Nursing Care Plan

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eNURSING CARE PLAN 50-3
Patient With Cushing Syndrome
NURSING DIAGNOSIS: Risk for infection related to lowered resistance to stress and
suppression of immune system
PATIENT GOALS: Experiences no signs or symptoms of infection.
Outcomes (NOC)
Interventions (NIC) and Rationales
Infection Severity
 Fever _____
 Sputum culture colonization _____
 Urine culture colonization _____
 Blood culture colonization _____
 Wound site culture colonization _____
 White blood count elevation _____
 Pain/tenderness _____
Infection Protection
 Monitor for systemic and localized signs
and symptoms of infection so infection can
be detected early and treatment initiated
promptly.
 Provide private room.
 Maintain asepsis for patient at risk.
 Screen all visitors for communicable
diseases to reduce the risk of infection
exposure.
 Monitor absolute granulocyte count, WBC
count, and differential results to detect
infection and plan treatment.
 Obtain cultures as indicated to identify and
treat infectious organisms.
 Inspect skin and mucous membranes for
redness, extreme warmth, or drainage
because other signs and symptoms of
infection may be minimal or absent.
 Teach patient and family members how to
avoid infections (e.g., hand washing).
 Teach the patient and family about signs
and symptoms of infection and when to
report them to the health care provider.
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
Risk Control
 Modifies lifestyle to reduce risk _____
 Avoids exposure to health threats _____
Measurement Scale
1 = Never demonstrated
2 = Rarely compromised
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
NURSING DIAGNOSIS: Imbalanced nutrition: more than body requirements related to
increased appetite, high caloric intake, and inactivity as evidenced by statement of increased
appetite; weight 10% or more than optimum for height
PATIENT GOALS:
1. Attains weight appropriate for height (target weight _____ lb/kg).
2. Maintains low-calorie diet that meets nutritional needs.
Copyright © 2014, 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, an imprint of Elsevier Inc.
Outcomes (NOC)
Interventions (NIC) and Rationales
Nutritional Status
 Nutrient intake _____
 Food intake _____
 Weight/height ratio _____
 Muscle tone _____
Nutrition Management
 Determine, in collaboration with dietitian,
number of calories and type of nutrients
needed to meet nutrition requirements (e.g.,
high protein, low fat, low carbohydrate,
low sodium, high potassium, high calcium)
to help correct the effects of excess
corticosteroids.
 Provide appropriate information about
nutritional needs and how to meet them to
promote self-care.
 Monitor recorded intake for nutritional
content and calories.
 Weigh patient at appropriate intervals to
evaluate progress toward goal.
Measurement Scale
1 = Severe deviation from normal range
2 = Substantial deviation from normal range
3 = Moderate deviation from normal range
4 = Mild deviation from normal range
5 = No deviation from normal range
Knowledge: Diet
 Recommended diet _____
 Rationale for diet _____
 Relationship among diet, exercise, and
weight _____
 Strategies to change dietary habits _____
Measurement Scale
1 = No knowledge
2 = Limited knowledge
3 = Moderate knowledge
4 = Substantial knowledge
5 = Extensive knowledge
Nutritional Counseling
 Discuss patient’s knowledge of the food
groups, as well as perceptions of the
needed diet modification.
 Evaluate progress of dietary modification
goals at regular intervals.
 Provide referral/consultation with other
members of the health care team (e.g.,
dietitian, physical therapist) to help address
weight gain, muscle wasting, and altered
mineral levels.
NURSING DIAGNOSIS: Situational low self-esteem related to altered body image, emotional
lability, and diminished physical capabilities as evidenced by verbalization of negative feelings
regarding personal appearance and inability to perform usual activities
PATIENT GOALS:
1. Reports increased acceptance of appearance.
2. Uses self-care methods to improve appearance.
Outcomes (NOC)
Interventions (NIC) and Rationales
Self-Esteem
 Acceptance of self-limitations _____
 Description of self _____
 Maintenance of grooming/hygiene _____
 Acceptance of compliments from others
_____
Self-Esteem Enhancement
 Encourage patient to identify strengths to
promote awareness of capabilities.
 Reinforce the personal strengths that
patient identifies.
 Make positive statements about the patient
Copyright © 2014, 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, an imprint of Elsevier Inc.
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Description of pride in self _____
Feelings about self-worth _____
Fulfillment of personally significant roles
_____
Measurement Scale
1 = Never positive
2 = Rarely positive
3 = Sometimes positive
4 = Often positive
5 = Consistently positive

to boost morale by providing positive
feedback.
Encourage increased responsibility for self
to improve patient’s appearance and selfesteem.
Teaching: Disease Process
 Provide reassurance about patient’s
condition (e.g., explaining physical and
emotional changes will resolve with
hormonal balance) to increase their
understanding and assist with coping.
NURSING DIAGNOSIS: Risk for impaired skin integrity related to thin fragile skin, edema,
redistribution of fat, and impaired healing
PATIENT GOAL: Experiences no skin impairment, maintaining intact skin.
Outcomes (NOC)
Interventions (NIC) and Rationales
Tissue Integrity: Skin and Mucous
Membranes
 Skin integrity _____
 Thickness _____
 Texture _____
 Elasticity _____
Skin Surveillance
 Observe extremities for color, warmth,
swelling, pulses, texture, edema, and
ulcerations for early detection of skin
impairment.
 Monitor for sources of pressure and friction
to prevent injury to easily traumatized
tissue.
 Monitor skin for rashes and abrasions to
promote early treatment.
 Monitor skin and mucous membranes for
areas of discoloration, bruising, and
breakdown to provide early treatment.
 Document skin or mucous membrane
changes to provide early intervention.
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
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Skin lesions _____
Abnormal pigmentation _____
Erythema _____
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
Skin Care: Topical Treatments
 Provide support to edematous areas to
promote circulation to edematous areas.
 Use devices on the bed (e.g., sheepskin)
that protect the patient.
Nursing diagnoses listed in order of priority.
Copyright © 2014, 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, an imprint of Elsevier Inc.
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