1. High risk of infection related to an inadequate secondary defenses (decreased hemoglobin leucopenia, or a decrease in granulocytes (inflammatory response depressed)).
Infection does not occur.
Expected Outcomes :
- Identify the behaviors to prevent / reduce the risk of infection.
- Improving wound healing, free of purulent drainage or erythema, and fever.
- Increase of good hand washing; by care givers and patients.
Rational: to prevent cross-contamination / bacterial colonization. Note: patients with severe anemia / aplastic can be risky due to the normal flora of the skin.
- Maintain strict aseptic technique in the procedure / treatment of injuries.
Rational: reducing the risk of colonization / infection of bacteria.
- Provide skin care, perianal and oral carefully.
Rational: reducing the risk of damage to the skin / tissue and infection.
- Motivation changes in position / ambulation frequently, coughing and breathing exercises that deep.
Rational: to improve the ventilation of all lung segments, and help mobilize secretions to prevent pneumonia.
- Increase adequate fluids.
Rational: to assist in the dilution of respiratory secretions to facilitate the spending and prevent stasis of body fluids such as respiratory and kidney.
- Monitor / limit visitors. Provide insulation if possible.
Rational: to limit exposure to the bacteria / infection. Protection of insulation required in aplastic anemia, when the immune response is disrupted.
- Monitor body temperature. Note the chills and tachycardia with or without fever.
Rational: the process of inflammation / infection require evaluation / treatment.
- Observe erythema / wound fluid.
Rational: indicators of local infection. Note: the formation of pus may not exist when granulocytes depressed.
- Take specimens for culture / sensitivity as indicated (collaboration)
Rational: differentiate an infection, identify the specific pathogen and affect treatment options.
- Give a topical antiseptic; systemic antibiotics (collaboration).
Rational: propilaktik may be used to reduce colonization or for the treatment of local infection process.
2. Activity intolerance related to imbalance between oxygen supply (delivery) and demand.
Able to maintain / improve ambulation / activity.
Expected Outcomes :
- Reported an increase in activity tolerance (including daily activities).
- Indicates decrease in physiological signs of intolerance, such as pulse, respiration, and blood pressure is still within the normal range.
- Monitor vital sign (Blood Pressure, pulse, and respirations) during and after activity.
Rational : Cardiopulmonary manifestations result from attempts by the heart and lungs to supply adequate amounts of oxygen to the tissues.
- Assess patient ability to perform ADLs
Rational : Influences choice of interventions and needed assistance.
- Provide or recommend assistance with activities and ambulation as necessary, allowing client to be an active participant as much as possible.
Rational : Although help may be necessary, self-esteem is enhanced when client does some things for self.
- Suggest client change position slowly; monitor for dizziness.
Rational : Postural hypotension or cerebral hypoxia may cause dizziness, fainting, and increased risk of injury.
- Identify and implement energy-saving techniques
Rational : Encourages client to do as much as possible, while conserving limited energy and preventing fatigue.
- Instruct client to stop activity if palpitations, chest pain, shortness of breath, weakness, or dizziness occur.
Rational : Cellular ischemia potentiates risk of infarction, and excessive cardiopulmonary strain and stress may lead to decompensation and failure.