Nursing diagnosis: risk for Infection
Risk factors may include
Contamination of the catheter during insertion, periodic changing of tubing and bags
Skin contaminants at catheter insertion site
Sterile peritonitis (response to the composition of dialysate)
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Identify interventions to prevent or reduce risk of infection.
Experience no signs or symptoms of infection.
Nursing intervention with rationale:
1. Observe meticulous aseptic technique and wear masks during catheter insertion, dressing changes, and whenever the system is opened. Change tubing per protocol.
Rationale: Prevents the introduction of organisms and airborne contamination that may cause infection, the most common complication of PD.
2. Change dressings as indicated, being careful not to dislodge the catheter. Note character, color, odor, or drainage from insertion site.
Rationale: Moist environment promotes bacterial growth. Purulent drainage at insertion site suggests presence of local infection, often involving skin organisms, which can be difficult to treat and sometimes require catheter removal and temporary HD. Note: Polyurethane adhesive film (e.g., blister film) dressings have been found to decrease amount of pressure on catheter and exit site as well as incidence of site infections.
3. Observe color and clarity of effluent.
Rationale: Cloudy effluent is suggestive of peritoneal infection.
4. Apply povidone-iodine (Betadine) barrier in distal, clamped portion of catheter when intermittent dialysis therapy used.
Rationale: Reduces risk of bacterial entry through catheter between dialysis treatments when catheter is disconnected from closed system.
5. Investigate reports of nausea or vomiting, increased or severe abdominal pain, rebound tenderness, or fever.
Rationale: Signs and symptoms suggesting peritonitis, requiring prompt intervention.
6. Monitor white blood cell (WBC) count of effluent.
Rationale: Presence of WBCs initially may reflect normal response to a foreign substance; however, continued or new elevation of WBCs suggests developing infection.
7. Obtain specimens of blood, effluent, and drainage from insertion site, as indicated, for culture and sensitivity.
Rationale: Identifies types of organism(s) present and influences choice of interventions.
8. Monitor renal blood urea nitrogen (BUN) and creatinine (Cr) clearance.
Rationale: Choice and dosage of antibiotics are influenced by level of clearance.
9. Administer antibiotics systemically or in dialysate, as indicated.
Rationale: Treats infection and prevents sepsis.
Showing posts with label Risk for Infection. Show all posts
Showing posts with label Risk for Infection. Show all posts
Friday, June 3, 2011
Tuesday, May 24, 2011
Risk for Infection | Nursing Care Plan for Renal Failure
Nursing diagnosis: risk for Infection
Risk factors may include
Depression of immunological defenses (secondary to uremia)
Invasive procedures or devices, such as urinary catheter
Changes in dietary intake, malnutrition
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Immune Status
Experience no signs or symptoms of infection.
Nursing intervention with rationale:
1. Promote good hand washing by client and staff.
Rationale: Reduces risk of cross-contamination.
2. Avoid invasive procedures, instrumentation, and manipulation of indwelling catheters whenever possible. Use aseptic technique when caring for IV and invasive lines. Change site and dressings per protocol. Note edema and purulent drainage.
Rationale: Limits introduction of bacteria into body. Early detection and treatment of developing infection may prevent sepsis.
3. Provide routine catheter care and promote meticulous perianal care. Keep urinary drainage system closed and remove indwelling catheter as soon as possible.
Rationale: Reduces bacterial colonization and risk of ascending UTI.
4. Encourage deep breathing, coughing, and frequent position changes.
Rationale: Prevents atelectasis and mobilizes secretions to reduce risk of pulmonary infections.
5. Assess skin integrity.
Rationale: Excoriations from scratching may become secondarily infected.
6. Monitor vital signs.
Rationale: Fever higher than 100.4°F (38.0°C) with increased pulse and respirations is typical of increased metabolic rate resulting from inflammatory process, although sepsis can occur without a febrile response.
7. Monitor laboratory studies, such as WBC count with differential.
Rationale: Although elevated WBCs may indicate generalized infection, leukocytosis is commonly seen in ARF and may reflect inflammation or injury within the kidney. A shifting of the differential to the left is indicative of infection.
8. Obtain specimen(s) for culture and sensitivity and administer appropriate antibiotics, as indicated.
Rationale: Verification of infection and identification of specific organism aids in choice of the most effective treatment. Note: A number of anti-infective agents require adjustments of dose or time while renal clearance is impaired.
Risk factors may include
Depression of immunological defenses (secondary to uremia)
Invasive procedures or devices, such as urinary catheter
Changes in dietary intake, malnutrition
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Immune Status
Experience no signs or symptoms of infection.
Nursing intervention with rationale:
1. Promote good hand washing by client and staff.
Rationale: Reduces risk of cross-contamination.
2. Avoid invasive procedures, instrumentation, and manipulation of indwelling catheters whenever possible. Use aseptic technique when caring for IV and invasive lines. Change site and dressings per protocol. Note edema and purulent drainage.
Rationale: Limits introduction of bacteria into body. Early detection and treatment of developing infection may prevent sepsis.
3. Provide routine catheter care and promote meticulous perianal care. Keep urinary drainage system closed and remove indwelling catheter as soon as possible.
Rationale: Reduces bacterial colonization and risk of ascending UTI.
4. Encourage deep breathing, coughing, and frequent position changes.
Rationale: Prevents atelectasis and mobilizes secretions to reduce risk of pulmonary infections.
5. Assess skin integrity.
Rationale: Excoriations from scratching may become secondarily infected.
6. Monitor vital signs.
Rationale: Fever higher than 100.4°F (38.0°C) with increased pulse and respirations is typical of increased metabolic rate resulting from inflammatory process, although sepsis can occur without a febrile response.
7. Monitor laboratory studies, such as WBC count with differential.
Rationale: Although elevated WBCs may indicate generalized infection, leukocytosis is commonly seen in ARF and may reflect inflammation or injury within the kidney. A shifting of the differential to the left is indicative of infection.
8. Obtain specimen(s) for culture and sensitivity and administer appropriate antibiotics, as indicated.
Rationale: Verification of infection and identification of specific organism aids in choice of the most effective treatment. Note: A number of anti-infective agents require adjustments of dose or time while renal clearance is impaired.
Wednesday, May 18, 2011
Risk for Infection | Nursing Care Plan for Leukemia
Nursing diagnosis: risk for Infection
Risk factors may include
Inadequate secondary defenses—alterations in mature WBCs with low granulocyte and abnormal lymphocyte count, increased number of immature lymphocytes; immunosuppression, bone marrow suppression (effects of therapy, transplant)
Inadequate primary defenses—stasis of body fluids, traumatized tissue
Invasive procedures
Malnutrition; chronic disease
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Infection Control
Identify actions to prevent or reduce risk of infection.
Demonstrate techniques or lifestyle changes to promote safe environment and achieve timely healing.
Nursing intervention with rationale:
1. Place in private room. Screen and limit visitors, as indicated. Prohibit use of live plants or cut flowers. Restrict fresh fruits and vegetables or make sure they are washed or peeled.
Rationale: Protect client from potential sources of pathogens and infection. Note: Profound bone marrow suppression, neutropenia, and chemotherapy place client at great risk for infection.
2. Model and require good hand-washing protocol for all personnel and visitors.
Rationale: Prevents cross-contamination and reduces risk of infection.
3. Monitor temperature. Note correlation between temperature elevations and chemotherapy treatments. Observe for fever associated with tachycardia, hypotension, and subtle mental changes.
Rationale: Although fever may accompany some forms of chemotherapy, progressive hyperthermia occurs in some types of infections, and fever unrelated to drugs or blood products occurs in most leukemia clients. Note: Septicemia may occur without fever.
4. Prevent chilling. Force fluids and administer tepid sponge bath.
Rationale: Helps reduce fever, which contributes to fluid imbalance, discomfort, and central nervous system (CNS) complications.
