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Nursing diagnosis: Ineffective protection r/t abnormal blood profiles secondary to ALL and neutropenia aeb WBC 1.0, RBC 3.19, HCT 30.3, HGB 10.4, PLT 132, Neut. 11

Goal: Patients blood profiles will trend toward normal.

OUTCOME INTERVENTION RATIONALE EVALUATIONPatient’s temperature will trend toward 98.1-98.3*F, heart rate will trend toward 70-110 beats per minute, BP will trend toward 92-126/55-86 as assessed

Assess VS q4 hrs This patient has a history of ALL and was admitted with fever and neutropenia. Assessing vital signs can help prevent further complications of myelosuppression and help provide some protection and interventions for this neutropenic patient. Fever is one of the body’s responses to infection. Any sign of infection should be treated promptly as fever in the setting of neutropenia is a medical emergency. Tachycardia occurs because of sympathetic nervous system stimulation secondary to stress response and to compensate for an infection if present. Changes in vital signs can indicate onset of infection. Lewis 280

Patient outcome was partially met. Patient’s heart rate trended a little above this range. Plan is ongoing

Patient’s WBC will trend toward 4.5-13,RBC will trend toward 4.0-5.2, HCT will trend toward 35-45, HGB will trend toward 11.5-15.5, PLT will trend toward 150-400, Neutrophils will trend toward 21-63

Assess CBC with diff as ordered

CBC is used to identify the cellular characteristics of the peripheral blood and help manage side effects of chemotherapy treatment which this patient was on maintenance dose for history of ALL. Leukocytes maintain the general function of combating infection and inflammation. Depressed values in leukopenia can be caused by response to overwhelming infection that has exhausted the neutrophils and bone marrow reserves. It can also be due to leukemia, bone marrow depression after chemo or because of toxic reaction to medication. SAUNDERS p.638

Patient outcome was unmet. Blood values trended below range. Plan is ongoing.

Patient will consume 100% at all meals Assess nutritional status at meals and prn

This patient has history of ALL and is currently neutropenic which weakens his immune system defenses by provide nutritionally complete diet will aid to support body's natural defenses.

Patient outcome was unmet. Patient consumed ¼-1/2 at meal times. Plan is ongoing.

Nutrition status is an important factor contributing to immune system competence. Under nutrition impairs the immune system. The patient with cancer may experience protein and calorie malnutrition characterized by fat and muscle depletion. Foods high in protein facilitate repair and regeneration of cells that are depleted in this neutropenic patient. High-calorie foods provide energy and minimize weight loss. (Lewis 293)

Patient will have neutropenic precautions to promote safe environment and minimize sources of infection at all times.

Place patient on neutropenic precautions aat

Neutropenia is most common in patients receiving chemotherapy and can place them at serious risk for life-threatening infection and sepsis. Significant neutropenia will prompt treatment delay or modification (i.e., lower dosages). Take every possible measure to prevent infections in these patients. Hand hygiene is the mainstay of patient protection, and patients, as well as all of their contacts (including hospital staff), should follow hand-washing guidelines. (Lewis 280)

Patient outcome is partially met. Patient is still neutropenic. Plan is ongoing.

Patient’s Neutrophils will trend toward 21-63 assessed as ordered

Request order for Neupogen IV 5 mcg/kg/day as a single injection daily for up to 2 wk

This patient is neutropenic with a history of ALL. He would benefit from this med because it is a Granulocyte colony-stimulating factor (G-CSF). WBC growth factors are routinely used to reduce the duration of chemotherapy-induced neutropenia, and as a prophylactic measure to prevent neutropenia when highly myelosuppressive chemotherapy drugs are used. (Lewis 280-281)

Patient outcome is unmet. Did not request order for this med. Plan is ongoing.

