Objective Data

Preventive Care
1. Checkup visits recommended every 1 to 3 years until age 65 and then yearly thereafter. See Table 7-1 for suggested timelines.
2. Individuals with special risk factors may need more frequent and additional types of preventive care.
3. Adult immunizations - prevention of disease and reduction in the severity of disease (Table 7-2).
Assessment is followed by analysis of data and formulation of a nursing diagnosis. Possible nursing diagnoses for each category of human functioning are given in the following sections.

TABLE 7-1 Preventive Care Timelines

Vaccine Name and Route	For Whom It Is Recommended	Schedule	Contraindications and Precautions (Mild Illness Is Not a Contraindication)
Influenza (“flu shot") — give IM	Adults who are 60 years of age or older. People 6 mo-65yr of age with medical problems such as heart disease, lung disease, diabetes, renal dysfunction, hemoglobinopathies, immunosuppression, or those living in chronic care facilites. People (≥6 mo of age) working or living with at-risk people. All health care workers and those who provide key community. Healthy pregnant women who will be in their 2nd or 3rd trimesters during the influenza season. Pregnant women who have underlying medical conditions should be vaccinated before the flu season, regardless of the stage of pregnancy. Anyone who wishes to redusce the likelihood of becoming ill with influenza. Travelers to areas where influenza activity exists or when traveling among people from areas of the world where there is current influenza activity.	Given every year October through November is the optimal time to receive an annual flu shot to maximize protection, but the vaccine may be given at any time during the influenza season (typically December through March) or at other times when the risk of influenza exists. May be given anytime during the influenza season. May be given wit all other vaccines but at a separate site.	Routinely given as a one-time dose; administer if previous vaccination history is unknown. One-time revaccination is recommended 5 years later for people at highest risk of fatal pneumococcal infection or rapid antibody loss (eg. renal disease) and for people ≥65 years if the 1st dose was given before age 65 and ≥5 years have elapsed since previous dose. May be given with all other vaccines but at a separate site.
Pneumococcal—give IM or SC	Adults who are 65 years of age or older. People 2 yr-65 yr of age who have chronic illness or other risk factors including chronic cardiac or pulmonary diseases, chronic liver disease, alcoholism, diabetes mellitus, CSF leaks, as well as persons living in special environments or social settings(including Alaska natives and certain American Indian populations). Those at highest risk of fatal pneumococcal infection are persons with anatomical or functional asplenia (including sickle cell disease); immunocompromised persons, including those with HIV infection, leukemia, lymphoma, Hodgkin's disease, multiple myeloma, generalized malignancy, chronic renal failure, or nephrotic syndrome; those receiving immunosuppressve chemotherapy (including corticosteroids); and those who received an organ or bone marrow transplant.	Given every year October through November is the optimal time to receive an annual flu shot to maximize protection, but the vaccine may be given at any time during the influenza season (typically December through March) or at other times when the risk of influenza exists. May be given anytime during the influenza season. May be given wit all other vaccines but at a separate site.	Previous anaphylactic reaction to this vaccine, to any of its components. Moderate or severe acute illness.
Hepatitis B—Hepatitis B (hep-B)— give IM; brands may be used interchangeably.	High-risk adults including household contacts and sex partners of HBsAg-positive persons; users of illicit injectable drugs; heterosexuals with more than one sex partner in 6 months; men who have sex with men; people with recently diagnosed STDs; patients in hemodialysis units and patients with renal disease that may result in dialysis; recipients of certain blood products; health care workers and public safety workers who are exposed to blood; clients and staff of institutions for the developmentally disabled; inmates of long-term correctional facilites; and certain international travelers, Note: Prior serological testing may be recommended depending on the specific level of rsk or likelihood of previous exposure. All adolescents. Note: In 1997, the NIH Consensus Development Conference, a panel of national experts, recommended that hepatitis B vaccination be given to all persons infected with hepatitis C virus. Do serolagic screening for people who have emigrated from endemic areas. When HBsAg-positive persons are identified, offer them appropriate disease management. In addition, screen their household members and intimate contacts and, if found susceptible, vaccinate.	Three doses are needed on a 0, 1, 6 mo schedule. Alternative timing options for vaccination include: 0, 2, 4 months 0, 1, 4 months There must be 4 wk between doses #1 and #2, and 8 wk between doses #2 and #3. Overall there must be at least 4 mo between doses #1 and #3. Schedule for those who have fallen behind: Ifthe series is delayed between doses, do not start the series over. Continue from where you left off. May be given with all other vaccines but at a separate site.	Previous anaphylactic reaction to this vaccine, to any of its components. Moderate or severe acute illness.