5. Encourage frequent turning and deep breathing.
Rationale: Prevents stasis of respiratory secretions, reducing risk of atelectasis and pneumonia.
6. Auscultate breath sounds, noting crackles and rhonchi; inspect secretions for changes in characteristics, such as increased sputum production or change in sputum color. Observe urine for signs of infection: cloudy, foul-smelling, or presence of urgency or burning with voids.
Rationale: Early intervention is essential to prevent sepsis or septicemia in immunosuppressed person.
7. Handle client gently. Keep linens dry and wrinkle free.
Rationale: Prevents sheet burns and skin excoriation.
8. Inspect skin for tender, erythematous areas and open wounds. Cleanse skin with antibacterial solutions.
Rationale: May indicate local infection. Note: Open wounds may not produce pus because of insufficient number of granulocytes.
9. Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care.
Rationale: The oral cavity is an excellent medium for growth of organisms and is susceptible to ulceration and bleeding.
10. Promote good perianal hygiene. Examine perianal area at least daily during acute illness. Provide sitz baths, using Betadine or Hibiclens, if indicated. Avoid rectal temperatures and use of suppositories.
Rationale: Promotes cleanliness, reducing risk of perianal abscess; enhances circulation and healing. Note: Perianal abscess can contribute to septicemia and death in immunosuppressed clients.
Risk factors may include
Inadequate secondary defenses—alterations in mature WBCs with low granulocyte and abnormal lymphocyte count, increased number of immature lymphocytes; immunosuppression, bone marrow suppression (effects of therapy, transplant)
Inadequate primary defenses—stasis of body fluids, traumatized tissue
Invasive procedures
Malnutrition; chronic disease
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Infection Control
Identify actions to prevent or reduce risk of infection.
Demonstrate techniques or lifestyle changes to promote safe environment and achieve timely healing.
Nursing intervention with rationale:
1. Place in private room. Screen and limit visitors, as indicated. Prohibit use of live plants or cut flowers. Restrict fresh fruits and vegetables or make sure they are washed or peeled.
Rationale: Protect client from potential sources of pathogens and infection. Note: Profound bone marrow suppression, neutropenia, and chemotherapy place client at great risk for infection.
2. Model and require good hand-washing protocol for all personnel and visitors.
Rationale: Prevents cross-contamination and reduces risk of infection.
3. Monitor temperature. Note correlation between temperature elevations and chemotherapy treatments. Observe for fever associated with tachycardia, hypotension, and subtle mental changes.
Rationale: Although fever may accompany some forms of chemotherapy, progressive hyperthermia occurs in some types of infections, and fever unrelated to drugs or blood products occurs in most leukemia clients. Note: Septicemia may occur without fever.
4. Prevent chilling. Force fluids and administer tepid sponge bath.
Rationale: Helps reduce fever, which contributes to fluid imbalance, discomfort, and central nervous system (CNS) complications.
5. Encourage frequent turning and deep breathing.
Rationale: Prevents stasis of respiratory secretions, reducing risk of atelectasis and pneumonia.
6. Auscultate breath sounds, noting crackles and rhonchi; inspect secretions for changes in characteristics, such as increased sputum production or change in sputum color. Observe urine for signs of infection: cloudy, foul-smelling, or presence of urgency or burning with voids.
Rationale: Early intervention is essential to prevent sepsis or septicemia in immunosuppressed person.
7. Handle client gently. Keep linens dry and wrinkle free.
Rationale: Prevents sheet burns and skin excoriation.
8. Inspect skin for tender, erythematous areas and open wounds. Cleanse skin with antibacterial solutions.
Rationale: May indicate local infection. Note: Open wounds may not produce pus because of insufficient number of granulocytes.
9. Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care.
Rationale: The oral cavity is an excellent medium for growth of organisms and is susceptible to ulceration and bleeding.
10. Promote good perianal hygiene. Examine perianal area at least daily during acute illness. Provide sitz baths, using Betadine or Hibiclens, if indicated. Avoid rectal temperatures and use of suppositories.
Rationale: Promotes cleanliness, reducing risk of perianal abscess; enhances circulation and healing. Note: Perianal abscess can contribute to septicemia and death in immunosuppressed clients.
Sunday, May 15, 2011
Risk for Infection | Nursing Care Plan for Anemia
Nursing diagnosis: risk for Infection
Risk factors may include
Inadequate secondary defenses—decreased Hgb, leukopenia, or decreased granulocytes (suppressed inflammatory response)
Inadequate primary defenses—broken skin, stasis of body fluids, invasive procedures, chronic disease, malnutrition
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Identify behaviors to prevent and reduce risk of infection.
Immune Status
Be free of signs of infection; achieve timely wound healing if present.
Nursing intervention with rationale:
1. Perform and promote meticulous hand washing by caregivers and client.
Rationale: Prevents cross-contamination or bacterial colonization. Note: Client with severe or aplastic anemia may be at risk from normal skin flora.
2. Maintain strict aseptic techniques with procedures and wound care.
Rationale: Reduces risk of bacterial colonization and infection.
3. Provide meticulous skin, oral, and perianal care.
Rationale: Reduces risk of skin or tissue breakdown and infection.
4. Encourage frequent position changes and ambulation, coughing, and deep-breathing exercises.
Rationale: Promotes ventilation of all lung segments and aids in mobilizing secretions to prevent pneumonia.
5. Promote adequate fluid intake.
Rationale: Assists in liquefying respiratory secretions to facilitate expectoration and prevent stasis of body fluids in lungs and bladder.
6. Emphasize need to monitor and limit visitors, as indicated. Provide protective isolation, if appropriate. Restrict live plants and cut flowers.
Rationale: Limits exposure to infectious agents. Protective isolation may be required in aplastic anemia, when immune response is most compromised.
7. Monitor temperature. Note presence of chills and tachycardia with or without fever.
Rationale: Reflective of inflammatory process or infection, requiring evaluation and treatment. Note: With bone marrow suppression, leukocytic failure may lead to fulminating infections.
8. Observe for wound erythema and drainage.
Rationale: Indicators of local infection. Note: Pus formation may be absent if granulocytes are depressed.
9. Obtain specimens for culture and sensitivity, as indicated.
Rationale: Verifies presence of infection, identifies specific pathogen, and influences choice of treatment.
10. Administer topical antiseptics and systemic antibiotics.
Rationale: May be used prophylactically to reduce colonization or used to treat specific infectious process.
Risk factors may include
Inadequate secondary defenses—decreased Hgb, leukopenia, or decreased granulocytes (suppressed inflammatory response)
Inadequate primary defenses—broken skin, stasis of body fluids, invasive procedures, chronic disease, malnutrition
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Identify behaviors to prevent and reduce risk of infection.
Immune Status
Be free of signs of infection; achieve timely wound healing if present.
Nursing intervention with rationale:
1. Perform and promote meticulous hand washing by caregivers and client.
Rationale: Prevents cross-contamination or bacterial colonization. Note: Client with severe or aplastic anemia may be at risk from normal skin flora.
2. Maintain strict aseptic techniques with procedures and wound care.
Rationale: Reduces risk of bacterial colonization and infection.
3. Provide meticulous skin, oral, and perianal care.
Rationale: Reduces risk of skin or tissue breakdown and infection.
4. Encourage frequent position changes and ambulation, coughing, and deep-breathing exercises.
Rationale: Promotes ventilation of all lung segments and aids in mobilizing secretions to prevent pneumonia.
5. Promote adequate fluid intake.
Rationale: Assists in liquefying respiratory secretions to facilitate expectoration and prevent stasis of body fluids in lungs and bladder.
6. Emphasize need to monitor and limit visitors, as indicated. Provide protective isolation, if appropriate. Restrict live plants and cut flowers.
