2 Nanda Nursing Diagnosis and Interventions for Leukemia

Label: 2 Nanda Nursing Diagnosis and Interventions for Leukemia, Nursing Diagnosis,Nursing Interventions Leukemia Definition Leukemia is a neoplasm of acute or chronic blood-forming cells in bone marrow and spleen ( eeves, 2!!"#$ %he other characteristic of leukemia is the proliferation of irregular or accumulation of white blood cells in bone marrow, replace normal bone marrow elements$ &roliferation also occurs in the liver, spleen, and l'mph nodes$ %he invasion of non-haematological organs such as the meninges, gastrointestinal tract, kidne', and skin$ (cute l'mphoc'tic leukemia ((LL# often occurs in children$ Leukemia classified as acute if there is proliferation of the blastoc'st ('oung blood cells# from bone marrow$ (cute leukemia is a malignant primar' bone marrow resulting in normal blood components late decision b' abnormal blood components (blastoc'st#, accompanied b' the spread of other organs$ Leukemia is classified as chronic if found cell e)pansion and accumulation of old and 'oung cells (%e*awinata, "++,#$ In addition to acute and chronic, there is also a congenital leukemia is leukemia were found in infants aged - weeks or 'ounger infants$

Etiology %he cause of (LL until now not clear, but most likel' due to a virus (oncogenic viruses#$ .ther factors that pla' a role include:

"$ 2$ 2$

/)ogenous factors such as 0 ra's, radioactive ra's, and chemicals (ben1ol, arsenic, sulfate preparations#, infections (viruses and bacteria#$ /ndogenous factors such as race 3onstitutional factors such as chromosomal abnormalities, hereditar' (sometimes encountered cases of leukemia in siblings or twins one egg#$

&redisposing factors:

"$ 2$ 2$ -$ 8$ ,$

4enetic factors: a certain virus causes changes in gene structure (% cell leukemial'mphoma virus 5 6%L7# Ioni1ing radiation: the work environment, prenatal care, previous cancer treatment /)posure to chemicals such as ben1ene, arsenic, chloramphenicol, phen'lbuta1one, and antineoplastic agents$ Immunosuppressive medications, drugs carcinogens such as dieth'lstilbestrol 6ereditar' factors such as the twins one egg 3hromosomal abnormalities

If the cause of leukemia is caused b' a virus, the virus will easil' fit into the human bod' if the structure of the viral antigen is consistent with the structure of the human antigen$ %he structure of the human antigen is formed b' the antigen structure of various organs, especiall' the skin and mucous membranes located on the surface of the bod' (tissue antigen#$ 9' :6., tissue antigens defined b' the term 6L-( (human

leucoc'te locus (#$

Signs and Symptoms "$ (nemia 3aused b' red blood cell production is less a result of the failure of the bone marrowto produce red blood cells$ 3haracteri1ed b' reduced hemoglobin concentration, a decrease in hematocrit, red blood cell count less$ 3hildren with leukemia have pale, tiredness, shortness of breath sometimes$ 2$ 6igh bod' temperature and eas' to infections Due to a decrease in leukoc'tes, it will automaticall' lower the bod' resistance due to leukoc'tes serves to maintain the immune s'stem can not work optimall'$ 2$ 9leeding ;igns of bleeding can be viewed and anal'1ed from the presence of mucosal bleeding such as gums, nose (epista)is# or bleeding under the skin which is often called petechiae$ 9leeding ma' occur spontaneousl' or due to trauma$ If ver' low levels of platelets, bleeding can occur spontaneousl'$ -$ Decreased consciousness Due to infiltration of abnormal cells to the brain can cause a variet' of disorders such as sei1ures to coma$ 8$ Decrease in appetite ,$ :eakness and ph'sical e)haustion$

Clinical Manifestation %'pical s'mptoms of pale (ma' occur suddenl'#, bod' heat, and bleeding accompanied b' splenomegal' and sometimes hepatomegal' and l'mphadenopath'$ 9leeding can be diagnosed ecch'moses, petekia, epista)is, bleeding gums, etc$$ ;'mptoms are not t'pical is *oint pain or bone pain can be mistaken for rheumatic diseases$ .ther s'mptoms can arise as a result of infiltration of leukemic cells in organs such as purpuric lesions on the skin, pleural effusion, cerebral sei1ures in leukemia$

2 Nursing Diagnosis and Interventions for Leukemia "$ Risk for Fluid related to olume Deficit

fluid intake and output, e)cessive loss: vomiting, bleeding, diarrhea decrease in fluid intake: nausea, anore)ia increased need for fluids: fever, h'permetabolic$

