Need/nursing Diagnosis/cues Need: Physiologic Need Nursing Diagnosis: • Nutrition Imbalanced

Need/Nursing Diagnosis/Cues Need: Physiologic need Nursing Diagnosis: • Nutrition imbalanced less than body requirements related to disease process as evidenced by anorexia and vomiting Objective: -anorexia -vomiting -Weight loss -restlessness -lethargic

Scientific Analysis Leukemias affects all blood cells, and blood influences the health and function of all organs and systems, thus many body areas and system cells may be affected. The following manifestations occur with the acute luekemias. Some of this findings may also be present in the client with chronic leukemia in the blast phase, which includes weight loss, anorexia, bleeding gums, fatigue, headache, bone pain and joint swelling.

Objective After 6-8 hours of nursing intervention, the patient will be able to: the client will be able to maintain usual weight.

Nursing Intervention Independent: • Auscultate bowel sounds, noting absence or hyperactive sounds.

• Inflammation or irritation of the intestine may be accompanied by intestinal hyperactivity, diminished water absorption and diarrhea.

• Eliminate smells from the environment.

• Reduces gastric stimulation and Vomiting response.

• Avoid foods that might cause or exacerbate abdominal cramping like caffeinated beverages, chocolate, orange juice.

• Might increase abdominal cramping.

• Measure abdominal girth.

• Provides quantitative evidence of changes in gastric or intestinal distention.

• Observe skin or mucous membrane dryness, and turgor. Note peripheral edema and sacral edema.

• Hypovolemia, fluid shifts and nutritional deficits contribute to poor skin turgor, edematous tissue.

• Assess abdomen frequently for return to softness, appearance of normal bowel sounds, and passage of flatus.

• Indicates return of normal bowel function and ability to resume oral intake.

• Weigh daily.

• Initial losses or gains reflect changes in hydration.

Rationale

Collaborative: • Monitor BUN, protein, prealbumin or albumin, glucose, nitrogen balance as indicated.

• Reflects organ function and nutritional status and needs.

• Advance diet as tolerated.

• Careful progression of diet when intake is resumed reduces risk of gastric irritation.

Evaluation After 6-8 hours of nursing intervention, the patient was able to: the client was be able to maintain usual weight.