SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
Nursing Care Management
Patient’s Name (Initials): S.M.G. Admitting Diagnosis/Medical Diagnosis/CC: Idiopathic Thrombocytopenic Purpura
Age: 4 YRS OLD Sex: F Physician (Initials): DR. S.V.
Room No: 6 Diet: DIET FOR AGE
SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED
DIAGNOSIS ANALYSIS OUTCOME
A low platelet After 4-6 hours of >Monitor vital >To know the After 4-
N/A >platelet Risk for count (called nursing signs. stability of 6hrs
count of injury thrombocytopenia) intervention, the her body. of nursing
10 related refers to an patient’s parents interventi
to the abnormally low will verbalize on the
>bruises decrease number of understanding >Ascertain >Indicator of patient’s
on of platelets, the regarding to the knowledge of needs need for parents
extremiti platelet particles in blood big potential of or injury information, are able
es and in the that help with the patient being prevention and assistance to
abdomen blood. clotting. As a injured because of motivation to with making verbalize
result, blood does her low platelet prevent further positive understand
not clot normally. count. injury. changes, ing
Usually, the promoting regarding
platelet count is safety, and to the big
about 150,000 to sense of potential
350,000 platelets activity. of the
in a microliter of patient
blood. In people being
with a low >Discuss >Recognizing injured
platelet count, importance of these factors because of
bleeding is more self-monitoring of and dealing her low
likely to occur, conditions/emotion with them platelet
even after a s that can appropriately count.
slight injury. contribute to can reduce
When the platelet occurrence of individual
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SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
count is very low injury. risk.
(below 20,000),
massive bleeding
may occur even >Note >May
when there is no socioeconomic determine the
injury. Bleeding status/ ability to
may be life availability and access help
threatening. use of resources. for
identified Evaluation
problem.
(http://www.merck.
com/pubs/mmanual_h >Encourage the >To prevent
a/sec3/ch49/ch49c. patient to use gum bleeding.
html) soft-bristled
toothbrush.
>Advise the >To prevent
patient to watch further
out safety injury.
precaution on her
activity.
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SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EXPECTED
DIAGNOSIS OUTCOME
Immunosuppression After 4-6 hours of -Stress proper -A first After 4-
N/A >Use of Risk for involves an act that nursing hand hygiene line 6hrs
immunosuppre infection reduces the activation intervention the by all care defense of nursing
ssive drugs r/t or efficacy of the patient’s parents givers and against interventi
Inadequate immune system. Some will identify SO’s health on the
secondary portions of the immune interventions to care patient’s
defense system itself have prevent/reduce the associate parents
mechanism. immuno-suppressive risk of infection d are able
effects on other parts on the patient. infection to
of the immune system, identify
and immunosuppression interventi
may occur as an adverse -Monitor -To limit ons to
reaction to treatment patient’s exposures prevent/re
of other conditions. visitors/careg , thus duce the
Deliberately induced ivers for reduce risk of
immunosuppression is respiratory cross infection
generally done to illness. Offer contamina on the
prevent the body from masks and tion patient.
rejecting an organ tissue to
transplant, treating client Evaluation
graft-versus-host visitors who
disease after a bone are coughing
marrow transplant, or or sneezing.
for the treatment of
auto-immune diseases
such as rheumatoid Monitor/assist -To
arthritis or Crohn's with the use prevent
disease. This is of adjuncts pneumonia
typically done using
drugs, but may involve
surgery (splenectomy),
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SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
plasmapharesis, or -Maintain -To avoid
radiation. adequate bladder
hydration, distentio
(http://en.wikipedia.or stand and sit n/urinary
g/wiki/Immunosuppressiv to void. status
e)
-Administer/ -To
monitor determine
medication effective
regimen and ness of
note client’s therapy/p
response resence
of side
effects
-Instruct -to
client/SO in prevent
techniques to further
protect the injury
integrity of
skin, and
prevention of
infection
-Emphasize -
necessity of Premature
taking discontin
antiviral/ uation of
antibiotics, treatment
as directed when
client
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SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
begins to
feel may
result in
return of
infection
and
potential
drug
resistant
strains.
-Provide -To
information/in increase
volve in awareness
appropriate of and
community and preventio
education n of
programs communica
ble
diseases
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SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
DIAGNOSIS ANALYSIS
N/A >taking Risk for Patients who After 4-6 >Evaluate >to determine After 4-6hrs
prednisone impaired are receiving hours of current need for of nursing
dentition corticosteroi nursing status of instruction, intervention the
related to d long term intervention, dental assistive patient’s
the use of are at risk the patient’s hygiene and devices parents are able
corticosteroi for parent will oral health. and/or to verbalize and
d drugs. complication verbalize and referral to demonstrate
including demonstrate dental care effective dental
osteoporosis, effective providers. hygiene skills
proximal dental towards the
muscle hygiene >Document >To determine patient.
wasting, skills presence of possible
cataract towards the factors intervention
formation and patient. affecting or treatment Evaluation
dental conditions. needs/.
caries.
>Ascertain >to provide
(Brunners. client’s continuity of
p1098) usual method care or to
of oral care. build on
client’s
existing
knowledge
base and
current
practices in
developing
plan of care.
>Instruct the >to prevent
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SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
patient to the oral
use soft mucous
bristled membrane from
toothbrush. bleeding.
>Instruct the >to prevent
patient not oral mucous
to do membrane from
flossing of bleeding.
teeth.
>provide >the food
appropriate left at night
diet for is more
optimal likely to
nutrition, cause
limiting cavities.
between meal,
sugary foods
and bedtime
snacks
>increase >to enhance
oral fluid hydration and
intake general well-
being of oral
mucous
membranes.
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