Nursing Care Plan Splenectomy

Splenectomy is the surgical removal of the spleen. It is done for rupture or tearing of the spleen caused by trauma, for damage caused by diseases such as infections mononucleosis, or for hypersplenism caused by idiopathic thrombocytopoenic purpura or lymphoma, leukemia diseases.

Nursing diagnosis: high risk for infection related to inadequate secondary defenses by immunosuppresion resulting from decreased immunoglobulins.

Expected outcomes: Absence of infection evidenced by temperature, white blood cell, urinalysis, cultures within normal ranges, breath sounds, urinary pattern, mucous membranes within baseline levels.

Nursing intervention and rationale:
I. Assess for:
  1. Temperature elevation above 101 degrees Celsius, chills, increased pulse above 100. Low grade temperature common following splenectomy for 7-10 days.
  2. Tachypnea, ronchi, crackles, cloudy foul smelling urine, urgency frequency, irritation ulcers of oral, vaginal or other mucosa; redness or drainage from wound or invasive sites. Indicates pneumococcal infection or overwhelming infection as phagocytic ability of spleen to destroy encapsulated organisms is lost.
  3. Hypotension, shock-like state. Indicates potential for meningeal infection.
II. Monitor, Describe, Record:
  1. White blood cells increases, urine, blood and wound cultures and sensitivities. WBC of > 10,000 cu/mm positive cultures for infectious organisms.
  2. Immunoglobulins. IgM decreases, IgG ad IgA within normal ranges indicating deficiencies.
  3. Vital signs and temperature every four hours. Indicates presence of infection.
III. Administer:
  1. Antibiotics specific to identified infectious agent. Acts to destroy microorganisms by inhibiting cell wall synthesis.
  2. Antipyretic (acetaminophen). Reduces fever by inhibiting heat-regulating center.
IV. Perform or provide:
  1. Handwash techniques before giving care. Prevents cross-contamination.
  2. Aseptic technique for any invasive procedures. Prevents introduction of infectious agents.
  3. Adequate fluids, nutritional and activity support. Maintains support to prevent susceptibility to infection.
  4. Meticulous mouth and perineal care. Promotes comfort and care of suceptible mucosal areas


Post a Comment

Copyright © 2012. HealthWise - Posts · Comments
Theme Template by BTDesigner · Powered by Blogger