Rationale: Limits exposure to infectious agents. Protective isolation may be required in aplastic anemia, when immune response is most compromised.
7. Monitor temperature. Note presence of chills and tachycardia with or without fever.
Rationale: Reflective of inflammatory process or infection, requiring evaluation and treatment. Note: With bone marrow suppression, leukocytic failure may lead to fulminating infections.
8. Observe for wound erythema and drainage.
Rationale: Indicators of local infection. Note: Pus formation may be absent if granulocytes are depressed.
9. Obtain specimens for culture and sensitivity, as indicated.
Rationale: Verifies presence of infection, identifies specific pathogen, and influences choice of treatment.
10. Administer topical antiseptics and systemic antibiotics.
Rationale: May be used prophylactically to reduce colonization or used to treat specific infectious process.
Friday, May 6, 2011
Risk for Infection | Nursing Care Plan Total Nutritional Support
Nursing diagnosis: risk for infection
Risk factors may include
Invasive procedures—insertion of venous catheter, surgically placed gastrostomy or jejunostomy feeding tube
Malnutrition, chronic disease
Environmental exposure—access devices in place for extended periods; improper preparation and handling or contamination of the feeding solution
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Immune Status
Experience no fever or chills.
Demonstrate clean catheter insertion sites, free of drainage and erythema or edema.
Nursing intervention with rationale:
1. Stress and model proper hand-washing technique.
Rationale: Reduces risk of cross-contamination.
2. Maintain sterile technique for invasive procedures. Provide routine site care, as appropriate.
Rationale: Prevents entry of bacteria, reducing risk of nosocomial infections.
3. Encourage frequent position changes and being out of bed or ambulation, as tolerated.
Rationale: Limits stasis of body fluids, promotes optimal functioning of organ systems and GI tract.
4. Screen visitors and care providers for infectious processes, especially upper respiratory infection (URI).
Rationale: Reduces risk of transmission of viruses that are difficult to treat.
5. Monitor and assist with respiratory exercises and use of adjuncts, such as incentive spirometer. Auscultate lungs for adventitious sounds.
Rationale: Promotes deep breathing to clear airways and reduce risk of pneumonia. Presence of wheezes suggests retained secretions and potential complications requiring intervention.
6. Assess vital signs, including temperature, per protocol.
Rationale: A rise in pulse and temperature may provide warning of infectious process unless client’s immune system is too compromised to respond.
7. Maintain an optimal aseptic environment during bedside insertion of central venous catheters and during changes of TPN bottles and administration tubing.
Rationale: Catheter-related sepsis may result from entry of pathogenic microorganisms through skin insertion tract or from touch contamination during manipulations of TPN system.
8. Secure external portion of catheter and administration tubing to dressing with tape. Note intactness of skin suture.
Rationale: Manipulation of catheter in and out of insertion site can result in tissue trauma or coring and potentiate entry of skin organisms into catheter tract.
9. Maintain a sterile occlusive dressing over catheter insertion site. Perform central or peripheral venous catheter dressing care per protocol.
Rationale: Protects catheter insertion sites from potential sources of contamination. Note: Central venous catheter sites can easily become contaminated from tracheotomy or endotracheal secretions, or from wounds of the head, neck, and chest.
10. Inspect insertion site of catheter for erythema, induration, drainage, and tenderness.
Rationale: The catheter is a potential irritant to the surrounding skin and subcutaneous skin tract, and extended use may result in insertion site irritation and infection.
Risk factors may include
Invasive procedures—insertion of venous catheter, surgically placed gastrostomy or jejunostomy feeding tube
Malnutrition, chronic disease
Environmental exposure—access devices in place for extended periods; improper preparation and handling or contamination of the feeding solution
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Immune Status
Experience no fever or chills.
Demonstrate clean catheter insertion sites, free of drainage and erythema or edema.
Nursing intervention with rationale:
1. Stress and model proper hand-washing technique.
Rationale: Reduces risk of cross-contamination.
2. Maintain sterile technique for invasive procedures. Provide routine site care, as appropriate.
Rationale: Prevents entry of bacteria, reducing risk of nosocomial infections.
3. Encourage frequent position changes and being out of bed or ambulation, as tolerated.
Rationale: Limits stasis of body fluids, promotes optimal functioning of organ systems and GI tract.
4. Screen visitors and care providers for infectious processes, especially upper respiratory infection (URI).
Rationale: Reduces risk of transmission of viruses that are difficult to treat.
5. Monitor and assist with respiratory exercises and use of adjuncts, such as incentive spirometer. Auscultate lungs for adventitious sounds.
Rationale: Promotes deep breathing to clear airways and reduce risk of pneumonia. Presence of wheezes suggests retained secretions and potential complications requiring intervention.
6. Assess vital signs, including temperature, per protocol.
Rationale: A rise in pulse and temperature may provide warning of infectious process unless client’s immune system is too compromised to respond.
7. Maintain an optimal aseptic environment during bedside insertion of central venous catheters and during changes of TPN bottles and administration tubing.
Rationale: Catheter-related sepsis may result from entry of pathogenic microorganisms through skin insertion tract or from touch contamination during manipulations of TPN system.
8. Secure external portion of catheter and administration tubing to dressing with tape. Note intactness of skin suture.
Rationale: Manipulation of catheter in and out of insertion site can result in tissue trauma or coring and potentiate entry of skin organisms into catheter tract.
9. Maintain a sterile occlusive dressing over catheter insertion site. Perform central or peripheral venous catheter dressing care per protocol.
Rationale: Protects catheter insertion sites from potential sources of contamination. Note: Central venous catheter sites can easily become contaminated from tracheotomy or endotracheal secretions, or from wounds of the head, neck, and chest.
10. Inspect insertion site of catheter for erythema, induration, drainage, and tenderness.
Rationale: The catheter is a potential irritant to the surrounding skin and subcutaneous skin tract, and extended use may result in insertion site irritation and infection.
Wednesday, May 4, 2011
Risk for Infection | Nursing Care Plan for Pancreatitis
Nursing diagnosis: risk for Infection
Risk factors may include
Inadequate primary defenses: stasis of body fluids, altered peristalsis, change in pH of secretions
Immunosuppression
Nutritional deficiencies
Tissue destruction, chronic disease
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Immune Status
Achieve timely healing; be free of signs of infection.
Be afebrile.
Risk Control
Participate in activities to reduce risk of infection.
Nursing intervention with rationale:
1. Use strict aseptic technique when changing surgical dressings or working with IV lines, indwelling catheters, tubes, or drains. Change soiled dressings promptly.
Rationale: Limits sources of infection, which can lead to sepsis in a compromised client.
2. Model and emphasize importance of good hand washing.
Rationale: Reduces risk of cross-contamination.
3. Observe rate and characteristics of respirations and breath sounds. Note occurrence of cough and sputum production.
Rationale: Pulmonary complications of pancreatitis include atelectasis, pleural effusion, pneumonia, and ARDS. Fluid accumulation and limited mobility predisposes client to respiratory infections and atelectasis. Accumulation of ascites fluid may cause elevated diaphragm and shallow abdominal breathing.
4. Encourage frequent position changes, deep breathing, and coughing. Assist with ambulation as soon as stable.
Rationale: Enhances ventilation of all lung segments and promotes mobilization of secretions.
5. Observe for signs of infection, such as the following: Fever and respiratory distress in conjunction with jaundice
Rationale: Cholestatic jaundice and decreased pulmonary function may be first sign of sepsis or ARDS.
6. Increased abdominal pain, rigidity and rebound tenderness, diminished or absent bowel sounds
Rationale: Suggestive of peritonitis.
