Nursing Care Plan

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Medical Diagnoses: Ineffective Protection, inadequate nutrition, impairment of primary defenses and medical interventions

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

           

Client stated, “I was having this pain when I was trying to breathe.  I felt like I just wasn’t getting air in enough. I’ve been getting tired easy.”

           

           

Objective: 

 -client is on Cellcept

-client is on prednisone

-client is on Prograf

-client has several invasive therapeutic sites including two chest tubes, III/V leads, and a PICC line

-client’s total protein level is 4.3 (low)

-client’s neutrophils count is elevated (9.3)

-Client’s monocyte serum level is low (2)

-Granulocytes are elevated (87)

-HgB is low (3.33)

-hematocrit is low (9.7)

-RBC is elevated (10.7)

-client was easily fatigued during bath

-Sternal incision

-client in protective isolation


Problem:  Ineffective protection

Long Term:

           

Client will remain free of infection during the duration of this hospital visit.

-Observe and report signs of infection such as warmth, redness, discharge and increased body temperature.  Surveillance for nosocomial infection should include fever of unknown origin as the single most common and clinically important finding for detecting infection  (Englehart,et. al 2002)

-Use strategies to prevent infection transmission including washing hands before and after client contact and wearing gloves during any contact with body fluids, and changing gloves in between contacts of various systems (i.e. GU, oral mucosa, etc.).  Meticulous infection control precautions are required to prevent the transmission of infectious organisms (Gould, 2004).

*

Evaluation of this goal is set for 22:00,[date].  Client was free of signs/symptoms of infectious processes throughout the shift, some progress made.


-Observed client for signs and symptoms of infection including fever, warmth, redness, and discharge. 

-Wore mask throughout contact with patient

-Washed hands before and after all client contact.  Wore gloves during all care that had potential for contact with body fluids and changed them in between contact with body systems where body fluid could be transferred to minimize risk of infection. 

Client showed no signs of infection.  Some progress towards goal made.  Continue interventions.

Evaluation of this goal set for [date] at 22:00.

R/T:

inadequate nutrition, impairment of primary defenses and medical interventions

Short Term:

Client will state symptoms of infection (fever, redness and/or warmth at IV site, warmth and/or redness or irritation at the incisional site) of which to be aware and monitor for by 13:00 on [date].


-Assess client’s current level of knowledge r/t infection s/s

-Seek teachable moments to encourage health promotion.  The provision of information should not be restricted to just treatment information but also any information that prepares the client to manage health-related issues (Timmons, et. al 2006)

-Teach client the signs and symptoms of infection both generalized and local by invasive site (i.e. fever being generalized and localized redness and irritation at the IV site).  Education programs based on empowerment, client participation, and adult learning principles have demonstrated effectiveness (Kennedy, et. al, 2003).

*

Client stated the symptoms of infection to monitor for at 9:15 on  [date].  Goal achieved.

At 9:30  on [date] assessed client’s current level of knowledge related to signs and symptoms of infection of which he stated, “when I get hot and my skin feels hot and I just don’t feel good.”  He also stated “even if I am a little bit sick I have to call the doctor.”

Sought teachable moments to encourage health promotion, provided education on nutrition and easy meals to freeze and make at home.

Taught client the generalized and localized signs and symptoms of infection to monitor for both within the hospital and at home.

Goal achieved.

AEB:

 Low serum hemoglobin, low serum hematocrit, total protein is low, elevated neutrophils, low monocyte count, elevated granulocyte count, and elevated RBC.  Client also has a sternal incision, two chest tubes, leads from an LVAD explantation and a PICC line.


*I = Implementation.  Check those interventions/actions/orders that were implemented.

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References

Ackley, B. J., & Ladwig, G. B. (2008). Nursing Diagnosis Handbook. St. Louis: Elsevier.

Pender NJ, Murdaugh CL, Parsons MA: Health promotion in nursing practice, ed 5, Upper Saddle River, NJ, 2006, Pearson Prentice Hall.

Engelhart S, Glasmacher A, Exner M et al: Surveillance for nosocomial infections and fever of unknown origin among adult hematology-oncology patients, Infect Control Hosp Epidemiol 23(5):244, 2002.

Gould D: Systematic observation of hand decontamination, Nurs Stand 18(47):3944, 2004.

Kennedy A, Nelson E, Reeves D et al: A randomised controlled trial to assess the impact of a package comprising a patient-orientated, evidence-based self-help guidebook and patient-centered consultations on disease management and satisfaction in inflammatory bowel disease, Health Technol Assess 7(28):3, 1113, 2003.

Timmins F: Exploring the concept of information need, Int J Nurs Pract 12(6):375381, 2006.