Nursing Diagnosis-readiness For Enhanced Immunization Status 491y42

Nursing

Outcome

Diagnosis

Criteria

Nursing Intervention

Readiness for

After 3 hours of

enhnaced

nursing

current immunizaton

immunization

intevention, the

status.

status

patient will be able to:

related to the

1. Determine patient's

Evaluation

Goal met.

Discharge Planning

Medication 1. Gardasil and Cervarix

After 3 hours of

protect against the two HPV types (HPV-16

nursing

and HPV-18) that cause 70% of cervical

* Assess client's history of

intevention, the

cancers, 80% of anal cancers, 60% of

immunizations.

patient was able

vaginal cancers, and 40% of vulvar

to:

cancers.

desire to

1. Express

*Determine if the patient is high

enhance

understanding of

risk to develop sexually

knowledge on

immunization

transmitted infections to review

Express

include:very high fever, weakness, tingling,

new HPV

recommendations

potential exposures.

understanding

or paralysis (which may be signs of

* Address client's concern .This

of immunization

Guillain-Barré syndrome),

will help clarify plans and deal

recommendatio

signs of an allergic reaction, including

with misconceptions or myths.

ns; She

difficulty breathing, wheezing, an unusual

vaccine

2. The side effects of these medications

* Ascertain or discuss conditions verbalized,

skin rash, itching, or hives

that may hinder the client from

" Damu nga

Environmental Modificatons

receiving the HPV vaccine.

banepisyo ang

1. It is recommended that patients be

mahatag sang

observed for 15 minutes after the

HPV vaccine.

vaccination, to make sure that fainting does

develop or strengthen

Mapaimmunize

not occur in a dangerous situation (such as

plan to meet identified

ako."

while driving). Keep the patient safe at

2. Assisst the client to

needs.

home. Teaching

* Review patient's knowledge or

1. Vaccinated women will still need regular

information regarding

cervical cancer screening (Pap tests)

immunizations recommended to

because the vaccines protect against most

discuss appropriate intervals for

but not all HPV types that cause cervical

follow up.

cancer. Also, women who got the vaccine

* Discuss with the client the

after becoming sexually active may not get

protective benefit of th HPV

the full benefit of the vaccine if they had

vaccine, route of istration,

already acquired HPV.

expected side effects and

Home Instuction

potential adverse reactions so

1. Note for development of side effects or

that the client can make

adverse reactions.

inforemed decisions.

2. Have a written record of the patient’s

* Discuss appropriate time

next shot to help compliance.

intervals for the HPV vaccine .

Out-patient Follow Up 1.Encourage patient’s compliance with

3. Promote wellness.

appointments with the health care provider and encourage regular health check ups.

* Review reasons to continue

Drug Interactions

immunization programs.

1. Drugs that may interact with the HPV

* Discuss management of

vaccine include immunosuppressants and

common side effects.

anti coagulants. Provide information to patient. Social 1.Ask for the of the patient’s significant others to assist th patient.