Patients mucous membranes will be free of ulcerations and inflammation as assessed

Assess mucous membranes Q shift This patient has history of ALL and has been on

maintenance dose of MTX and mercaptopurine chemotherapeutic drugs work on fast proliferating cells and cannot determine

Patient outcome is met. Patient is still hospitalized so plan is ongoing.

between the good and the bad. Epithelial cells are destroyed by chemotherapy treatment. Inflammation and ulceration occur due to rapid cell destruction. The cells of the mucosal lining of the GI tract are highly proliferative, with surface cells replaced every 2 to 6 days. The intestinal mucosa is one of the most sensitive tissues to chemotherapy. (Lewis 283 &281)

Patient’s BUN will trend toward 5-18 as assessed

Monitor BUN as ordered This patient has history of ALL and has been on maintenance dose of MTX and mercaptopurine, chemotherapeutic drugs. This patient could suffer from direct renal cell damage due to exposure to nephrotoxic agents (MTX). The BUN level is used to evaluate renal function in this patient. (Lewis 282)

Patient outcome is unmet BUN is below range. Plan is ongoing.

Patient will not exhibit any s/s of infection as assessed (i.e. Elevate temp., body aches, headache, mouth sores, redness, warmth or swelling to iv site, painful urination)

Zosyn 2100 mg IV Q 6hrs daily

This patient presented with fever and neutropenia after initial blood cultures per the guideline of Upstate University hospital the starting of Zosyn prophylaxis as soon as possible is to ensure safe and consistent quality of care to the pediatric client. Zosyn is an anti infective, extended spectrum penicillin which causes death to susceptible bacteria. Piperacillin binds to bacterial cell wall membrane, causing cell death. Tazobactam inhibits beta lactamase, an enzyme that can destroy penicillins. Davis 1032 and upstate PP

Patient outcome is met.Plan is ongoing.

Patient’s fever will reduce 1 hr after administration prn

Acetaminophen 325 mg oral prn (MDD 2.6g)

This patient presented with fever this hospital admission, Tylenol will help with fever reduction. The action of Tylenol is to inhibit the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. Therapeutic Effects: Analgesia. Antipyresis. Davis 112


Nursing diagnosis: Risk for Infection related to depressed body defenses

Goal: Patient will remain free of signs and symptoms of infection.

OUTCOME INTERVENTION RATIONALE EVALUATIONPatient and visitors will demonstrate proper hand hygiene prn

Teach hand hygiene q shift and prn

This patient has history of ALL and is currently neutropenic which weakens his immune system defenses. With the use good hand-washing technique this will help to minimize exposure to infective organisms. If the patient as well as visitors and staff practice good hand washing techniques this will reduce the number of microorganisms on his skin and decrease transmission from others, thus, decreasing his risk for infection. Wong 932


Patient will avoid contact with visitors who are ill at all times

Encourage all staff and guests with illness to avoid contact with client at all times

People with known infections are sources of opportunistic infections for this immune-compromised patient. Children are commonly exposed to sick playmates. This patient has history of ALL and is currently neutropenic which weakens his immune system defenses further it is appropriate to screen all visitors and staff for signs of infection, to decrease exposure to possible infective organisms. Gulanick 755

Patient outcome is partially met. Patient left floor to visit library x2 which increases risk of opportunistic infection.Plan is ongoing.

Patient’s temperature will trend toward 98.1-98.3*F, heart rate will trend toward 70-110 beats per minute, BP will trend toward 92-126/55-86 as assessed

Assess vital signs q4 hrs This patient has a history of ALL and was admitted with fever and neutropenia. Assessing vital signs can help prevent further complications of myelosuppression and help provide some protection and interventions for this neutropenic patient. Fever is one of the body’s responses to infection. Any sign of infection should be treated promptly as fever in the setting of neutropenia is a medical

Patient outcome was partially met. Patient’s heart rate trended a little above this range. Plan is ongoing.

emergency. Tachycardia occurs because of sympathetic nervous system stimulation secondary to stress response and to compensate for an infection if present. Changes in vital signs can indicate onset of infection. Lewis 280

