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Kapiolani Community College!

Associate Degree Nursing Program!


Nurs320 Nursing Care Plan

Student Name

Elizabeth Nartatez

Date of Care:

04/23/15

Date Submitted:

Nursing Diagnosis: Risk for infection


Related to: inability to clear thick secretions.
As manifested by:
Scientific Rationale: Patients with cystic fibrosis produce thick abnormal secretions that primarily affects respiratory and gastrointestinal tracts.
The cycle of lung disease in CF is caused by inflammation, infection, and impaired airway clearance (Gulanick & Myers, pp. 394)
Outcomes (measurable)
Short Term

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Patient will not develop an


infection during one week of
hospitalization.

Long Term

Patient will maintain effective


airway with no signs of infection
and respiratory distress within 6
months.

Interventions
Assess for signs and symptoms of
infection such as fever, malaise
and coughing/wheezing. Monitor
vitals signs and nutritional status.

Rationale
Pulmonary infections are
associated with general symptoms
of infection such as increased
respiratory rate and heart
rate.Patient with poor nutritional
status may be anergic or unable to
muster a cellular immune
response to pathogens and are
therefore susceptible to infections.

Evaluation
Patient did not have a fever or a
cough. Patients O2 sat was 98%
and 99%. Lungs sound clear. Vital
signs within normal limits.
Patient was NPO since midnight
as a preparation to sedation.
Patient had a bottle of milk when
he returned from sedation.

Establish appropriate infection


control precaution and ensure that
there is no cohort.

According to CF Infection Control


Census Guidelines, its not
recommended to cohort patients
with CF. Prevention of infection to
the patient.

Patient has his own room with


contact precaution noted and
implemented. Patient protected
self by wearing a mask prior to
leaving his room and kept it on
while heading to sedation.

Administer respiratory treatment


(albuterol, hyperSal7%)

Prophylaxis to assist with airway


clearance. Prevention of thick
secretion from building up making
patient prone to infection and
obstruction.

Unable to evaluate. Patient was


off floor most of the day.

Teach patient and family members To prevent patient from infection.


about infection prevention and
Knowing signs and symptoms will
signs and symptoms of infection.
allow patient to seek medical
assistance immediately.
Monitor labs such as WBC, IgE
and obtain cultures (as ordered).

Unable to evaluate. Patient and


family members gone most of the
day.

WBC and IgE may be elevated


Unable to evaluate due to no
due to pulmonary exacerbations or results found.
infection.

Reference: Gulanick, M. & Myers, J. (2011). Nursing care plans: Diagnoses, interventions and outcomes (7th ed.). St. Louis: Elsevier.