Hepatitis A (hcp-A)— give IM: brands may be used interchangeably	People who travel outside of the United States (except for Northern and Western Europe, New Zealand, Australia, Canada, and Japan). People with chronic liver disease, including people with hepatitis C virus infection; people with hepatitis B who have chronic liver disease: illicit drug users: men who have sex with men: people with clotting-factor disorders; people who work with hepatitis A virus in experimental lab settings (this does not refer to routine medical laboratories); and food handlers where health authorities or private employers determine vaccination to be cost-effective. Note: Prevaccination testing is likely to be cost-effective for persons >40 yr of age, as well as for younger persons in certain groups with a high prevalence of hepatitis A virus infection.	Two doses are neeeded The minimum interval between dose #1 and #2 is 6 mo. If dose #2 is delayed, do not repeat dose #1. Just give dose #2. May be given with all other vaccines but at a separate site.	Previous anaphylactic reaction to this vaccine, to any of its components. Moderate or severe acute illness. Safety during pregnancy has not been determined, so benefits must be weighed against potential risk.
Td(tetanus, diphtheria)—give IM	All adolescents and adults. After the primary series has been completed, a booster dose is recommended every 10 years. Make sure your patients have received a primary series of 3 doses. A booster dose as early as 5 years later may be needed for the purpose of wound management, so consult ACIP recommendations.	Booster dose every 10 years after completion of the primary series of three doses. For those who have fallen behind: The primary scries is three doses: Give dose #2 four weeks after fl. #3 is given 6-12 months after #2. May be given with all other vaccines but at a separate site.	Previous anaphylactic reaction to this vaccine, to any of its components. Moderate or severe acute illness.
MMR(measles, mumps, rubella)—give SC	Adults born in 1957 or later who arc ≥18 yr of age (including those born outside the United States) should receive at least one dose of MMR if there is no serological proof immunity or documentation of a dose given on or after 1st birthday. Adults in higli-risk groups, such as health care workers, students entering colleges and other post-high school educational institutions, and international travelers should receive a total of two doses. All women of childbearing age (i.e., adolescent girls and premenopausal adult women) who do not have acceptable evidence of rubella immunity or vaccination. Note: Adults born before 1957 are usually considered immune, but proof of immunity may be desirable for health care workers.	One or two doses are needed. If dose #2 is recommended, give it no sooner than 4 wk after dose #1. May be given with all other vaccines but at a separate site. If varicella vaccine and MMR are both needed and are not administered on the same day, space them at least 4 wk apart.	Previous anaphylactic reaction to this vaccine or to any of its components. (Anaphylactic reaction to eggs is no longer a contraindication to MMR.) Pregnancy or possibility of pregnancy within 3 months. Immunocompromised persons due to cancer, leukemia, lymphoma, immunosuppressive drug therapy, including high-dose steroids or radiation therapy. If blood products or immune globulin has been administered during the past 11 months, consult the ACIP recommendations regarding time to wait before vaccinating. Moderate or severe acute illness. Note: MMR is not contraindicated if a PPD test was done recently. PPD should be delayed for 4-6 weeks after an MMR has been given.
Varicella (var), “chickenpox shot"—give SC	All susceptible adults and adolescents should be vaccinated. Make special efforts to vaccinate susceptible persons who have close contact with persons at high risk for serious complications (e.g., health care workers and family contacts of immunocompromised persons) and susceptible persons who are at high risk of exposure (e.g., teachers of young children, day care employees, residents and staff in institutional settings such as colleges and correctional institutions, military personnel, adolescents and adults living with children, nonpregnant women of childbearing age. and international travelers who do not have evidence of immunity). Note: People with reliable histories of chickenpox (such as self or parental report of disease) can be assumed to be immune. For adults who have no re liable history, serological testing may be cost-effective because most adults with a negative or uncertain history of varicella are immune.	Two doses are neeeded Dose #2 is given 4-8 wk after dose #1. May be given with all other vaccines but at a separate site. If varicella vaccine and MMR are both needed and arc not administered on the same day, space them at least 4 wk apart. if the second dose is delayed, do not repeat dose #1. Just give dose #2.	Previous anaphylactic reaction to this vaccine or to any of its components. Pregnancy, or possibility of pregnancy within 1 month. Immunocompromised persons due to malignancies and primary or acquired cellular immunodeficiency, including HIV/AIDS. Note: For those on highdose immunosuppressive therapy, consult ACIP recommendations regarding delay time. If blood products or immune globulin have been administered during the past 5 months, consult the ACIP recommendations regarding time to wait before vaccinating. Moderate or severe acute illness. Note: Manufacturer recommends that salicylates be avoided for 6 weeks after receiving varicella vaccine because of a theoretical risk of Rcye syndrome.
