Need/nursing Diagnosis/cues
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Need/Nursing Diagnosis/Cues Risk for infection related to inadequate primary defences. OBJECTIVE: • •
Irritability Pallor of skin and mucous membranes
Scientific Analysis Leukemias are cancers of the bloodforming tissues. White blood cells may be produced in excessive amounts and are unable to work properly which weakens the immune system.
Nursing Intervention
Objective After 8 hours of nursing interventions the patient will: -identify actions to prevent or reduce the risk for infection.
INDEPENDENT: • Place the patient in private room. Limit visitors as indicated. Prohibit use of live plants or cut flowers. Restrict fresh fruits and vegetables or make sure they are washed or peeled. • Require good handwashing protocol for all personnel and visitors. • Encourage frequent turning and deep breathing.
Rationale •
Protect patient from potential sources of pathogens or infection.
•
Prevents crosscontamination or reduce risk for infection.
•
Prevents stasis of respiratory secretions, reducing risk of atelectasis or pneumonia.
•
Handle patient gently. Keep linens dry or wrinkle free.
•
Prevents sheet burn or skin excoriation.
•
Inspect skin for tender, erythematous areas, open wounds. Cleanse skin with antibacterial solutions. Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care. Promote good perineal hygiene. Examine perianal area at least daily during acute illness and provide sitz baths. Coordinate procedures and tests to allow for uninterrupted rest periods.
•
May indicate local infection.
•
The oral cavity is an excellent medium for growth of organism and is susceptible to ulceration and bleeding.
•
Promotes cleanliness, reducing risk of perianal abscess; enhances circulation and healing. Conserves energy for healing, cellular regeneration.
•
•
•
COLLABORATIVE: • Prepare for or assist patient with leukemia treatments such as chemotherapy, radiation, and bone marrow transplantation.
•
•
Leukemia is usually treated with a combination of these agents, each requiring
Evaluation After 8 hours of nursing interventions the patient was able to identify actions to prevent or reduce the risk for infection.
Irritability Pallor of skin and mucous membranes
Scientific Analysis Leukemias are cancers of the bloodforming tissues. White blood cells may be produced in excessive amounts and are unable to work properly which weakens the immune system.
Nursing Intervention
Objective After 8 hours of nursing interventions the patient will: -identify actions to prevent or reduce the risk for infection.
INDEPENDENT: • Place the patient in private room. Limit visitors as indicated. Prohibit use of live plants or cut flowers. Restrict fresh fruits and vegetables or make sure they are washed or peeled. • Require good handwashing protocol for all personnel and visitors. • Encourage frequent turning and deep breathing.
Rationale •
Protect patient from potential sources of pathogens or infection.
•
Prevents crosscontamination or reduce risk for infection.
•
Prevents stasis of respiratory secretions, reducing risk of atelectasis or pneumonia.
•
Handle patient gently. Keep linens dry or wrinkle free.
•
Prevents sheet burn or skin excoriation.
•
Inspect skin for tender, erythematous areas, open wounds. Cleanse skin with antibacterial solutions. Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care. Promote good perineal hygiene. Examine perianal area at least daily during acute illness and provide sitz baths. Coordinate procedures and tests to allow for uninterrupted rest periods.
•
May indicate local infection.
•
The oral cavity is an excellent medium for growth of organism and is susceptible to ulceration and bleeding.
•
Promotes cleanliness, reducing risk of perianal abscess; enhances circulation and healing. Conserves energy for healing, cellular regeneration.
•
•
•
COLLABORATIVE: • Prepare for or assist patient with leukemia treatments such as chemotherapy, radiation, and bone marrow transplantation.
•
•
Leukemia is usually treated with a combination of these agents, each requiring
Evaluation After 8 hours of nursing interventions the patient was able to identify actions to prevent or reduce the risk for infection.
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