8/3/2019 4ncp

1/3

DIAGNO

SIS

PLANNI

NG

INTERVENTION RATIONALE EVALUATI

ON

Risk forinfectionr/timmunodeficiency

Goal:

After 1hour ofnursinginterven

tion thepatientwillexhibitno signsorsymptoms ofinfection.

Independent:

Promote hand washing and other precautions to preventinfections.

Monitor vital signs, including temperature, at least every 4hours or per clinical condition.

Monitor for signs of infection by assessing I.V. and injectionsites, mucous membranes (including the rectum andvagina), and wounds or skin breaks for changes in color,texture, or sensation; swelling; pain; induration; purulentdrainage; or other abnormalities. Watch closely for signsand symptoms of systemic, skin, mucocutaneous,hematologic, ophthalmologic, oral cavity, esophageal, GI,pulmonary, and central nervous system opportunisticinfections.

Assess pulmonary status for evidence of new pulmonaryinfections, checking breath sounds at least every 8 hours.Report crackles, decreased breath sounds, and other

abnormal findings promptly.

Collaborative:

Monitor CBC daily, and report increasing leukopenia orneutropenia.

Obtain cultures, as ordered, from blood, stool, urine, sputum,or wound drainage. Evaluate sensitivity results and verifythe appropriateness of antibiotic therapy.

Administer antibiotics and anti-infectives as ordered. Noteindications of adverse effects, and report your findings.

Administer antipyretics, use a hypothermia blanket, monitorfor signs of dehydration, and replace fluids as needed whenthe patient experiences fever.

Such precautions minimize the patient's exposure to infectiousorganisms. Hand washing is the gold standard for infectioncontrol.

Frequent observation of vital signs and temperature can detecta change in the patient's condition and prompt accuratetreatment.

Regular, careful, and prompt recognition of signs of infection isessential in immunocompromised patients because of the rateat which infection can spread. Early detection and treatment ofneurologic infection is crucial because advanced infection isassociated with a poor prognosis.

Prompt recognition and treatment of pulmonary infections canbe lifesaving for immunocompromised patients.

These changes indicate further compromise of the body'sability to resist or fight infection.

If new signs of infection are evident, immediate cultures willidentify the causative organism. Sensitivity results guideantibiotic therapy.

Depending on the organism, therapy may involve severaldrugs simultaneously. Antibiotics may also be orderedprophylactically. Specific acute and prophylactic drugtreatment may vary with the patient, depending on the

effectiveness of the medication and the patient's tolerance. A hypothermia blanket reduces body temperature when

antipyretics are ineffective or contraindicated. Prolonged feverincreases the metabolic rate and promotes diaphoresis,contributing to dehydration.

Goal metasevidencedby:

The patient

exhibit nosigns orsymptomsofinfection.

DIAGNO

SIS

PLANNI

NG

INTERVENTION RATIONALE EVALUATI

ON

Impairedgasexchange r/t

respiratory

Goal:

After 15minutes

ofnursing

Independent:

Teach coughing and deep-breathing exercises, andencourage hourly use of an incentive spirometer. Suction asneeded.

Deep breathing helps expand the lungs fully and preventsareas of atelectasis associated with pneumonia and bed rest.Incentive spirometry and coughing also promote lungexpansion; however, exercise caution because coughing andpositive-pressure breathing can cause alveolar rupture

Goalpartiallymet asevidenced

by:

8/3/2019 4ncp

2/3

implications

intervention thepatientwillexhibitdecreaseddyspnea

as wellasexhibitoximeter orarterialbloodgasmeasurementsimproved from

baseline.

Assist with self-care activities as needed. Teach energyconservation measures, such as using a shower chair,organizing activities and grouping procedures, using largemuscles, avoiding activities that involve raising the armsover the head, and scheduling rest periods betweenactivities.