Polio(IPV)—give IM or SC	Not routinely recommended for persons 18 years of age and older. Note: Adults living in the United States who never received or completed a primary series of polio vaccine need not be vaccinated unless they intend to travel to areas where exposure to wild-type virus is likely. Previously vaccinated adults should receive one booster dose if traveling to polio endemic areas.	Four doses of inactivated polio vaccine (IPV) at 2,4, and 6-18 mo, and 4-6 yr. May be given with all other vaccines but at a separate site.
Lyme disease—give IM	Consider for persons 15-70 years of age who reside, work, or recreate in areas of high or moderate risk and who engage in activities that result in frequent or prolonged exposure to tick-infested habitat. Persons with a history of previous uncomplicated Lyme disease who are at continued high risk for Lyme disease. (Sec description in the first bullet.) See ACIP statement for a definition of high and moderate risk.	Three doses are needed. Give at intervals of 0, 1, and 12 mo. Schedule dose #1 (given in year 1) and dose #3 (given in year 2) to be given several weeks before tick season. See ACIP statement for details. Safety of administering Lyme disease vaccine with other vaccines has not been established. ACIP says if it must be administered concurrently with other vaccines, give it at a separate site.	Previous anaphylactic reaction to this vaccine or to any of its components. Pregnancy. Moderate or severe acute illness. Persons with treatment-resistant Lyme arthritis. There are not enough data to recommend Lyme disease vaccine to persons with these conditions: immunodeficiency, diseases associated with joint swelling (including rheumatoid arthritis) or diffuse muscular pain, chronic health conditions due to Lyme disease.
Hepatitis A (hcp-A)— give IM: brands may be used interchangeably	People who travel outside of the United States (except for Northern and Western Europe, New Zealand, Australia, Canada, and Japan). People with chronic liver disease, including people with hepatitis C virus infection; people with hepatitis B who have chronic liver disease: illicit drug users: men who have sex with men: people with clotting-factor disorders; people who work with hepatitis A virus in experimental lab settings (this does not refer to routine medical laboratories); and food handlers where health authorities or private employers determine vaccination to be cost-effective. Note: Prevaccination testing is likely to be cost-effective for persons >40 yr of age, as well as for younger persons in certain groups with a high prevalence of hepatitis A virus infection.	Two doses are neeeded The minimum interval between dose #1 and #2 is 6 mo. If dose #2 is delayed, do not repeat dose #1. Just give dose #2. May be given with all other vaccines but at a separate site.	Previous anaphylactic reaction to this vaccine, to any of its components. Moderate or severe acute illness. Safety during pregnancy has not been determined, so benefits must be weighed against potential risk.
Td(tetanus, diphtheria)—give IM	All adolescents and adults. After the primary series has been completed, a booster dose is recommended every 10 years. Make sure your patients have received a primary series of 3 doses. A booster dose as early as 5 years later may be needed for the purpose of wound management, so consult ACIP recommendations.	Booster dose every 10 years after completion of the primary series of three doses. For those who have fallen behind: The primary scries is three doses: Give dose #2 four weeks after fl. #3 is given 6-12 months after #2. May be given with all other vaccines but at a separate site.	Previous anaphylactic reaction to this vaccine, to any of its components. Moderate or severe acute illness.
