Diagnosis: Risk for infection related to immune deficiency as evidenced by fever.
Goals: Rule out infection, identify both new infections and possible causes of infection.
Nurses should:
- Identify and participate in behaviors to reduce risk of infection.
- Assess patient knowledge adhere to medication regimen
- Implement isolation precautions to prevent nosocomial infections
- Administer both prophylactic and suppressive therapy.
Diagnosis: Impaired gas exchange related to pneumocystis carinii pneumonia (PCP) as evidenced by restlessness, confusion and/or dyspnea.
Goal: the patient will experience adequate O2/CO2 exchange
Nurses should:
- Preform respiratory assessment (reporting any increased shortness of breath, cough or chest pain) and pulse oximetry
- administer and titrate oxygen to a physician-prescribed oxygen saturation level
- administering antibiotics and monitoring for side effects.
- organizing care to provide maximal periods of rest.
- repositioning the patient as necessary to facilitate excursion and promote postural drainage.
- educating the patient regarding purse-lipped breathing to decrease tachypnea and anxiety.
Diagnosis: Acute/chronic pain related to procedures, medications and/or tissue damage as evidenced by patient reports of pain.
Goal: Patient reports pain as relieved/controlled.
Nurses should:
- Use analgesics or other techniques to prevent/control pain along with evaluating their efficacy
- preform ongoing assessment for the presence and characteristics of pain (location, quality, and intensity on a 0-10 scale, and its aggravating and relieving factors)
- evaluating and preventing untoward side effects (constipation from chronic opiate or tricyclic antidepressant use
- using nonpharmacologic techniques as appropriate, such as assuring adequate periods of undisturbed rest, positioning, heat and cold applications, warm baths, massage, and other relaxation techniques
- instruct and encourage patient to report pain as it develops rather than waiting until level is severe.
Diagnosis: At risk for falls related to orthostatic hypotension (due to adrenal insufficiency, dehydration, medication side effects and sensory/perceptual problems), central nervous system lesions, and/or peripheral neuropathy as evidenced by weakness, fatigue, confusion, and/or incontinence.
Goal: Patient will experience no falls during hospital stay
Nurses should:
- assess for fall risk factors (confusion, mobility problems, incontinence, orthostatic hypotension
- informing all other caregivers about patients at risk for fall
- instructing the patient and family to request assistance when transferring or ambulating
- Keep the call light, bedpan urinal and belongings within the patient’s reach
- keeping the bed in low position with side rails up
- increasing direct observations and if necessary moving the patient’s room nearer to the nurses station
- offering frequent assistance with ADLs
- using safety devices (bed alarms)
One diagnosis I would like to go more indepth with is risk for infection:
Diagnosis: risk for infection
Potential or actual: potential
Related to: immune deficiency
Plan and outcome: Patient will show no signs of infection. The patient will be properly educated on handwashing and personal hygiene.
Nursing intervention: Administer both prophylactic and suppressive therapy.
http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=248
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