Nursing Diagnosis Risk for Infection Definition: Increased risk of entry of pathogenic organisms Risk factors:

Invasive procedure Insufficient knowledge to avoid exposure to pathogens Trauma Tissue damage and increased exposure to environmental Rupture of amniotic membranes Pharmaceutical agent (immunosuppressants) Malnutrition Increased exposure to environmental pathogens Imonusupresi Inadequate artificial immunity Inadequate secondary defenses (decreased Hb, Leukopenia, suppression of inflammatory response) Inadequate defenses primary (non-intact skin, tissue trauma, decreased cilia work, static body fluids, secretions changes in pH, changes in peristalsis) Chronic Disease Risk for Infection NANDA NOC Nursing Outcomes Classification Immune Status Knowledge: Infection Control Risk Control Criteria Results: The client is free from signs and symptoms of infection Demonstrated ability to prevent infection The number of leukocytes within normal limits Demonstrate healthy behavior Risk for Infection NANDA NIC Nursing Intervention Classification

Infection Control Clean up the environment after use of other patients Maintain isolation techniques Limit the visitor when necessary Instruct visitors to wash their hands after visiting during a visit and left the patient Use anti-microbial soap for washing hands Wash hands before and after every nursing action Use the clothes, gloves as a protective device Maintain aseptic environment during the installation of equipment Change the location of peripheral IV and central line and dressing in accordance with the general directions Use of intermittent catheters to reduce bladder infections Increase the intake of nutrients Provide antibiotic therapy if necessary Infection Protection Monitor signs and symptoms of systemic and local infections Monitor granulocyte count, WBC Monitor susceptibility to infection Limit visitors Filter the visitors to an infectious disease Maintain aseptic technique in patients who are at risk Maintain isolation techniques if necessary Give skin care in the area epidema Inspection of skin and mucous membranes of the redness, heat, drainage

Inspection of the condition of the wound / surgical incision Push the insert adequate nutrition Encourage fluid intake Encourage the rest Instruct patients to take antibiotics as prescribed Teach the patient and family the signs and symptoms of infection Teach how to avoid infection Report suspected infection Report a positive culture

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Care Plan RISK FOR INFECTION

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1.

Oct 3, '08 by araujojr Does my care plan look okay ? what do you all think? thanks

Subjective

I do not feel like eating

Objective

Solu-Cortef 100 mg IV Q8hr RAC PICC Foley Catheter Wound L. Foot Recent hx of UTI Albumin 9/30/08 2.5 L Unwillingness to eat Wbc 9/30 8.4 and 10/02 10.7 normal Hgb 9/30 11.3 L 10/02 9.7 L

Risk for Infection R/T inadequate secondary defenses, immunosuppression, invasive procedures, and malnutrition.

GOAL: Client will remain free of infection, as evidenced by normal WBC count, temp < 100 F, and absence of purulent drainage from incisions. Or

1. Client will show no signs and symptoms of infection by discharge? Note ( cannot teach pt) does not recall information

Assessment 1. Assess for presence, existence of, and history of risk factors of infection. 2. Monitor white blood count (WBC)

3. Observed/Monitor for signs and symptoms of infection. 4. Assess for nutritional status. 5. Assess immunization status.

Decrease stressors: 6. Stress proper hand washing technique by all caregivers between therapies. 7. Encourage deep breathing, coughing, and turning q 2hr. 8. Provide regular catheter/perineal care and proper foley care daily. 9. Obtain appropriate tissue/fluid specimens for observation and culture/sensitivities testing.

Teaching/counseling/referrals: 10. Teach family members and caregivers about protecting susceptible patient from themselves and others with infections or cold. 11. Teach patient and caregiver the signs and symptoms of infection, and when to report to physician 12. Review individual nutritional needs, appropriate exercise program, and need for rest. Assessment 1. Assess clt at 1530 am. and clt has a Foley catheter present, wound on the L. heel, PICC RAC and Hx of UTI as a risk factor. 2. Monitor WBC count, labs within normal parameters 9/30 (8.4) and 10/02 (10.7). 3. No signs and symptoms (redness, swelling, purulent drainage) at PICC, and Foley clear yellow urine w/o visible sediment and Temp of 98.1 F 4. Albumin level of 2.5 L and unwillingness to eat, pt states I do not feel like eating. and < 25% food eaten. Enjoys strawberry ice cream and hot chocolate, but drinks Ensure chocolate. 5. No records of a pneumonax vaccine given. MD placed an ordered and SN administered it.

