Question

Create A NURSING CARE PLAN FOR A CHILD DIAGNOSED WITH

1) Immunodeficiency disorders.

2) Kawasaki

Answer 1

GOAL	INTERVENTION	RATIONALE	EXPECTED OUTCOME
1. Risk for Infection related to	immunosuppression
	NIC Priority Intervention: Infection		NOC Suggested Outcome: Risk
	Control: minimizing the acquisition		Control: Actions to eliminate or
	and transmission of infectious agents.		reduce actual, personal, and
			modifiable health threats.
Risk factors for infection will be	■ Assess the child every 2–4 hours for	■ Fever is one of the few signs of	The child has no fever and shows no
eliminated as evidenced by infection	fever; lesions in the mouth; redness,	infections in the immunosuppressed	other signs of infection.
control.	inflammation, soreness, and lesions	child who does not have a sufficient
		on the skin or around intravenous	number of white blood cells.
		lines.
		■ Auscultate for changes in breath	■ Pneumonia is a likely infection in
		sounds every 2 hours. Perform	the child with AIDS.
		pulmonary toilet (coughing, deep
		breathing, incentive spirometry)
		every 2–4 hours.
		■ Enforce strict handwashing. Allow	■ Control of environmental factors
		no fresh flowers, fruits, or	helps prevent infection.
		vegetables in child’s room. Screen
		visitors for colds or recent exposure
		to varicella. Use blood and body
		fluid precautions (refer to the Skills
		Manual). Practice strict asepsis for
		dressing changes and suctioning.
		■ Coordinate patient care	■ Planning minimizes chances for
		assignments to avoid exposing the	infection.
		child to individuals with recent
		infections or immunizations.
		■ Organize patient care activities to	■ Rest periods allow the child to
		allow for adequate period of rest.	regain energy.
		■ Follow recommendations of CDC	■ Special recommendations consider
		and AAP for immunizing	the child’s decreased immune
		immunosuppressed children. Avoid	response and the danger of
		live oral polio virus vaccine and live	acquiring disease from certain live
		varcella vaccine. Perform annual TB	virus vaccines.
		testing.
2. Altered Nutrition: Less Than	Body	Requirements related to Loss of	appetite and decreased absorption	of nutrients
		NIC Priority Intervention: Nutrition				NOC Suggested Outcome:
		Management: Assistance with or				Nutritional Status: Nutrient value:
		provision of a balanced dietary intake				adequacy of nutrients taken into the
		of food and fluids.				body
The child will demonstrate adequate	■ Encourage frequent small meals to	■ Additional nutrition is required to	The child eats frequent meals of
nutritional status to meet metabolic	promote nutritional and fluid intake.	rebuild the immune system.	adequate nutritional content.
needs.	■ Maintain nasogastric tube feeding,
		if ordered. Hyperalimentation may
		be necessary to ensure adequate
		nutrition.
		■ Eliminate unpleasant stimuli and	■ Unpleasant stimuli decrease the
		odors from the environment during	desire for food.
		meals.
		■ Monitor skin turgor every shift.	■ Skin turgor reflects hydration status.
		■ Involve a nutritionist in planning a	■ Including favorite foods encourages
		diet for the child that includes	intake.
		favorite foods.
3. Risk for Impaired Skin Integrity related to skin infection, immobility,	or diarrhea
	NIC Priority Intervention: Skin		NOC Suggested Outcome: Risk
	Surveillance: Collection and analysis		Control: Actions to eliminate or
	of patient data to maintain skin		reduce actual, personal, and
	integrity.		modifiable health threats.
The child will have structural	■ Observe all pressure areas closely	■ Skin care is important in the	The child is free of preventable skin
intactness and normal physiologic	for signs of infection or breakdown.		immunocompromised child. The breakdown
function of skin.			skin may be the only intact defense
			the child has.
		■ Keep skin clean and dry. Provide	■ Prevents breaking or cracking of
		perineal care to minimize irritation	skin.
		from diarrhea.
4. Risk for Altered Oral Mucous	Membrane related to infection
	NIC priority Intervention: Oral		NOC Suggested Outcome: Tissue
	Health Restoration: Promotion of		Integrity: Structural intactness and
	healing for a patient who has an oral		normal physiologic function of
	mucosa lesion.		mucous membranes.
The child will have intact oral	■ Inspect mouth for sign of blistering	■ Candidal infection is frequently	The child has intact oral mucous
mucous membranes.	or lesions.		associated with immunodeficiency. Membranes
		■ Provide mouth care with normal	■ Provides comfort and promotes
		saline solution or lemon-glycerine	healing.
		swabs every 2–4 hours.
5. Pain related to infections
	NIC Priority Intervention: Pain		NOC Suggested Outcome: Comfort
	Management: Alleviation of pain or		Level: Feelings of physical and
	a reduction in pain to level of comfort		psychologic ease.
	that is acceptable to the patient.
The child will be free of pain or	■ Observe for signs of pain and	■ Pain relief adds to comfort of the	The child shows evidence of pain
experience only mild pain/discomfort.	discomfort.		child and family. Relief
		■ Medicate for pain as ordered and
		document results.
		■ Implement general comfort
		measures (holding, rocking, etc).
6. Knowledge Deficit (Parent) related to home care of child with AIDS
	NIC Priority Intervention: Teaching,		NOC Suggested Outcome:
	Treatment: Preparing a patient and		Knowledge, Treatment Regimen:
	family to understand and mentally		Extent of understanding conveyed
	prepare for a treatment.		about AIDS treatment.
The parent(s) will demonstrate	■ Explain the importance of	■ Knowledge about the disorder and	The parent describes appropriate
knowledge about home care,	optimizing the child’s health status	preventive measures is necessary to	home care and preventive measures
measures to prevent infection, and	and reducing risk of complications	provide safe and effective home	for a child with AIDS.
signs and symptoms to report to	through diet, rest, and meticulous	care for the child.
health care providers.	personal hygiene. Be sure that
	parents and other family members
	understand how AIDS is spread and
	appropriate precautions.
	■ Discuss with the parents and the	■ Knowledge of rationale increases
	child reasons for protective	compliance.
	measures.
6. Knowledge Deficit (Parent)	related	to home care of child with AIDS
			■ Inform the family about signs and	■ Prompt treatment improves
				symptoms of infection that should		outcome.
				be reported promptly to the
				physician or nurse (fever, chills,
				cough, mild erythema).
7. Caregiver Role Strain related	to	anxiety about child’s condition	and	demands of providing care
			NIC Priority Intervention: Caregiver				NOC Suggested Outcome:
			support: Provision of the necessary				Caregiver Emotional Health:
			information, advocacy, and support to				Feelings, attitudes, and emotions of a
			facilitate primary patient care by				family care provider while caring for
			someone other than a health				the child over an extended period of
			professional.						time.
The parent(s) will demonstrate		■ Encourage family members to	■ Expression of fears helps to	The parent states decreased anxiety.
emotional health as evidenced by			express fears and concerns		decrease anxiety.
decreased anxiety related to the			regarding the child’s prognosis.
child’s condition and care.		■ Advise family about support	■ Provides additional support to help
				services or other resources available		family cope with the child’s illness
				in the community.				and the dying process, when
									needed.