Problem#9: Risk for Infection

Cues
S> O
O> The patient
manifested:
- productive cough
- with
oxygen
hooked via nasal
cannula regulated
at 2 lpm
with condom
catheter attached to
urine bag
continuous
cardiac monitoring
> The patient may
manifest:
- fever
- chills
- DOB
- increase in RR,
PR
- increase in WBC
levels
and
neutrophils

Nursing Diagnosis
Risk for Infection r/t
inadequate primary
defenses
(decreased ciliary
action)

Scientific
Explanation
Upper
airway
characteristics
normally
prevent
potentially infectious
particles
from
reaching the sterile
lower
respiratory
tract.
Pneumonia
involves
the
inflammation of the
lung
parenchyma
which
eventually
leads
to
a
decreased
ciliary
action and
may
further lead to stasis
of
respiratory
secretions the client
is at risk for the
spread of infection
since the continuous
production of mucus
secretions
is
a
perfect
breeding
place
for
microorganisms.
And if the body does
not cope well the
infection
may
spread to the rest of
the body.

Objectives
Short term:
After 2 hours of
nursing intervention
patient will identify
interventions
to
prevent/reduce
risk/spread
of/secondary
infection.

Long term:
After 4 days of NI,
the
patient
will
achieve
timely
resolution of current
infection
without
complications.

Nursing Interventions

Rationale

Evaluation

>Establish rapport

>to gain trust and

cooperation

>Assess
condition

>to determine s/sx

Short term:
After 2 hours of
NI, the patient
shall
have
identified
interventions
to
prevent/reduce
risk/spread
of/secondary
infection..

patients

>Monitor VS

>to obtain baseline

data

>Obtain
appropriate
tissue/fluid specimens

>for observation for

culture
and
sensitivity testing

>Stress proper hand

washing techniques by
all care givers between
therapies and client

> it is a first line

defense
against
nosocomial
infection or cross
contamination

>Encourage coughing
&, position change

>for mobilization of
respiratory
secretions

>Monitor
clients
visitors or caregivers
for
presence
of
respiratory
illnesses.
Offer masks/tissues to
client/visitors who are
coughing or sneezing

>to limit exposures,

thus reduce cross
contamination

>Encourage
deep
breathing,
coughing
and frequent position
changes

>for mobilization of
secretions
and
prevention
of
aspiration
or
respiratory

Long term:
After 4 days of NI,
the patient shall
have
achieved
timely resolution
of
current
infection without
complications

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infection
> Encourage adequate
rest
balanced
with
moderate
activity.
Promote
adequate
nutritional intake

> Facilitates healing

process and
enhances natural
resistance.

>Administer or monitor
medication
regimen
and
note
clients
response

>to
determine
effectiveness
of
therapy
and
presence of side
effects

>Administer
prophylactic
as indicated

>to correct nor

reduce existing risk
factors

antibiotic

> Investigate sudden

changes/deterioration
in condition, such as
increasing chest pain,
extra heart sounds,
altered
sensorium,
recurring
fever,
changes in sputum
characteristics

> Delayed recovery

or
increase
in
severity
of
symptoms
suggests
resistance
to
antibiotics
or
secondary infection

>Review
individual
nutritional
needs,
appropriate
exercise
program and need for
rest

>to
wellness

>Emphasize needs for

taking
antiviral
or
antibiotics as directed

>Premature
discontinuation of
treatment
when
client feels well
may result in return
of infection and

promote

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may
potentiate
drug-resistant
strains
>Provide information or
involve in appropriate
community
and
national
education
programs

>to
increase
awareness of and
prevention
of
aommunicable
diseases

Problem#10: Activity Intolerance

Cues

Nursing Diagnosis

S> The pt. may

verbalize:
- exertional dyspnea
or discomfort
- reports of fatigue or
weakness

Activity Intolerance
r/t
cardiac
dysfunction,
imbalance in oxygen
supply
and
consumption
as
evidenced
by
shortness of breath
upon exertion

O>
the
patient
manifested:
- need for assistance
upon movement
- limited range of
motion
- with
oxygen
hooked via nasal
cannula regulated at
2 lpm
with
condomcatheter
attached to urine

Scientific
Explanation
The
underlying
mechanism of a
heart attack is the
destruction of heart
muscle cells due to
a lack of oxygen. If
these cells are not
supplied
with
sufficient oxygen by
the coronary arteries
to
meet
their
metabolic demands,
they die
by a
process
called
infarction.
The
decrease in blood
supply may bring
about necrosis of the
heart muscle which
would
make
it

Objectives
Short term:
After 4 hours of NI,
the patient will use
identified techniques
to increase activity
tolerance.

