Download PRIORITY NURSING DIAGNOSIS Risk for infection related to

PRIORITY NURSING DIAGNOSIS
Risk for infection related to
DESIRED PATIENT OUTCOME (ONE) Measurable & Patient Centered
Patient will remain free from symptoms of infection
NURSING INTERVENTIONS
RATIONALE
1. Increase good hand washing; by the care
1. To prevent cross contamination/ bacterial
givers and patients.
colonization. Note: patients with severe
anemia/aplastic be at risk due to the normal
2. Maintain strict aseptic technique on the
flora of the skin.
procedure/ treatment of wounds.
2. To reduce the risk of colonization/infection
3. Give skin care, perianal, and oral carefully.
of bacteria.
4. Motivation changes in position/ambulation
often, coughing and deep breathing
exercises.
5. Nurse should maintain adequate nutrition
and fluid and electrolyte balance. A well
balanced diet should be provided with
increased amounts of vitamin C, sufficient
iron and 2400-2800 mL of fluid daily.
6. Monitor/limit visitors. Give isolation room
whenever possible.
7. Observe erythema/wound fluid. The
formation of pus may not exist when
granulocytes depressed.
8. Take a specimen for culture & sensitivity as
indicated.
9. Leave a topical antiseptic; Administer
systemic antibiotics.
10. Assess incision site for signs of infection
every 2h. Change dressing as needed
11. Assess oral temperature and report if
greater than 101.0°F. Note chills and
tachycardia.
12. Consider targeted surveillance for MRSA.
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13. Observe and report signs of infection such
as redness, warmth, discharge, and
increased body temperature.
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14. Note and report laboratory values (e.g,
WBC, serum protein, serum albumin,
cultures).
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15. Monitor weight loss, leaving 25% or more
of food uneaten at most meals.
16. Follow standard precaution and wear
gloves during contact with blood mucous
membranes, nonintact skin, or any body
substance except sweat. Use goggles,
powder-free gloves, and gowns when
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Reducing the risk of damage to the
skin/tissue and infection.
Increased pulmonary ventilation all
segments and help mobilize secretions to
prevent pneumonia.
To assist in the dilution secret breathing, to
ease spending and prevent stasis of body
fluids such as respiratory and kidney.
Limiting exposure to bacteria / infection.
Protection in isolation required in aplastic
anemia, when the immune response is very
disturbed.
Indicators of local infection.
To distinguish the presence of infection,
identify specific pathogens and influence
the choice of treatment.
May be used to reduce colonization or
prophylactic treatment for localized
infection process.
To prevent infection or treat immediately
upon signs of infection
Monitor for infection. The process of
inflammation / infection require evaluation /
treatment.
Targeted surveillance for MRSA
colonization was cost-effective and
provided substantial benefits by reducing
the rate of health care-acquired MRSA
infections in a community hospital system.
Prospective surveillance study for health
care acquired infection on hematologyoncology units should include fever of
unknown origin as the single most common
and clinically important entity.
The WBC count and the automated
absolute neutrophil count are better
diagnostic tests for adults and most
children.
This study demonstrated the above criteria
as significant predictors of protein calorie
malnutrition.
Research has shown that several
appropriate. Standard precautions apply to
all clients. You must assume all clients are
carrying blood-borne pathogens.
17. Use alternatives to indwelling catheters
whenever possible (external catheters,
incontinence pads, bladder control
techniques). Sterile technique must be
used when inserting urinary catheters.
postsurgical complications can occur when
powder particles from surgical and exam
gloves gall into an open incision or are
accidentally placed in the body with an
instrument on which the particles have
attached themselves.
17. UTIs account for almost half of all health
care-associated infections (HAI), and a
significant number of these infections are
related to the insertion of urinary catheters.