Wednesday, 22 February 2012

Nursing Care Plan for Peritonitis Nursing Diagnosis Risk for Infection

Nursing Diagnosis Risk for Infection Nursing Care Plan

Definition: At increased risk for being invaded by pathogenic organisms
Related Factors: See Risk Factors.

Risk Factors:

Invasive procedures; insufficient knowledge regarding avoidance of exposure to pathogens; trauma; tissue destruction and increased environmental exposure; rupture of amniotic membranes; pharmaceutical agents (e.g., immunosuppressants); malnutrition; increased environmental exposure to pathogens; immunosuppression; inadequate acquired immunity; inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response); inadequate primary defenses (e.g., broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis); chronic disease.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

Immune Status
Knowledge: Infection Control
Risk Control
Risk Detection

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Infection Control
Infection Protection

Client Outcomes

Remains free from symptoms of infection
States symptoms of infection of which to be aware
Demonstrates appropriate care of infection-prone site
Maintains white blood cell count and differential within normal limits
Demonstrates appropriate hygienic measures such as hand washing, oral care, and perineal care.

Nursing Interventions Risk for Infection for Peritonitis

Independent:

1. Note the example of individual risk factors abdominal trauma, acute appendicitis, peritoneal dialysis.
Rational: Affects choice of interventions

2. Assess vital signs with frequent, noted no improvement or continuing hypotension, decreased pulse pressure, tachycardia, fever, tachypnea.
Rationale: Signs of septic shock, endotoxin circulation causes vasodilation, loss of fluid from the circulation, and low cardiac output status.

3. Note the change in mental status (eg, confusion, fainting).
Rational: Hypoxaemia, hypotension, and acidosis can cause irregularities in mental status.

4. Note the color, temperature, humidity.
Rational: Warm, redness, dry skin is an early sign of septicemia. Further manifestations include cold, pale skin moist and cyanosis as a sign of shock.

5. Monitor urine output.
Rational: Oliguria occurred as a result of reduced renal perfusion, the toxin in the circulation affects the antibiotic.

6. Maintain strict aseptic technique in the treatment of abdominal drain, wound incision / open, and the invasive side.
Rationale: Prevent the spread and limit the spread of infectious organisms / cross contamination.

7. Observations on wound drainage.
Rationale: Provides information about the status of infection.

8. Maintain sterile technique when the patient is placed catheters, and catheter care provided / or perineal hygiene routine.
Rasonal: Preventing the spread, limiting the growth of bacteria in the urinary tract.

9. Supervise / limit visitors and staff as needed. Provide insulation protection when indicated.
Rational: Reduce the risk of exposure to / add a secondary infection in patients who experienced immune pressure.

Collaboration:

1. Take for example / watch the results of serial blood, urine, wound cultures.
Rationale: Identifying microorganisms and assist in assessing the effectiveness of antimicrobial program.

2. Assist in the peritoneal aspiration, if indicated.
Rational: Guide to drain fluids and to identify infectious organisms so that appropriate antibiotics but can be given.

3. Prepare for surgical intervention when indicated
Rationale: Treatment of choice (curative) in acute peritonitis or local, for example a local abscess drainage, peritoneal exudate throw, throw rupturapendiks / gall bladder, cope with perforated ulcer, or bowel resection.

Reference : http://careplannursing.blogspot.com/2011/12/risk-for-infection-nursing-care-plan.html