Nursing Care Plan: readiness for enhanced Immunization Status

Creat by Nursing Guide

in Nursing Care Plans

on 21 Aug 12

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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

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

1. Assess client’s history of immunizations. Rationale: Response may vary widely depending on client’s

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).

2. Ascertain motivation and expectations for change.

3. Determine if adult client works in or frequents high-risk areas (e.g., doctor’s 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.

4. Address client’s/SO’s 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.

5. 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.

6. Review community plan for dealing with immunizations and disease outbreak.   Rationale:   Identifies

community strengths and limitations.

7. 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. 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.

9. 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 vaccine-preventable disease in geographical area of client’s 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 follow-through.

Specific referrals made, coalitions formed.

References: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2011).Nurse’s pocket guide, diagnoses,

prioritized interventions, and rationales. (12 ed.). F A Davis Co.