Patient’s infusaport site will be free of redness, warmth and edema as assessed q 4 hrs

Assess Infusaport q 4hrs This patient’s first line of defense against invading organisms is his skin. With placement of the infusaport as well as any other invasive procedure this increases the patient’s risk of infection. This patient has history of ALL and is currently neutropenic which weakens his immune system defenses further. With assessment of the infusaport can lead to early intervention if infection is suspected. NDH 674


Patient will complete ADL’s (i.e. oral care, peri care) daily

Encourage completion of hygienic care q shift

The perineal area is a source of many pathogens and frequent portal of entry for microorganisms. Daily showers can help reduce the number of bacteria on the client’s skin, thus reducing the risk for infection in this neutropenic patient. Meticulous oral hygiene before and after meal time and at bed time is important in prevention of periodontal disease as a locus of infection. NDH 493


Patient will not exhibit any s/s of infection as assessed (i.e. Elevate temp., body aches, headache, mouth sores, redness, warmth or swelling to iv site, painful urination)

Zosyn 2100 mg IV Q 6hrs daily

This patient presented with fever and neutropenia after initial blood cultures per the guideline of Upstate University hospital the starting of Zosyn prophylaxis as soon as possible is to ensure safe and consistent quality of care to the pediatric client. Zosyn is an anti infective, extended spectrum penicillin which causes death to susceptible bacteria. Piperacillin binds to bacterial cell


wall membrane, causing cell death. Tazobactam inhibits beta lactamase, an enzyme that can destroy penicillins. Davis 1032 and upstate PP

Patient’s Neutrophils will trend toward 21-63 assessed as ordered

Request order for Neupogen IV 5 mcg/kg/day as a single injection daily for up to 2 wk

This patient is neutropenic with a history of ALL. He would benefit from this med because it is a Granulocyte colony-stimulating factor (G-CSF). WBC growth factors are routinely used to reduce the duration of chemotherapy-induced neutropenia, and as a prophylactic measure to prevent neutropenia when highly myelosuppressive chemotherapy drugs are used. (Lewis 280-281)

Patient outcome is unmet. Did not request order.Plan is ongoing.

Patient will consume 30ml/hr of fluid po assessed q shift

Encourage po fluid intake q 1 hr

This patient presented with fever and neutropenia, encouraging fluid intake can help replace fluids lost during the fever. Fluid intake also helps to thin secretions preventing a medium for bacteria to grow. Thus, decreasing the risk for infection. NDH 492


Nursing diagnosis: Risk for Imbalanced Nutrition: Less than Body Requirements related to loss of appetite

Goal: Patient will have adequate nutritional intake.

OUTCOME INTERVENTION RATIONALE EVALUATIONParents will verbalize 1 reason for the loss of appetite as assessed

Educate parents on loss of appetite as needed

This patient has history of ALL and has been on maintenance dose of MTX and mercaptopurine, a consequence of chemotherapeutic drugs is a loss of appetite. Epithelial cells which line the GI tract from mouth to anus can be destroyed by chemotherapy treatment which can cause inflammation and ulceration making it uncomfortable for this patient to eat. Another theory is that cancer cells release substances that may alter tastes of foods decreasing the patient desire to eat or causing loss of appetite. (Lewis 283 &281&293)


Patient will consume 75% at all meals and prn

Encourage po intake as needed

Patients that present with fever such and this one need to increase caloric intake to maintain nutritional requirements and counteract the loss of vitamins and nutrients depleted during fever. To maximize quality of intake, Fortify foods with nutritious supplements are preferred. But the main goal is to provide food; selections can improve once appetite increases .Allow child to be involved in food preparation and selection. To encourage eating. Make food appealing. Allow child any food tolerated. Wong 933

Patient outcome unmet. Patient consumed ¼-1/2 of meals. Plan is ongoing.

