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A NCP

This nursing care plan is for a 12-year-old patient named A.P. who has been diagnosed with chronic myelogenous leukemia. The patient was experiencing ineffective tissue perfusion as evidenced by a capillary refill time of 4 seconds, a respiratory rate of 36 breaths per minute, and use of the sternocleidomastoid muscle for breathing. The goal is for the patient to have effective tissue perfusion, normal respiratory rate, and no accessory muscle use by 2:00 PM on September 14. As of a previous evaluation, the goal was partially met as respiratory rate was still elevated and accessory muscle use continued. Further nursing interventions are ongoing.

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Narianne Mae Solis Bedoy
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82 views2 pages

A NCP

This nursing care plan is for a 12-year-old patient named A.P. who has been diagnosed with chronic myelogenous leukemia. The patient was experiencing ineffective tissue perfusion as evidenced by a capillary refill time of 4 seconds, a respiratory rate of 36 breaths per minute, and use of the sternocleidomastoid muscle for breathing. The goal is for the patient to have effective tissue perfusion, normal respiratory rate, and no accessory muscle use by 2:00 PM on September 14. As of a previous evaluation, the goal was partially met as respiratory rate was still elevated and accessory muscle use continued. Further nursing interventions are ongoing.

Uploaded by

Narianne Mae Solis Bedoy
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City NURSING CARE PLAN Name of Patient: A.

P Age: 12 years old Clustered Cues 9/13/12 9:00 am Attending Physician: Dr. A Impression / Diagnosis: Chronic myelogenous leukemia Nursing Interventions Rationale Evaluation 9/14/12 2:00 PM Goal partially met. The client had effective tissue perfusion as manifested by capillary refill of 2 seconds, client verbalized daw wala naman ko gawa nabudlayan mag ginhawa. However, RR still not within normal range (RR=28 bpm) and use of respiratory muscle (sternocleidomastoid) was still noted. Further nursing interventios are still on-going.

Ward/Bed Number: PSW-A/ Bed No. 8 Nursing Diagnosis Rationale Outcome Criteria

Ineffective tissue perfusion related Nabudlayan ako to decreased magginhawa as hemoglobin verbalized. Capillary Refill of 4 concentration in the blood sec RR=36 breaths/min Use of accessory muscles for respireation (sternocleidomast oid)

Ineffective tissue perfusion is the decrease in oxygen resulting in the failure to nourish the tissue at the capillary level. (Doenges, et. al., 2010. Nurses Pocket Guide).

In leukemia, there is over production in WBC. This overproduction of WBC results production of WBC halts the production of RBCs and platelets. This also decreases the

The client will have an effective tissue perfusion as manifested by capillary refill >3 sec, RR within normal range (12-20 breaths per min), no use of accessory muscle for respiration, client verbalized absence of dyspnea by 2:00 pm of 9/14/12.

1. Identify changes related to systemic and/ or peripheral alterations in the circulation such as altered vital signs, pain, changes in skin/tissue/organ function and signs of metabolic imbalances. 2. Note customary baseline data such as usual BP, weight and laboratory study values. (BUN, creatinine levels, serum electrolytes, CBC, ALT and SGPT) 3. Dtermine

1. To assess causative/ contributing factors 2. It provides comparison with current findings and to note degree of impairment or organ involvement 3. To detect presence of cerebral impairment 4. To detect changes in gastrointestin al function

hemoglobin concentration in the blood. Because of this there is a decrease in oxygen that is carried into the tissues. Thus, ineffective tissue perfusion occurs.
Sources: *Doenges, et. al.Nurses Pocket Guide 8th edition *Sommers, et. al. Diseases and Disorders A Nursing Therapeutics Manual

presence of sensorimotor changes, headaches, dizziness, altered mental status, and personality changes. 4. Watch out for nausea, vomiting, location/type/inte nsity of pain; auscultate bowel sounds; measure abdominal girth; and note changes in stool/ presence of blood.

Students Name: __________________________________________ Clinical Instructor: _________________________________________

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