Nursing Diagnosis: Altered Protection related to Decrease Immune Function

Assessment Scientific Basis Expected Interventions & Rationale Actual Outcome

data Outcome
Subjective Short-term I. Safe & Quality Nursing After 8 hours of
Cues: The immune system Goal; Care nursing
is the one protecting Identifies health needs of the intervention
Dali ra kaayo the body from After 3 hours of patient. patient remain
ko kapoyon ug opportunistic nursing II. Management of free from any
hangakon pathogens and intervention Resources and signs of infection.
dayon akong bacteria. The The client will Environment
ginhawa as immune system of a be Provides an environment that
verbalized by cancer patient works able to state is safe for the client and other
the patient. by destroying about the health care team.
10,000 mutant reason for Makes use of available
cancer cells in the treatment, resources efficiency.
Objective cues: body every day, with proper III. Health Education
all its activity. The hygiene Assesses patients learning
- Pale lips system becomes practices needs.
- Pale compromised. When including IV. Legal Responsibility
Conjunctiva the immune system Hand washing, Documents care rendered to
- Easy Bruising is compromised, and patients appropriately.
- PR = 124 there is greater risk other ways to Provides accurate
- RR = 24 for infection to be prevent documentation in all matters
- Low acquired by a infection. concerning patient care.
hemoglobin = person. V. Ethico-Moral
85g/L Long-term Responsibility
- Low Source: Goal;
Medical Surgical Respects the rights of patient.
hematocrit = The client will
th
Nursing, 12 ed. by Accepts responsibility and
0.27 remain free of
Brunner & Suddarths. any signs of accountability for own actions.
- Low RBC =
VI. Personal and Professional
3.56 infection such
Development
as fever and
Displays appropriate behavior
chills.
at all times.

VII. Quality Improvement

 Constructs and implements
therapeutic solutions for the
well being of the patient.
VIII. Research
Utilizes findings in research in
the provision of nursing care
IX. Records Management
Completes updated
documentation of patient care.
X. Communication
Listens attentively to patients
concern.
XI. Collaboration and
Teamwork
Refer patient to appropriate
personnel.
Nursing Diagnosis: Altered Skin Integrity related to alteration of skin appearance as manifested by
presence of lesions
Assessment Scientific Basis Expected Interventions & Rationale Actual Outcome
data Outcome
Subjective Skin is the primary At the end of III. Safe & Quality After 8 hours of
Cues: defense of the body; the shift, the Nursing Care nursing intervention
it protects the body patient will Identifies health needs of patient was able to
Daghan na against infections be able to the patient. demonstrate
kaayo ni tubo and eases brought demonstrate Provides an environment techniques to prevent
mga lesions about by the invasion behaviours/ that is safe for the client skin breakdown.
sakong lawas of microbes in the techniques to and other health care
as verbalized body. A normal skin prevent team.
by the patient. is more prone to skin IV. Management of
friction that may breakdown. Resources and
result to impairment Environment
Objective cues: of the skin integrity Makes use of available
as compared with a resources efficiency.
- Presence of moist skin. III. Health Education
purple lesions Assesses patients learning
on both legs, needs.
the right IV. Legal Responsibility
periorbital Source: Documents care rendered
region, trunk, Medical Surgical to patients appropriately.
and oral Nursing, 8th ed. by Provides accurate
mucosa Black, Joyce and Jane documentation in all
- scratching Hokanson Hawks; p. matters concerning patient
- disruption of 1190 care.
skin surface V. Ethico-Moral
Responsibility
Respects the rights of
patient.
Accepts responsibility and
accountability for own
 actions.

