2 Nursing Diagnosis and Interventions for Leukemia

1. Risk for Fluid Volume Deficit

related to :

1. fluid intake and output,

2. excessive loss: vomiting, bleeding, diarrhea

3. decrease in fluid intake: nausea, anorexia

4. increased need for fluids: fever, hypermetabolic.

Purpose : the volume of fluid being met

Expected outcomes:

1. Adequate fluid volume

2. The mucosa moist

3. Vital signs are stable: BP 90/60 mm Hg, pulse 100x/menit, RR 20x/menit

4. Pulse palpated

5. Urine output 30 ml / hour

6. Capillaries and refill less than 2 seconds

Intervention:

1. Monitor fluid intake and output

2. Monitor body weight

3. Monitor BP and heart frequency

4. Evaluation of skin turgor, capillary refill and mucous membrane conditions

5. Give fluid intake 3-4 L / day

6. 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.

7. Implement measures to prevent tissue injury / bleeding

8. Limit oral care to wash mouth when indicated

9. Give diet a smooth

10. Collaboration:

a. Give IV fluids as indicated

b. Supervise laboratory tests: platelet count, Hb / Ht, freezing

c. Provide HR, platelets, clotting factors

d. Maintain a central vascular access device external (sub-clavicle artery

catheter, tunneld, implantable ports)
2. Acute pain

related to an agent of physical injury

Purpose: pain is resolved

Expected outcomes:

1. The patient stated the pain disappeared or controlled

2. Shows the behavior of pain management

3. Looks relaxed and able to rest, sleep

Intervention:

1. Assess complaints of pain, notice changes in the degree of pain (using a scale of
0-10)

2. Monitor vital signs, note the non-verbal clues such as muscle tension, anxiety

3. Provide quiet environment and reduce stressful stimuli.

4. Place the client in a comfortable position and prop joints, extremities with
pillows.

5. Change the position of periodic and soft assistive range of motion exercises.

6. Provide comfort measures (massage, cold compresses and psychological

support)

7. The review / enhance client comfort interventions

8. Evaluate and support the client's coping mechanisms

9. Encourage the use of pain management techniques. Example: relaxation

exercises / breathing in, touch.

10. Auxiliary therapeutic activity, relaxation techniques.

11. Collaboration: Monitor levels of uric acid, give the medication as indicated.