NURSING CARE PLAN (NCP) FOR ACUTE LYMPHOCYTIC LEUKEMIA

Page 12
PATIENT PROBLEMS PLANNING & IMPLEMENTATION EVALUATION
DATE OUTCOME
ACTUAL & POTENTIAL NURSING INTERVENTION DATE COMMENTS

07.1.11 Risk for bleeding related to Skin will remain intact Assess vital signs every 4 hours and body 12.1.11 Client skin was intact
to decreased platelet count with no signs of bleeding systems every shift for bleeding: and no signs of bleeding
12.1.11
Mucuos membrane will * Skin and mucous membranes for petechiae, Mucuos membrane
remain intact ecchymoses, and hematoma formation intact
* Gums and nasal membranes for bleeding
Urine and stool will remain * Vomitus, stool and urine for visible occult Urine and stool free of
free of blood. blood blood
* Neurologic changes e.g., headache, visual
changes, altered mentation, decreased LOC
seizures

Early detection of bleeding helps prevent

significant blood loss and potential shock.
Internal hemorrage may lead to tachycardia,
hypotension, pallor, and diaphoresis. Bleeding
in the abdomen causes increased girth, pain,
and guarding. Intracranial bleeding affects
mental status and LOC.

Avoid invasive procedures as possible e.g

rectal temperature and suppositories, parenteral
injection and CBD to prevent tissue trauma and
bleeding

Apply pressure to injection sites for 3 - 5 min.

and arterial punctures for 15 to 20 min.
Pressure prevents prolonged bleeding by
prompting hemostasis and clot formation.
 NURSING CARE PLAN (NCP) FOR ACUTE LYMPHOCYTIC LEUKEMIA
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PATIENT PROBLEMS ApplyPLANNING & IMPLEMENTATION
pressure to injection sites for 3 - 5 min. EVALUATION
DATE OUTCOME
ACTUAL & POTENTIAL and arterial punctures for 15
NURSING INTERVENTIONto 20 min. DATE COMMENTS
Pressure prevents prolonged bleeding by
prompting hemostasis and clot formation.

Instruct client to avoid forceful blowing,

coughing, sneezing and straining to have a
bowel movement. Theses activities can
damage mucous membrane increasing the risk
of bleeding

Encourage use of soft-bristle toothbrush or

sponge to clean teeth and gums to prevent
bleeding and risk of infection
 NURSING CARE PLAN (NCP) FOR ACUTE LYMPHOCYTIC LEUKEMIA
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PATIENT PROBLEMS PLANNING & IMPLEMENTATION EVALUATION
DATE OUTCOME
ACTUAL & POTENTIAL NURSING INTERVENTION DATE COMMENTS

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 NURSING CARE PLAN (NCP) FOR ACUTE LYMPHOCYTIC LEUKEMIA
Page 14
PATIENT PROBLEMS PLANNING & IMPLEMENTATION EVALUATION
DATE OUTCOME
ACTUAL & POTENTIAL NURSING INTERVENTION DATE COMMENTS

07.1.11 Fever related to decreased Client will have body Take client temperature every 4 hourly 12.01.2011 Client body temperature reduced
to immunity temperature of 36.5 - to evaluate effectiveness of the to 37 degrees C
12.1.11 37.3 C treatment e.g., PCM and antibiotic

Client will be Advise client to take a complete rest to Client is comfortable

comfortable minimize unnecessary energy
expenditure which may increase body
temperature

Promote client heat loss by dressing

client with lightweight material e.g.
cotton cloting

Perform tepid sponging every 4hourly

to reduce heat

Frequent changing of position and linen

on the client bed to reduce discomfort

Give client antibiotic as order by doctor

to treat infection causing fever e.g. i/v
Tazocin 4.5mg every 6 hourly

Serve client antipyretic e.g.

paracetamol 1g 6 hourly or as ordered
by doctor to reduce fever and make
sure pcm is serve after temperature is
taken to prevent false-refer
paracetamol 1g 6 hourly or as ordered
by doctor to reduce fever and make
sure pcm is serve after temperature is
taken to prevent false-refer
 NURSING CARE PLAN (NCP) FOR ACUTE LYMPHOCYTIC LEUKEMIA
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PATIENT PROBLEMS PLANNING & IMPLEMENTATION EVALUATION
DATE OUTCOME
ACTUAL & POTENTIAL NURSING INTERVENTION DATE COMMENTS

07.1.11 Altered nutrition:less than Client will get enough Weigh regularly and evaluate weight 12.01.2011 Client have enough nutrition
to body requirements related to nutrition loss over time to determine degree of
12.1.11 loss of appetite and weakness malnutrition. Good intake is necessary
for health and tissue repair

Client's appetite will be Offer client small but frequent meal Client's appetite was improved
improved and snacks including low-fat,high-
caloric food e.g., potatoes, bread. Big
meal will suppress the appetite and
small-frequent meal are often better
tolerated.

Client will have more Provide familiar and home cook foods Client was more energetic
energy to promote good appetite

Give supplemental nutrition e.g.,

multivitamins to improve the nutritional
status

Avoid unpleasant procedures

immediately before and after meals to
promote good appetite.

Provide mouth care before meals to

prevent halitosis that may aggravate
loss of appetite

Increase liquid intake with meals to

promote good hydration.
 NURSING CARE PLAN (NCP) FOR ACUTE LYMPHOCYTIC LEUKEMIA
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PATIENT PROBLEMS PLANNING & IMPLEMENTATION EVALUATION
DATE OUTCOME
ACTUAL & POTENTIAL NURSING INTERVENTION DATE COMMENTS

Provide clean and conducive

environment during meal time to
improve appetite

Arrange dietician to discuss with client

or family on proper diet intake and
helpful dietary medifications