Decreased platelets 9. Iron deficiency is defined as a decreased total iron body content. Barriers to oral self-care 4. Which of the following blood study results would the nurse expect as most likely when caring for the child with iron deficiency anemia? Search results. Oral fluids are needed for moisture to membranes. Encouragement and reinforcement of oral care are significant to oral outcomes. Information collected during the assessment must be understood and discussed with team members, client families, and interdisciplinary service providers. Eating a diet high in fiber and drinking a lot of fluids to avoid constipation or using a stool softener and other laxatives as prescribed if having difficulty passing stool. Class 5. Hematopoietic stem cell transplantation (HCT) is an effective therapy for many life-threatening diseases. Get Essay. Diagnosing a type of anemia will be based on the changes in the RBC indexes and the findings in the bone marrow aspiration. Explain that immunosuppressive therapy is the treatment of choice in clients without HLA-matched donors and/or older than 40 years of age. Client will verbalize understanding of own disease and treatment plan. The care plans' structure is formed according to the nursing care system applied, and for this reason, it can take a variety of forms (Björvell, 2002; Mason, 1999). Inaccurate follow-through of instructions. The treatment of choice in clients without HLA-matched donors is immunosuppression with granulocyte-macrophage-colony-stimulating factors, cyclophosphamide, anti-thymocyte globulin, and cyclosporine. Earliest symptoms include a red maculopapular rash, dryness of the eye, abdominal pain, and jaundice. Client will have a reduced risk for bleeding, as evidenced by normal or adequate platelet levels and absence of bruises and petechiae. Depression 11. Looking for nursing daignosis Nurseslabs – NCLEX Practice Questions, Nursing Study Guides, and Care Plans, Impaired Oral Mucous Membrane Nursing Care Plan, Nursing Test Bank and Nursing Practice Questions for Free, NCLEX Practice Questions Test Bank (2021 Update), Nursing Pharmacology Practice Questions & Test Bank for NCLEX (500+ Questions), Arterial Blood Gas Analysis Made Easy with Tic-Tac-Toe Method, Select All That Apply NCLEX Practice Questions and Tips (100 Items), IV Flow Rate Calculation NCLEX Reviewer & Practice Questions (60 Items), EKG Interpretation & Heart Arrhythmias Cheat Sheet. Nursing care plan is categorized and organized into four columns which include nursing diagnosis, outcomes and goals, nursing interventions, and their further evaluation. Baseline and subsequent assessment findings to include signs and symptoms. Client will have a reduced risk of infection as evidenced by an absence of fever, normal white blood cell count, and implementation of preventive measures such as proper hand washing. See Also. Mycostatin, nystatin, and Mycelex Troche are commonly prescribed. Iron uptake in the proximal small bowel occurs by 3 separate pathways; these are the heme pathway and 2 distinct pathways for ferric and ferrous iron. Iron deficiency anemia develops when body stores of iron drop too low to support normal red blood cell (RBC) production. Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale. Risk for Infection: At increased risk for being invaded by pathogenic organisms. Intramuscular injections are also available given via Z-track method to prevent leakage of the solution in the subcutaneous tissue along the needle tract. Educate the client and the family regarding food rich in iron, folic acid, and vitamin B12. Floss smoothly. Nursing Diagnosis: Pain related to joint inflammation secondary to gout, as evidenced by pain score of 10 out of 10, guarding sign on the affected joints, restlessness, and irritability. The therapist also can help the client and family evaluate the need for additional energy-conservation measures in the home setting. The nurse determines that the client understands the dietary instructions if she selects which of the following from her menu? Anticipate the need for a platelet transfusion once the platelet count drops to a very low value. Attainment or progress toward the desired outcome. Interventions: Rationales: Assess the patient’s vital signs. It serves as a guide in anticipating the patient’s healthcare needs. Packed RBCs increase oxygen-carrying capacity of the blood. Whereas body loss of iron quantitatively is as important as absorption in terms of maintaining iron equilibrium, it is a more passive process than absorption. Educate the client and the family regarding replacement therapy with folic acid and iron. It is critical to compare serial laboratory values to evaluate progression or deterioration in the client and to identify changes before they become potentially life-threatening. Oral examination can show signs of oral disease, symptoms of systemic disease, drug side effects, or trauma of the oral cavity. Risk for Bleeding: At risk for a decrease in blood volume that may compromise health. Chemical trauma (e.g., acidic foods, drugs, noxious agents, alcohol) 6. Cultures of the teeth of critically ill patients have produced notable bacterial colonization, which can cause nosocomial. It is very rare a non-breastfeeding woman can experience mastitis but it does happen. Alcohol dries the oral mucous membranes Hydrogen peroxide can injure oral mucosa and is remarkably foul-tasting to patients. 