CHAPTER 32 / Nursing Care of Clients with Hematologic Disorders 969

CHART 323

LINKAGES BETWEEN NANDA, NIC, AND NOC

The Client with Leukemia

NURSING DIAGNOSES

NURSING INTERVENTIONS

NURSING OUTCOMES

Fatigue

Energy Management
Nutrition Management
Self-Care Assistance

Endurance
Energy Conservation
Nutritional Status: Energy

Ineffective Protection

Bleeding Precautions
Infection Protection
Neurologic Monitoring

Coagulation Status
Immune Status
Neurological Status: Consciousness

Imbalanced Nutrition: Less than

Body Requirements
Impaired Oral Mucous Membrane

Nutrition Management
Nutrition Monitoring
Oral Health Restoration
Oral Health Maintenance

Nutritional Status
Nutritional Status: Food and Fluid Intake
Oral Health
Tissue Integrity: Skin and Mucous
Membranes

Note. Data from Nursing Outcomes Classification (NOC) by M. Johnson & M. Maas (Eds.), 1997, St. Louis: Mosby; Nursing Diagnoses: Definitions & Classification 20012002 by
North American Nursing Diagnosis Association, 2001, Philadelphia: NANDA; Nursing Interventions Classification (NIC) by J.C. McCloskey & G. M. Bulechek (Eds.), 2000, St. Louis:
Mosby. Reprinted by permission.

Avoiding foodborne illnesses by washing fruits and vegetables, proper food storage
Dental hygiene measures
Avoiding immunizations
Manifestations to report: fever, chills, burning on urination, foul-smelling urine, vaginal or rectal discharge, skin
lesions
Avoiding contact sports or strenuous exercise if platelet
count is low
Using an electric razor for shaving, avoiding rectal or vaginal suppositories, vaginal tampons, or enemas
Increasing dietary fiber and using a bulk-forming laxative as
needed to prevent straining
Avoiding over-the-counter or prescription drugs that interfere with platelet function (see Box 32-11)
The importance of reporting any bleeding (nosebleeds, rectal bleeding, vomiting blood, excessive menstrual periods,

blood in the urine, bleeding gums, bruises, or collections of

blood under the skin) or changes in behavior to the health
care provider

Promoting Nutrition
Eating several small, low-fat, high-calorie meals and drinking five to eight glasses of water daily
Reporting continued weight loss, loss of appetite, or inability to eat for 24 hours
Discussing dietary needs with the dietitian
Assistance with physical care, finances, and transportation
may be required following discharge. Refer the client and family to social services, support groups, home care services as
needed, and other agencies that can provide needed services
(such as local chapters of the American Cancer Society, which
can provide hospital beds and transportation for outpatient cancer treatment).

Nursing Care Plan

A Client with Acute Myelocytic Leukemia
Catherine Cole is a 37-year-old secretary who lives with her husband, Ray, and teenage daughter, Amy, in an apartment in a large
metropolitan area. About 2 months ago, Mrs. Cole began to tire
easily and experience night sweats several times a week. She
also noted that she was pale, bruised easily, and was having
heavier menstrual periods. Blood tests ordered by her primary
care provider are abnormal. She is admitted for a bone marrow
biopsy.

ASSESSMENT
Mary Losapio, RN, obtains a nursing history and physical assessment for Mrs. Cole. Mrs. Cole tells her, Im so tired, and I have
these bruises all over me. Im so afraid of the results of the bone

marrow examination. I dont know what we

will do if I have cancer. Mrs. Cole clutches her
husbands hand and then begins to cry. Physical assessment data
include: Height 64 inches (156 cm), weight 106 lb (48.1 kg); vital
signs T 100F, P 102, R 22, BP 130/82. Numerous petechiae scattered over trunk and arms; ecchymoses noted on lower right arm
and right calf. Oral mucosa is red, with several small ulcerations
in buccal areas.
Blood count shows reduced RBCs,hemoglobin,and hematocrit
levels. The WBC is high, with myeloblasts seen on differential. The
platelet count is very low. A tentative diagnosis of acute myelogenous leukemia is made.
(continued)

970 UNIT IX / Responses to Altered Peripheral Tissue Perfusion

Nursing Care Plan

A Client with Acute Myelocytic Leukemia
DIAGNOSES
Ms. Losapio identifies the following nursing
diagnoses for Mrs. Cole.
Risk for infection related to altered WBC production and immune function
Ineffective protection related to reduced platelet count and risk
for bleeding
Impaired oral mucous membrane secondary to anemia and reduced platelets
Fatigue related to anemia
Anxiety related to fear of leukemia diagnosis

(continued)

Ask the dietitian to work with Mrs. Cole to identify preferred

foods. Instruct to avoid foods that may damage oral mucosa,
such as very hot, very cold, or highly acidic or spicy foods.
Provide for periods of rest alternating with activity.
Teach about the bone marrow biopsy. Allow time for questions
and to verbalize fears.
Refer to the oncology nurse specialist for further teaching and
support.

