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Ackley, B. J., et al. (2016) Chronic Lymphocytic Leukemia.Leukemia Research. Updated April 2020. Website: https://www.student.wvc.edu:2940/lna/document.do?bid=4&did=863099&searchTerm=Lymphocytic%20Leukemia&hits=leukemia,lymphocytic,leukemias

Growth Charts - Clinical Growth Charts. (2017, June 16). Retrieved May 2, 2020, from https://www.cdc.gov/growthcharts/clinical_charts.htm

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: concepts for interprofessional collaborative care (9th ed.). St. Louis, MO: Elsevier.

McKinney, E. S. (2018). Maternal-child nursing (5th ed.). St. Luis, MO: Elsevier.

Murr, A. C., Doenges, M. E., & Moorhouse, M. F. (2019). Nurses Pocket Guide, 15e: Diagnoses, Prioritized Interventions and Rationales. FA Davis Company.

Vallerand, A. H., Sanoski, C. A., & Quiring, C. (2019). Daviss drug guide for nurses (16th ed.). Philadelphia, PA: F. A. Davis Company.

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Acute Lymphocytic Leukemia

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Eli Aguilar, Krysten Cleek, Craig Johnston, Mariah Kruse, Claire Rader, Raquel Wisemore, Megan Yanda

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Anxiety r/t threat of death as evidence by patient states multiple times that she doesn't want to die, Lulu observes guardians scared emotions which has caused her to be concerned, and Lulu doesn't make eye contact with health care provider when she enters room.

Outcome:
Lulu will verbalize three interventions to help decrease anxiety levels by the end of shift.

Interventions:

1. Nurse will provide an environment that fits lulu's comfort before being admitted.

2. Nurse will provide lulu time for listening and answering questions during each shift.

3. Nurse will set up a consistent schedule for lulu and her family so that she feels comfortable by end of shift.

4.Nurse will use cartoons movies that explain ways to manage anxiety by end of shift.

Evaluation:
Outcome not met, this will be an ongoing assessment and will need more time to evaluate Lulu.

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Risk for infection AEB risk factors of malnutrition, elevated WBC's, and inadequate secondary defenses.

Outcome:
Patient and parents will use teach back method and repeat 3 signs and symptoms of infection by end of shift.

Interventions:
1. Nurse will assess for signs and symptoms of infection every four hours during twelve-hour shift and educate patient about signs and symptoms of infection.

2. Nurse will teach the patient and family to wash hands often, especially after toileting, before meals, and before and after administering self-care by end of shift.

3. Nurse will educate patient on avoiding large crowds and sick people by end of shift.

4. Nurse will educate patient on importance of a high protein, high calorie, and vitamin diet by end of shift.

Evaluation:
Outcome met, patient and parents were able to say three signs of infection. This will be an ongoing situation throughout her treatment.

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Fatigue r/t chemo treatments and the decreased ability of hemoglobin to carry oxygen AEB pallor, tachycardia, and pt lying on the couch most of the time.

Outcome:
Patient will repeat back 2 ways to help manage fatigue, after nurse’s teaching.

Interventions:
1. Nurse will communicate with provider about options to improve RBC count PRN.

2. Nurse will educate pt about importance of eating high protein meals twice a daily, at the start of shift.

3. Nurse will teach/encourage pt on importance of resting to promote healing and rehabilitation.

4. Nurse will provide quiet environment with limited visitors to promote rest and recovery. daily.

Evaluation:
Outcome not met, although this outcome in still relevant for Lulu to help decrease/manage fatigue.

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Imbalance nutrition r/t unwillingness to eat AEB Lulu states, "My stomach, mouth and throat hurt really bad and then I don't want to eat," she has lost five pounds in the last 6 months, and she is fatigued easily.

Outcome:
Lulu will finish two full meals each day until her next appointment.

