Page 43 - PowerPoint Presentation

Sample Care Plan using Case Study

NANDA Nursing Diagnoses NOC Outcomes and Indicators NIC Intervention Label and select nursing activities
Risk for infection related to 0702Immune Status 6550 infection protection
immunosuppression Definition: Natural and acquired appropriately Definition: Prevention and early detection of infection in a patient at risk
secondary to chemotherapy, targeted resistance to internal and external antigens. Activities:
inadequate primary defenses 1=severely compromised thru 5= not compromised Monitor for systemic and localized signs & symptoms of infection (central line
(central venous catheter), Absolute WBC values WNL(within normal limits) site check every 4 hours.)
chronic disease (ALL) and 1 2 3 4 5 Monitor WBC, and differential results (qod)
developmental level. Differential WBC values WNL(within normal limits) Follow neutropenic precautions
1 2 3 4 5 Provide a private room
Skin integrity Limit number of visitors
1 2 3 4 5 Screen all visitors for communicable disease
Mucosa integrity Maintain asepsis
1 2 3 4 5 Inspect skin and mucous membranes for redness, extreme warmth or
Body temperature IER( in expected range) drainage (q4 hours)
1 2 3 4 5 Inspect condition of surgical incision
Gastrointestinal function (central line insertion site q 4 hours)
1 2 3 4 5 Obtain cultures, as needed (Blood cultures prn T>38.3 C q 24 hours) (Drainage
Respiratory Function @ Central line site)
1 2 3 4 5 Promote Nutritional intake (1500 kcal per day, Pt likes cereal)
Genitourinary Function Encourage fluid intake (1225 cc per day, Pt likes orange Gatorade)
1 2 3 4 5 Encourage rest (naps daily 1-3 PM, bedtime t 8:30 PM)
1= severe thru 5= None Monitor for change in energy level/malaise
Recurrent Infections Instruct patient to take anti-infective as prescribed
1 2 3 4 5 (Bactrim po BID; Nystatin 5cc,swish & swallow, TID)
Weight Loss Teach Family about s & symptoms of infection and when to report them to
1 2 3 4 5 HCP
Tumors (Immature -Teach patient and family how to avoid infections
WBC’s) (NIC, 2008)
1 2 3 4 5
(NOC, 2008 p.399)