VI. Personal and

Professional Development
Displays appropriate
behavior at all times.
VII. Quality Improvement
Constructs and
implements therapeutic
solutions for the well being
of the patient.
VIII. Research
Utilizes findings in
research in the provision
of nursing care
IX. Records Management
Completes updated
documentation of patient
care.
X. Communication
Listens attentively to
patients concern.
XI. Collaboration and
Teamwork
Refer patient to
appropriate personnel.
Nursing Diagnosis: Risk for Infection related to compromised immune system
Assessment Scientific Basis Expected Interventions & Rationale Actual Outcome
data Outcome
Subjective Risk of infection is a After 8 hours V. Safe & Quality After 8 hours
Cues: nursing diagnosis of nursing Nursing Care of nursing care,
which is defined as care, the Identifies health needs of the patient was
Dali na kaayo "the state in which patient the patient. able to Identify the
ko matakdan an will be able to: VI. Management of risk
ug mga sakit2x individual is at risk to Short term: Resources and factors present
ubo, sipon ug be invaded by an A. Identify the Environment in the client
hilanat as opportunistic or risk Makes use of available condition. Client
verbalized by pathogenic agent factors present resources efficiency. understanding
the patient. (virus, fungus, in the client III. Health Education about infection
bacteria, condition. Assesses patients learning and its risk
protozoa, or other B. Client partial needs. Factors. Infection was
Objective cues: parasite) from understanding IV. Legal Responsibility currently
endogenous or about infection Documents care rendered Prevented.
- WBC exogenous and its risk to patients appropriately.
increased sources". factors. Provides accurate
with result of Although anyone Long term: documentation in all
17.1 10^9/L can become infected A. Effective matters concerning patient
- Restlessness by a prevention of care.
- Weakness pathogen, infection to the V. Ethico-Moral
patients with this client. Responsibility
diagnosis are at B. Client full Respects the rights of
an elevated risk understanding patient.
and extra to the risk Accepts responsibility and
infection controls factors of
accountability for own
should be infection
actions.
considered.
VI. Personal and
Professional Development
Displays appropriate
behavior at all times.
VII. Quality Improvement
Constructs and
implements therapeutic
solutions for the well being
of the patient.
VIII. Research
Utilizes findings in
research in the provision
of nursing care
IX. Records Management
Completes updated
documentation of patient
care.
X. Communication
Listens attentively to
patients concern.
XI. Collaboration and
Teamwork
Refer patient to
appropriate personnel.
Nursing Diagnosis: Social Isolation related to Presence of Skin Lesions
Assessment Scientific Basis Expected Interventions & Rationale Actual Outcome
data Outcome
Subjective Social isolation is the Short term I. Safe & Quality Nursing Care After 8 hours of
Cues: condition of Goal: nursing
aloneness Develop a therapeutic nurse intervention,
Mauwaw nako experienced by the After 8 hours of client relationship through patient was able
mugawas kay individual and nursing frequent brief contacts and an to verbalized and
lain kayo akong perceived as intervention accepting attitude. express feeling
panitas imposed by others the patient will Show unconditional and that lead to poor
verbalized by and as a negative or be able to positive regard. social interaction.
the patient. threatened state; verbalize Identifies health needs of the
impaired social feelings that patient.
interaction is an lead to poor Provides an environment that
insufficient or social is safe for the client and other
Objective cues: excessive quantity or interaction. health care team.
ineffective quality of II. Management of Resources and
> Presence of social exchange. Environment
lesions in lower Place patient to a safe
extremities Long Term environment that could harm
> Lack of Goal: the patient.
support system Source: Provide a place of acceptance
> Discomfort in Fundamentals of After 3 days of III. Health Education
social situation Nursing , 8th ed. Vol 2 nursing Assesses patients learning
pp. 467 intervention
needs.
the patient will
IV. Legal Responsibility
voluntary
Documents care rendered to
spend time
patients appropriately.
with family and
Provides accurate
friends.
documentation in all matters
 concerning patient care.
V. Ethico-Moral Responsibility
Respects the rights of patient.
Accepts responsibility and
accountability for own actions.
VI. Personal and Professional
Development
Displays appropriate behavior
at all times.
VII. Quality Improvement
Constructs and implements
therapeutic solutions for the
well being of the patient.
VIII. Research
Utilizes findings in research in
the provision of nursing care
IX. Records Management
Completes updated
documentation of patient care.
X. Communication
Listens attentively to patients
feelings
Encourage patient to express
feelings to others to gain self-
worth.
XI. Collaboration and
Teamwork
Refer patient to appropriate
personnel.
Encourage attendance in
group activities.