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EHS:NursingCarePlanningGuidesCarePlanner:Diagnosis:Riskforinfection

NURSINGDIAGNOSIS:Riskforinfection
1.

pneumoniarelatedtostasisofsecretionsinthelungs(secretionsprovideagoodmediumfor
bacterialgrowth)

2.

urinarytractinfectionrelatedto:

A. increasedgrowthandcolonizationofmicroorganismsassociatedwithurinarystasis
B. introductionofpathogensintotheurinarytractassociatedwiththepresenceofanindwelling
catheterand/ordifficultymaintaininggoodperinealhygieneduringperiodofimmobility.

DesiredOutcome

Theclientwillnotdeveloppneumoniaasevidencedby:
1.
2.
3.
4.
5.
6.
7.
8.

normalbreathsounds
resonantpercussionnoteoverlungs
absenceoftachypnea
coughproductiveofclearmucusonly
afebrilestatus
absenceofpleuriticpain
bloodgasesandWBCcountwithinnormalrangeforclient
negativesputumculture.

NursingActionsandSelectedPurposes/Rationales
1. Assessforandreportsignsandsymptomsofpneumonia:
A. abnormalbreathsounds(e.g.crackles[rales],pleuralfrictionrub,bronchialbreath
sounds,diminishedorabsentbreathsounds)
B. dullpercussionnoteoveraffectedlungarea
C. tachypnea
D. coughproductiveofpurulent,green,orrustcoloredsputum
E. chillsandfever
F. pleuriticpain
G. elevatedWBCcount
H. abnormaloximetryandbloodgasresults
I. positivesputumcultureresults
J. chestxrayresultsindicativeofpneumonia.
2. Implementmeasurestopreventpneumonia:
A. performactionstopromoteeffectiveairwayclearance(seeDiagnosis2,actionb)
B. protectclientfrompersonswithrespiratorytractinfections
C. encourageandassistclienttoperformfrequentoralhygieneinordertoremove
pathogensandsecretionsthatcouldbeaspirated.
3. Ifsignsandsymptomsofpneumoniaoccur:
A. administeroxygenasordered
B. administerantimicrobialsifordered.

DesiredOutcome

Theclientwillremainfreeofurinarytractinfectionasevidencedby:
1.
2.
3.
4.
5.

clearurine
absenceoffrequency,urgency,andburningonurination
absenceofchillsandfever
fewerthan5WBCsandabsenceofnitritesandbacteriainurine
negativeurineculture.

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2/15/2016

EHS:NursingCarePlanningGuidesCarePlanner:Diagnosis:Riskforinfection

NursingActionsandSelectedPurposes/Rationales
1. Assessforandreportsignsandsymptomsofurinarytractinfection(e.g.cloudyurinereports
offrequency,urgency,orburningonurinationchillselevatedtemperatureurinalysis
showingaWBCcountgreaterthan5orthepresenceofnitritesorbacteriapositiveurine
culture).
2. Implementmeasurestopreventurinarytractinfection:
A. performactionstopreventurinarystasis(seeDiagnosis12,actionB.1inrenalcalculi
complication)
B. maintainafluidintakeofatleast2500ml/dayunlesscontraindicatedtopromoteurine
formationandsubsequentvoiding,whichflushespathogensfromtheurethraandbladder
C. instructfemaleclienttowipefromfronttobackafterurinatingordefecating
D. assistclientwithperinealcareroutinelyandaftereachbowelmovement
E. maintainsteriletechniqueduringurinarycatheterizationandirrigations
F. ifanindwellingurinarycatheterispresent:
I. securethecathetertubingtolowerabdomenorthighonmalesortothighon
femalestominimizeriskofaccidentaltractiononthecatheterandsubsequent
traumatothebladderandurethraanchortubingsecurelytoreducetheamountof
inandoutmovementofthecatheter(thismovementcanresultinintroductionof
pathogensintotheurinarytractandcausetissuetrauma,whichcanresultin
colonizationofmicroorganisms)
II. performcathetercareasoftenasneededtopreventaccumulationofmucusaround
themeatus
III. maintainacloseddrainagesystemwheneverpossibletoreducetheriskof
introductionofpathogensintotheurinarytract
IV. keepurinecollectioncontainerbelowbladderlevelatalltimestopreventrefluxor
stasisofurine
V. changecatheteraccordingtohospitalpolicy.
3. Ifsignsandsymptomsofurinarytractinfectionoccur,administerantimicrobialsifordered.

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