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. 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 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.