Interventions:
1. Nurse will discuss with provider about prescribing ondansetron to help with her nausea and vomiting that come as a SE of Vincristine, Doxorubicin and Cyclophosphamide therapy prior to discharge.

2. Nurse will provide Lulu with a dietary guide showing pictures of foods high in nutrition to ensure that the food she is eating is giving the most benefit during nutrition assessment.

3. Nurse will educate on having six small meals throughout the day versus three large meals by end of appointment.

4. Nurse will provide a sticker chart for Lulu to track when she finishes a meal she is eating by end of appointment.

Evaluation:
Outcome not met but is ongoing and still relevant to Lulu.

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Acute pain r/t leukocyte infiltration of systemic tissues AEB bone pain worse in bilateral legs and arms; joint swelling worse in bilateral hips and knees; enlarged submental/axillary/inguinal lymph nodes; enlarged spleen; HR of 120; Lulu stating "her legs hurt all of the time" and reporting 4/5 constant stomach/mouth/throat/chest pain on FACES scale.

Outcome:
Lulu will report 1/5 pain on FACES scale by end of shift.

Interventions:
1. Nurse will administer 3.6 mg dexamethasone IV daily per doctor's order by end of shift.

2. Nurse will administer 1.8 mg morphine IV every 3-4 hours PRN per doctor's order by end of shift.

3. Nurse will advise Lulu and parents to engage in distraction activities (such as playing a card game, coloring, arts & crafts) PRN during episodes of pain exacerbation throughout shift.

4. Nurse will teach Lulu and parents breathing exercises (such as blowing bubbles or using a 4-square breathing technique) within first 2 hours of shift.

Evaluation:
Outcome met. Patient's pain was a 1/5 on FACES scale by end of shift. Goal is still relevant and should be continued until discharge.

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Heart Rate:
120 bpm (reg: 60-95, tachycardic)

BP:
89/53 (Low because of low RBC and platelet values)

Respiratory Rate:
20 (WNL)

Temperature:
100 F (ref: 97.5-98.6F, Elevated d/t low grade fever, increased susceptibility to infection)

Oxygen Saturation:
92% RA (Lower because of decreased Hgb values)

Pain Score:
4/5 on FACES scale

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HEENT:
Enlarged submental lymph nodes, axillary lymph nodes, and inguinal lymph nodes; minimal swelling of face and neck; minimal oropharynx swelling, hearing is intact, mucosa is pink and moist

CV:
Decreased radial pulses, cap refill >3 sec, tachycardia, murmur, mild substernal chest tenderness to palpation

LUNGS:
Hacking productive cough, dyspnea on exertion, crackles in bilateral lower lobes

GI:
Weight loss, anorexia, enlarged spleen, hypoactive bowel tones x4 quadrants

GU:
Hematuria

MSK:
Bone pain throughout worse in bilateral upper and lower extremities, joint swelling worse in hips and knees

NEURO:
A&Ox4, fatigue, headache, fever

SKIN:
Cool skin, facial pallor, petechiae on lower legs bilaterally, bluish-red pigmentation to skin over face, neck, arms, and upper chest

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Parents: Steven and Michelle Whiting

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HT: 47 in (25th percentile)
WT: 40 lbs (3rd percentile)
BMI: 12.7 (below 3rd percentile)

Erickson's Industry vs Inferiority: Mastering useful skills and tools of the culture. Learning how to play and work with peers. Characterized by competence.
Piaget's Concrete operations: thinking becomes more systematic and logical, but concrete objects and activities are needed.
Kohlberg's Morality of conventional role of conformity: avoiding disapproval or disturbing the conscience, becoming more socially sensitive.

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7 year old female presenting with recent episodes of fatigue, shortness of breath, nosebleeds, night sweats and fever. Wt loss of 5lbs over 6 months. Quit her soccer team because "her legs hurt all of the time." Hasn't been eating because "her stomach, mouth, throat, and chest hurt all the time." When pt heard her diagnosis she began crying and stated "I don't want to die!"