A child is receiving chemotherapy induction for acute lymphocytic leukemia (ALL)

Question

Taking common side effects into consideration, which nursing diagnoses would be appropriate during the induction chemotherapy? Standard Text: Select all that apply. 1. Risk for injury: hemorrhagic cystitis
2. Skin integrity: impaired mucous membrane
3. Fluid and electrolyte impairment: nausea and vomiting
4. Risk for infection
5. Impaired sleep pattern
6. Diarrhea

Answer 1

1,2,3,6
Rationale 1: Hemorrhagic cystitis is a common early side effect of chemotherapy and is usually prevented with large amount of IV fluids to adequately protect the kidneys.
Rationale 2: Mouth sores are a common early side effect of chemotherapy and usually occur two to five days after the administration of chemotherapy.
Rationale 3: Nausea and vomiting are common early side effects of chemotherapy.
Rationale 4: Bone marrow suppression does not peak until 7 to 10 days post-induction. This nursing diagnosis would be appropriate at that time.
Rationale 5: Impaired sleep patterns are not directly related to chemotherapy.
Rationale 6: Diarrhea is a common early side effect of chemotherapy.
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