Potential for injury. -question: what nursing diagnosis is seen with acute lymphocytic leukemia and thromocytopenia? needed info: thromocytopenia: decreased platelet count increases the patients risk for injury, normal count: 200,000-400,000 per mm3. leukemia: group of malignant disorders involving overproduction of immature leukocytes in bone marrow. this shuts down normal bone marrow production of erythrocytes, platelets, normal leukocytes. causes anemia, leukopenia, and thrombocytopenia leading to infection and hemorrhage. symptoms: pallor of nail beds and conjunctiva, petechiae (small hemorrhagic spot on skin), tachycardia, dyspnea, weight loss, fatigue. treatment: chemotherapy, antibiotics, blood transfusions, bone marrow transplantation. nursing responsibilities: private room, no raw fruits or vegs, small frequent meals, o2, good skin care. potential for injury correct: low platelet increases risk of bleeding from even minor injuries. safety measures: shave with an electric razor, use soft tooth brush, avoid sq or im meds and invasive procedures (urinary drainage catheter or a nasogastric tube), side-rails up, remove sharp objects, frequently assess for signs of bleeding, bruising, hemorrhage. self-care deficit may feel weak, doesnt address condition potential for self-harm implies risk for purposeful self-injury, not given any info, assumption alteration in comfort patient is not comfortable, and comfort measures would address problem
