Nursing Diagnosis for Infection

LpAngel81 · Mar 26, 2009

for interventions you could use : clean catheter area to make sure it remains clean from feces

Daytonite, BSN, RN · Mar 26, 2009

Risk for Infection R/T invasive indwelling urinary catheter.

Goal: Client will remain free of infection.

Valerie Salva, BSN, RN · Mar 26, 2009

For interventions- think- how would you know if the pt were to develop a UTI? This is what to look for.

RN BSN 2009 · Mar 26, 2009

and also, what s/sx can you educate the patient on to report to the nurse asap?

Daytonite, BSN, RN · Mar 26, 2009

Interventions for "Risk for" nursing diagnoses are limited to:

strategies to prevent the problem (in this case, infection) from happening in the first place
monitoring for the specific signs and symptoms of this problem (in this case, infection)
reporting any symptoms that do occur to the doctor or other concerned

deemarys · Mar 26, 2009

Interventions for "Risk for" nursing diagnoses are limited to:
strategies to prevent the problem (in this case, infection) from happening in the first place
monitoring for the specific signs and symptoms of this problem (in this case, infection)
reporting any symptoms that do occur to the doctor or other concerned

This patient doesn't speak, he uses nonverbal communication (example) nodding the head when asked a question.

How would I know if he had UTI? Would the color of his urine be an indicator? He has a high tolerance for pain, usually never complains about anything. His vitals are normal. I will do more research on this...

deemarys · Mar 26, 2009

Interventions for "Risk for" nursing diagnoses are limited to:
strategies to prevent the problem (in this case, infection) from happening in the first place
monitoring for the specific signs and symptoms of this problem (in this case, infection)
reporting any symptoms that do occur to the doctor or other concerned

I input nursing interventions for this diagnosis:

Minimize patients risk of infection washing hands before and after providing care.

Use sterile technique when inserting indwelling urinary catheter.

Clean catheter area to make sure it remains clean from feces. Ensure that perianal area is clean after elimination.

Wearing gloves to maintain asepsis when providing direct care

SolaireSolstice, BSN, RN · Mar 26, 2009

How would I know if he had UTI?

I know you said you would research this, but here's a clue: Vital signs. What vital signs would be affected by infection, and how?

And just because a patient is non-verbal does not mean that he cannot communicate discomfort. Think of the face scale for pain.

Would the color of his urine be an indicator?

The urine itself can also have indicators of infection. Change in odor and color, and Urinalysis lab results. Research those changes that would occur with UTI.

deemarys · Mar 27, 2009

Risk for Infection R/T invasive indwelling urinary catheter.
Goal: Client will remain free of infection.

For Target date/Goal

I entered Client will remain free of infection. I was told that I had to put in a time or date. I am confused because shouldn't it always remain free of infection from point of procedure until its removed. How would I

word that since they want specific dates?

Daytonite, BSN, RN · Mar 27, 2009

for target date/goal
i entered client will remain free of infection. i was told that i had to put in a time or date. i am confused because shouldn't it always remain free of infection from point of procedure until its removed. how would i
word that since they want specific dates?

ask your instructors what they would prefer as appropriate target dates for goals. all care plans must be reviewed periodically and those are the target dates that are used in facilities. an open date is never posted otherwise it would be assumed that this specific nursing problem would never get addressed or updated ever again and that is not cool at all.

see post #157 on this sticky: https://allnurses.com/general-nursing-student/careplans-help-please-121128.html - careplans help please! (with the r\t and aeb) which explains how goal statements should be constructed. it has this information:

goal statements have four components:

a
behavior
- this is the desired patient response/action you expect to see/hear as a direct result of your nursing interventions.
- you must be able to observe the behavior

[*]it is

measurable

criteria that identifies exactly what you are measuring in terms of
- how much
- how long
- how far
- on what scale you are using

[*]sets the

conditions

under which the behavior should occur

such conditions as
- when
- how frequently
[*]take into account the patient's overall state of health (this requires knowing the pathophysiology of their disease process)
[*]take into account the patient's ability to meet the goals you are recommending
[*]it is a good idea to get the patient's agreement to meet the intended goal so both the nurse and the patient are working toward the same goal

[*]have a realistic

time frame

for completing the goal

long-term goals usually take weeks or months
short-term goals can take as little time as a day
it all depends on knowing what your nursing interventions are designed to do and what you believe your patient is capable of doing.

the symptoms of sepsis and infection can be found here: http://www.merck.com/mmpe/sec06/ch068/ch068a.html. sepsis is infection accompanied by an acute inflammatory reaction with systemic manifestations associated with release into the bloodstream of numerous endogenous mediators of inflammation. the inflammatory reaction typically manifests with 2 or more of the following

- temperature > 38° c or
- heart rate > 90 beats/min
- respiratory rate > 20 breaths/min or paco2
- wbc count > 12,000 cells/μl or 10% immature form
[*]severe sepsis is sepsis accompanied by signs of failure of at least one organ. cardiovascular failure is typically manifested by hypotension, respiratory failure by hypoxemia, renal failure by oliguria, and hematologic failure by coagulopathy
[*]septic shock is severe sepsis with organ hypoperfusion and hypotension that are poorly responsive to initial fluid resuscitation
[*]with sepsis, the patient typically has fever, tachycardia, and tachypnea; bp remains normal. other signs of the causative infection are generally present. as severe sepsis or septic shock develops, the first sign may be confusion or decreased alertness. bp generally falls, yet the skin is paradoxically warm. oliguria (

note: inflammatory response precedes all signs of any infection. infection occurs first. if untreated it continues to become sepsis. urosepsis, a form of sepsis, can occur in people with foley catheters. here are some of the specific behaviors you will need to list out in your goal statement. you would be assessing vital signs as frequently as the facility policy wants them assessed for someone with an evasive piece of medical equipment in them. therefore, i would also make the time frame of the goal that same time frame. so, if vs are done weekly, then make the goal of the client remaining free of infection (only re-write this) "in one week. . .the client" and add specific signs and symptoms that this client will be show no evidence of.

behavior:
- short term: normal temperature and normal appearing urine
- long term: normal urine tests and normal blood tests that indicate no infection
[*]measurable:
- short term
  - temperature is measurable: normal oral temperature is 96.8 to 99.5 f
  - urine can also be assessed: normal urine should be clear yellow but it can also be cloudy because of the ingestion of certain foods. there should be a fresh aromatic smell to it because of the presence of acids in it.
  [*]long term
  - labs
[*]conditions (when and how frequently)
- short term: every week
- long term: determine how often labs can be done (sometimes this involves financial problems)
[*]time frame for completion (realistic): theoretically this nursing problem will be ongoing as long as the foley is in place.

now, write the goal(s).

for example:

short term goal: in one week client will show no evidence of urosepsis as evidenced by having a temperature between 96.8 to 99.5 f and urine that is clear yellow in color (or you could also say, "remains slightly cloudy yellow in color" or "yellow in color with sediment") with no foul odor.
long term goal: in 3 months client will show no evidence of sepsis as evidenced by monitoring of lab studies that include negative urine culture and sensitivity tests and blood profiles showing normal wbc counts.