and avoiding
sharp razors when shaving; avoiding forceful nose
blowing and needlesticks when possible; using
sustained pressure (sandbags or pressure
dressings) on oozing puncture/IV sites.
Limit oral care to mouthwash if indicated (a mixture
of 1/4 tsp baking soda or salt in 48 oz water or
hydrogen peroxide in water). Avoid mouthwashes
with alcohol.
Collaborative
Administer IV fluids as indicated.
Allopurinol (Zyloprim);
May be used to alkalinize the urine, preventing or
minimizing tumor lysis syndrome/kidney stones.
Potassium acetate or citrate, sodium
bicarbonate;
Stool softeners.
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ACTIONS/INTERVENTIONS
RATIONALE
Collaborative
Administer RBCs, platelets, clotting factors.
ACTIONS/INTERVENTIONS
RATIONALE
Independent
Investigate reports of pain. Note changes in degree
(use scale of 010) and site.
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ACTIONS/INTERVENTIONS
RATIONALE
Independent
Place in position of comfort and support joints,
extremities with pillows/padding.
Collaborative
Monitor uric acid level as appropriate.
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ACTIONS/INTERVENTIONS
RATIONALE
Independent
Evaluate reports of fatigue, noting inability to
participate in activities or ADLs.
Collaborative
Provide supplemental oxygen.
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ACTIONS/INTERVENTIONS
RATIONALE
Independent
Review pathology of specific form of leukemia and
various treatment options.
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At the end of Eight hours of Nursing Interventions, the patient will be able
to Identify actions to prevent/reduce risk of infection.
After Eight hours of Nursing Interventions, the patient was able to Identify
actions to prevent/reduce risk of infection
Maka lihok man ko peru luya lang gyud, as verbalized by the patient. Tabangan
gyud namo na sya pag mangihi o malibang as verbalized by the mother
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> Fatigue
> Pale and weak in appearance
At the end of Eight hours of Nursing Interventions, the patient will be able to
demonstrate a decrease in physiologic signs of intolerance
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