Need/Nursing Scientific Nursing
Objective Rationale Evaluation
Diagnosis/Cues Analysis Intervention
Risk for infection Leukemias are After 8 hours of INDEPENDENT:
related to inadequate cancers of the blood- nursing • Place the patient in private
primary defences. forming tissues. White interventions the room. Limit visitors as
blood cells may be patient will: indicated. Prohibit use of live
produced in excessive plants or cut flowers. Restrict
OBJECTIVE: amounts and are -identify actions to fresh fruits and vegetables or
unable to work prevent or reduce make sure they are washed
• Irritability properly which the risk for or peeled.
• Pallor of skin and weakens the immune infection. • Require good handwashing
mucous system. protocol for all personnel and
membranes visitors.
• Encourage frequent turning
and deep breathing.
• Handle patient gently. Keep
linens dry or wrinkle free.
• Inspect skin for tender,
erythematous areas, open
wounds. Cleanse skin with
antibacterial solutions.
• Inspect oral mucous
membranes. Provide good
oral hygiene. Use a soft
toothbrush, sponge, or swabs
for frequent mouth care.
• Promote good perineal
hygiene. Examine perianal
area at least daily during
acute illness and provide sitz
baths.
• Coordinate procedures and
tests to allow for
uninterrupted rest periods.
COLLABORATIVE:
• Prepare for or assist patient
with leukemia treatments
such as chemotherapy,
radiation, and bone marrow
transplantation.
After 8 hours of
• Protect patient from potential nursing
sources of pathogens or interventions
infection. the patient was
able to identify
actions to
prevent or
reduce the risk
• Prevents cross- for infection.
contamination or reduce risk
for infection.
• Prevents stasis of respiratory
secretions, reducing risk of
atelectasis or pneumonia.
• Prevents sheet burn or skin
excoriation.
• May indicate local infection.
• The oral cavity is an
excellent medium for growth
of organism and is
susceptible to ulceration and
bleeding.
• Promotes cleanliness,
reducing risk of perianal
abscess; enhances
circulation and healing.
• Conserves energy for
healing, cellular
regeneration.
• Leukemia is usually treated
with a combination of these
agents, each requiring