Nursing Study Guide/Care of Haematological Needs

Care for client with immune impairment

• Isolate client and provide gloves, gown and masks for visitors and health workers to reverse barrier (protect client)
• Prioritize care to minimize disruption to clients environment, clean procedures first.
• Use single room if CRP >15 Pressuruized room if client CRP>60
• Avoid introduced food, gifts and flowers
• Allocate daily cleaning
• Select diet with high lactobacillus and good food safety (eg no icecream because of the bacteria count)
• Eliminate fresh salads and unpeeled fresh fruits or vegetables.
• Deep breathing and coughing to avoid stagnation.
• Provide client with mask for ambulation outside room.
• Observe and protect skin (prevent breakdown)
• Observe fastidious hygiene measures and five moments of hand hygiene.
• Mouth care and disinfectant mouthwash
• Monitor IV site and Consider Central line to prevent peripheral thrombophlebitis.
• Four hourly vital signs.
• Continue until white cell count is in normal range (ANS Absolute Neutrophile count >1500 cells per microliter)
• ICNP diagnosis 10022996 Immunologic Impairment or equivalent

References

• International Classification for Nursing Practise browser
• ICNP maps to other codes
• Australian immunization schedule