7. Increased abdominal pain and tenderness, recurrent fever (higher than 101°F [38.3°C]), leukocytosis, hypotension, tachycardia, and chills
Rationale: Abscesses can occur 2 weeks or more after the onset of pancreatitis and should be suspected whenever client is deteriorating despite supportive measures.
8. Obtain culture specimens, such as blood, wound, urine, sputum, or pancreatic aspirate.
Rationale: Identifies presence of infection and causative organism.
9. Administer anti-infective therapies as indicated, such as imipenem/cilastatin (Primaxin), metronidazole (Flagyl), and levofloxacin (Levaquin); cephalosporins, such as cefoxitin sodium (Mefoxin); and aminoglycosides, such as gentamicin (Garamycin) and tobramycin (Nebcin).
Rationale: Broad-spectrum anti-infectives are generally recommended for pancreatitis sepsis; however, therapy will be based on the specific organisms cultured.
10. Prepare for surgical intervention, as necessary.
Rationale: Abscesses may be surgically drained with resection of necrotic tissue. Sump tubes may be inserted for antibiotic irrigation and drainage of pancreatic debris. Pseudocysts (persisting for several weeks) may be drained because of the risk and incidence of infection and rupture.
Risk factors may include
Inadequate primary defenses: stasis of body fluids, altered peristalsis, change in pH of secretions
Immunosuppression
Nutritional deficiencies
Tissue destruction, chronic disease
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Immune Status
Achieve timely healing; be free of signs of infection.
Be afebrile.
Risk Control
Participate in activities to reduce risk of infection.
Nursing intervention with rationale:
1. Use strict aseptic technique when changing surgical dressings or working with IV lines, indwelling catheters, tubes, or drains. Change soiled dressings promptly.
Rationale: Limits sources of infection, which can lead to sepsis in a compromised client.
2. Model and emphasize importance of good hand washing.
Rationale: Reduces risk of cross-contamination.
3. Observe rate and characteristics of respirations and breath sounds. Note occurrence of cough and sputum production.
Rationale: Pulmonary complications of pancreatitis include atelectasis, pleural effusion, pneumonia, and ARDS. Fluid accumulation and limited mobility predisposes client to respiratory infections and atelectasis. Accumulation of ascites fluid may cause elevated diaphragm and shallow abdominal breathing.
4. Encourage frequent position changes, deep breathing, and coughing. Assist with ambulation as soon as stable.
Rationale: Enhances ventilation of all lung segments and promotes mobilization of secretions.
5. Observe for signs of infection, such as the following: Fever and respiratory distress in conjunction with jaundice
Rationale: Cholestatic jaundice and decreased pulmonary function may be first sign of sepsis or ARDS.
6. Increased abdominal pain, rigidity and rebound tenderness, diminished or absent bowel sounds
Rationale: Suggestive of peritonitis.
7. Increased abdominal pain and tenderness, recurrent fever (higher than 101°F [38.3°C]), leukocytosis, hypotension, tachycardia, and chills
Rationale: Abscesses can occur 2 weeks or more after the onset of pancreatitis and should be suspected whenever client is deteriorating despite supportive measures.
8. Obtain culture specimens, such as blood, wound, urine, sputum, or pancreatic aspirate.
Rationale: Identifies presence of infection and causative organism.
9. Administer anti-infective therapies as indicated, such as imipenem/cilastatin (Primaxin), metronidazole (Flagyl), and levofloxacin (Levaquin); cephalosporins, such as cefoxitin sodium (Mefoxin); and aminoglycosides, such as gentamicin (Garamycin) and tobramycin (Nebcin).
Rationale: Broad-spectrum anti-infectives are generally recommended for pancreatitis sepsis; however, therapy will be based on the specific organisms cultured.
10. Prepare for surgical intervention, as necessary.
Rationale: Abscesses may be surgically drained with resection of necrotic tissue. Sump tubes may be inserted for antibiotic irrigation and drainage of pancreatic debris. Pseudocysts (persisting for several weeks) may be drained because of the risk and incidence of infection and rupture.
Tuesday, April 19, 2011
Risk for Infection | Nursing Care Plan for Hepatitis
Nursing diagnosis: risk for infection
Risk factors may include
Inadequate secondary defenses—leukopenia, suppressed inflammatory response
Immunosuppression
Malnutrition
Insufficient knowledge to avoid exposure to pathogens
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Verbalize understanding of individual causative and risk factor(s).
Demonstrate techniques and initiate lifestyle changes to avoid reinfection and transmission to others.
Nursing intervention with rationale:
1. Establish isolation techniques for enteric and respiratory infections according to infection guidelines and policy. Model and emphasize need for effective hand washing.
Rationale: Prevents transmission of viral disease to others. Thorough hand washing is effective in preventing virus transmission. HAV and HEV are transmitted by oral-fecal route and contaminated water, milk, and food, especially inadequately cooked shellfish. Types A, B, C, and D are transmitted by contaminated blood or blood products; needle punctures; open wounds; and contact with saliva, urine, stool, and semen. Incidence of both HBV and HCV has increased among healthcare providers and high-risk clients. Note: Toxic and alcoholic types of hepatitis are not communicable and do not require special measures or isolation.
2. Stress need to monitor and restrict visitors, as indicated.
Rationale: Client exposure to infectious processes, especially respiratory, potentiates risk of secondary complications.
3. Explain isolation procedures to client and SO.
Rationale: Understanding reasons for safeguarding themselves and others can lessen feelings of isolation and stigmatization. Isolation may last 2 to 3 weeks from onset of illness, depending on type and duration of symptoms.
4. Administer anti-infective medications, as appropriate.
Rationale: Used to treat or limit secondary infections
Risk factors may include
Inadequate secondary defenses—leukopenia, suppressed inflammatory response
Immunosuppression
Malnutrition
Insufficient knowledge to avoid exposure to pathogens
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Verbalize understanding of individual causative and risk factor(s).
Demonstrate techniques and initiate lifestyle changes to avoid reinfection and transmission to others.
Nursing intervention with rationale:
1. Establish isolation techniques for enteric and respiratory infections according to infection guidelines and policy. Model and emphasize need for effective hand washing.
Rationale: Prevents transmission of viral disease to others. Thorough hand washing is effective in preventing virus transmission. HAV and HEV are transmitted by oral-fecal route and contaminated water, milk, and food, especially inadequately cooked shellfish. Types A, B, C, and D are transmitted by contaminated blood or blood products; needle punctures; open wounds; and contact with saliva, urine, stool, and semen. Incidence of both HBV and HCV has increased among healthcare providers and high-risk clients. Note: Toxic and alcoholic types of hepatitis are not communicable and do not require special measures or isolation.
2. Stress need to monitor and restrict visitors, as indicated.
Rationale: Client exposure to infectious processes, especially respiratory, potentiates risk of secondary complications.
3. Explain isolation procedures to client and SO.
Rationale: Understanding reasons for safeguarding themselves and others can lessen feelings of isolation and stigmatization. Isolation may last 2 to 3 weeks from onset of illness, depending on type and duration of symptoms.
4. Administer anti-infective medications, as appropriate.
Rationale: Used to treat or limit secondary infections
Thursday, April 7, 2011
Risk for Infection | Nursing Care Plan for Diabetes Mellitus
Risk factors may include
High glucose levels, decreased leukocyte function, alterations in circulation
Preexisting respiratory infection or UTI
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Infection Control
Identify interventions to prevent or reduce risk of infection.
Demonstrate techniques and lifestyle changes to prevent development of infection.
Nursing intervention with rationale:
1. Observe for signs of infection and inflammation—fever, flushed appearance, wound drainage, purulent sputum, and cloudy urine.
Rationale: Client may be admitted with infection, which could have precipitated the ketoacidotic state, or may develop a nosocomial infection.
2. Promote good hand washing by staff and client.
Rationale: Reduces risk of cross-contamination.
