Friday, March 30, 2012

Acute Lymphocytic Leukemia - Risk for Infection Nursing Diagnosis and Interventions

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:
  • Bone and joint pain
  • Easy bruising and bleeding (such as bleeding gums, skin bleeding, nosebleeds, abnormal periods)
  • Feeling weak or tired
  • Fever
  • Loss of appetite and weight loss
  • Paleness
  • Pain or feeling of fullness below the ribs
  • Pinpoint red spots on the skin (petechiae)
  • Swollen glands (lymphadenopathy) in the neck, under arms, and groin
  • Night sweats

Note: 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

Goal : no infection.

Expected outcomes are:
Clients will:
  • Identify the risk factors that can be reduced
  • State the signs and symptoms of early infection
  • No signs of infection

Nursing Interventions Acute Lymphocytic Leukemia : Risk for Infection

1. Take action to prevent exposure to known or potential sources of infection:
  • Keep the protective insulation, according to institutional policy
  • Maintain a careful hand washing technique
  • Give good hygiene
  • Limit visitors who were fever, flu or infections
  • Give two times daily perianal hygiene and each bowel movement
  • Limit fresh flowers and fresh vegetables
  • Use the oral care protocol
  • Hospitalized with neutropenic clients first.

Rational: Vigilance, minimizing client exposure to bacteria, viruses, and fungal pathogens either endogenous or exogenous.

2. Report if there are changes in vital signs
Rationale: Changes in vital signs is an early sign of sepsis, especially if there is an increase in body temperature.

3. Get culture of sputum, urine, diarrhea, abnormal blood and body secretions as recommended
Rational: The culture can confirm infection and identify the causative organism.

4. Explain the reasons for vigilance and abstinence
Rational: The culture can confirm infection and identify the causative organism.

5. Reassure the client and his family that the increased susceptibility to infection while only
Rational: granulocytopenia may persist 6-12 weeks. The notion of a temporary nature can help prevent anxiety granulocytopenia clients and their families

6. Minimize invasive procedures
Rational: certain procedures may cause tissue trauma, increased susceptibility of infection.

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