DQ acute lymphoblastic leukemia

Cindy is a 9-year-old female with acute lymphoblastic leukemia (ALL) who presents to the emergency department with a temperature of 38.4 degrees C. (101.2 F.) and a complaint of a sore throat. She has been receiving chemotherapy since her diagnosis 4 months ago. Cindy’s mom reports that her fever has been unresponsive to acetaminophen. No reports of nausea, vomiting, or diarrhea noted. She weighs 57 lbs. (25.9 kg), is 51.5 inches (128.8 cm.) and has NKDA. Cindy lives at home with her mom and dad, and her 3-year-old brother. Her mom stays at home with the children because of her diagnosis and resulting hospitalizations and treatment. Cindy has missed quite a few days of school and does not return telephone calls from her friends.

1. What patient history has clinical significance to the nurse and why?

Her most recent vital signs were:

T: 100.8 F/38.2 C (oral)

P: 112 (reg)

R: 24 (reg)

BP: 102/66

O2 sat: 96% on room air

1. What patient vital signs have clinical significance to the nurse and why?

Current Assessment:

• GENERAL APPEARANCE: Resting in bed with eyes closed, pale in appearance.
• RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
• CARDIAC: Skin is pale, cool to touch. Cap. refill 3-4 seconds in both hands. No edema noted, heart sounds regular with no abnormal beats, radial and pedal pulses present and strong.
• NEURO: Patient appears lethargic, drowsy, oriented x4
• GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants. Last BM yesterday evening
• GU: Voiding without difficulty.
• SKIN: Skin integrity intact. Central venous access device (CVAD) in place, dressing intact

1. What patient assessment findings has clinical significance to the nurse and why?
2. What is the nursing priority at this time?
3. What nursing interventions will the nurse initiate based on the priority at this time?