3. Maintain aseptic technique for IV insertion procedure, administration of medications, and providing site care. Rotate IV sites, as indicated.
Rationale: High glucose in the blood creates an excellent medium for bacterial growth.
4. Provide catheter and perineal care. Teach the female client to clean from front to back after elimination.
Rationale: Minimizes risk of UTI. Comatose client may be at particular risk if urinary retention occurred before hospitalization. Note: Elderly female diabetic clients are especially prone to UTIs and vaginal yeast infections. Many UTIs are asymptomatic, possibly related to neurogenic bladder.
5. Provide conscientious skin care, gently massage bony areas, keep the skin dry, and keep linens dry and wrinkle-free.
Rationale: Peripheral circulation may be impaired, placing client at increased risk for skin irritation and breakdown and infection.
6. Inspect client’s feet, noting presence of ulcers or infected ingrown toenails, or other problems requiring medical or nursing intervention.
Rationale: Foot injuries and impaired circulation are associated with many complications in diabetics, including cellulitis and amputations. Note: Cellulitis can precipitate episode of DKA.
7. Auscultate breath sounds.
Rationale: Rhonchi indicate accumulation of secretions possibly related to pneumonia or bronchitis that may have precipitated the DKA.
8. Place in semi-Fowler’s position.
Rationale: Facilitates lung expansion and reduces risk of aspiration.
9. Reposition and encourage coughing and deep breathing if client is alert and cooperative. Otherwise, suction airway, using sterile technique, as needed.
Rationale: Aids in ventilating all lung areas and mobilizing secretions. Prevents stasis of secretions with increased risk of infection.
10. Provide tissues and trash bag in a convenient location for sputum and other secretions. Instruct client in proper handling of secretions.
Rationale: Minimizes spread of infection.
High glucose levels, decreased leukocyte function, alterations in circulation
Preexisting respiratory infection or UTI
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Infection Control
Identify interventions to prevent or reduce risk of infection.
Demonstrate techniques and lifestyle changes to prevent development of infection.
Nursing intervention with rationale:
1. Observe for signs of infection and inflammation—fever, flushed appearance, wound drainage, purulent sputum, and cloudy urine.
Rationale: Client may be admitted with infection, which could have precipitated the ketoacidotic state, or may develop a nosocomial infection.
2. Promote good hand washing by staff and client.
Rationale: Reduces risk of cross-contamination.
3. Maintain aseptic technique for IV insertion procedure, administration of medications, and providing site care. Rotate IV sites, as indicated.
Rationale: High glucose in the blood creates an excellent medium for bacterial growth.
4. Provide catheter and perineal care. Teach the female client to clean from front to back after elimination.
Rationale: Minimizes risk of UTI. Comatose client may be at particular risk if urinary retention occurred before hospitalization. Note: Elderly female diabetic clients are especially prone to UTIs and vaginal yeast infections. Many UTIs are asymptomatic, possibly related to neurogenic bladder.
5. Provide conscientious skin care, gently massage bony areas, keep the skin dry, and keep linens dry and wrinkle-free.
Rationale: Peripheral circulation may be impaired, placing client at increased risk for skin irritation and breakdown and infection.
6. Inspect client’s feet, noting presence of ulcers or infected ingrown toenails, or other problems requiring medical or nursing intervention.
Rationale: Foot injuries and impaired circulation are associated with many complications in diabetics, including cellulitis and amputations. Note: Cellulitis can precipitate episode of DKA.
7. Auscultate breath sounds.
Rationale: Rhonchi indicate accumulation of secretions possibly related to pneumonia or bronchitis that may have precipitated the DKA.
8. Place in semi-Fowler’s position.
Rationale: Facilitates lung expansion and reduces risk of aspiration.
9. Reposition and encourage coughing and deep breathing if client is alert and cooperative. Otherwise, suction airway, using sterile technique, as needed.
Rationale: Aids in ventilating all lung areas and mobilizing secretions. Prevents stasis of secretions with increased risk of infection.
10. Provide tissues and trash bag in a convenient location for sputum and other secretions. Instruct client in proper handling of secretions.
Rationale: Minimizes spread of infection.
Saturday, April 2, 2011
Risk for Infection | Nursing Care Plan for Total Hip Replacement
Risk factors may include
Inadequate primary defenses—broken skin, exposure of joint
Inadequate secondary defenses, immunosuppression—long-term corticosteroid use, cancer
Invasive procedures; surgical manipulation; implantation of foreign body
Decreased mobility
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Infection Status
Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.
Nursing intervention with rationale:
1. Promote good hand washing by staff and client.
Rationale: Reduces risk of cross-contamination.
2. Use strict aseptic or clean technique, as indicated, to reinforce or change dressings and when handling drains. Instruct client not to touch or scratch incision.
Rationale: Prevents contamination and risk of wound infection, which could require removal of prosthesis.
3. Maintain patency of drainage devices (e.g., Hemovac, Jackson-Pratt) when present. Note characteristics of wound drainage.
Rationale: Reduces risk of infection by preventing accumulation of blood and secretions in the joint space, which is a medium for bacterial growth. Purulent, nonserous, odorous drainage is indicative of infection, and continuous drainage from incision may reflect developing skin tract, which can potentiate infectious process.
4. Assess skin and incision color, temperature, and integrity; note presence of erythema, inflammation, and loss of wound approximation.
Rationale: Provides information about status of healing process and alerts staff to early signs of infection.
5. Investigate reports of increased incisional pain and changes in characteristics of pain.
Rationale: Deep, dull, aching pain in operative area may indicate developing infection in joint. Note: Infection can be devastating because, once infection sets in, joint may not be salvagable and prosthetic loss may occur.
6. Monitor temperature. Note presence of chills.
Rationale: Although temperature elevations are common in early postoperative phase, elevations occurring 5 or more days postoperatively and/or presence of chills usually require intervention to prevent more serious complications, such as sepsis, osteomyelitis, tissue necrosis, and prosthetic failure.
7. Encourage fluid intake coupled with a high-protein diet with roughage.
Rationale: Maintains fluid and nutritional balance to support tissue perfusion and provide nutrients necessary for cellular regeneration and tissue healing.
8. Maintain reverse or protective isolation, if appropriate.
Rationale: May be done initially to reduce contact with sources of possible infection, especially in an elderly, immunosuppressed, or diabetic client.
9. Administer antibiotics, as indicated.
Rationale: Used prophylactically in the operating room and for the first 24 hours to prevent infection. Late infections may require intravenous (IV) antibiotic treatments for several weeks, in an effort to save the prosthetic joint.
Inadequate primary defenses—broken skin, exposure of joint
Inadequate secondary defenses, immunosuppression—long-term corticosteroid use, cancer
Invasive procedures; surgical manipulation; implantation of foreign body
Decreased mobility
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Infection Status
Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.
Nursing intervention with rationale:
1. Promote good hand washing by staff and client.
Rationale: Reduces risk of cross-contamination.
2. Use strict aseptic or clean technique, as indicated, to reinforce or change dressings and when handling drains. Instruct client not to touch or scratch incision.
Rationale: Prevents contamination and risk of wound infection, which could require removal of prosthesis.
3. Maintain patency of drainage devices (e.g., Hemovac, Jackson-Pratt) when present. Note characteristics of wound drainage.
Rationale: Reduces risk of infection by preventing accumulation of blood and secretions in the joint space, which is a medium for bacterial growth. Purulent, nonserous, odorous drainage is indicative of infection, and continuous drainage from incision may reflect developing skin tract, which can potentiate infectious process.
4. Assess skin and incision color, temperature, and integrity; note presence of erythema, inflammation, and loss of wound approximation.
Rationale: Provides information about status of healing process and alerts staff to early signs of infection.