&urpose : the volume of fluid being met

/)pected outcomes:

(de<uate fluid volume %he mucosa moist 7ital signs are stable: 9& +!5,! mm 6g, pulse "!!)5menit, &ulse palpated =rine output 2! ml 5 hour 3apillaries and refill less than 2 seconds
Intervention:

2!)5menit

o o o o

>onitor fluid intake and output >onitor bod' weight >onitor 9& and heart fre<uenc' /valuation of skin turgor, capillar' refill and mucous membrane conditions 4ive fluid intake 2-- L 5 da' Inspection of skin 5 mucous membranes for petechiae, ecch'moses 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 in*ur' 5 bleeding Limit oral care to wash mouth when indicated 4ive diet a smooth 3ollaboration: 4ive I7 fluids as indicated ;upervise laborator' tests: platelet count, 6b 5 6t, free1ing &rovide 6 , platelets, clotting factors >aintain a central vascular access device e)ternal (sub-clavicle arter' catheter, tunneld, implantable ports#
2! "cute pain related to an agent of ph'sical in*ur' &urpose: pain is resolved /)pected outcomes:

%he patient stated the pain disappeared or controlled ;hows the behavior of pain management

Looks rela)ed and able to rest, sleep

Intervention:

(ssess complaints of pain, notice changes in the degree of pain (using a scale of !-"!# >onitor vital signs, note the non-verbal clues such as muscle tension, an)iet' &rovide <uiet environment and reduce stressful stimuli$ &lace the client in a comfortable position and prop *oints, e)tremities with pillows$ 3hange the position of periodic and soft assistive range of motion e)ercises$ &rovide comfort measures (massage, cold compresses and ps'chological support# %he review 5 enhance client comfort interventions /valuate and support the client@s coping mechanisms /ncourage the use of pain management techni<ues$ /)ample: rela)ation e)ercises 5 breathing in, touch$ (u)iliar' therapeutic activit', rela)ation techni<ues$ 3ollaboration: >onitor levels of uric acid, give the medication as indicated$ Acute lymphocytic leukemia (ALL) is a fast-growing cancer of a type of white blood cells called lymphocytes. These cells are found in the bone marrow and other parts of the body. Acute lymphocytic leukemia (ALL) makes you more likely to bleed and develop infections. Symptoms include

!one and "oint pain #asy bruising and bleeding (such as bleeding gums$ skin bleeding$ nosebleeds$ abnormal periods) %eeling weak or tired %ever Loss of appetite and weight loss &aleness &ain or feeling of fullness below the ribs &inpoint red spots on the skin (petechiae) Swollen glands (lymphadenopathy) in the neck$ under arms$ and groin 'ight sweats

'ote These symptoms can occur with other conditions. Talk to your doctor about the meaning of your specific

symptoms.www.nlm.nih.gov Nursing Diagnosis for Acute Lymphocytic Leukemia : Risk for Infection related to changes in maturity of red blood cells$ increased number of immature lymphocytes$ immunosuppression (oal no infection. #)pected outcomes are *lients will

+dentify the risk factors that can be reduced State the signs and symptoms of early infection 'o signs of infection

Nursing Interventions Acute Lymphocytic Leukemia : Risk for Infection ,. Take action to prevent e)posure to known or potential sources of infection

-eep the protective insulation$ according to institutional policy .aintain a careful hand washing techni/ue (ive good hygiene Limit visitors who were fever$ flu or infections (ive two times daily perianal hygiene and each bowel movement Limit fresh flowers and fresh vegetables 0se the oral care protocol 1ospitali2ed with neutropenic clients first.

3ational 4igilance$ minimi2ing client e)posure to bacteria$ viruses$ and fungal pathogens either endogenous or e)ogenous. 5. 3eport if there are changes in vital signs 3ationale *hanges in vital signs is an early sign of sepsis$ especially if there is an increase in body temperature. 6. (et culture of sputum$ urine$ diarrhea$ abnormal blood and body secretions as recommended 3ational The culture can confirm infection and identify the causative organism. 7. #)plain the reasons for vigilance and abstinence 3ational The culture can confirm infection and identify the causative organism. 8. 3eassure the client and his family that the increased susceptibility to infection while only 3ational granulocytopenia may persist 9-,5 weeks. The notion of a temporary nature can help prevent an)iety granulocytopenia clients and their families 9. .inimi2e invasive procedures 3ational certain procedures may cause tissue trauma$ increased susceptibility of infection.

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