NURSING PROCESS RECORD (STEP 2)
NURSING DIAGNOSIS EXPECTED OUTCOME INTERVENTIONS RATIONALES EVALUATION
1. Risk for infection related to decrease number of neutrophils. Patient will remain free from infection. Observe and report signs of infection such as redness, warmth or discharge.
Assess temperature every 4 hours and report temperature of >38.5° C
Use proper hand washing techniques before and after giving care to client and any time hands become soiled, even if gloves are worn.
Monitor lab values. WBC count falls and especially neutrophils count.
Administer antibiotics as prescribed. In patients with neutropenia the signs of infection can be mask so is important to look for physical signs.
Neutropenic clients do not produce an …show more content…
Risk for Deficient Fluid Volume
Demonstrate adequate fluid volume, as evidenced by stable vital signs; palpable pulses and urine output. Monitor BP and HR.
Monitor and document temperature.
Inspect skin or mucous membranes for petechiae, note bleeding gums, frank or occult blood in stools and urine.
Monitor BP for orthostatic changes.
Evaluate skin turgor, capillary refill, and general condition of mucous membranes. Changes may reflect effects of hypovolemia due to bleeding.
Febrile states decrease body fluids by perspiration and increased respiration.
Suppression of bone marrow and platelet production places patient at risk for spontaneous or uncontrolled bleeding this can lead to deficient fluid volume.
A common manifestation of fluid loss is orthostatic hypotension. It is manifested by a 20-mm Hg drop in systolic BP and a 10 mm Hg drop in diastolic BP.
Indirect indicators of fluid status or hydration Patient was losing small amounts of blood in the stools. Patient BP was low. Blood pressure 96/61 and HR 61.
3. Risk for Unstable Blood Glucose related to prednisone intake. Patient will show blood glucose reading of less than 151mg/dL. Assess for signs of
NURSING DIAGNOSIS EXPECTED OUTCOME INTERVENTIONS RATIONALES EVALUATION
1. Risk for infection related to decrease number of neutrophils. Patient will remain free from infection. Observe and report signs of infection such as redness, warmth or discharge.
Assess temperature every 4 hours and report temperature of >38.5° C
Use proper hand washing techniques before and after giving care to client and any time hands become soiled, even if gloves are worn.
Monitor lab values. WBC count falls and especially neutrophils count.
Administer antibiotics as prescribed. In patients with neutropenia the signs of infection can be mask so is important to look for physical signs.
Neutropenic clients do not produce an …show more content…
Risk for Deficient Fluid Volume
Demonstrate adequate fluid volume, as evidenced by stable vital signs; palpable pulses and urine output. Monitor BP and HR.
Monitor and document temperature.
Inspect skin or mucous membranes for petechiae, note bleeding gums, frank or occult blood in stools and urine.
Monitor BP for orthostatic changes.
Evaluate skin turgor, capillary refill, and general condition of mucous membranes. Changes may reflect effects of hypovolemia due to bleeding.
Febrile states decrease body fluids by perspiration and increased respiration.
Suppression of bone marrow and platelet production places patient at risk for spontaneous or uncontrolled bleeding this can lead to deficient fluid volume.
A common manifestation of fluid loss is orthostatic hypotension. It is manifested by a 20-mm Hg drop in systolic BP and a 10 mm Hg drop in diastolic BP.
Indirect indicators of fluid status or hydration Patient was losing small amounts of blood in the stools. Patient BP was low. Blood pressure 96/61 and HR 61.
3. Risk for Unstable Blood Glucose related to prednisone intake. Patient will show blood glucose reading of less than 151mg/dL. Assess for signs of