Patient’s albumin level will trend toward 3.8-5.4, total protein level will trend toward 6.4-8.3 assessed as ordered

Assess albumin & total protein levels as ordered

Decreased values of total protein can occur because of poor nutritional intake, intestinal malabsorption, malignancy, failure of liver to manufacture proteins, or losses via urinary tract or skin which can occur during fever.

Patient outcome is unmet. Values trended below range. Plan is ongoing.

Total serum protein is a nonspecific test that provides general information about the patient’s nutritional status. Liver tissue manufactures serum protein including albumin, fibrinogen, and other coagulation factors. Various plasma proteins function to maintain oncotic pressure in the blood vessels, provide a reserve source of protein for tissue growth and repair which is helpful for this neutropenic patient. Saunders 522

Patient’s I/O difference will be within 300ml daily

Monitor I/O daily Accurate measurements of fluid intake and output are essential for children receiving IV therapy to assess fluid balance. This patient presented with fever and neutropenia, during state of fever a child can dehydrate losing fluid and electrolytes. Loss of fluids and electrolytes can result in malnutrition. Wong 732


Patient will receive D5W/ 0.45% NACL with 20 mEq of KCL IVF @ 10 ml q hr as assessed

D5W/ 0.45% NACL with 20 mEq of KCL IVF @ 10 ml/hr

This patient presented with fever and neutropenia, it is beneficial to initiate IV fluids to help increase caloric intake especially in a pediatric client who may have more resistance increasing calories po. Dextrose 5% in 0.45% NaCl is a hypertonic solution that provides an additional 170 calories. KCl can help prevent deficiencies with mineral and electrolytes that may be lost during fever. (Lewis 327) Davis

Patient outcome is metPlan is ongoing.

Nursing Diagnosis: Risk for Fatigue r/t disease state secondary to ALL

Goal: Patient will not experience fatigue

OUTCOME INTERVENTION RATIONALE EVALUATIONPatient will state fatigue is at a 0 in a scale of 0-10 as assessed q 4hrs.

Assess for Fatigue on scale of 0-10 q4hrs prn

Fatigue is the persistent subjective sense of tiredness associated with cancer and its treatment that interferes with usual day-to-day functioning. One theory is that the accumulation of muscle metabolites such as lactate, hydrogen ions, and other end products from the destruction of cells results in decreased muscle strength. Other explanations include cytokine production, changes in neuromuscular function, serotonin dysregulation, and an indirect association with anorexia, fever, and infection typical in patients undergoing treatment. (Lewis 283)


Parent/ Client will verbalize 1 cause of fatigue q4hrs prn

Assess for causes of fatigue q4hrs prn

Causative factors may be temporary or permanent, physical or psychological. Identifying the related factors with the fatigue can aid in determining possible causes and establishing a collaborative care plan. This patient was admitted with fever and neutropenia and has a history of ALL and has been on maintenance therapy with chemotherapeutic agent which can all contribute to increased fatigue in this patient. Gulanick 67


Patient will state “ I feel good” with a smile as assessed for fatigue q4hrs prn

Assess Emotional response to fatigue q4hrs prn

Fatigue is a very distressing symptom that significantly affects quality of life. Depending on acute or chronic nature of the fatigue, anxiety and depression are common emotional responses associated with fatigue. These emotional states can add to this patients fatigue level and create a vicious


cycle. Gulanick 67

Parent/client will verbalize 1 way to conserve energy q shift

Teach ways to conserve energy q-shift and prn

This patient is neutropenic and has abnormal blood profiles which put him at increased risk for fatigue. Setting priorities while conserving energy will allow this patient to achieve most desired goals and feel a sense of accomplishment. Energy conservation techniques reduce oxygen consumption, allowing more prolonged activity. Gulanick 732


Nursing Diagnosis: Risk for anxiety r/t health status and hospitalization

Goal: Patient will be free of anxiety

OUTCOME INTERVENTION RATIONALE EVALUATIONPatient will have relaxed posture, facial expressions, gestures and activity levels that reflect decreased distress as assessed q shift

