ASUHAN KEPERAWATAN

TUJUAN

INTERVENSI

RASIONAL

1. RISK FOR INFECTION RELATED TO IMMUNOSUPPRESSION

NIC Priority Intervention: Infection
Control: minimizing the acquisition
and transmission of infectious agents
Risk factor for infection
will be eliminated as
evidenced by infection
control

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Assess the child every 2-4 hour for fever;lesions in

the mouth;rednes;inflammation;soreness;and
lesions on the skin or around intravenous lines
Auscultate for changes in breath sounds every 2
hours. Perform pulmonary toilet (coughing, deep
breathing, incentive spirometry) every 24 hours.
Enforce strict handwashing. Allow no fresh
flowers, fruits, or vegetables in childs room.
Screen visitors for colds or recent exposure to
varicella. Use blood and body fluid precautions
(refer to the Skills Manual). Practice strict asepsis
for dressing changes and suctioning
Coordinate patient care assignments to avoid
exposing the child to individuals with recent
infections or immunizations
Organize patient care activities to allow for
adequate period of rest
Follow recommendations of CDC and AAP for
immunizing immunosuppressed children. Avoid
live oral polio virus vaccine and live varcella
vaccine. Perform annual TB testing.

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Fever is one of the few signs of

infections in the immunoappressed
child who does not have o sufficient
number of white blood child
Pneumonia is a likely infection in
the child with AIDS
Control of environmental factors
helps prevent infection.
Planning minimizes chances for
infection.
Rest periods allow the child to
regain energy.
Special recommendations consider
the childs decreased immune
response and the danger of acquiring
disease from certain live virus
vaccines.