Nursing Care Plan for Leukemia
Nursing Diagnosis : Risk for Fluid Volume Deficit related to excessive loss: vomiting, bleeding, diarrhea. Decreased fluid intake: nausea, anorexia. Increased fluid requirements: fever, hypermetabolic.
Goal:
Fluid volume are met.
Expected outcomes:
- Adequate fluid volume.
- Mucosa moist.
- Stable vital signs.
- Palpable pulse.
- Urine output: 30 ml / h.
- Capillary refill: less than 2 seconds.
- Nursing Intervention:
- Monitor input / output.
- Weigh weight per day.
- Monitor blood pressure and heart frequency.
- Evaluation tugor skin, capillary and conditions of mucous membranes.
- Give fluid intake of 3-4 liters / day.
- Inspection for ptekie skin, ecchymosis area, noticed bleeding gums, rust-colored blood, faeces and urine occult bleeding from the puncture invasive further.
- Implementation of measures to prevent tissue injury.
- Limit oral care to wash the mouth when indicated.
- Give refined diet.
- Give IV fluids as indicated.
- Supervise laboratory tests.
- Give the red blood cells, platelets, clotting factors.
- Maintain a central vascular access device.
- Give medications as indicated.