Decrease stressors: 6. Washed hands before and after pt. contact between therapies. Staff is aware of proper hand washing technique. 7. Taught patient to deep breath, cough and turn q hr, pt needs to be reminded. 8. Provided a total sponge bath on 10/02 at 1000, secured the foley catheter with tape and reminded pt not to pull on catheter, and cleaned the skin around the catheter and washed my hands before and after catheter care. 9. Obtain a Mersa swap at 1700 and results pending

Teaching/counseling/referrals: 10. Taught son preventive hygiene practices/ methods by return demonstration and to gown up, wear a mask and glove if they have infection or cold. 11. Unable to teach patient the signs and symptoms of infection, pt has short term memory loss, taught patients son the signs and symptoms of infection( fever >100 F, foul smelly urine, confusion, redness, purulent drainage at the wound) 12. Advice the nurse the best way to treat this patient is to be placed on routine care, provide enough rest and at

sleep use BIPAP 35 %, and provided active and passive ROM. Unable to let patient get out of bed due to high risk of injury.

We do not have to do rationales. Last edit by araujojr on Oct 3, '08

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2.

Leave a Comment

2 Comments so far...

3. Oct 3, '08 by SuesquatchRN

Nothing about proper Foley care?

araujojr likes this.

4.

Oct 4, '08 by jenawade25

That's a great care plan. The only thing you could add is a specific time frame for the goals to be met. For example, the temp will be <100 F within 48 hours. Remember goals should be measurable and specific. With your care plan temperature is able to be measured, but when you add a time frame it makes it more specific. I got enough care plans back with red ink on them to know that.

Good luck

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Risk for Infection R/T inadequate secondary defenses, immunosuppression, invasive procedures, and malnutrition. GOAL: Client will remain free of infection, as evidenced by normal WBC count, temp < 100 F, and absence of purulent drainage from incisions. Or 1. Client will show no signs and symptoms of infection by discharge? Note ( cannot teach pt) does not recall information Assessment 1. Assess for presence, existence of, and history of risk factors of infection. 2. Monitor white blood count (WBC) 3. Observed/Monitor for signs and symptoms of infection. 4. Assess for nutritional status. 5. Assess immunization status. Decrease stressors: 6. Stress proper hand washing technique by all caregivers between therapies. 7. Encourage deep breathing, coughing, and turning q 2hr. 8. Provide regular catheter/perineal care and proper foley care daily. 9. Obtain appropriate tissue/fluid specimens for observation and culture/sensitivities testing. Teaching/counseling/referrals: 10. Teach family members and caregivers about protecting susceptible patient from themselves and others with infections or cold. 11. Teach patient and caregiver the signs and symptoms of infection, and when to report to physician 12. Review individual nutritional needs, appropriate exercise program, and need for rest. Assessment 1. Assess clt at 1530 am. and clt has a Foley catheter present, wound on the L. heel, PICC RAC and Hx of UTI as a risk factor. 2. Monitor WBC count, labs within normal parameters 9/30 (8.4) and 10/02 (10.7). 3. No signs and symptoms (redness, swelling, purulent drainage) at PICC, and Foley clear yellow urine w/o visible sediment and Temp of 98.1 F 4. Albumin level of 2.5 L and unwillingness to eat, pt states I do not feel like eating. and < 25% food eaten. Enjoys strawberry ice cream and hot chocolate, but drinks Ensure chocolate. 5. No records of a pneumonax vaccine given. MD placed an ordered and SN administered it. Decrease stressors: 6. Washed hands before and after pt. contact between therapies. Staff is aware of proper hand washing technique. 7. Taught patient to deep breath, cough and turn q hr, pt needs to be reminded. 8. Provided a total sponge bath on 10/02 at 1000, secured the foley catheter with tape and reminded pt not to pull on catheter, and cleaned the skin around the catheter and washed my hands before and after catheter care. 9. Obtain a Mersa swap at 1700 and results pending Teaching/counseling/referrals: 10. Taught son preventive hygiene practices/ methods by return demonstration and to gown up, wear a mask and glove if they have infection or cold. 11. Unable to teach patient the signs and symptoms of infection, pt has short term memory loss, taught patients son the signs and symptoms of infection( fever >100 F, foul smelly urine, confusion, redness, purulent drainage at the wound) 12. Advice the nurse the best way to treat this patient is to be placed on routine care, provide enough rest and at

sleep use BIPAP 35 %, and provided active and passive ROM. Unable to let patient get out of bed due to high risk of injury.