Assess patients level of anxiety q shift

A patient with mild anxiety will have minimal or no physiological symptoms of anxiety. Vital signs will be within normal ranges. The patient will appear calm but may report feelings of nervousness such as "butterflies in the stomach" or commonly with pediatrics report of feeling scared. A patient with moderate anxiety may appear energized with more animated facial expressions and tone of voice. Vital signs may be normal or slightly elevated. The patient may report feeling tense. With severe anxiety, the person will have symptoms of increased autonomic nervous system activity, such as elevated vital signs, diaphoresis, urinary urgency and frequency, dry mouth, and muscle tension. The patient may be agitated, irritable, and report feeling overloaded or overwhelmed by new stimuli. In the panic level of anxiety, the autonomic nervous system increases to the level of sympathetic neurotransmitter release. The patient becomes pale, hypotensive, and experiences poor muscle coordination. The person reports feeling completely out of control and may display extremes of behavior from combativeness to withdrawal. NDH 143


Patient will exhibit decreased anxiety at all times

Encourage parents to stay with child if possible at all times

This promotes sense of security, which will decrease the child’s anxiety. Reassure the patient that he is safe; being a pediatric client, the presence of a trusted person such as mom or dad may help the patient feel less threatened. Anxiety may escalate to a panic


level if the patient feels threatened and unable to control environmental stimuli. NDH 143

Patient will demonstrate techniques to control anxiety q day

Therapeutic play at all times Allowing child to put (for example) a blood pressure cuff on staff or doll. Explaining the purpose of equipment used on a child through play therapy increases the understanding of equipment. Thus decreases fear of pain which in turn will decrease anxiety. NDH 143


Parent/Patient will verbalize understanding of procedures q shift as needed

Communicate to patient with age appropriate language at all times

Use simple language and brief statements when instructing the patient about self-care measures or about diagnostic procedures. When experiencing moderate to severe anxiety, patients may be unable to comprehend anything more than simple, clear, and brief instructions. NDH 143


Parent/Child will verbalize 2 stimulants that increase anxiety q shift

Provide a quiet/private room at all times

Increased stimuli increases anxiety. Anxiety may escalate to a panic state with excessive conversation, noise, and equipment around the patient. Increasing anxiety may become frightening to the patient and others. Reduce sensory stimuli by maintaining a quiet environment; keep "threatening" equipment out of sight. NDH 143


Nursing diagnosis: Risk for Fear related to diagnostic tests, procedures, treatment

Goal: Patient will verbalize reduction or absence of fear.

OUTCOME INTERVENTION RATIONALE EVALUATIONPatient will verbalize understanding of procedures q shift and prn

Explain procedures carefully at child's level of understanding.

Age- appropriate explanations are one of the most widely used interventions for reducing fear in children undergoing procedures as simple as vital signs and head to toe assessment. Before performing procedure, explain what will take place and what child will feel, see, and hear to reduce fear of unknown. To provide sense of control. Listen to special requests of child when possible. To encourage cooperation.Wong 692


Patient will verbalize fears assumed with equipment involved in procedures q day and prn.

Involve child in procedure Provide child with some means of involvement with procedures. Allowing this patient to handle actual items that will be used during his care, such as stethoscope, BP cuff, and thermometer will help him develop familiarity with these items and reduces the threat often associated with their use .To provide sense of control, encourage cooperation, and support child's coping skills. Wong 692-693


Patient will verbalize feelings of security q shift and prn

Expect Success Approaching the child with confidence and conveying the impression that success is expected we are less likely to encounter difficulty. It is best to approach a child as though cooperation is expected. A


firm approach with positive attitude tends to convey a feeling of security in most children thus reducing fear. Wong 693

Patient will verbalize absence of fear q day

Establish trust and provide support Spending time with and established a positive relationship with this patient will make it easier to gain cooperation. A relationship that is based on trust will help with decreasing fears. The child will associate the nurse with care giving activities that give comfort and pleasure most of the time. Wong 690


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