TUGAS MATA KULIAH

BAHASA INGGRIS

ASSESSMENT AND NURSING DIAGNOSE OF

LEUKEMIAS
Dosen Pembimbing : Mahdalena, S.Pd, M. kes

Disusun Oleh :
AKHMAD BENNY OKRIWANDI PO7120006003
DESSY RUSMILAWATI PO7120006009
HARIS FAISAL PO7120006015
IMA SEPTIANA PO7120006017
NOOR ELVA ARIANI PO7120006028

DEPARTEMEN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN BANJARMASIN
JURUSAN KEPERAWATAN
BANJARBARU
2007
 LEUKEMIAS

The term leukemia describes a variety of cancers that arise in the blood-forming organs
of the body (spleen, lymphatic system, bone marrow). They are differentiated according
to the leukocytic system that is involved. The common trait of all leukemias is the
unregulated proliferation of WBCs in the bone marrow that replaces the normal
elements. There is an apparent abnormality in the hematopoietic stem cell, which result in
its inability to differentiate into normal cell. As the normal cells are replaced by leukemic
cells, anemia, neutropenia, thrombocytopenia occur. In adults, the most common of the
acute leukemias is acute myelocytic, which involves neutrophils, a type of granulocyte.
The most common of the chronic leukemias is chronic lymphocytic leukemia, which is
characterized by an abnormal increase lymphocytes.

PATIENT ASSESSMENT DATA BASE

The date are dependent on degree/duration of the disease and other organ involvement.

ACTIVITY/REST
May report :Fatigue, malaise, weakness; inability to engage in usual activities.
May exhibit :Muscle wasting.

CIRCULATION
May report :Palpitations.
May exhibit :Tachycardia, heart murmurs.
Pallor of skin, mucous membranes.
Cranial nerve deficits and/or signs of cerebral hemorrhage.

ELIMINATION
May report :Diarrhea: perianal tenderness, pain.
Bright red blood on tissue paper, tarry stools.
Blood urine, decreased urine output.
My exhibit :Perianal abscess: hematuria
EGO INTEGRITY
May report :Feelings of helplessness/ hopelessness.
May exhibit :Depression, withdrawal, anxiety, fear, anger, irritability.
Mood changes, confusion.

FOOD/FLUID
May report :Loss of appetite, anorexia, vomiting.
Change in taste/taste distortions.
Weight loss.
Pharyingitis, dysphagia.
May exhibit :Abdominal distention, decreased bowel sounds.
Splenomegaly, hepatomegaly; jaundice.
Stomatitis, oral ulcerations.
Gum hypertrophy (gum infiltration may be indicative of acute monocyte
leukemia)

NEUROSENSORY
May report :Lack of coordination/ decreased coordination.
Mood change, confusion, disorientation, lack of concentration.
Dizziness; numbness, tingling, paresthesias.
May exhibit :Muscle irritability, seizure activity.

PAIN/COMFORT
May report :Abdominal pain, headaches, bone/joint paint; sternal tenderness, muscle
cramping.
May exhibit :Guarding/distraction behaviors, restlessness; self-focus.

RESPIRATION
May report :Shortness of breath with minimal exertion.
May exhibit :Dyspnea, tachypnea.
 Cough.
Crackles, rhonchi.
Decreased breath sounds.

SAFETY
May report :History of recent/recurrent infection; falls.
Visual disturbances/ impairment.
Spontaneous uncontrollable bleeding with minimal trauma.
May exhibit :Fever, infection.
Bruises, purpura, retinal hemorrhages, gum bleeding or epitaxis.
Enlarged lymph nodes, spleen, or liver (due to tissue invasion).
Papilledema and exophthalamus.
Leukemic infiltrates in the dermis.

SEXUALITY
May report :Changes in libido
Changes in menstrual flow, menorrhagia
Impotence.

