Nursing Care Plan: readiness for enhanced Immunization Status

Creat by Nursing Guide in Nursing Care Plans

on 21 Aug 12 0 Comments

Nursing Care Plan: readiness for enhanced Immunization Status Definition: A pattern of conforming to local, national, and/or international standards of immunization to prevent infectious disease(s) that is sufficient to protect a person, family, or community and can be strengthened Defining Characteristics Subjective

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Expresses desire to enhance: Knowledge of immunization standards Immunization status Identification of providers of immunizations Record-keeping of immunizations Identification of possible problems associated with immunizations Behavior to prevent infectious diseases Desired Outcomes/Evaluation Criteria Client Will: Express understanding of immunization recommendations. Develop plan to obtain appropriate immunizations. Identify and adopt behaviors to reduce risk of infectious disease. Maintain and update immunization records. Community Will: Provide information to community regarding immunization requirements or recommendations. Identify underserved populations requiring immunization support and ways to meet their needs. Develop plan to provide mass immunizations in time of major threat or disease outbreak. Actions/Interventions Assess clients history of immunizations. Rationale: Response may vary widely depending on clients age (infant to adult), cultural influences, travel history, family beliefs about immunization, and medical conditions (e.g., some vaccines should not be given to children with certain cancers, persons taking immunosuppressant drugs, or those with serious allergies to eggs).

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Ascertain motivation and expectations for change. Determine if adult client works in or frequents high-risk areas (e.g., doctors office, home care, homeless or immigrant shelters or clinics, correctional facility). Rationale: to review potential exposures and determine new vaccines or boosters client may need. Address clients/SOs concerns (e.g., client may wonder if annual flu shots are truly beneficial, or whether adult boosters may be needed for particular immunizations received in child- hood; parent may be concerned about safety of vaccine supply). Rationale: Helps to clarify plans and deal with misconceptions or myths.

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Identify conditions that may preclude client receiving specific immunizations Rationale: such as history of prior adverse reaction, current fever illness, pregnancy, and current cancer or other immunosuppressant treatments. Review community plan for dealing with immunizations and disease outbreak. Rationale: Identifies community strengths and limitations. Review parents knowledge regarding immunizations recommended or required to enter school (e.g., hepatitis B, rotavirus, Haemophilus influenzae, mumps/measles/rubella (MMR), varicella, and hepatitis A prior to kindergarten;

tetanus/diphtheria/pertussis (TDP), human papillomavirus by middle-school age; meningitis for college freshmen planning to live in dorm) Rationale: to document status, plan for boosters, and/ or discuss appropriate intervals for follow-up. 8. 9. Review protective benefit of each vaccine, route of administration, expected side effects, and potential adverse reactions. Rationale: so that client/SO(s) can make informed decisions. Discuss appropriate time intervals for all recommended immunizations, as well as catch-up and booster options for children birth to 18 years. 10. Identify requirements for client preparing for international travel Rationale: to ascertain potential for contracting vaccinepreventable disease in geographical area of clients travel, so that vaccines can be provided, if needed. 11. Inform of exemptions when client/SO desires. Rationale: Some states permit medical, religious, personal, and philosophical exemptions when parent does not want child to participate in immunization programs. Refer to appropriate care providers for further discussion or intervention. 12. Define and discuss current needs and anticipated or projected concerns of community health promotion programs. Rationale: Agreement on scope and parameters of needs is essential for effective planning. 13. Prioritize goals. Rationale: to facilitate accomplishment. 14. Identify available community resources (e.g., persons, groups, financial, governmental, as well as other communities). 15. Seek out and involve underserved and at-risk groups within the community. Rationale: Supports communication and commitment of community as a whole. 16. Review reasons to continue immunization programs. Rationale: Viruses and bacteria that cause vaccine-preventable disease and death still exist and can be passed on to people who are not protected, thus increasing medical, social, and economic costs. 17. Provide reliable vaccine information in written form or Internet Web sites (e.g., brochures or fact sheets from the CDC, American Academy of Pediatrics, National Network for Immunization Information). 18. Identify community resources for obtaining immunizations, such as Public Health Department, family physician. 19. Discuss management of common side effects (e.g., muscle pain, rash, fever, site swelling). 20. Support development of community plans for maintaining and enhancing efforts Rationale: to increase immunization level of population. 21. Establish mechanism for self-monitoring of community needs and evaluation of efforts. 22. Use multiple formats: for example, TV, radio, print media, billboards and computer bulletin boards, speakers bureau, reports to community leaders and groups on file and accessible to the public. Rationale:to keep community informed regarding immunization needs, disease prevention. Documentation Focus Assessment/Reassessment

Assessment findings of immunization status, potential risks or disease exposure. Identified areas of concern, strengths and limitations. Understanding of immunization needs, safety concerns, and disease prevention. Motivation and expectations for change. Planning Action plan and who is involved in planning. Teaching plan. Implementation/Evaluation Individual/family responses to interventions, teaching, and actions performed. Response of community entities to the actions performed. Attainment or progress toward desired outcome(s). Modifications to plan.

Discharge Planning

Identified needs, referrals for follow-up care, support systems. Short- and long-term plans to deal with current, anticipated, and potential community needs and who is responsible for followthrough. Specific referrals made, coalitions formed. References: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2011). Nurses pocket guide, diagnoses, prioritized interventions, and rationales. (12 ed.). F A Davis Co.