Question

construct a nursing care plan for a syphilis patient involving one physiological, pschological and potential diagnosis?

Answer 1

Nursing care plan :-

1..Risk for Infection: At increased risk for being invaded by pathogenic organisms.

Risk Factors

Inadequate primary defenses (e.g., broken skin, stasis of body fluids).

Inadequate secondary defenses (e.g., decreased hemoglobin, immunosuppression).

Inadequate acquired immunity.

#. Nursing Interventions and Rationale

Obtain information regarding client’s past and present sexual partners and exposure to any STDs.

Multiple sexual partners or intercourse with bisexual men increases risk of exposure to STDs and HIV/AIDS.

Obtain information about client’s cultural background for risk factors.

In Africa, male-to-female ratio of HIV is 1:1 owing to cultural sexual practices, poor hygiene, and inadequate health care while recent arrivals from Asia, South America, and the Caribbean islands have increased the risk of exposure to Hepatitis B virus.

Review lifestyle and profession for the presence of associated risk factors. Drug abusers and healthcare professionals are at risk for exposure to HIV/AIDS and HBV through contact with contaminated needles, body fluids, and blood products; tuberculosis through airborne droplets.

Assess for any specific signs and symptom, if present, notify healthcare provider: Identifiable signs of infection assist in determining the mode of treatment. Some organisms have a predilection for the fetoplacental unit and the neonate, although the client may be asymptomatic; i.e., Mycoplasma and Ureaplasma organisms affect a significant number of pregnant women and have been cultured in aborted fetuses, even though the mothers have been free of symptoms.

Visible lesions/warts;

May indicate herpes simplex virus type II (HSVII)/condyloma, which can be transmitted to the newborn at the time of delivery if a lesion is present at term or if viral shedding is occurring.

Urinary frequency; dysuria; cloudy, foul-smelling urine;

May be associated with Escherichia coli or GBS, or client may have asymptomatic bacteriuria.

Change in color, consistency, and amount of vaginal discharge.

Thick white discharge may suggest Candida albicans infection;

thin or purulent drainage may reflect Chlamydia;

Gray-green discharge may indicate trichomoniasis;

thin, watery, yellow-gray foul-smelling (“fishy”) discharge may indicate Gardnerella.

Determine if the viral infection is either primary or recurrent. Both herpes viruses (CMV and herpes simplex virus II [HSV-II]) recur in times of stress. Yet only primary CMV is problematic to the fetus, and only 50% of fetuses exposed are affected. Although recurrent HSV-II is associated with reduced viral shedding time, the newborn, if exposed to the virus at delivery, can be affected with either visible lesions or a disseminated type of the disease

Administer antibiotics and otheredications as prescribed .

2. Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

May be related to

Body response to an infective agent, properties of infection (e.g., skin/tissue irritation, development of lesions)

#. Nursing Interventions Rationale

Identify source, location, and extent of discomfort; note signs and symptoms of infectious process.To determine the course of treatment and individual interventions.

Provide information about hygienic measures such as frequent bathing, use of cotton underwear, and application of cornstarch for client with vaginal discharge associated with STDs (chlamydial infection or gonorrhea).Helps promote dryness and prevent skin breakdown.

Provide information regarding use of warm sitz baths, use of hair dryer on genital area, urinating through an empty toilet paper tube, and wearing loose-fitting jeans/pants and cotton underwear for client with HSV-II. Prevents discomfort associated with urine coming in contact with lesions; Helps keep genital area dry/clean;

Encourage increasing oral fluid intake and voiding in warm sitz bath for client with Urinary tract infection. Helps prevent stasis; warmth relaxes perineum and urinary meatus to facilitate voiding.

Encourage the use of humidified air, increased fluid intake, and use of semi-Fowler’s position during sleep for clients with respiratory infections, such as tuberculosis. Helps liquefy secretions and facilitates respiratory functioning. Upright position allows diaphragm to descend, thereby facilitating lung expansion.

Encourage rest for client who has tuberculosis or flu-like symptoms associated with listeriosis, rubella, or toxoplasmosis. Reduces metabolic rate; facilitates response of individual immune system to infection.

Administer medications as indicated.