Ministry of Health
Ha Noi Medical University
NURSING CARE PLAN FOR LEUKEMIA DISEASE
Student Name : Nguyễn Tuấn Anh
Class Y4P
Student ID : 1655010137
1
MINISTRY OF HEALTH
HA NOI MEDICAL UNIVERSITY
CLIENT INFORMATION SHEET/ NURSING CARE PLAN
Student:
Date of Care:
Nguyễn Tuấn Anh
16/08/2019
Unit:
Grade:
Concept Map/Pathophysiology _____/ 40pts
Cardiology
Nursing Process
Patient Initials:
Vũ Anh Tuấn
Admission Date:
______/24pts
Labs/meds
_____/ 20pts
Patient Teaching
_____/ 10
pts
10/08/2019
APA
_____/6pts
TOTAL
_____/100pts
Age & Gender:
67/Male
Code Status:
Allergies:
None
Social Support:
Chief Complaint on Admission:
Left chest pain
Present History
3 hours from the hospital, the patient appeared intense left chest pain, feeling the heart beating fast. Then
was transferred to emergency A9 diagnosed with ventricular tachycardia.-> c1
Medical history
2
Unidentified coronary artery disease has been hot, not stent placed for 10 years
Hypertension, diabetes without treatment, functional foods
Focused assessment
- Patient feel fatigue, anorexia
- No sign of infection
- No sign of hemorrhega
- Liver and spleen not large
Admitting Diagnosis and Current Diagnosis
Admittin
Myocardio infarction
Current:
Myocardio infarction
Physical Exemination
General appearance
Alert, good communication.
No fever, pale skin and membrane
Cardio-vascular
Blood pressure: 110/ 80 mmHg equal in 2 arms, Heart rate: 200bpm, regular
.Heart sounds is regular and clear.T1, T2 is clear, regular. No have advaned
sounds
Respiratory
No difficult breathing
Respiratory rate: 19 times/ minute
Sp02: 100%
Urinary system
No edema
No urine retention, no thirsty.
3
Urine volume: 2500mL/ day
Gastrointestinal
system
Anorexia
No nausea, no vomiting.
No diarrhea, constipation.
Abdominal is soft
Significant Medical History and Co-Morbidities:
V.S. (baseline)
O2 Administration
Pulse: 87 beats/minute
None
Respiratory rate: 21 times/minute
Body temperature: 37oC
Rationale
Blood pressure: 110/70 mmHg
Sp02: 100%
Tubes/Drains (Intake & Output)
Intravenous Therapy
None
The right arm
Rationale
4
DIAGNOSTIC EVALUATION (10 pts)
LABORATORY
TEST
REFERENCE VALUE
ADMISSION
RANGES
(BASELINE)
9/1/2017
WBC
3.5- 10.5 G/L
6.03
Neutrophils
%
39.6
Lymphocytes
%
53.7
Monocytes
%
6.1
Eosinophils
%
0.01
Basophils
%
0.02
RBC
3.9-5.03 T/L
3.63
Hgb
120-155 g/L
106
MCV
85-95 fl
89.1
MCH
28-32 pg
29.0
MCHC
320-360 g/l
326
RDW
11-14%
18.5
Platelets
150-450 G/L
259
Ure
2.5-7.5 mmol/l
2.3
Acid uric
180-420 umol/l
72
Glucose
3.9-6.4 mmol/l
8.9
Basic Metabolic
Panel:
5
AST (GOT)
<37 U/L
24
Cl
98-106
102.3
135-145
136.6
K
3.5-5
3.6
Creatinine
53-110umol/l
241
APTTr
0.85-1.25
0.8
PT %
70-140
112
INR
0.95
Na
Coagulation:
OTHER DIAGNOSTICS OR SIGNIFICANT INFORMATION (x-rays, MRI, other studies):
Ultrasound : mild hepatic steatosis
X-ray : Not found abnormal bone and chest software
Heart does not large
6
CONCEPT MAP/ PATHOPHYSIOLOGY
Risk and causative
factors :
1,Ionizing radiation,
exposure to
chemicals or drug
LEUKEMIA
2. Immunologic
factors like
immunodeficiency
Clonal malignant disorder of
the blood and blood forming
organs begins with a single
progenitor cell that
undergoes transformation
3. Family history of
leukemia
4. Increase
incidence in
association with
other hereditary
abnormalities
Produces a leukemic cell that
not mature and respond to
normal regulatory
mechansisms
Leukemic cells
accumulate continuously
and compete with
normal cellular
proliferation
Leukemic cell divide much
more slowly and take
longer to synthesize DNA
5. Unknow reasons
Also can develop in
pluripotent stem cells that
give rise to all other type
of blood cells
Leukemia blasts or
precursor cells crowed out
the marrow and cause
cellular proliferation of
the other cell lines to sease
Fatigue
Anorexia
Risk of infection
Treatment by drugs and
chemtherapy
Result in a reduction in
all cellular components of
the blood
Other risk
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NURSING CARE PLAN
DOMAIN: PHYSICAL
NURSING DIAGNOSIS 1
Risk for infection related to altered WBC production and immune function
DESIRED PATIENT OUTCOME
Identify the risk factors that can be reduced
State the signs and symptoms of early infection
No signs of infection
NURSING INTERVENTIONS AFTER
ASSESSMENT
RATIONALE
1. Place in a private room. Limit visitors as
pathogens or infection. Bone marrow suppression,
indicated.