3. The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. Moisture promotes the cleansing effect of saliva and helps avert mucosal drying, which can result in erosions, fissures, or lesions. Not all self-care and hygiene activities need to be completed i the morning. He weighs 44 lbs. Skin rash and mouth sores are among the common initial signs of the disease. Nutritional expertise may be necessary to optimize the therapeutic diet needed to facilitate healing. One unit of packed RBC raises the hemoglobin level by 1 g/dL. These food items can harbor bacteria. (Ackley, 2014 p. 179) Identify the NANDA defining characteristics that … Very severe pain–Client rate her pain as 8 from the range of 110(Having the rate of 10 as the most painful and 1 as the least painful) ? A simple fever is significant enough not to pay attention to. Inspect the status of the oral mucosa; include the: A well-organized assessment should be performed of listed sites using a tongue blade to show areas of the oral cavity. Iron deficiency is the most prevalent single deficiency state on a worldwide basis. Lemon-glycerin swabs can result in decreased salivary amylase and oral moisture, as well as erosion of tooth enamel. Client will have vital signs within the normal limit. Good luck! Chewing stimulates gingival tissue and promotes circulation. Nurses assigned to the patient continuously update the plan as they carry out planned interventions in their respective shifts. Once you learn how to write nursing care plans, your confidence will increase. Maternal and Child Health Nursing (NCLEX Exams), Medical and Surgical Nursing (NCLEX Exams), Pharmacology and Drug Calculation (NCLEX Exams), Medical & Surgical Nursing (Mnemonics and Tips), Pharmacology Nursing (Mnemonics and Tips), Psychiatric Nursing Nursing (Mnemonics and Tips), Human Chorionic Gonadotropin (hCG) Pregnancy Test. Assess the client’s ability to perform activities of daily living (ADLs), and the demands of daily living. Assess current knowledge of the diagnosis, disease process, possible causative factors, and treatment. Refer the patient to the dietitian for instructions on the maintenance of a well-balanced diet. If whitish plaques are evident in the mouth or on the tongue and can be rubbed off readily with gauze, leaving a red base that bleeds, suspect a fungal infection and contact the physician for follow-up. Holistic approach in providing safe and quality patient care is integrated. Assess the severity of ulcerations involving the intraoral soft tissues, including the palate, tongue, gums, and lips. Clients with Chronic GVHD may present with a variety of symptoms. A nursing care plan (NCP) is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. The oral cavity has seldom been described as a mirror because it reflects the health of a person. This nursing care plan is for patients who have impaired oral mucous membranes. Instruct patient to hold solution for several minutes before expectoration. Baking soda promotes further cleansing of teeth. Instruct the client about medications that may stimulate RBC production in the bone marrow. *FREE NURSING … Severe mucositis may manifest as any of the following: Fungal infection due to any type of Candida (a type of yeast); cottage cheese-like white or pale yellowish patches on tongue, buccal mucosa, and, Common viral infection; painful itching vesicle (typically on upper lips) that ruptures within 12 hours and becomes encrusted with a dried exudate, Dry, raised, wartlike yellowish-brown, round plaques on buccal mucosa, creamy to yellow-white, shiny, nonpurulent patches often seated on painful, red, superficial mucosal ulcers and erosions. Click here to visit Care24 and know more about av fistula nursing care plan and broach other such areas. Organization and time management can help the client conserve energy and reduce fatigue. Client will verbalize reduction of fatigue, as evidenced by reports of increased energy and ability to perform desired activities. 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