DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: Dexter Binay Date of Admission: October 15,2023 Room: 315
Age: 66 Sex: M Civil Status: Not indicated Chief Complaint: Acute onset shortness of breath
Attending Physician: Dr. Sabido

GOALS & NURSING

DATE/ CUES NURSING RATIONALE EVALUATION
OBJECTIVES INTERVENTIONS
TIME DIAGNOSIS
10/15/2023 SUBJECTIVE: After 8 hours of nursing 1. Assess factors 1. Age (very young or very old)
@7-3PM Risk for infection intervention, the patient contributing to an and other conditions such as GOAL PARTIALLY
related to will be able to: increased risk for viruses or chronic diseases MET
OBJECTIVE: compromised infection. increase the risk for infection.
(+) diarrhea defense 1. The vital signs After 8 hours of
(+) fever mechanisms will decrease nursing intervention,
secondary to Lung 2. Monitor and report 2. Assess for the following signs
(+) weak compared to any signs and and symptoms: Redness, the patient was able
(+) exhausted Cancer admission. symptoms of infection. swelling, increased pain, a to:
purulent discharge from
Vital Signs: incisions, injury, and exit sites of
Temp: 37.7 C Scientific Basis: 2. There will be tubes (IV tubings), drains, or
RR: 38 cpm absence of catheters. Elevated 1. Vital signs
HR: 115 bpm Cancer can damage infection and temperature. Color of displayed a
BP: 146/86 other parts of the patient will be respiratory secretions. The decrease in
Sp02: 91% immune system. able to name appearance of urine. result while
Pain scale: 7/10 Cancer cells can get signs and the
into the bone symptoms of an 3. Monitor white blood 3. An increasing WBC count temperature
WBC: 1.3 X marrow cells where infection. returned to
cell (WBC) count. indicates the body’s efforts to
10^/L (low) blood cells are combat pathogens. This is normal.
RBC: 3.32 X made. The cancer referred to as leukocytosis and
10^12/L (low) cells then compete is composed primarily of 2. Verbalized
Hgb: 10.1 g/dL with the normal 3. Demonstrate neutrophils. It is commonly a that eating
Hct: 29.4 % (low) bone marrow cells measures to sign of an inflammatory nutritious food
CBG: 155 mg/dL for space and prevent response such as infection but and getting
CEA level: 13.5 nutrients. If too infection such can occur during parasitic adequate rest
ng/ml many normal bone as hand infections or cancers such as can boost the
marrow cells are leukemia (Rowe, 2022).
hygiene,
 destroyed or pushed wearing of 4. Assess and monitor 4. Clients with inadequate immune
(+) pancytopenia out of the bone mask, nutritional status, nutrition may be anergic or system.
(+) pleural marrow, the few consuming weight, history of weight unable to muster a cellular
effusion cells that are left nutritious food, loss, and serum immune response to
albumin. pathogens, making them
(+) pericardial won't be able to and getting 3. Demonstrated
susceptible to infection.
effusion make enough white enough rest. an
(+) minor ascites blood cells (WBCs) understanding
(+) lung cancer to help the body 5. Assess immunization 5. People with incomplete of the
fight infection. 4. Demonstrate status and history and immunizations may not have imparted
Past Medical Tumors in the lungs understanding encourage appropriate sufficient acquired active teachings as
Hx: may also block of the imparted immunizations. immunity. The nurse may ask fever is one of
(+) COPD normal mucus health teaching. clients during history taking the signs of
(+) DM drainage, which can when they were last immunized. infection.
lead to infections. Successful vaccine programs
And, other types of have reduced the incidence of 4. Verbalized the
many infectious diseases.
tissues that have importance of
been damaged by good hygiene
cancer can be more 6. Maintain strict 6.The aseptic technique and
prone to infections. asepsis for dressing decreases the chances of immunization
changes, wound care, transmitting or spreading given his
intravenous therapy, pathogens to or between condition.
and catheter handling. clients. Interrupting the chain of
infection effectively prevents
the spread of infection.

7. Wash hands or 7. Friction and running water

perform hand hygiene effectively remove
before having contact microorganisms from hands.
with the client. Also, Washing between procedures
impart these duties to reduces the risk of transmitting
the client and their pathogens from one area of the
significant others and body to another.
know the instances
when to perform hand
hygiene or “5 moments
for hand hygiene”:

8. Encourage the intake 8. Proper nutrition and a

of protein-rich and balanced diet support the
calorie-rich foods and a immune system’s
balanced diet. responsiveness and enhance
the health of all the body’s
 tissues. Adequate nutrition
enables the body to maintain
and rebuild tissues and helps
keep the immune system
functioning well.

9. Encourage sleep and 9. Adequate sleep is an

rest. essential modulator of immune
responses. A lack of sleep can
weaken immunity and increase
susceptibility to infection.

10. Assist the client to 10. Excessive stress

learn stress-reducing predisposes clients to infection.
techniques. Engaging in stress-reduction
techniques, such as meditation,
deep breathing exercises, or
mindfulness practices, can help
lower stress hormones and
promote a more balanced
immune response.

11. Administer anti- 11. Antibiotic treatment might

infective agents as start with an empiric approach
ordered. until the culture results can
further narrow down the
appropriate antimicrobial
therapy. Management may
include antibacterial, antifungal,
antiviral, or antiparasitic, and
antipyretic treatment.

Name of Student: Irish Cacayan

REFERENCES:
Bsn, M. V., RN. (2023). Risk for infection and infection control nursing care plan and management. Nurseslabs.
https://nurseslabs.com/risk-for-infection/
Why People with Cancer Are More Likely to Get Infections. (n.d.-b). American Cancer
Society. https://www.cancer.org/cancer/managing-cancer/side-effects/low-blood-counts/infections/why-people-with-
cancer-are-at-risk.html