Priority nursing diagnoses Risk for infection Fatigue Anxiety Risk for injury

Priority nursing diagnoses risk for infection fatigue

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Priority nursing diagnoses: Risk for infection; Fatigue; Anxiety; Risk for injury; Imbalanced nutrition: less than body requirements; Deficient fluid volume; Disturbed body image; Social isolation
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5. Immunosuppression a. Client education for immunosuppression 1) Risk for infection is high when WBC count is low 2) Avoid crowds, people with infections, and small children when WBC is low 3) Use meticulous personal hygiene to avoid infection 4) Wash hands before and after eating, after toileting, and after contact with other people and pets 5) Consume a low-bacteria diet; avoid undercooked meat and raw fruits and vegetables 6) Be aware of signs and symptoms of infection and report them immediately to primary care provider b. Nursing management of immunosuppression 1) Monitor laboratory values: CBC with differential, platelets, BUN, liver enzymes 2) Assess for infection; monitor vital signs for early indication of infec- tion: fever, tachycardia, and tachypnea 3) WBC suppression, malnutrition and presence of disease increase the risk of infection 4) Utilize neutropenic precautions (low-bacteria diet, no fresh plants or flowers in room, no pets, no visitors with infections) when WBC level falls below predetermined level (such as 2,000 mm 3 ) c. Evaluation of care for immunosuppression: client demonstrates techniques to reduce risk of infection, participates in activities that reduce risk of infection, and remains free from infection 6. Thrombocytopenia a. Client education for thrombocytopenia 1) Monitor stools and urine for bleeding 2) For shaving, use electric razor only 3) Avoid contact sports and other activities that may cause trauma 4) If trauma does occur, apply ice to area and seek medical assistance 5) Avoid dental work or other invasive procedures 6) Inform all healthcare providers of chemotherapy andfor radiation treatments 7) Avoid aspirin and aspirin-containing products 8) Safety precautions for oral hygiene: use soft toothbrushes and do not floss
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b. Nursing management of thrombocytopenia 1) There is a high risk for spontaneous hemorrhage when platelet count is <20,000: precautions are necessary for platelet count <50,000 2) Assess for bleeding, monitor stools and urine for occult blood 3) Assess skin for ecchymoses, petechiae, and trauma 4) Educate client about bleeding safety precautions 5) Avoid intramuscular injections and limit venipunctures c. Evaluation of care for thrombocytopenia: client demonstrates understanding of risks for hemorrhage, participates in activities that reduce the risk of hemorrhage, and client remains free from complications of bleeding 7. Stomatitis and mucositosis a. Client education for stomatitis and mucositosis 1) Use a soft toothbrush; mouth swabs may be needed during acute episode 2) Avoid mouthwashes containing alcohol; do not use lemon glycerin swabs or dental floss 3) Consider using chlorhexidine mouthwash (Peridex) to decrease risk of hemorrhage and protect gums from trauma 4) Assess daily for lesions, infection, bleeding, or irritation 5)
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  • Fall '17
  • Adrian Hailey

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