5. Investigate reports of increased incisional pain and changes in characteristics of pain.
Rationale: Deep, dull, aching pain in operative area may indicate developing infection in joint. Note: Infection can be devastating because, once infection sets in, joint may not be salvagable and prosthetic loss may occur.
6. Monitor temperature. Note presence of chills.
Rationale: Although temperature elevations are common in early postoperative phase, elevations occurring 5 or more days postoperatively and/or presence of chills usually require intervention to prevent more serious complications, such as sepsis, osteomyelitis, tissue necrosis, and prosthetic failure.
7. Encourage fluid intake coupled with a high-protein diet with roughage.
Rationale: Maintains fluid and nutritional balance to support tissue perfusion and provide nutrients necessary for cellular regeneration and tissue healing.
8. Maintain reverse or protective isolation, if appropriate.
Rationale: May be done initially to reduce contact with sources of possible infection, especially in an elderly, immunosuppressed, or diabetic client.
9. Administer antibiotics, as indicated.
Rationale: Used prophylactically in the operating room and for the first 24 hours to prevent infection. Late infections may require intravenous (IV) antibiotic treatments for several weeks, in an effort to save the prosthetic joint.
Friday, April 1, 2011
Risk for Infection | Nursing Care Plan for Bariatric Surgery
Risk factors may include
Inadequate primary defenses—broken or traumatized tissues, decreased ciliary action, stasis of body fluids
Invasive procedures
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Immobility Consequences: Physiological
Be free of nosocomial infection.
Wound Healing: Primary Intention
Achieve timely wound healing free of signs of local or generalized infectious process.
Nursing intervention with rationale:
1. Emphasize and model proper hand-washing technique.
Rationale: Prevents spread of bacteria and cross-contamination.
2. Maintain aseptic technique in dressing changes and invasive procedures.
Rationale: Reduces risk of nosocomial infection.
3. Inspect surgical incisions and invasive line sites for erythema and purulent drainage.
Rationale: Early detection of developing infection provides for prevention of more serious complications.
4. Encourage frequent position changes, deep breathing, coughing, and use of respiratory adjuncts, such as incentive spirometer.
Rationale: Promotes mobilization of secretions, reducing risk of pneumonia.
5. Provide routine catheter care; encourage good perineal care. Remove catheter as early as possible.
Rationale: Prevents ascending bladder infections.
6. Encourage client to drink acid-ash juices, such as cranberry.
Rationale: Maintains urine acidity and prevents bacteria from adhering to the bladder wall to retard bacterial growth.
7. Observe for reports of abdominal pain, especially after third postoperative day, elevated temperature, and increased white blood cell (WBC) count.
Rationale: Suggests possibility of developing peritonitis.
8. Apply topical antimicrobials or antibiotics, as indicated.
Rationale: Reduces bacterial or fungal colonization on skin; prevents infection in the wound.
9. Administer IV antibiotics, as indicated.
Rationale: A prophylactic antibiotic regimen is usually standard in these clients to reduce risk of perioperative contamination and peritonitis.
10. Obtain specimen of purulent drainage or sputum for culture and sensitivity.
Rationale: Identifies infectious agent; aids in choice of appropriate therapy.
Inadequate primary defenses—broken or traumatized tissues, decreased ciliary action, stasis of body fluids
Invasive procedures
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Immobility Consequences: Physiological
Be free of nosocomial infection.
Wound Healing: Primary Intention
Achieve timely wound healing free of signs of local or generalized infectious process.
Nursing intervention with rationale:
1. Emphasize and model proper hand-washing technique.
Rationale: Prevents spread of bacteria and cross-contamination.
2. Maintain aseptic technique in dressing changes and invasive procedures.
Rationale: Reduces risk of nosocomial infection.
3. Inspect surgical incisions and invasive line sites for erythema and purulent drainage.
Rationale: Early detection of developing infection provides for prevention of more serious complications.
4. Encourage frequent position changes, deep breathing, coughing, and use of respiratory adjuncts, such as incentive spirometer.
Rationale: Promotes mobilization of secretions, reducing risk of pneumonia.
5. Provide routine catheter care; encourage good perineal care. Remove catheter as early as possible.
Rationale: Prevents ascending bladder infections.
6. Encourage client to drink acid-ash juices, such as cranberry.
Rationale: Maintains urine acidity and prevents bacteria from adhering to the bladder wall to retard bacterial growth.
7. Observe for reports of abdominal pain, especially after third postoperative day, elevated temperature, and increased white blood cell (WBC) count.
Rationale: Suggests possibility of developing peritonitis.
8. Apply topical antimicrobials or antibiotics, as indicated.
Rationale: Reduces bacterial or fungal colonization on skin; prevents infection in the wound.
9. Administer IV antibiotics, as indicated.
Rationale: A prophylactic antibiotic regimen is usually standard in these clients to reduce risk of perioperative contamination and peritonitis.
10. Obtain specimen of purulent drainage or sputum for culture and sensitivity.
Rationale: Identifies infectious agent; aids in choice of appropriate therapy.
Monday, March 14, 2011
Risk for Infection | Nursing Care Plan for Peritonitis
Nursing diagnosis: risk for Infection
Risk factors may include
Inadequate primary defenses—broken skin, traumatized tissue, altered peristalsis
Inadequate secondary defenses—immunosuppression
Invasive procedures
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Infection Status
Achieve timely healing, be free of purulent drainage or erythema, and be afebrile.
Risk Control
Verbalize understanding of the individual causative or risk factor(s).
Nursing intervention with rationale:
1. Note individual risk factors: abdominal trauma, acute appendicitis, and peritoneal dialysis.
Rationale: Influences choice of interventions.
2. Assess vital signs frequently, noting unresolved or progressing hypotension, decreased pulse pressure, tachycardia, fever, and tachypnea.
Rationale: Signs of impending septic shock. Circulating endotoxins eventually produce vasodilation, shift of fluid from circulation, and a low cardiac output state. Note: These clients frequently are critically ill and medical or postsurgical intensive care is required.
3. Note changes in mental status, such as new onset confusion and stupor.
Rationale: Hypoxemia, hypotension, and acidosis can cause deteriorating mental status.
4. Note skin color, temperature, and moisture.
Rationale: Warm, flushed, dry skin is early sign of septicemia. Later manifestations include cool, clammy, pale skin and cyanosis as shock becomes refractory.
5. Monitor urine output.
Rationale: Oliguria develops as a result of decreased renal perfusion, circulating toxins, and effects of antibiotics.
6. Maintain strict aseptic technique in caring for abdominal drains, incisions or open wounds, dressings, and invasive sites. Cleanse with appropriate solution.
Rationale: Prevents access or limits spread of infecting organisms and cross-contamination.
7. Perform and model good hand-washing technique. Monitor staff and client compliance with hand washing.
Rationale: Reduces risk of cross-contamination and spread of infection.
8. Observe drainage from wounds or drains.
Rationale: Provides information about status of infection.
9. Maintain sterile technique when catheterizing client, provide catheter care, and encourage perineal cleansing on a routine basis.
Rationale: Prevents access and limits bacterial growth in urinary tract.
10. Monitor or restrict visitors and staff, as appropriate. Provide protective isolation if indicated.
Rationale: Reduces risk of exposure to, or acquisition of, secondary infection in immunosuppressed client.
Risk factors may include
Inadequate primary defenses—broken skin, traumatized tissue, altered peristalsis
Inadequate secondary defenses—immunosuppression
Invasive procedures
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Infection Status
Achieve timely healing, be free of purulent drainage or erythema, and be afebrile.
Risk Control
Verbalize understanding of the individual causative or risk factor(s).
Nursing intervention with rationale:
1. Note individual risk factors: abdominal trauma, acute appendicitis, and peritoneal dialysis.
Rationale: Influences choice of interventions.
2. Assess vital signs frequently, noting unresolved or progressing hypotension, decreased pulse pressure, tachycardia, fever, and tachypnea.
