Infection, hight risk for related to external factors

1.2.3 Infection, hight risk for related to external factors

1.2.3.1 Definition
Presence of internal or external hazards that threten physical well-being.

1.2.3.2 Assessment
- Health history, including accidents, allergies, falls, hyperthermia, hypothermia, poisoning, seizures, trauma, exposure to pollutants.
- Sensory or perceptual changes (auditory, tactile, visual).
- Circumstances of present situation that could lead to infection.
- Neurologic status, including level of consciousnes, mental status, orientation.
- Laboratory studies, including cloting factors, hemoglobin and hematocrit, platelet count, serum albumin, white blood cell count, and cultures of blood, body fluid, sputum, urine, wounds.

1.2.3.3 Risk factors
- Admission to hospital
- Age (over 65)
- Chemotherapy
- Hemodialysis
- Hemodialysis
- Hospitalized longer than 1 month
- Immobility
- Indwelling urinary catheter
- Intravenous catheter
- Invasive monitoring procedures
- Obesity
- Prophylactic antibiotic therapy
- Respiratory treatments (endotracheal or tracheostomy tube, humidifier or nebulizer, ventilator)
- Steroid therapy
- Surgical procedure

1.2.3.4 Expecected outcomes
- Temperature stays within normal range.
- White blood cell count and differential stay within normal range.
- No pathogens appear in cultures.
- Patient maintains good personal and oral hygiene.
- Respisatory secretions are clear and odorless.
- Urine remains clear yellow, odorless, with no sediment.
- Patient shows no evidence of diarhea.
- Wounds and incisions appear clean, pink, and free of purulent drainage.
- I.V. sites show no signs of inflammation.
- Patient shows no evidence of skin breakdown.
- Patient takes___ml of fluid and___g of protein daily.
- Patien states infection risk factors.
- Patient identifies signs and symptoms of infection.
- Patient remains free of all signs and symptoms of infection.
1.2.3.5 Interventions and retionales
INTERVENTIONS
1. Minize patient' risk of infection by:
- Washing hands before and after providing care.
- Wearing gloves to maintain asepsis when providing direct care.
2. Monitor temperature at least every 4 hours and record on graph peper. Report elevations immediately.
3. Monitor WBC count, as ordered. Report elevations or depressions.
4. Culture urine, respiratory secretions, Wound drainage, or blood according to hospital policy and doctor's order.
5. Help patient wash hands before and after meals and after using the bathroom, bedpan, or urinal.
6. Assist patient when necessary to ensure that the perianal area is clean after elimination.
7. Intruct patient to report incidents of loose stools or diarrhea. Inform the doctor immediately.
8. Offer oral hygiene to the patient every 4 hours to prevent colonization of bacteria and reduce the risk of de scending infection.
9. Use strict aseptic technique when suctioning the lower airway, inserting indwelling urinary catheters, inserting I.V. catheters and providing wound care.
10. Change I.V. tubing and give site care every 24 to 48 hours or as hospital policy dictates.
11. Rotate I.V. sites every 48 to 72 hours or as hospital policy dictates.
12. Have patient cough and deepbreathe every 4 hours after sugery.
13. Provide tissues and disposal bag for expectorated sputum.
14. Help patient turn every 2 hours. Provide skin care, particularly over bony prom4nences.
15. Use sterile water for humidifcation or nebulization oxygen.
16. Encourage fluid intake of 3,000 to 4,000 ml daily, unless contraindicated.
17. Arrange for reverse isolation if patient has comprimised immune system. Monitor flow and number of visitors.
18. Educate the patient regarding:
-good hand-washing technique
-factors that increase infection risk
-infection signs and symptoms.

RATIONALES
1.
- Handwashing is the single best way to avoid spreading pathogens.
- Gloves offer protection when handling wound dressings or carriying out various treatments.
2. Sustained temperature elevation after surgery may signal onset of pulmonary complications, wound infection or dehiscence, urinary tract infection, or thrombophlebitis.
3. Elevated total WBC count indicates infection. Markedly decreased WBC count may indicate decreased production resulting from extreme debilitation or severe lack of vitamins and amino acids. any damage to bone marrow may suppress WBC formation.
4. This identifies pathogens and guides antibiotic therapy.
5. Hand washing prevents spread of pathogens to other objects and food.
6. Cleaning perineal area by wiping from area of least contamination (urinary meatus) to area of most contamination (anus) helps prevent genitourinary infections.
7. Disease and malnutrition may reduce moisture in mocous membranes of mounth and lips.
8. To avoid spreading pathogens.
9. To help keep pathogens from entering the body.
10. To reduce chances of infection at individual sites.
11. To help remove secretions and prevent pulmonary complications.
12. Convenient disposal encourages expectoration; sanitary disposal reduces spread of infection.
13. To help prevent venous stasis and skin breakdown.
14. This prevents drying and irritation of respiratory mucosa, impared ciliary action, and thickening of secretions within respiratory tract.
15. To help thin mucous secretions.
16. This helps stabilize weight, imroves muscle tone and mass, and aids wound healing.
17. These measures protect patient from pathogens in the environment.
18. These measures allow patient to participate in care and help patient modify life-style to maintain optimum health level.

1.2.3.6 Evaluations for expected outcomes
- Patient's temperature remains within normal range.
- Patient's WBC count and differential remain within normal range.
- Cultures do not exhibit pathogen growth.
- Patient demonstrates appropiate personal and oral hygiene.
- Patient's respiratory secretions remain clear and odorless.
- Patient's urine remains clear, yellow, odorless, and free of sediment.
- Patient's bowel patterns remain normal.
- Patient's incisions or wounds remain clear, pink, and free of purulent drainage.
- Patient's I.V. sites do not show signs of inflammation.
- Patient' skin does not exhibit signs of break down.
- Patient's fluid intake remains at specified level.
- Patient consumes specified amount of protein daily.
- Patien risk factors for infection.
- Patien risk factors and symptoms of infection.
- Patient remains free of signs and symptoms of infection.

1.2.3.7 Documentation
- Temperature
- Dates, time, and sites of all cultures
- Dates, time, and sites of all catheter insertions
- Appearance of all invasive catheter sites, tube sites, and wounds
- Interventions performed to reduce infection risk
- Patient's response to nursing interventions
- Evaluations for each expected outcome