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Saturday, January 28, 2012

Risk for Infection NCP



Problem Identified:
 Risk for Infection
Nursing Diagnosis: 

  • Risk for Infection related to inadequate primary defenses
  • Risk for Infection related to invasive procedures
  • Risk for Infection related to surgical incision


Cause Analysis:

ASSESSMENT
OBJECTIVES
INTERVENTION
RATIONALE


Subjective Cues:


Objective Cues:


Short Term:

After 8 hours of giving nursing interventions and health teachings, the client will be able to identify behaviors and practices to prevent and reduce the risk for infection.


Long Term:


After 3 days of giving nursing interventions, the client will achieve timely wound healing, free of signs of infection and inflammation, purulent drainage, erythema, and fever.


Independent:

  • Stress and model proper hand-washing technique to client and caregivers. 

  • Maintain aseptic technique with any procedures. Provide routine site care/wound care, as appropriate.

  • Inspect dressings and wound; note characteristics of drainage. 


  • Encourage frequent position changes and being out of bed or ambulation, as tolerated. 

  • Provide routine catheter care and promote meticulous perianal care. Keep urinary drainage system closed and remove indwelling catheter as soon as possible.

  • Monitor vital signs. 






Collaborative:
  • Obtain drainage specimens, if indicated. 



  • Administer antibiotics, as indicated.





    • Reduces risk of cross-contamination/bacterial colonization.

    • Prevents entry of bacteria, reducing risk of nosocomial infections. 



    • Early detection of developing infection provides opportunity for timely intervention and prevention of more serious complications.

    • Limits stasis of body fluids, promotes optimal functioning of organ systems and GI tract. 


    • Reduces bacterial colonization and risk of ascending UTI. 




    • Temperature elevation and tachycardia may reflect developing sepsis. 





    • Gram’s stain, culture, and sensitivity testing is useful in identifying causative organism and choice of therapy.

    • Wide-spectrum antibiotics may be used prophylactically, or antibiotic therapy may be geared toward specific organisms.





      Reference: Doenges, M. E., Moorehouse, M. F., Murr, A. C. (2009). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th ed. (p. 346-347, 651-652)



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