neutropenia, and chemotherapy places the patient at
1. To protect the patient from potential sources of
high risk for infection.
2. Require good hand washing protocol for all
2. Prevents cross-contamination and reduces risk of
personnel and visitors.
infection.
3. Closely monitor temperature. Note correlation
3. Although fever may accompany some forms of
between temperature elevations and chemotherapy
chemotherapy, progressive hyperthermia occurs in
treatments. Observe for fever associated with
some types of infections, and fever (unrelated to
tachycardia, hypotension, subtle mental changes.
drugs or blood products) occurs in most leukemia
patients.
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4. Inspect oral mucous membranes. Provide good
4. The oral cavity is an excellent medium for growth
oral hygiene. Use a soft toothbrush, sponge, or
of organisms and is susceptible to ulceration and
swabs for frequent mouth care.
bleeding.
5. Promote good perianal hygiene. Examine perianal
5. Promotes cleanliness, reducing risk of perianal
abscess; enhances circulation and healing
area at least daily during acute illness.
6. Limit invasive procedures (venipuncture and
7. Monitor sign of infection : fever, dry lips, tongue
6. Break in skin could provide an entry for
pathogenic or potentially lethal organisms. Use of
central venous lines (tunneled catheter or implanted
port) can effectively reduce need for frequent
invasive procedures and risk of infection
dirty
7. To know patient conditions
8. Monitor laboratory studies: CBC, noting whether
8. Decreased numbers of normal or mature WBCs
can result from the disease process or chemotherapy,
compromising the immune response and increasing
risk of infection
injections) as possible
WBC count falls or sudden changes occur in
neutrophils; Gram’s stain cultures and sensitivity;
Review serial chest x-rays.
EVALUATION OF DESIRED PATIENT OUTCOMES (MET, PARTIALLY MET, NOT MET)
MET
NURSING DIAGNOSIS 2
Fatigue related to disease process and side effect of chemotherapy
DESIRED PATIENT OUTCOME
Report improved sense of energy.
Perform ADLs and participate in desired activities at level of ability
NURSING INTERVENTIONS AFTER
ASSESSMENT
RATIONALE
1. Frequent rest periods and naps are needed to
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1. Plan care to allow for rest periods. Schedule
restore and conserve energy
activities for periods when patient has most energy
2. Establish realistic activity goals with patient.
2. Provides for a sense of control and feelings of
accomplishment.
3. Assist with self-care needs when indicated; keep
3. Weakness may make ADLs difficult to complete
bed in low position, pathways clear of furniture
or place the patient at risk for injury during
4. Monitor physiological response to activity
(changes in BP, heart and respiratory rate).
5. Provide supplemental oxygen if it has indicated.
activities.
4. Tolerance varies greatly depending on the stage of
the disease process, nutrition state, fluid balance, and
reaction to therapeutic regimen.
5. Presence of anemia and hypoxemia reduces
6. Refer to physical or occupational therapy
O2available for cellular uptake and contributes to
fatigue.
6. Programmed daily exercises and activities help
patient maintain and increase strength and muscle
tone, enhance sense of well-being. Use of adaptive
devices may help conserve energy
EVALUATION OF DESIRED PATIENT OUTCOMES (MET, PARTIALLY MET, NOT MET)
MET
NURSING DIAGNOSIS 3
Risk for hemorrhage related to disease condition
DESIRED PATIENT OUTCOME
Skin will remain intactwith no signs of bleeding
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Mucuos membrane willremain intact
Urine and stool will remainfree of blood.
