Care Plan

Student: Madison McLuen Date: 1/25/20

Course: NSG-434CC Instructor: Alisa Kurth

Clincial Site: Phoenix Children’s Hospital Client Identifier: A.G. Age: 8 years

Reason for Admission: A.G. came into the ER on 12/31 compaining of abdominal pain and generalized weakness. After an abnormal lab
count, she was diagnosed with acute myelogenous leukemia (AML).

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

Acute Myelogenous Leukemia (AML): AML is a malignant disease in
the blood and bone marrow. It is defined as a clonal disorder caused by
malignant transformation of a bone marrow–derived, self-renewing stem
cell or progenitors, leading to accumulation of immature, nonfunctional
myeloid cells (Childhood Acute Myeloid Leukemia, 2018).
First, the production of normal blood cells decreases, resulting in anemia,
thrombocytopenia, and neutropenia. Second, a rapid proliferation of
abnormal myeloblasts results in their accumulation in the bone marrow
blood, and often times the spleen and liver. Although there is no known
cause, risk factors include congenital abnormalities, environmental
exposures, and familial syndromes.
A.G.’s clinical manifestations: A.G. currently has abdominal pain,
generalized weakness, anemia, and neutropenia, and weight loss.
The patient reportely has been extremely fatgiued that past couple
of weeks, with weight loss of 1.5 lbs in past 2 weeks. She
complains of 5/10 abdominal pain. She has only had one round of
blood transfusions, and has had only a mild fever since then (NIH,
2019)
General clinical manifestations of AML: Increased WBC count
(>100,000), low ANC, anemia, neutropenia, thrombocytopenia,
fever, shortness of breath, bone pain, unexplained weight loss, flu-
like symptoms (NIH, 2019)

Assessment Data
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
Subjective Data: Mom has many questions about AML and what to expect with the treatments and the next few months. She said that she is
taking a class on Feb. 6th about central line dressing care to better prepare her and her family to take the patient home. A.G. was content playing
with her ipad, and walking around. Patient teaching will be needed for central line care, medications, and hospital visits.
VS: T : 37 C Labs: Diagnostics:
BP: 109/70 ANC: 120 (previous ANC levels were at 40, labs EKG/echo
trending upward)
HR: 98 bpm CXR
RR: 18 breaths/min Platelet count 19

O2 Sat: 99% on ”room air” Hgb 8.8

Sodium 137
Potassium 3.8
Chloride 105
BUN/creatinine ratio 56 (high)
Albumin 3.3 (low)
AST 20
ALT 141
WBC 2.4 (low)
RBC 3.0 (low)
Hct 26.0 (low)
Lymphocytes 81
Monocytes 14

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Assessment: Orders:
Pt hx: No previous medical history Broviac line placement
Mental Status Assessment: A&O X 4 Complete metabolic panel
Skin: Skin is warm, dry, and intact CBC and differential
Skin color is uniform throughout body and is appropriate for ethnicity Blood culture
Skin turgor is appropriate bilaterally; no tenting noted Immunocompromised diet
Capillary refill is less than 2 seconds bilaterally Child Life assessment
No upper or lower body edema noted bilaterally PT consult
Moderate bruising from lumbar puncture on sacrum area (skin still
intact)
Head, Face, and Neck: Head is normocephalic shape, hair distribution
is normal for age, face is symmetrical and neck is proportionate to the
head and face
Temporal and carotid arteries are palpable bilaterally
No presense of TMJ
CN V Trigeminal is intact
CN VII Facial is intact
CN XII Hypoglossal is intact
Lymph nodes are non-palpable and non-tender
Trachea is midline (tracheostomy is intact, skin is intact and dry) collar
Airway is patent

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Thyroid is non-enlarged, no nodules present
Eyes: Eyes are symmetrical. Conjunctiva is pink, sclera is white, no
jaundice or drainage noted bilaterally
CN III Oculomotor, CN IV Trochlear, CN VI Abducens is intact
Pupils are equal, round, reactive to light (direct and consensual), and
accommodation. Convergence is also noted. Pupil size is at 3 mm
bilaterally
Ears: External ears are intact, and symmetrical. Color is consistent with
exposed skin, no drainage noted. Tragus is mobile and non-tender
bilaterally
Nose, Mouth, and Throat: No known tenderness in maxillary or
frontal sinuses bilaterally
Nose is midline, nares are symmetrical and patent bilaterally (some
congestion noted in the nose and throat)
Septum is midline, no redness, swelling. Drainage is noted bilaterally
Tongue is pink, moist, and without lesions bilaterally
Dentition is intact
CN IX Glossopharyngeal is intact
Thorax: Respirations non-labored bilaterally
The rise/fall of posterior chest is symmetrical and color is consistent
with exposed skin
No crackles or wheezing noted bilterally in anterior and posterior
No carotid bruits noted bilaterally

