Page 1268 - Saunders Comprehensive Review For NCLEX-RN

B. Assessment

1. Anorexia, fatigue, weakness, weight loss
2. Anemia
3. Overt bleeding (nosebleeds, gum bleeding, rectal
bleeding, hematuria, increased menstrual flow) and
occult bleeding (e.g., as detected in a fecal occult
blood test)
4. Ecchymoses, petechiae
5. Prolonged bleeding after minor abrasions or
lacerations
6. Elevated temperature
7. Enlarged lymph nodes, spleen, liver
8. Palpitations, tachycardia, orthostatic hypotension
9. Pallor and dyspnea on exertion
10. Headache
11. Bone pain and joint swelling
12. Normal, elevated, or reduced WBC count
13. Decreased hemoglobin and hematocrit levels
14. Decreased platelet count
15. Positive bone marrow biopsy identifying leukemic
blast–phase cells
C. Infection

1. Infection can occur through autocontamination or
cross-contamination. The WBC count may be
extremely low during the period of greatest bone
marrow depression, known as the nadir.
2. Common sites of infection are the skin, respiratory
tract, and gastrointestinal tract.
3. Initiate protective isolation procedures.
4. Ensure frequent and thorough hand washing by the
client, family, and health care providers.
5. Staff and visitors with known infections or exposure to
communicable diseases should avoid contact with the
client.
6. Use strict aseptic technique for all procedures.
7. Keep supplies for the client separate from supplies for
other clients; keep frequently used equipment in the
room for the client’s use only.
8. Limit the number of staff entering the client’s room to
reduce the risk of cross-infection.
9. Maintain the client in a private room with the door
closed.
10. Place the client in a room with high-efficiency
particulate air filtration or a laminar airflow system if
possible.

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