NRS 220

Transition Bridge

Comprehensive Nursing Care Plan

Sara Conrad
___________________________________________________________
Name

4/8/2020
_________________________________
Date

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 Priority Nursing Diagnosis List

Problem: Risk for bleeding

Etiology: r/t thrombocytopenia secondary to chemotherapy treatment
Signs & Symptoms: aeb low platelet count

Problem: Ineffective protection

Etiology: r/t cancer and chemotherapy treatment
Signs & Symptoms: aeb chills, fatigue, deficient immunity, fever of 102.2, dyspnea,
and low white blood cell count (1.5)

Problem: Social Isolation

Etiology: r/t altered state of wellness and introversion
Signs & Symptoms: aeb absence of support system, declining to notify friends,
reports not wanting any visitors, and rarely returns to homeland.

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 NURSING CARE PLAN
P: Ineffective protection
E: r/t cancer and chemotherapy treatment
S: aeb chills, fatigue, deficient immunity, dyspnea, and low white blood cell count (1.5)
GOAL AND EXPECTED NURSING INTERVENTIONS RATIONALE FOR EVALUATION OF
OUTCOMES INTERVENTIONS (INCLUDE OUTCOMES AND CLIENT
AUTHOR AND PAGE #) RESPONSE TO
INTERVIENTIONS
Nursing student will Clients with depressed GOAL MET:
Client will remain free 1. Monitor for and report immune function are
from complications of any signs of infection (e.g. unable to mount the usual Client assessed for signs
neutropenic sepsis at all fever, chills, flushed skin, immune responses to the and symptoms of
times. drainage, edema, redness, onset of infection; fever infection throughout
abnormal lab values, and may be the only sign of entire stay. Any deviations
Client will be able to pain) and notify the infection. A neutropenic were promptly provided
explain precautions to health care provider client with fever to healthcare provider for
take to prevent infection promptly. If the client’s represents an absolute further advisement.
including hand hygiene by immune system is emergency.
discharge depressed, notify the A & L p. 695 (EB)
health care provider of
elevated temperatures,
even in the absence of
other symptoms.
2. Avoid any invasive Classic organisms such as
procedures including influenza cause infections Client did not need to
catheterization, in the have any invasive
injections, or rectal or immunocompromised procedures during stay.
vaginal procedures unless host; often their Staff used aseptic
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 absolutely necessary. presentation is difficult technique when providing
and more serious. care to client.

A & L p. 695 (EBN)

3. Administer granulocyte Clients most likely to Client received
growth factor as ordered. benefit from therapy granulocyte growth factor
would be those with as ordered and an
profound neutropenia or increase of WBC to
neutropenia with normal levels was noted.
infections not responding
to antimicrobial therapy.

A & L p. 695 (EB)

TEACH/DISCHARGE
PLANNING: Approaches to avoiding Client was verbally
4. Teach precautions to infection at homes for the instructed on the
use to decrease the client with neutropenia precautions to decrease
chance of infection (e.g. include good hand as chance of infection as
avoiding uncooked fruits hygiene and careful well as given
and vegetables, using management of food, informationally handouts.
appropriate self-care drink, and the client’s Client was able to
including good hand environment. physically demonstrate
hygiene, and ensuring a the appropriate hand
safe environment.) Teach A & L p. 697 (CEBN) washing technique and
the client to avoid crowds verbalize any questions or
and contact with persons concerns.
who have infections.
Teach the need for good
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 nutrition, avoidance of
stress, and adequate rest
to maintain immune
system function.

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 TEACHING PLAN

Teaching Topic
Proper infection control and hand washing technique

Client’s Current Understanding of Topic

Client has minimal understanding of infection control and hand washing technique.
Client does not know the appropriate length of time to wash hands and certain infection
control precautions.

Client’s Learning Style

Client is an auditory and visual learner

Client’s Readiness to Learn

Client shows willingness to learn

Teaching Methods Used

Methods used include demonstration, verbal, and resource pamphlets provided.

Content Taught: provide content outline AND attach content from reliable CITED source
(Add pages as needed)
Client was taught to wash hands before, during, and after preparing food,
before eating after blowing your nose, coughing, or sneezing, after using the restroom,
after touching an animal, before and after treating a wound, and also remind others to
wash their hands frequently when they are around her. When washing you hands you
should first wet your hands, then apply soap and lather your hands together, remembering
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to scrub the front and back, in between fingers, and under nails. Scrub your hands for at
least 20 seconds. Rinse you hands with running water and dry with a clean towel or air
dry. Hand sanitizer is also an option but should not be the only method used and should
not be used when hands are visible dirty. Use hand sanitizer like you would when
washing your hands, except you do not need to rinse hands with water or dry them with a
towel. A good rule of thumb is to rub the hand sanitizer into your hands until it is dry and
make sure to use enough to coat your entire hands. Client was also taught how to watch
out for infection and prevent infection. Things that were taught include to watch out for a
fever. If a temperature of 100.4 or higher is noticed call the PCP right away. Wash hands
often. Hand washing is the number one way to prevent infection. Carry hand sanitizer
around with you, wear gloves when gardening and wash hands after removing gloves,
brush your teeth at least twice a day with a soft tooth brush and ask PCP if flossing is
okay, make sure to wash up at least twice a day, do not go to salons or spas, do not enter
ponds, water parks, or hot tubs, wear shoe all the time, use electric shavers, if you cut
yourself clean and bandage right away (make sure to change bandage if it becomes
compromised, do not keep fresh flowers or live plants in your home, use hot water to
clean dishes, and do not share towels or drinking glasses. These are just some of the
precautions taught.

Evaluation of Learning
Client was able verbalize understanding and was able to identify where to get
access to resources should she need any. Client was able to demonstrate proper hand
washing technique and the proper use of hand sanitizer.

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 Resources:

Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing diagnosis handbook: an evidence-based

guide to planning care. St. Louis: Elsevier.

Watching for and Preventing Infections in People with Cancer. (n.d.). Retrieved from

https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/low-blood-

counts/infections/preventing-infections-in-people-with-cancer.html

When and How to Wash Your Hands. (2020, April 2). Retrieved from

https://www.cdc.gov/handwashing/when-how-handwashing.html

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