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S1 and S2 heart sounds ausculated with regular rate and rhythm, no S3
or S4 sounds or murmurs auscultated
Extremities
No swelling, tenderness, redness, or nodules noted in the shoulder,
elbow, wrist, ankle, or knee joints bilaterally.
No redness or swelling around the skin
Strength has equal range of motion in neck and upper body joints
bilaterally.
CN XI Spinal Accessory is intact
Radial pulses are strong, equal, and palpable bilaterally at 2+
GI:
Bowel sounds present in all four quadrants
No abdominal distention
IV Access
Right upper arm double lumen 4 french power PICC
No infiltration, redness, or swelling
IV and PO goal is 60 mL/hr

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 Medications
ALLERGIES: etoposide: reaction is through swelling and hives
Name Dose Route Frequency Indication/Therapeutic
Effect
gabapentin 200 mg PO TID Mainly used for neuropathic
pain, along with postthermic
neurolgia. Affects the transport
of amino acids across and
stabilize neuronal membranes.
Decreases incidence of seizures
and postherpetic pain.
(Vallerand, Sanoski, & Deglin,
2017).
fluconazole 40 mg/mL PO Daily Use for fungal infections
caused by susceptible
organisms. Prevention of
candidiasis in patients who
have undergone bone marrow
transplantation by inhibiting the
synthesis of fungal sterols, a
necessary component of the cell
membrane (Vallerand, Sanoski,
& Deglin, 2017).
cefepime 1200 mg IV Q8hrs Treatment of the following
infections caused by susceptible
organisms: skin and skin
structure infections, urinary
tract infections, and respiratory
tract infections. It binds to
bacterial cell wall membrane,
Adverse Effects
Suicidal thoughts, confusion,
depression, sedation, anxiety
(Vallerand, Sanoski, & Deglin,
2017).
Headache, dizziness, seizures,
hepatotoxicity, abdominal
discomfort, diarrhea, nausea,
vomiting, and SJS (Vallerand,
Sanoski, & Deglin, 2017).
Seizures, headache, CDAD,
diarrhea, nausea, bleeding, pain,
phlebitis, anaphylaxis, and
thrombocytopenia (Vallerand,
Sanoski, & Deglin, 2017).
Nursing
Considerations
Advise patient not to
take gabapentin within
2 hrs of an antacid
Common side effects
are drowsiness and
dizziness
Caution patient to avoid
driving or activities
requiring alertness
(Vallerand, Sanoski, &
Deglin, 2017).
Notify HCP if patient
develops a skin rash,
abdominal pain, fever,
and diarrhea
Monitor BUN and
creatinine before and
during therapy
Specimens for cultures
should be obtain before,
during, and after
therapy
Monitor liver functions
(Vallerand, Sanoski, &
Deglin, 2017).
Assess patient for
infection (vital signs,
urine, stool, WBC)
Obtain specimens for
culture and sensitivity
before initiating
therapy.
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 causing cell death. It has a
bactericidal action against
susceptible bacteria (Vallerand,
Sanoski, & Deglin, 2017).
dronabinol 2.5 mg PO Daily Used for the prevention of
serious nausea and vomiting
from cancer chemotherapy
when other more conventional
agents have failed. It inhibits
the vomiting control
mechanism in the medulla
oblongata (Vallerand, Sanoski,
& Deglin, 2017).
ondansetron 3.5 mg IV Q8hrs Prevention of N/V associated
with radiation therapy or
postoperative
Decreased incidence and
severity of nausea and vomiting
following surgery (Vallerand,
Sanoski, & Deglin, 2017).
Anxiety, concentration
difficulty, confusion, mood
change, abnormal thinking,
depression, disorientation, dry
mouth, palpitations, syncope,
tachycardia, abdominal pain
(Vallerand, Sanoski, & Deglin,
2017).
Serotonin syndrome, weakness,
fatigue, dry mouth, Steven’s-
Johnson syndrome
Abdominal pain, constipation,
diarrhea (Vallerand, Sanoski, &
Deglin, 2017).
Observe patient for
signs and symptoms of
anaphylaxis (rash,
laryngeal edema,
wheezing)
Monitor bowel function
May cause increase
serum AST and ALT
Common side effect is
nausea (Vallerand,
Sanoski, & Deglin,
2017).
Assess nausea,
vomiting, appetite,
bowel sounds, and
abdominal pain prior to
and following
administration of the
drug.
Instruct patient to
change positions slowly
due to orthostatic
hypotension
Advise family to use
general measures to
reduce nausea
Common side effects
include dizziness and
drowsiness (Vallerand,
Sanoski, & Deglin,
2017).
Assess patient for N/V,
abdominal distention,
and bowel sounds prior
to and following
administration
Monitor for mental
status changes
Common side effect:
abdominal pain
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 Assess patient for
extrapyamidal effects
(facial grimacing,
rigidity, shuffling walk)
periodically during
therapy
Common side effects
include dizziness and
drowsiness (Vallerand,
Sanoski, & Deglin,
2017).
scopolamine 1.5 mg or Transdermal Q72hrs Management of nausea and Drowsiness, confusion, blurred Inform family that
0.5 mg patch vomiting associated with opioid vision, mydriasis, photophobia, frequent mouth rinses,
analgesia or general tachycardia, palpitations, dry good oral hygiene, and