NURSING INTERVENTIONS AFTER
ASSESSMENT
RATIONALE
1.Assess vital signs every 4 hours and bodysystems
preventsignificant blood loss and potential
every shift for bleeding:
shock.Internal hemorrage may lead to
Skin and mucous membranes for petechiae,
tachycardia,hypotension, pallor, and diaphoresis.
ecchymoses, and hematoma formation
Bleedingin the abdomen causes increased girth,
1. Early detection of bleeding helps
pain,and guarding. Intracranial bleeding
Gums and nasal membranes for bleeding
affectsmental status and LOC
Vomitus, stool and urine for visible occult blood
Neurologic changes e.g., headache, visual changes,
altered mentation, decreased LOC seizure
2. Avoid invasive procedures as possible e.grectal
temperature and suppositories, parenteralinjection
2. Prevent tissue trauma and bleeding
and CBD
3. Encourage use of soft-bristle toothbrush or sponge
3. Theses activities candamage mucous membrane
to clean teeth and gums to prevent bleeding and risk
increasing the risk of bleeding
of infection
4. Maintain patient rest on the bed, limited activity
can overload or injury for patient
4. limit trauma lead to injury vacular
EVALUATION OF DESIRED PATIENT OUTCOMES (MET, PARTIALLY MET, NOT MET)
MET
NURSING DIAGNOSIS 4
Imbalance nutrition less than body requirement related to anorexia
DESIRED PATIENT OUTCOME
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Demonstrate stable weight/progressive weight gain toward goal with normalization of laboratory
values and be free of signs of malnutrition.
Verbalize understanding of individual interferences to adequate intake.
Participate in specific interventions to stimulate appetite/increase dietary intake.
NURSING INTERVENTIONS AFTER
ASSESSMENT
RATIONALE
1. Identifies nutritional strengths and deficiencies
1. Monitor daily food intake; have patient keep food
diary as indicated
2. If these measurements fall below minimum
standards, patient’s chief source of stored energy (fat
2. Measure height, weight, and tricep skinfold
tissue) is depleted.
thickness (or other anthropometric measurements as
appropriate). Ascertain amount of recent weight loss.
Weigh daily or as indicated.
3. Metabolic tissue needs are increased as well as
3. Encourage patient to eat high-calorie, nutrient-rich fluids (to eliminate waste products). Supplements
can play an important role in maintaining adequate
diet, with adequate fluid intake. Encourage use of
supplements and frequent or smaller meals spaced
caloric and protein intake.
throughout the day.
4. Maintain patient have enough enegy
4.Perform diet order : BT01 with 1600kcal/day
5. Makes mealtime more enjoyable, which may
5. Create pleasant dining atmosphere; encourage
enhance intake.
patient to share meals with family and friends
6. In the presence of severe malnutrition (loss of
6. Insert and maintain NG or feeding tube for enteric
25%–30% body weight in 2 mo) or if patient has
feedings, or central line for total parenteral nutrition
been NPO for 5 days and is unlikely to be able to eat
(TPN) if indicated
for another week, tube feeding or TPN may be
necessary to meet nutritional needs.
EVALUATION OF DESIRED PATIENT OUTCOMES (MET, PARTIALLY MET, NOT MET)
12
MET
DOMAIN: PSYCHOSOCIAL
NURSING DIAGNOSIS 5
Anxiety related to situational crisis
DESIRED PATIENT OUTCOME
Display appropriate range of feelings and lessened fear.
Appear relaxed and report anxiety is reduced to a manageable level.
Demonstrate use of effective coping mechanisms and active participation in treatment regimen.
NURSING INTERVENTIONS AFTER
ASSESSMENT
RATIONALE
1. Determine what the doctor has told patient and
identification of fear(s) and misconceptions based on
what conclusion patient has reached.
diagnosis and experience with disease.
2. Encourage patient to share thoughts and feelings.
2. Provides opportunity to examine realistic fears
1. Clarifies patient’s perceptions; assists in
and misconceptions about diagnosis.
3. Provide open environment in which patient feels
safe to discuss feelings or to refrain from talking.
3. Helps patient feel accepted in present condition
without feeling judged, and promotes sense of
dignity and control.