Rationale: Signs of impending septic shock. Circulating endotoxins eventually produce vasodilation, shift of fluid from circulation, and a low cardiac output state. Note: These clients frequently are critically ill and medical or postsurgical intensive care is required.
3. Note changes in mental status, such as new onset confusion and stupor.
Rationale: Hypoxemia, hypotension, and acidosis can cause deteriorating mental status.
4. Note skin color, temperature, and moisture.
Rationale: Warm, flushed, dry skin is early sign of septicemia. Later manifestations include cool, clammy, pale skin and cyanosis as shock becomes refractory.
5. Monitor urine output.
Rationale: Oliguria develops as a result of decreased renal perfusion, circulating toxins, and effects of antibiotics.
6. Maintain strict aseptic technique in caring for abdominal drains, incisions or open wounds, dressings, and invasive sites. Cleanse with appropriate solution.
Rationale: Prevents access or limits spread of infecting organisms and cross-contamination.
7. Perform and model good hand-washing technique. Monitor staff and client compliance with hand washing.
Rationale: Reduces risk of cross-contamination and spread of infection.
8. Observe drainage from wounds or drains.
Rationale: Provides information about status of infection.
9. Maintain sterile technique when catheterizing client, provide catheter care, and encourage perineal cleansing on a routine basis.
Rationale: Prevents access and limits bacterial growth in urinary tract.
10. Monitor or restrict visitors and staff, as appropriate. Provide protective isolation if indicated.
Rationale: Reduces risk of exposure to, or acquisition of, secondary infection in immunosuppressed client.
Friday, March 11, 2011
Risk for Infection | Nursing Care Plan for Appendectomy
Nursing diagnosis: risk for Infection
Risk factors may include
Inadequate primary defenses, perforation or rupture of the appendix, peritonitis, abscess formation
Invasive procedures, surgical incision
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Wound Healing: Primary Intention
Achieve timely wound healing, free of signs of infection and inflammation, purulent drainage, erythema, and fever.
Nursing intervention with rationale:
1. Practice and instruct in good hand-washing and aseptic wound care. Encourage and provide perineal care.
Rationale: Reduces risk of spread of bacteria.
2. Inspect incision and dressings. Note characteristics of drainage from wound or drains (if inserted) and presence of erythema.
Rationale: Provides for early detection of developing infectious process and monitors resolution of preexisting peritonitis.
3. Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in mentation, and reports of increasing abdominal pain.
Rationale: Suggestive of presence of infection, developing sepsis, abscess, and peritonitis.
4. Obtain drainage specimens, if indicated.
Rationale: Gram’s stain, culture, and sensitivity testing is useful in identifying causative organism and choice of therapy.
5. Administer antibiotics, as appropriate.
Rationale: Antibiotics given before appendectomy are primarily for prophylaxis of wound infection and are not usually continued postoperatively. Therapeutic antibiotics are administered if the appendix is ruptured or abscessed, or peritonitis has developed.
6. Prepare for and assist with incision and drainage (I&D) if indicated.
Rationale: May be necessary to drain contents of localized abscess.
Risk factors may include
Inadequate primary defenses, perforation or rupture of the appendix, peritonitis, abscess formation
Invasive procedures, surgical incision
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Wound Healing: Primary Intention
Achieve timely wound healing, free of signs of infection and inflammation, purulent drainage, erythema, and fever.
Nursing intervention with rationale:
1. Practice and instruct in good hand-washing and aseptic wound care. Encourage and provide perineal care.
Rationale: Reduces risk of spread of bacteria.
2. Inspect incision and dressings. Note characteristics of drainage from wound or drains (if inserted) and presence of erythema.
Rationale: Provides for early detection of developing infectious process and monitors resolution of preexisting peritonitis.
3. Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in mentation, and reports of increasing abdominal pain.
Rationale: Suggestive of presence of infection, developing sepsis, abscess, and peritonitis.
4. Obtain drainage specimens, if indicated.
Rationale: Gram’s stain, culture, and sensitivity testing is useful in identifying causative organism and choice of therapy.
5. Administer antibiotics, as appropriate.
Rationale: Antibiotics given before appendectomy are primarily for prophylaxis of wound infection and are not usually continued postoperatively. Therapeutic antibiotics are administered if the appendix is ruptured or abscessed, or peritonitis has developed.
6. Prepare for and assist with incision and drainage (I&D) if indicated.
Rationale: May be necessary to drain contents of localized abscess.
Tuesday, January 4, 2011
Risk for Infection | Nursing Care Plan for Craniocerebral Trauma
Nursing diagnosis: risk for Infection
Risk factors may include
Traumatized tissues, broken skin, invasive procedures
Decreased ciliary action, stasis of body fluids
Nutritional deficits
Suppressed inflammatory response—steroid use
Altered integrity of closed system—CSF leak
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Immune Status
Maintain normothermia, free of signs of infection.
Achieve timely wound healing when present.
Nursing intervention with rationale:
1. Provide meticulous, clean, or aseptic care; maintain good hand-washing techniques.
Rationale: First-line defense against nosocomial infections.
2. Observe areas of impaired skin integrity (wounds, suture lines, invasive line insertion sites), noting drainage characteristics and presence of inflammation.
Rationale: Early identification of developing infection permits prompt intervention and prevention of further complications.
3. Monitor temperature routinely. Note presence of chills, diaphoresis, and changes in mentation.
Rationale: May indicate developing sepsis requiring further evaluation and intervention.
4. Encourage deep breathing and aggressive pulmonary toilet. Observe sputum characteristics.
Rationale: Enhances mobilization and clearing of pulmonary secretions to reduce risk of pneumonia and atelectasis. Note: Postural drainage should be used with caution if risk of increased ICP exists.
5. Provide perineal care. Maintain integrity of closed urinary drainage system if used. Encourage adequate fluid intake.
Rationale: Reduces potential for bacterial growth and ascending infection.
6. Observe color and clarity of urine. Note presence of foul odor.
Rationale: Indicators of developing urinary tract infection (UTI) requiring prompt intervention.
7. Screen and restrict access of visitors or caregivers with upper respiratory infections (URIs).
Rationale: Reduces exposure of “compromised host.”
8. Obtain specimens, as indicated.
Rationale: Culture with sensitivities may be done to verify presence of infection and identify causative organism and appropriate treatment choices.
Thursday, December 23, 2010
Risk for Infection | Nursing Care Plan for Tuberculosis
Risk factors may include
Inadequate primary defenses, decreased ciliary action and stasis of secretions
Tissue destruction, extension of infection
Lowered resistance, suppressed inflammatory process
Malnutrition
Environmental exposure
Insufficient knowledge to avoid exposure to pathogens
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Identify interventions to prevent or reduce risk of spread of infection.
Demonstrate techniques and initiate lifestyle changes to promote safe environment.
Nursing care plan intervention with rationale:
1. Review pathology of disease—active or inactive phases, dissemination of infection through bronchi to adjacent tissues or via bloodstream and lymphatic system—and potential
spread of infection via airborne droplet during coughing, sneezing, spitting, talking, laughing, and singing.
Rationale: Helps client realize and accept necessity of adhering to medication regimen to prevent reactivation and complications. Understanding of how the disease is passed and awareness of transmission possibilities help client and significant other (SO) take steps to prevent infection of others.
2. Identify others at risk, such as household members, close associates, and friends.
Rationale: Those exposed may require a course of drug therapy to prevent development of infection.
3. Instruct client to cough, sneeze, and expectorate into tissue and to refrain from spitting. Review proper disposal of tissue and good hand-washing techniques. Request return
demonstration.
Rationale: Behaviors necessary to prevent spread of infection.