EVALUATION

The expected outcomes for the plan of care specify that Mrs. Cole
will:
Remain free of infection.
Experience no significant bleeding.
Have intact oral mucous membranes.
Manage self-care activities despite fatigue.
Verbalize decreased anxiety.

The bone marrow biopsy confirms the diagnosis of acute myelogenous leukemia. Mrs. Cole is very upset, but calms as the physician and the oncology nurse discuss treatment plans and the
possibility of remission. She decides to have outpatient chemotherapy. During her hospital stay, Mrs. Cole remained free of infection or further bleeding. She tells Ms. Losapio that her mouth
feels better, although it is still painful. During routine assessment,
Mrs. Cole remarks,You know, I was so scared when I came here,
but I think I am a little less so now. Sometimes not knowing what
is wrong is worse than knowing.

PLANNING AND IMPLEMENTATION

Critical Thinking in the Nursing Process

EXPECTED OUTCOMES

Ms. Losapio implements the following nursing interventions.

Place in a private room.
Limit visitors to immediate family for the present.
Instruct all staff, the family, and client to carefully wash hands.
Post a sign over the washbasin in the room as a reminder.
Record vital signs every 4 hours.
Avoid invasive procedures unless absolutely necessary.
Monitor for bleeding every 4 hours, including skin, oral mucosa,
abdominal assessment, body fluids, and menstrual pad count.
Instruct to perform oral hygiene every 2 to 4 hours, using a
soft-bristle toothbrush.

THE CLIENT WITH MULTIPLE MYELOMA

Multiple myeloma is a malignancy in which plasma cells multiply uncontrollably and infiltrate the bone marrow, lymph
nodes, spleen, and other tissues. Plasma cells are B-cell lymphocytes that develop to produce antibodies (immunoglobins).
The incidence of multiple myeloma is increasing, with an
estimated 48,100 cases diagnosed annually. It affects blacks
more than twice as often as whites, and men more frequently
than women. The incidence of multiple myeloma increases
with age, rarely occurring before age 40. Its cause is unknown
(McCance & Huether, 2002). Possible contributing factors include genetic predisposition, oncogenic virus, inflammatory
stimuli, and chronic antigenic stimulation.

PATHOPHYSIOLOGY AND MANIFESTATIONS

Malignant plasma cells arise from one clone of B cells that
produce abnormally large amounts of a particular immunoglobin called the M protein. This abnormal protein interferes

1. Describe how alterations in WBCs can increase a persons susceptibility to infection.

2. List sources of potential infection for the hospitalized client.
3. What is the rationale for having the client do her own oral and
physical hygiene?
4. Outline a teaching plan for this client and her family for home
care to prevent infection.
5. Develop a care plan for Mrs. Cole for the nursing diagnosis,
Activity intolerance.
See Critical Thinking in the Nursing Process in Appendix C.

with normal antibody production and impairs the humoral immune response. It also increases blood viscosity and may
damage kidney tubules. As myeloma cells proliferate, they replace the bone marrow and infiltrate the bone itself. Cortical
bone is progressively destroyed by tumor growth and enzymes produced by myeloma cells. These enzymes facilitate
bone destruction, its infiltration by tumor cells, development
of new blood vessels to sustain the tumor, and growth of
myeloma cells (McCance & Huether, 2002). Affected bones
(primarily the vertebrae, ribs, skull, pelvis, femur, clavicle,
and scapula) are weakened and may break without trauma
(pathologic fracture).
The disease develops slowly. Manifestations of multiple
myeloma are due to its effects on the bone and the impaired immune response due to M protein production. Bone pain is the
most common presenting symptom. With progression of the
disease, the pain may increase in severity and become more localized. Rapid bone destruction releases calcium from the
bone, leading to hypercalcemia and manifestations of neurologic dysfunction, such as lethargy, confusion, and weakness.