Risk for infection related to inadequate secondary defenses (leukopenia, neutropenia), altered response to microbial Nursing diagnosis invasion, and environmental exposure to pathogens
Patient goals 1. Adheres to infection control and protection practices
2. Experiences no signs or symptoms of infection, reducing the risk of septic shock Intervention (NIC) Outcome (NOC) Infection Control Risk Control Maintain isolation techniques as appropriate to reduce exposure to Acknowledges risk factors ........... environmental pathogens. Follows selected risk control strategies ........... Wash hands beforeand after each patient care activity to prevent Avoids exposure to health threats ........... transmission of pathogens. Modifies lifestyle to reduce risk ........... Use antimicrobial soap for hand washing. Instruct visitors to wash hands on entering and leaving patient’s Infection Severity room to prevent the transmission of harmful pathogens to patient. Purulent sputum ........... Teach patient and caregiver how to avoid infections (e.g., personal Purulent drainage ........... hygiene techniques of hand washing, oral care, skin hygiene, and Chest x-ray infiltration ........... pulmonary hygiene). Fever ........... Teach the patient and caregivers about signs and symptoms of Pain/tenderness ........... infection and when to report them to the health care provider to Blood culture colonization ........... receive early treatment of infection. White blood count elevation ........... Instruct patient to take antibiotics as prescribed to prevent microbial resistance. Measurement Scale 1 = Severe Infection Protection 2 = Substantial Monitor for systemic and localized signs and symptoms of 3 = Moderate infection to promote early detection of infection. 4 = Mild
differential results to identify signs of and potential for infection. Inspect skin and mucous membranes for redness,extreme warmth, or drainage. Follow neutropenic precautions to avoid exposure to pathogens. Teach patient the importanceof and proper procedure for hand washing. Report suspected infections to infection control personnel in order to promptly initiate antibiotic therapy. Remove fresh flowers and plants from patient areas to avoid introduction of pathogens.