Long term:
After 4 days of NI,
the patient will be
able to increase and
achieve
desired
activity
level,
progressively, with
no
intolerance
symptoms
noted,

Nursing
Interventions

Rationale

Evaluation

>Establish rapport

>to gain trust and

cooperation

>Assess
condition

>to determine signs

and symptoms

Short term:
After 4 hours of
NI, the patient
shall have used
identified
techniques
to
increase
activity
tolerance.

patients

>Monitor VS

>changes in VS
assist
with
monitoring
physiologic
responses
to
increase in activity.

>Identify causative
factors leading to
intolerance of activity

>alleviation
of
factors that are
known to create
intolerance
can
assist
with
development of an
activity
level

Long term:
After 4 days of NI,
the patient shall
have
increased
and
achieved
desired
activity
level,
progressively, with

136

bag
- continuous cardiac
monitoring
The patient may
manifest:
tachypnea and
increased
blood
pressure
upon
performance
of
activities
- pallor
- cyanosis
- ischemic ECG
changes

weaker as a pump.
As a result, the
pumping mechanism
of the heart will be
ineffective
thus
giving the individual
an insufficient supply
of blood, bringing
about an inefficient
supply of oxygen to
the tissues thus
leading
to
easy
fatigability
upon
simple exertions. If
the
condition
becomes severe, the
patient may have
inability
in
performing activities
and show changes
in vital signs upon
performance
of
activities. Also, there
could be changes in
the ECG showing
signs of ischemia.

such as respiratory
compromise.

program
>Encourage patient
to
assist
with
planning activities,
with rest periods as
necessary

> to help give the

patient a feeling of
self-worth and wellbeing

>Instruct patient in
energy conservation
techniques

>
to
decrease
energy expenditure
and fatigue

>Assist with active

or passive ROM
exercises

> to maintain joint

mobility and muscle
tone

>Assist patient with

ambulation,
as
ordered,
with
progressive
increases
as
patients
tolerance
permits

>
to gradually
increase the body
to compensate for
the increase in
overload

>Adjust
activities
according
to
patients tolerance

>
to
prevent
overexertion

>Plan care with rest

periods
between
activities

> to reduce fatigue

>Provide
positive
atmosphere,
while
acknowledging
difficulty
of
the
situation
for
the
patient

> helps to minimize

frustration,
rechannel activities

>Assist patient with

activities
and

> to protect client

from injury

no
intolerance
symptoms noted,
such
as
respiratory
compromise

137

monitor
use
of
assistive devices
>Promote
comfort
measures
and
provide for relief of
pain

> to enhance ability

to participate in
activities

>Provide referral to
other disciplines as
indicated

>
to
develop
individually
appropriate
treatment regimen

> Instruct client/SO

in
monitoring
response to activity
and
recognizing
signs and symptoms

> may indicate a

need in alteration of
activities

Problem#11: Self Care Deficit r/t weakness

Cues
S>
O>
The
manifests:

Nursing Diagnosis
patient

cold clammy skin

good skin turgor
capillary refill < 3
sec.
irritability
weakness
when
taking a bath
easy fatigability even
only doing ADLs

Self
care
deficit
related to weakness
or tiredness.

Scientific
Explanation
The
nurse
may
encounter
the
patient with self care deficit in the
hospital. The deficit
may be a result of
transient limitations,
such as those one
might
experience
while
recovering
from surgery or the
result
of
the
progressive
deterioration
that
erodes
the
individuals ability or
willingness
to

Nursing
Interventions

Objectives
Short term:
After 3 hours of
nursing interventions
patient will be able
to
verbalize
understanding
on
the importance of
self-care.
Long term:
After 1 day of
nursing interventions
patient will safely
perform
self-care
activities.

Rationale

Evaluation

>Establish rapport

>to gain the trust

and cooperation of
the patient.

>Assess
condition

>to have a general

health status of the
patient.

Short term:
After 3 hours
nursing
interventions
patient shall have
verbalized
the
importance of selfcare.

patients

> Monitor vital signs

>to obtain baseline

data

>Assist
with
necessary
adaptations
to
accomplish ADLs

> to encourage and

build on successes

>

> to prevent injury

Arrange

for

Long term:
After 1 day of
nursing
interventions
patient shall have

138

The patient
manifests:
restlessness

may

perform the activities

required to care for
himself.
Careful
examination of the
patients deficit is
required in order to
be certain that the
patient is not failing
self-care because of
lack of materials with
arranging
the
environment to suit
the patients physical
limitations.

assistive devices as
necessary (seat/grab
bars)

performed safely
self-care activities.

>Instruct patient to
increase fluid intake
up to 8- 10 glasses
of water

>
to
prevent
dehydration and a
source of energy

>Encourage
food
choices
reflecting
individual likes and
abilities that meet
nutritional needs

> to increase energy

>Stretch linens

>to provide comfort

>Stress proper hand

washing

>to prevent infection.

>Instructed patient
to perform good
hygiene

>To relieve patient

and provide comfort

>Administer
as ordered.

>
for
wellness

drugs

optimum

139