Nursing Care Plan for Acute Lymphoblastic Leukemia
Acute lymphoblastic leukemia (ALL) also called acute lymphocytic leukemia or acute lymphoid leukemia is a malignant (clonal) disease of the bone marrow in which early lymphoid precursors proliferate and replace the normal hematopoietic cells of the marrow.
Causes
- Most of the time, no clear cause can be found. But the following may play a role in the development of leukemia in general:
- Certain chromosome problems
- Past treatment with chemotherapy drugs
- Exposure to radiation, including x-rays before birth
- Toxins, such as benzene
- Receiving a bone marrow transplant
Signs and symptoms
- Fever
- Bone and joint pain
- Feeling weak or tired
- Easy bruising and bleeding (such as bleeding gums, skin bleeding, nosebleeds, abnormal periods)
- Pain or feeling of fullness below the ribs
- Loss of appetite and weight loss
- Paleness
- Swollen glands (lymphadenopathy) in the neck, under arms, and groin
- Night sweats
- Pinpoint red spots on the skin (petechiae)
Nursing Diagnosis for Acute Lymphoblastic Leukemia : Imbalanced Nutrition Less Than Body Requirements related to fluid restriction, diet, and the loss of protein.
Definition : Intake of nutrients is not sufficient for the purposes of the body's metabolism.
Defining characteristics :
- Weight 20 % or more below the ideal.
- Reports of food intake less than RDA (Recomended Daily Allowance)
- Pale mucous membranes and conjunctiva.
- Weakness of the muscles used for swallowing / chewing.
- Wounds, inflammation of the oral cavity.
- Easy to feel full , shortly after the chewing of food.
- Reported or the fact that there is a shortage of food.
- Reported a change in taste sensation.
- The feeling of inability to chew food.
- Misconceptions.
- Losing weight with enough food.
- Reluctance to eat.
- Cramps in the abdomen.
- Poor muscle tone.
- Abdominal pain with or without pathology.
- Less interested in food.
- Fragile capillary vessels.
- Diarrhea and or steatorrhea.
- Hair loss is quite a lot (loss).
- Hyperactive bowel sounds.
- Lack of information, misinformation.
Related factors :
- Inability to enter or digest food or absorb nutrients associated with biological factors, psychological or economic.
NOC :
Nutritional status : food and Fluid Intake
Outcomes :
- An increase in body weight in accordance with the purpose.
- Ideal weight according to height.
- Being able to identify nutritional needs.
- No signs of malnutrition.
- Weight loss does not happen that means.
NIC :
Nutrition Management
- Assess the food allergy.
- Collaboration with a nutritionist to determine the amount of calories and nutrients needed by the patient.
- Instruct the patient to increase the intake of Fe.
- Instruct the patient to increase the protein and vitamin C.
- Give the substance of sugar.
- Make sure the diet contains high fiber eaten to prevent constipation.
- Give foods elected (already consulted with a nutritionist).
- Teach patients how to make food diaries.
- Monitor the amount of nutrients and calories.
- Provide information about nutritional needs.
Nutrition Monitoring
- Patient's weight within normal limits.
- Monitor change in body weight.
- Monitor the type and amount of regular activity.
- Monitor interaction between children or parents during meals.
- Monitor the environment for eating.
- Schedule of treatment and no action during a meal.
- Monitor dry skin and pigmentation changes.
- Monitor skin turgor.
- Monitor dryness, dull hair, and brittle.
- Monitor nausea and vomiting.
- Monitor levels of albumin, total protein, hemoglobin, and hematocrit levels.
- Monitor food preferences.
- Monitor growth and development.
- Monitor pale, redness, and dryness of the conjunctiva tissue.
- Monitor and calorie intake nuntrisi.
- Note the presence of edema, hyperaemic, hypertonic papillae of the tongue and oral cavity.
- Note if the tongue magenta, scarlet.
- Assess the patient's ability to get needed nutrients.
