About
Cancer of the blood usually causing an increase in one particular cell type ( monocytes, granulocytes, lymphocytes). They are named according to the stem cell they originate from ( myeloid or lymphoid) and are classified as acute or chronic. It frequently causes an increase of leukocytes in bone marrow thus decreasing room for other normal cells to mature.
Assess
CBC with altered ratios of blood cells, decreased erythrocytes and platelets ( Acute Myeloid Leukemia), elevated leukocyte counts ( Chronic Myeloid Leukemia), reduced leukocytes, erythrocytes and platelets with a high number of immature cells ( Acute Lymphocytic Leukemia), or elevated lymphocytes ( Chronic Lymphocytic Leukemia). Patients may be initially asymptomatic but as disease progresses have increased shortness of breath, bone pain, weight loss, fevers, infection, headache, vomiting, confusion, enlarged liver and spleen, weakness and bleeding.
Complications
Thrombocytopenia, bleeding, infection, sepsis, death
Diagnosis
- Risk for infection related to decreased body defenses.
- Fluid volume deficit related to insensible losses.
- Nutrition less than body requirements related to impaired oral intake.
- Risk for injury related to increased risk of bleeding and decreased platelet count
- Pain related to disease process.
Goals
- The client will remain free form infection.
- The client will state a pain level less than 4 after medication intervention.
- The client will discuss concerns and fears related to treatment and disease process.
- The client will maintain adequate fluid balance.
- The client will state methods to maintain adequate nutrition.
Interventions
- Assess CBC's, skin integrity, mouth for inflammation and sores, vital signs, pain levels, pulse-oximetry.
- Monitor for signs and symptoms of infection ( fever, malaise, inflammation) and bleeding ( hematuria, blood in stool or vomit, bruising, petechiae).
- Administer pain medicine, chemotherapy, antibiotics as ordered by a physician.
- Perform hand hygiene and prevent sick personnel or visitors from entering client room.
- Place patient on reverse isolation if neutropenia develops.
- Teach client methods to prevent infection including hand-washing, avoiding large crowds, monitoring temperature.
- Encourage client to verbalize concerns and feelings over diagnosis, treatment and lifestyle changes.
- Administer IV fluids to maintain fluid balance.
- Monitor intake and output.
- Encourage nutrient dense foods; small, frequent meals; and nutritional supplements.
- Notify physician immediately if onset of fever.
- Perform mouth care frequently to prevent mucositis from antibiotics and chemotherapy.
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