Collaborative:

Assess continuously for signs of hypoxemia. Monitor pulseoximetry and ABG results as ordered and as needed forincreasing dyspnea or inadequate respiratory effort.

Report abnormal findings immediately, and provideappropriate oxygen therapy or ventilatory support, asindicated by patient condition.

secondary to decreased surfactant in PCP. Suctioning canprovide airway clearance.

Activity increases oxygen demand, and hypoxemia can worsenwith exertion. Sitting requires less energy than standing.Organizing and grouping procedures reduces unnecessaryexertion. Large-muscle groups are more efficient. Raising thearms over the head rapidly causes fatigue.

Monitoring respiratory status allows for rapid identification andtreatment of respiratory failure.

Oxygen can improve hypoxemia. Ventilatory support may berequired to maintain oxygenation.

The patientis stillhavingdyspnea.

DIAGNO

SIS

PLANNING INTERVENTION RATIONALE EVALUATI

ON

Imbalancednutrition,less thanbodyrequirem

ents r/tdecreased oralintake

Goal:

After 1 hourof nursinginterventionthe patient

willmaintainadequateoral intakeof foodand/or willtolerateenteral orparenteralfeedingswithoutcomplicatio

ns.

Independent:

Assess the patient's appetite. Observe what he eats andhow much. Attempt to provide the patient with his foodpreferences.

Collaborative:

Administer appetite stimulants and antiemetics, as ordered;watch for adverse effects.

Administer medication for oral infections, and providefrequent mouth care.

Administer nasogastric tube feedings or parenteralnutrition, as ordered, if the patient is unable to tolerateadequate oral intake or has severe chronic diarrhea.Observe for tolerance and adverse effects.

Providing food that the patient likes may improve hisappetite.

Medication can help the patient with GI problems andimprove his ability to eat.

Improving the oral mucous membrane helps allow thepatient to eat without pain, which may improve oral intake.

NG tube feedings provide nutrients without as manyassociated complications as parenteral nutrition. However,severe diarrhea may reduce GI absorption, makingparenteral nutrition necessary.

Goal metasevidencedby:

The patient

maintainedadequateoral intakeof food.

8/3/2019 4ncp

3/3

DIAGNO

SIS

PLANNING INTERVENTION RATIONALE EVALUATION

Deficientknowledge r/tmeans ofpreventin

g diseasetransmission andself-care

Goal:

After 1 hour ofnursingintervention

the patientwill listprecautionarymeasures toavoidinfections,listsymptomsthat mayindicateinfections orothercomplications,

discussappropriatehome careand wastedisposalguidelines,and listprecautions topreventdisease.

Independent:

Teach the patient and his loved ones about thedisease and infection prevention measures.

Discuss the signs and symptoms that mayindicate AIDS-related complications.

Review with the family the recommendations forhome care and waste disposal.

Teach the patient and his loved ones how theAIDS virus is spread. Discuss precautionarymeasures.

Encourage the patient to explore treatmentoptions with the physician, including new orexperimental medications and alternatives to

traditional medicine.

Providing accurate information about the disease will helpthe patient and family cope better with the diseaseprocess.Infection control is essential to minimize the risk of furthercomplications. Immunosuppression renders the patientextremely susceptible to infections.

Early reporting of new signs and symptoms and prompttreatment of complications that may prolong an active life.

Thorough, specific teaching reduces anxiety for familymembers and promotes safe and effective care. The CDCrecommends that caregivers use blood and body fluidprecautions.

Awareness of transmission factors may help the patientavoid spreading the disease to others.

New or alternative therapies may offeras-yet-undocumented benefits. Such therapies may offer

the patient hope, energy, and an increased sense ofwellness.

Goal met asevidenced by:

The patient wasable to list

precautionarymeasures toavoid infections,listed symptomsthat mayindicateinfections orothercomplications,discussedappropriatehome care and

waste disposalguidelines, andlistedprecautions toprevent disease.

Neri, Ann Nicole G.BSN 4B