TEACHING/LEARNING
May report: History of exposure to chemicals, e.g., benzene, phenylbutazone, and
chloramphenocol; excessive levels of ionizing radiation; previous
treatment with chemotherapy, especially alkalating agants.
Chromosomal disorder, e.g., Down syndrome or Franconi’s aplastic
anemia.
Discharge DRG projected mean length of stay: 3,9 days.
Plan Consider-May need assistance with therapy and treatment needs/supplies, shopping,
rations: food preparation, self-care activities, homemaker/maintenance tasks,
transportation.
NURSING DIAGNOSIS: INFECTION, HIGH RISK FOR
Risk factors may Inadequate secondary defenses: Alterations in mature
include: WBC (low granulocyte and abnormal lymphocyte count),
increased number of immature lymphocytes
immunosuppression, bone marrow suppression effects of
therapy/transplant.
Inadequate primary defenses (stasis of body fluids,
transmatized tissue).
Invasive procedures.
Malnutrition; chronic disease.
Possibly evidenced by: [Not applicable; presence of signs and symptoms estab-
lishes an actual diagnosis.]
DESIRE OUTCOMES/ Identify actions to prevent/reduce risk of infection.
EVALUATION CRITERIA- Demonstrate techniques, lifestyle changes to promote safe
PATIENT WILL environment, achieve timely healing.

NURSING DIAGNOSIS: FLUID VOLUME DEFICIT, HIGH RISK FOR

Risk factors may Excessive losses e.g., vomiting, hemorrhage, diarrhea.
Include: Decreased fluid intake, e.g., nausea, anorexia.
Increased fluid need, e.g., hypermetabolik state, fever;
predisposition for kidney stond formation.
Possibly evidenced by: [Not applicable; presence of signs and symptoms estab-
lishes an actual diagnosis.]
DESIRED OUTCOMES/ Demonstrate adequate fluid volume, as evidenced by sta-
EVALUATION CRITERIA- ble vital sign; palpable pulses; urine output, specific grav-
PATIENT WILL: ity,and pH within normal limits.
Identify individual risk factors and and appropriate interven
tions.
Initiate behaviors / lifestyle changes to prevent
development of fluid volume deficit.
NURSING DIAGNOSIS: PAIN [ACUTE]
May be related to; Physical agents, e.g., enlarged organs/lymen nodes, bone
marrow packed with leukemic cells.
Chemical agents, e.g., antileukemic treatments.
Psychologic manifestations, e.g., anxiety, fear.
Possibly evidenced by: Reports of pain (bone, nerve, headaches, and so foren.)
Guarding /distraction behaviors, facial grimacing, alter-
ation in muscle tone.
Autonomic responses.
Report pain is relieved/controlled.
DESIRED OUTCOMES/ Demonstrate behaviors to manage pain.
EVALUATION CRETERIA-Appear relaxed and able to sleep/rest appropriately.
PATIEN WILL:

NURSING DIAGNOSIS: AKTIVITY INTOLERANCE

May be related to: Generalized weakness; reduced energy stores, increase
metabolic rate from massive production leukocytes
Imbalance between oxygen supply and demand
anemia/hypoxia).
Therapeutic restriction (isolation/bed rest); effect of drug
therapy.
Possibly evidenced by: Verbal report of fatigue or weakness.
Exertional discomfort or dyspnea.
Abnormal heart rate or BP response.
DESIRED OUTCOMES/ Report a measurable increase in activity tolerance.
EVALUATION CRITERIA- Participate in ADLs to level of ability.
PATIEN WILL: Demonstrate a decrease in physiologic signs of intolerance;
e.g., pulse, respiration, and BP remain within patients
normal range.
NURSING DIAGNOSIS: KNOWLEDGE DEFICIT [LEARNING NEED]
REGARDING DISEASE, PROGNOSIS AND
TREATMENT NEEDS
May be related to: Lack of exposure to resources.
Information misinterpretation/lack of recall.
Possibly evidenced by: Verbalization of problem/request for information.
Statement of misconception.
DESIRED OUTCOMES/ Verbalize understanding of condition/disease process and
EVALUATION CRITERIA- treatment.
PATIEN WILL: Initiate necessary lifestyle changes.
Participate in treatment regiment.
 BIBLIOGRAPHY

Doengoes, Marilynn E. (et:al). 1993. Nursing Care Plans Guidelines for

planning and documenting patient care edition 3. Philadelphia:
F.A. Davis Company.