anesthesia/recovery from mouth, constipation,urinary sugarless gum and
anesthesi by inhibiting the hesitancy, urinary retention candy may minimize
muscarinic activity of (Vallerand, Sanoski, & Deglin, dry mouth.
acetylcholine. Corrects the 2017). Apply to hairless, clean,
imbalance of acetylcholine and dry area behind the ear.
norepinephrine in the CNS, Effective for 3 days.
which may be responsible for Common side effects
motion sickness (Vallerand, are drowsiness and
Sanoski, & Deglin, 2017). dizziness (Vallerand,
Sanoski, & Deglin,
2017).
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why intervention Was goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Imbalanced nutrition: less than body requirements related to insufficient dietary intake AEB decrease in appetite and thirst (Phelps,
Ralph, & Taylor, 2017).
This was chosen as the primary nursing diagnosis since the patient has a new diagnosis of leukemia and has been experiencing side effects of
the transfusions and chemotherapy. Imbalanced nutrition will further decrease her immune system, skin integrity, and ability to developmentally
grow.
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Patient will take an adequate
amount of calories and nutrients
(Phelps, Ralph, & Taylor, 2017).
Secondary Nursing Diagnosis:
Impaired tissue integrity related to nutritional deficits and trauma AEB damaged, bruised subcutaneous tissue on the sacral area.
(Phelps, Ralph, & Taylor, 2017).
This was chosen as the secondary nursing diagnosis due to the importance of protecting the skin since this patient is immunocompromised. The
skin is a barrier that protects the rest of the body from harmful bacteria and other sources that can enter the blood stream of a patient diagnosed
with leukemia.
Patient’s skin with remain intact
(Phelps, Ralph, & Taylor,
2017).
Child will take in 2,000 kcal 1. Provide small, frequent
and will retain feedings without meals and feedings
emesis by 1700 at the end of throughout the day, and
the clinical shift (Phelps, Ralph, teach parents to
& Taylor, 2017). encourage high calorie
snacks throughout the
day.
2. Record and describe
food intake. Refer family
members to a dietitian or
nutritional support team
for dietary management.
3. Obtain and record the
child’s weight each
morning before the firsst
feeding (Phelps, Ralph,
& Taylor, 2017).
Patient will attain relief from 1. Change patient’s 1.
immediate signs and symptoms, position at least every
such as pain and bruising on the 2 hours; follow turning
site by 1700 at the end of the schedule schedule
clinical shift (Phelps, Ralph, & posted at bedside.
Taylor, 2017). 2. Monitor nutritional
intake; maintain 2.
adequate hydration.
1. To reduce daytime
fatigue and improve
intake.
2. A dietitian or
nutritional support team
can individualize the
child’s diet within
prescribed restrictions.
3. This will accurately
monitor the response to
therapy and any
improvements or
weight loss that needs
to be addressed (Phelps,
Ralph, & Taylor, 2017).
These measures reduce Goals met:
pressure on damaged
tissue, promote
circulation, and help
prevent skin
breakdown.
Anemia (less than 10
mg hemoglobin) and
Goal met:
1. Child and family
members
demonstrate
understanding of
nutritional principles
and requirements.
2. Child takes enough
calories and
essential nutrients
and retains feedings.
3. Was not able to
assess, however,
child’s weight
would stablize or
increase the next
morning when
taking daily weights
(Phelps, Ralph, &
Taylor, 2017).
1. Patient’s skin shows no
signs of infection or
impaired circulation
(additional bruising)
2. Patient weight remains
stable.
3. Patient uses
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 3. Encourage ambulation low serum albumin interventions with
and mobilization concentrations (less family, such as turning
around the room at than 2 mg) are in bed and walking, to
least every 4 hours associated with prevent further
when the patient is bruising and skin breakdown, and
awake (Phelps, Ralph, breakdown. Hydration facilitate healing of
& Taylor, 2017). helps maintain skin previous injury
integrity. (Phelps, Ralph, &
3. Exercise will prevent Taylor, 2017).
additional injury and
promotes circulation.
Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence based care for the achievement of
quality client outcomes.”

References
NIH: U.S. National Library of Medicine. (2019). Acute Myeloid Leukemia: AML. Retrieved from

https://medlineplus.gov/acutemyeloidleukemia.html

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Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylors nursing diagnosis reference manual (10th ed.). Philadelphia, PA:

Wolters Kluwer.

Vallerand, A., Sanoski, C., & Deglin, J. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA: F.A. Davis.

Childhood Acute Myeloid Leukemia. (2018). Myeloid Malignancy Treatments. Health Professional Version. Retrieved January 27,

2020, from https://www.cancer.gov/types/leukemia/hp/child-aml-treatment-pdq#_1

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