MMR(measles, mumps, rubella)—give SC	Adults born in 1957 or later who arc ≥18 yr of age (including those born outside the United States) should receive at least one dose of MMR if there is no serological proof immunity or documentation of a dose given on or after 1st birthday. Adults in higli-risk groups, such as health care workers, students entering colleges and other post-high school educational institutions, and international travelers should receive a total of two doses. All women of childbearing age (i.e., adolescent girls and premenopausal adult women) who do not have acceptable evidence of rubella immunity or vaccination. Note: Adults born before 1957 are usually considered immune, but proof of immunity may be desirable for health care workers.	One or two doses are needed. If dose #2 is recommended, give it no sooner than 4 wk after dose #1. May be given with all other vaccines but at a separate site. If varicella vaccine and MMR are both needed and are not administered on the same day, space them at least 4 wk apart.	Previous anaphylactic reaction to this vaccine or to any of its components. (Anaphylactic reaction to eggs is no longer a contraindication to MMR.) Pregnancy or possibility of pregnancy within 3 months. Immunocompromised persons due to cancer, leukemia, lymphoma, immunosuppressive drug therapy, including high-dose steroids or radiation therapy. If blood products or immune globulin has been administered during the past 11 months, consult the ACIP recommendations regarding time to wait before vaccinating. Moderate or severe acute illness. Note: MMR is not contraindicated if a PPD test was done recently. PPD should be delayed for 4-6 weeks after an MMR has been given.
Varicella (var), “chickenpox shot"—give SC	All susceptible adults and adolescents should be vaccinated. Make special efforts to vaccinate susceptible persons who have close contact with persons at high risk for serious complications (e.g., health care workers and family contacts of immunocompromised persons) and susceptible persons who are at high risk of exposure (e.g., teachers of young children, day care employees, residents and staff in institutional settings such as colleges and correctional institutions, military personnel, adolescents and adults living with children, nonpregnant women of childbearing age. and international travelers who do not have evidence of immunity). Note: People with reliable histories of chickenpox (such as self or parental report of disease) can be assumed to be immune. For adults who have no re liable history, serological testing may be cost-effective because most adults with a negative or uncertain history of varicella are immune.	Two doses are neeeded Dose #2 is given 4-8 wk after dose #1. May be given with all other vaccines but at a separate site. If varicella vaccine and MMR are both needed and arc not administered on the same day, space them at least 4 wk apart. if the second dose is delayed, do not repeat dose #1. Just give dose #2.	Previous anaphylactic reaction to this vaccine or to any of its components. Pregnancy, or possibility of pregnancy within 1 month. Immunocompromised persons due to malignancies and primary or acquired cellular immunodeficiency, including HIV/AIDS. Note: For those on highdose immunosuppressive therapy, consult ACIP recommendations regarding delay time. If blood products or immune globulin have been administered during the past 5 months, consult the ACIP recommendations regarding time to wait before vaccinating. Moderate or severe acute illness. Note: Manufacturer recommends that salicylates be avoided for 6 weeks after receiving varicella vaccine because of a theoretical risk of Rcye syndrome.
Polio(IPV)—give IM or SC	Not routinely recommended for persons 18 years of age and older. Note: Adults living in the United States who never received or completed a primary series of polio vaccine need not be vaccinated unless they intend to travel to areas where exposure to wild-type virus is likely. Previously vaccinated adults should receive one booster dose if traveling to polio endemic areas.	Four doses of inactivated polio vaccine (IPV) at 2,4, and 6-18 mo, and 4-6 yr. May be given with all other vaccines but at a separate site.
Lyme disease—give IM	Consider for persons 15-70 years of age who reside, work, or recreate in areas of high or moderate risk and who engage in activities that result in frequent or prolonged exposure to tick-infested habitat. Persons with a history of previous uncomplicated Lyme disease who are at continued high risk for Lyme disease. (Sec description in the first bullet.) See ACIP statement for a definition of high and moderate risk.	Three doses are needed. Give at intervals of 0, 1, and 12 mo. Schedule dose #1 (given in year 1) and dose #3 (given in year 2) to be given several weeks before tick season. See ACIP statement for details. Safety of administering Lyme disease vaccine with other vaccines has not been established. ACIP says if it must be administered concurrently with other vaccines, give it at a separate site.	Previous anaphylactic reaction to this vaccine or to any of its components. Pregnancy. Moderate or severe acute illness. Persons with treatment-resistant Lyme arthritis. There are not enough data to recommend Lyme disease vaccine to persons with these conditions: immunodeficiency, diseases associated with joint swelling (including rheumatoid arthritis) or diffuse muscular pain, chronic health conditions due to Lyme disease.