NURSING CARE PLAN PROCESS ANALYSIS

Nursing Diagnosis Priority Client Goal- Ex e!te" out!o#es

NAME( +anessa Prieto CLIENT INITIALS1 L.4. AGE( -, SE,( > DATE O- CARE( *+,5+ 0,3

PLANNING AND IMPLEMENTATION

Nursing Or"ers Rationale $or Nursing Or"ers

T&e Nurse *ill( Ineffective protection Relate" to Impairment of primary defenses "i#$ accordin# to Maslow%s "ierarc$y of needs. &$ysiolo#ical need is affected due to t$e decrease in t$e ability to #uard self from internal or e'ternal t$reats suc$ as illness or in(ury t$at may suppress immune system or even result in deat$. )ate written *+,-+ 0,3 ,. 4a6e vital si#ns every - $ours. T&e Client 'ill( Maintain or improve bodies% defenses As e)i"en!e" %y( . 4eac$ patient and family neutropenic precautions to perform li6e was$in# $ands fre7uently w$en enterin# and leavin# room. 4eac$ also to use a facemas6 for anyone visitin#. 3. Monitor for bleedin# every - $ours by inspectin# s6in8mucous membranes for petec$iae, ecc$ymosis areas, note bleedin# #ums, abdominal assessment, and fran6 or occult blood in body fluids. -. Implement measures to prevent tissue in(ury8bleedin#. Minimi9e invasive procedures, avoid s$arp ob(ects, use soft tip toot$brus$, and ma6e t$in#s wit$in reac$ to avoid falls. 5. .nsure t$at pt. is well nouris$ed. &rovide food wit$ lots of protein and administer vitamin supplements. Avoid raw fruits and ve#etables. )ate1 2*+,3+ 0,322 4ime1 2,50022 .valuate ,. &rospective surveillance study for nosocomial infection on $ematolo#y+ oncolo#y units s$ould include fever of un6nown ori#in as t$e sin#le most common and clinically important entity. :Ac6ley, p#. !35; . "and $y#iene $elps prevent infection and prevent transmission of microor#anisms. :deWit, p#. 35*; 3. <uppression of bone marrow and platelet production places pt. at ris6 for spontaneous bleedin#. :deWit, p#. 35=; -. >ra#ile tissues and altered clottin# mec$anisms increase t$e ris6 of $emorr$a#e followin# even minor trauma. :Ac6ley, p#. !*,; 5. A #ood, well balanced diet can $elp you feel stron#er, $ave more ener#y, and recover more 7uic6ly. &rotein pac6ed meals or drin6s will aid in t$is. ?aw foods often carry bacteria, w$ic$ could cause infection. :deWit, p#. 35*;

secondary to AML
As #ani$este" %y Low WBC of 0.3, low platelet count of 0, and low albumin level of .!

../. 0,+ &atient will maintain an infection

free state durin# s$ift

../.0 + &atient will $ave no episodes of

active bleedin# durin# s$ift

../.03+ &atient will maintain #ood safety

and nutrition durin# s$ift

E+ALUATION .valuate Client @oal and .'pected /utcomes )ate of .valuation @oal1 @oal was met. ../. 0 ,+ @oal met. )urin# time wit$ pt., s$e did not s$ow any new si#ns of infection. ../. 0 + @oal not met because pt. did $ave si#ns of a small active bleed in mout$ under ton#ue. ../. 0 3+ @oal not met because durin# s$ift pt. slipped w$ile bein# $eld up to use t$e restroom and bruised $er le#. 3+,5+ 0,3

REASSESSMENT ?eassess t$e .ntire &lan of Care, #ive rationale for additions deletions or continuations Ne' Data( &t. $ad to receive , ba# of blood and , ba# of platelets due to $er labs comin# bac6 low once a#ain. Nursing D,( Continue because patient still $as ineffective protection because of $er wea6ened immune system. Goal( Continue wit$ t$is #oal because t$is is w$at is needed for $er to start feelin# better. Out!o#es ./ 0 ,+ Continue+ Bein# free of infection will $elp $er from #ettin# fatally sic6 because $er low WBC cause $er to $ave a diminis$ed immune system. ./ 0 + Continue+ By not $avin# any active bleed s$e is not at ris6 for $emorr$a#in# due to low platelet count. ./ 0 3+ Continue+ <afety and nutrition is essential in #ettin# t$e pt. to feel and #et better. Nursing Or"ers A./. 0 ,+ Beep it because vital si#ns will $elp identify pain or infection w$ic$ will aid in t$e pro#ress of t$e recovery. 4$is will also s$ow si#ns of anyt$in# new t$at may arise. A./. 0 + Beep it because teac$in# proper $and $y#iene will $elp eliminate t$e ris6 of pt. contractin# any type of infection t$at will be detrimental to $er wea6ened immune system. A./. 0 3+ Beep it due to t$e fact t$at by assessin# t$e pt. fre7uently, t$is reduces t$e ris6 of in(uries from pro#ressin# wit$out bein# noticed. A./. 0-+ Beep it because any type of small bump or scrape can cause pt. to bleed internally or e'ternally and t$is will not $ave t$e ability to clot well and may cause $emorr$a#e. A./. 05+ Beep it because protein aids in $ealin# and also providin# t$e pt. wit$ a list of foods to avoid will $elp 6eep $er free of any new bacteria or viruses.