The nurse is caring for a child with aplastic anemia. Which nursing diagnoses are appropriate (Select all that apply)?
a. Acute Pain related to vaso-occlusion
b. Risk for Infection related to inadequate secondary defenses or immunosuppression
c. Ineffective Protection related to thrombocytopenia
d. Ineffective Tissue Perfusion related to anemia
e. Ineffective Protection related to abnormal clotting
ANS: B, C, D
These are appropriate nursing diagnosis for the nurse planning care for a child with aplastic anemia. Aplastic anemia is a condition in which the bone marrow ceases production of the cells it normally manufactures, resulting in pancytopenia. The child will have varying degrees of the disease depending on how low the values are for absolute neutrophil count (affecting the body's response to infection), platelet count (putting the child at risk for bleeding), and absolute reticulocyte count (causing the child to have anemia). Acute Pain related to vaso-occlusion is an appropriate nursing diagnosis for sickle cell anemia for the child in vaso-occlusive crisis, but it is not applicable to a child with aplastic anemia. Ineffective Protection related to abnormal clotting is an appropriate diagnosis for a child with hemophilia.
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