4. Maintain frequent contact with patient. Talk with
and touch patient as appropriate.
4. Provides assurance that patient is not alone or
rejected; conveys respect for and acceptance of the
5. Provide accurate, consistent information regarding
person, fostering trust.
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diagnosis and prognosis. Avoid arguing about
5. Can reduce anxiety and enable patient to make
patient’s perceptions of situation.
decisions and choices based on realities.
6. Explain the recommended treatment, its purpose,
and potential side effects. Help patient prepare for
treatments.
6. Treatment may include surgery (curative,
preventive, palliative), as well as chemotherapy,
radiation (internal, external), or organ-specific
treatments such as whole-body hyperthermia or
biotherapy. Bone marrow or peripheral progenitor
cell (stem cell) transplant may be recommended for
7. Promote calm, quiet environment.
some types of cancer.
7. Facilitates rest, conserves energy, and may
enhance coping abilities.
EVALUATION OF DESIRED PATIENT OUTCOMES (MET, PARTIALLY MET, NOT MET)
MET
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PATIENT TEACHING
DOMAIN: EDUCATION
Knowledge deficient regarding disease, prognosis, treatment, self-care and discharge needs
DESIRED PATIENT OUTCOME OF TEACHING SESSION (Measurable & Patient Centered)
Verbalize understanding of condition disease process and potential complications
Verbalize understanding of therapeutic needs
Initial necessary lifestyle changes
Participate in treatment regimen
METHOD OF INSTRUCTION (Demonstration, Discussion, Written Handouts)
Discussion
Written handouts
NURSING INSTRUCTION
1.Knowlegde regarding disease and treatment
- Leukemia is incurable disease and may die at any time
- The bone marrow produces abnormal white blood cells that are called leukemia cells and leukemic blast
cells. The abnormal cells can’t produce normal white blood cells.
- Unlike normal blood cells, leukemia cells don’t die when they become old or damaged. Because they don’t
die, leukemia cells can build up and crowd out normal blood cells. The low level of normal blood cells can
make it harder for the body to get oxygen to the tissues, control bleeding, or fight infections
15
- Treatment options may include:
Watchful waiting
Chemotherapy
Targeted therapy
Radiation therapy
Stem cell transplant
2. Knowledge about nutrition
- Eating well is important before, during, and after treatment for leukemia. You need the right amount of
calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may
help you feel better and have more energy.
- Sometimes, especially during or soon after treatment, you may not feel like eating. You may be
uncomfortable or tired. You may find that foods don’t taste as good as they used to. In addition, poor
appetite, nausea, vomiting, mouth blisters, and other side effects of treatment can make it hard for you to eat
3. Follow-up Care
- After treatment for leukemia, you’ll need regular checkups
- Leukemia may come back after treatment. Your doctor will check for the return of leukemia. Checkups
also help detect health problems that can result from cancer treatment.
- Checkups may include a physical exam, blood tests, and bone marrow tests
4. Self-care and changes lifestyle
- Eat well and keep to a healthy weight
- Stop smoking and drink alcohol
- Regular exercise
- Reducing stress
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EVALUATION OF DESIRED PATIENT OUTCOMES (Met, Partially met, Not met)
MET AND PARTIALLY MET
17
MEDICATIONS
ATTACH COMPLETED MEDICATION WORKSHEET FOR YOUR CLIENT(S) WITH
REFERENCES
CLINICAL MEDICATION WORKSHEET
CLIENT ALLERGIES: NONE
MEDICATION
DOSAGE, ROUTE,
TIME
EFFECT
SIDE EFFECT
Medoclor 500mg
4 table/day
Antibiotic
Oral
Prevent infection
Itchiness, urticaria.
Stevens-Johnson
syndrone. Reduced
muscle tone,
hallucinations, dizzy.
Thrombocytopenia,
increased eosinophils,
pseudomembranous
colitis.
Morning/2tablet
Afternoon/ 2tablet
Omeprem 20mg
4 table/day
Oral
Anti-peptic ulcer,
proton pump
inhibitors.
Nausea, headache;
bloating and
constipation are rare.
Occasional skin rash
Fluid replacement and
electrolytes
Increased blood
sodium and chloride
of many that can
cause loss of
bicarbonate with
acidification effects
9:00 2table
20:00 2table
Natri cloris 0.9%
500ml
2 bottle/day
IV
Morning, 30
drops/min
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