4. Review necessity of infection control measures, such as temporary respiratory isolation.
Rationale: May help client understand need for protecting others while acknowledging client’s sense of isolation and social stigma associated with communicable diseases. Note: AFB can
pass through standard masks; therefore, particulate respirators are required.
5. Monitor temperature, as indicated.
Rationale: Febrile reactions are indicators of continuing presence of infection.
6. Identify individual risk factors for reactivation of tuberculosis, such as lowered resistance associated with alcoholism, malnutrition, intestinal bypass surgery, use of immunosuppressant
drugs, presence of diabetes mellitus or cancer, or postpartum.
Rationale: Knowledge about these factors helps client alter lifestyle and avoid or reduce incidence of exacerbation.
7. Stress importance of uninterrupted drug therapy. Evaluate client’s potential for cooperation.
Rationale: Contagious period may last only 2 to 3 days after initiation of drug regimen, but in the presence of cavitation or moderately advanced disease, risk of spread of infection may
continue up to 3 months. Compliance with multidrug regimens for prolonged periods is difficult; therefore, DOT should be considered.
8. Review importance of follow-up and periodic reculturing of sputum for the duration of therapy.
Rationale: Aids in monitoring the effects of medications and client’s response to therapy.
9. Encourage selection and ingestion of well-balanced meals. Provide frequent small “snacks” in place of large meals as appropriate.
Rationale: Presence of anorexia or preexisting malnutrition lowers resistance to infectious process and impairs healing. Small snacks may enhance overall intake.
Monday, December 20, 2010
Risk for Infection | Nursing Care Plan for Ventilatory Assistance
Nursing diagnosis: risk for Infection
Risk factors may include
Inadequate primary defenses—traumatized lung tissue, decreased ciliary action, stasis of body fluids
Inadequate secondary defenses—immunosuppression
Chronic disease, malnutrition
Invasive procedure—intubation
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Infection Control
Indicate understanding of individual risk factors.
Identify interventions to prevent or reduce risk of infection.
Demonstrate techniques to promote safe environment.
Nursing care plan intervention with rationale:
1. Note risk factors for occurrence of infection.
Rationale: Intubation interferes with the normal defense mechanisms that keep microorganisms out of the lungs. ET tubes, especially cuffed ones, interfere with the mucociliary transport system that helps clear airway secretions. Secretions that accumulate below and above the ET tube cuff are ideal growth medium for pathogens. The ET tube also prevents normal closure of the epiglottis, resulting in an incomplete seal of the laryngeal structures that normally protect the lungs. This can contribute to aspiration, which often leads to ventilator-associated pneumonia (VAP) (Pruitt & Jacobs, 2006). VAP is the primary cause of hospital-acquired pneumonia (HAP) reportedly occurring in 10% to 25% of individuals receiving mechanical ventilation (Byrd et al, 2006). Other factors include prolonged mechanical ventilation, trauma, general debilitation, malnutrition, age, and invasive procedures. Awareness of individual risk factors provides opportunity to limit effects and helps prevent VAP.
2. Observe color, odor, and characteristics of sputum. Note drainage around tracheostomy tube.
Rationale: Yellow or green, purulent odorous sputum is indicative of infection; thick, tenacious sputum suggests dehydration.
3. Engage in proper hand washing or alcohol-based hand rubs, wear gloves when handling respiratory secretions and equipment contaminated with respiratory secretions, maintain sterile suction techniques in open system, use closedsystem ET tube allowing for continuous removal of secretions, reduce the number of times the ventilator tubes are open, and provide clean nebulizer and tubing changes.
Rationale: These factors may be the simplest but are the most important keys to prevention of hospital-acquired infection. Note: The Centers for Disease Control and Prevention’s (CDC) (2005) guidelines recommend changing tubing no more often than every 48 hours. Research indicates that less frequent tubing changes (every 5 to 7 days) may be acceptable.
4. Encourage deep breathing, coughing, and frequent position changes.
Rationale: Maximizes lung expansion and mobilization of secretions to prevent or reduce atelectasis and accumulation of sticky, thick secretions.
5. Auscultate breath sounds.
Rationale: Presence of rhonchi and wheezes suggests retained secretions requiring expectoration or suctioning.
6. Provide or instruct client and SO in proper oral care and secretion disposal, such as disposing of tissues and soiled tracheostomy dressings.
Rationale: Reduces risk of pneumonia associated with aspiration of oral bacteria, as well as transmission of fluidborne organisms. Note: Chlorhexidine mouth rinse has been found to reduce
plaque and gingival inflammation as a means of preventing VAP.
7. Monitor and screen visitors. Avoid contact with persons with respiratory infections.
Rationale: Individual is already compromised and is at increased risk with exposure to infections.
8. Provide respiratory isolation when indicated.
Rationale: Depending on specific diagnosis, client may require protection from others or must prevent transmission of infection, for example, tuberculosis (TB) to others.
9. Maintain adequate hydration and nutrition. Encourage fluids to 2,500 mL/day within cardiac tolerance.
Rationale: Helps improve general resistance to disease and reduces risk of infection from static secretions.
10. Measure pH of gastric secretions, and monitor use of antacid medications, as indicated.
Rationale: Maintaining acid level of stomach about pH of 7.2 may help reduce risk of nosocomial infection and stress ulcers and contamination of respiratory tract by means of reflux and
aspiration.
Friday, November 26, 2010
Nursing Diagnosis for Pneumonia | Risk for Infection
Nursing diagnosis: risk for infection
Risk factors may include
Inadequate primary defenses—decreased ciliary action, stasis of respiratory secretions
Inadequate secondary defenses—presence of existing infection, immunosuppression; chronic disease, malnutrition
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Infection Status
Achieve timely resolution of current infection without complications.
Knowledge: Infection Control
Identify interventions to prevent and reduce risk and spread of a secondary infection.
Nursing intervention with rationale:
1. Monitor vital signs closely, especially during initiation of therapy.
Rationale: During this period, potentially fatal complications, such as hypotension or shock, may develop.
2. Instruct client concerning the disposition of secretions (e.g., raising and expectorating versus swallowing) and reporting changes in color, amount, and odor of secretions.
Rationale: Although client may find expectoration offensive and attempt to limit or avoid it, it is essential that sputum be disposed of in a safe manner. Changes in characteristics of sputum
reflect resolution of pneumonia or development of secondary infection.
3. Demonstrate and encourage good hand-washing technique.
Rationale: Effective means of reducing spread or acquisition of infection.
4. Change position frequently and provide good pulmonary toilet.
Rationale: Promotes expectoration, clearing of infection.
5. Perform proper suctioning technique for ventilated clients as appropriate.
Rationale: Secretions that accumulate below and above the endotracheal (ET) tube cuff are an ideal growth medium for pathogens. The ET tube also prevents normal closure of the epiglottis,
resulting in an incomplete seal of the laryngeal structures that normally protect the lungs. This can contribute to aspiration and VAP (Pruitt & Jacobs, 2006).
6. Limit visitors as indicated.
Rationale: Reduces likelihood of exposure to other infectious pathogens.
7. Institute isolation precautions as individually appropriate.
Rationale: Depending on type of infection, response to antibiotics, client’s general health, and development of complications, isolation techniques may be instituted to prevent spread
and protect client from other infectious processes.
8. Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake.
Rationale: Facilitates healing process and enhances natural resistance.
9. Monitor effectiveness of antimicrobial therapy.
Rationale: Signs of improvement in condition should occur within 24 to 48 hours.
10. Investigate sudden changes or deterioration in condition, such as increasing chest pain, extra heart sounds, altered sensorium, recurring fever, and changes in sputum characteristics.
Rationale: Delayed recovery or increase in severity of symptoms suggests resistance to antibiotics or secondary infection. Complications affecting any organ system include lung
abscess, empyema, bacteremia, pericarditis, endocarditis, meningitis, encephalitis, and superinfections.
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