Nurseslabs » risk for infection

Risk for Infection — COPD Nursing Care Plans

Nurseslabs — Sat, 28 Apr 2012 19:58:49 +0000

NURSING DIAGNOSIS: Risk for Infection

Risk factors may include

Inadequate primary defenses (decreased ciliary action, stasis of secretions)
Inadequate acquired immunity (tissue destruction, increased environmental exposure)
Chronic disease process
Malnutrition

Desired Outcomes

Knowledge: Infection Control (NOC)

Verbalize understanding of individual causative/risk factors.
Identify interventions to prevent/reduce risk of infection.
Demonstrate techniques, lifestyle changes to promote safe environment.

Nursing Interventions & Rationale

Nursing Interventions	Rationale
Monitor temperature.	Fever may be present because of infection and/or dehydration.
Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake.	These activities promote mobilization and expectoration of secretions to reduce risk of developing pulmonary infection.
Observe color, character, odor of sputum.	Odorous, yellow, or greenish secretions suggest the presence of pulmonary infection.
Demonstrate and assist patient in disposal of tissues and sputum. Stress proper handwashing (nurse and patient), and use gloves when handling/disposing of tissues, sputum containers.	Prevents spread of fluid-borne pathogens.
Monitor visitors; provide masks as indicated.	Reduces potential for exposure to infectious illnesses, e.g., upper respiratory infection (URI).
Encourage balance between activity and rest.	Reduces oxygen consumption/demand imbalance, and improves patient’s resistance to infection, promoting healing.
Discuss need for adequate nutritional intake.	Malnutrition can affect general well-being and lower resistance to infection.
Recommend rinsing mouth with water and spitting, not swallowing, or use of spacer on mouthpiece of inhaled corticosteroids.	Reduces localized immunosuppressive effect of drug and risk of oral candidiasis.
Obtain sputum specimen by deep coughing or suctioning for Gram’s stain, culture/sensitivity.	Done to identify causative organism and susceptibility to various antimicrobials.
Administer antimicrobials as indicated.	May be given for specific organisms identified by culture and sensitivity, or be given prophylactically because of high risk.

Risk for Infection — COPD Nursing Care Plans Original source at: Nurseslabs

4 Appendectomy Nursing Care Plans

Nurseslabs — Sat, 21 Apr 2012 09:18:36 +0000

Appendectomy is the surgical removal of the appendix. Here are 4 nursing care plans for appendectomy.

An inflamed appendix may be removed using a laparoscopic approach with laser. However, the presence of multiple adhesions, retroperitoneal positioning of the appendix, or the likelihood of rupture necessitates an open (traditional) procedure.

Studies indicate that laparoscopic appendectomy results in significantly less postoperative pain, earlier resumption of solid foods, a shorter hospital stay, lower wound infection rate, and a faster return to normal activities than open appendectomy.

Diagnostic Studies for Appendectomy

WBC: Leukocytosis above 12,000/mm³, neutrophil count often elevated to greater than 75%.
Abdominal x-rays: May reveal hardened bit of fecal material in appendix (fecalith), localized ileus.
Ultrasound or CT scan: May be done for differentiation of appendicitis from other causes of abdominal pain (e.g., perforating ulcer, cholecystitis, reproductive organ infections) or to localize drainable abscesses.

Nursing Priorities for Appendectomy

Prevent complications.
Promote comfort.
Provide information about surgical procedure/prognosis, treatment needs, and potential complications.

Discharge Goals

Complications prevented/minimized.
Pain alleviated/controlled.
Surgical procedure/prognosis, therapeutic regimen, and possible complications understood.
Plan in place to meet needs after discharge.

4 Appendectomy Nursing Care Plans

4 Appendectomy Nursing Care Plans Original source at: Nurseslabs

Risk for Infection — Fractures Nursing Care Plans

Nurseslabs — Thu, 05 Apr 2012 05:33:31 +0000

Nursing Diagnosis: Risk for Infection

Risk factors may include

Inadequate primary defenses: broken skin, traumatized tissues; environmental exposure
Invasive procedures, skeletal traction

Desired Outcomes:

Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.

Nursing Interventions	Rationale
Inspect the skin for preexisting irritation or breaks in continuity.	Pins or wires should not be inserted through skin infections, rashes, or abrasions (may lead to bone infection).
Assess pin sites/skin areas, noting reports of increased pain/burning sensation or presence of edema, erythema, foul odor, or drainage.	May indicate onset of local infection/tissue necrosis, which can lead to osteomyelitis.
Provide sterile pin/wound care according to protocol, and exercise meticulous handwashing.	May prevent cross-contamination and possibility of infection.
Instruct patient not to touch the insertion sites.	Minimizes opportunity for contamination.
Line perineal cast edges with plastic wrap.	Damp, soiled casts can promote growth of bacteria.
Observe wounds for formation of bullae, crepitation, bronze discoloration of skin, frothy/fruity-smelling drainage.	Signs suggestive of gas gangrene infection.
Assess muscle tone, reflexes, and ability to speak.	Muscle rigidity, tonic spasms of jaw muscles, and dysphagia reflect development of tetanus.
Monitor vital signs. Note presence of chills, fever, malaise, changes in mentation.	Hypotension, confusion may be seen with gas gangrene; tachycardia and chills/fever reflect developing sepsis.
Investigate abrupt onset of pain/limitation of movement with localized edema/erythema in injured extremity.	May indicate development of osteomyelitis.
Institute prescribed isolation procedures.	Presence of purulent drainage requires wound/linen precautions to prevent cross-contamination.
Monitor laboratory/diagnostic studies, e.g.:Complete blood count (CBC); ESR; Cultures and sensitivity of wound/serum/bone; Radioisotope scans.	Anemia may be noted with osteomyelitis; leukocytosis is usually present with infective processes. Elevated in osteomyelitis. Identifies infective organism and effective antimicrobial agent(s). Hot spots signify increased areas of vascularity, indicative of osteomyelitis.
Administer medications as indicated, e.g.:IV/topical antibiotics; Tetanus toxoid.	Wide-spectrum antibiotics may be used prophylactically or may be geared toward a specific microorganism.Given prophylactically because the possibility of tetanus exists with any open wound. Note: Risk increases when injury/wound(s) occur in “field conditions” (outdoor/rural areas, work environment).
Provide wound/bone irrigations and apply warm/moist soaks as indicated.	Local debridement/cleansing of wounds reduces microorganisms and incidence of systemic infection. Continuous antimicrobial drip into bone may be necessary to treat osteomyelitis, especially if blood supply to bone is compromised.
Assist with procedures, e.g., incision/drainage, placement of drains, hyperbaric oxygen therapy.	Numerous procedures may be carried out in treatment of local infections, osteomyelitis, gas gangrene.
Prepare for surgery, as indicated.	Sequestrectomy (removal of necrotic bone) is necessary to facilitate healing and prevent extension of infectious process.

Risk for Infection — Fractures Nursing Care Plans Original source at: Nurseslabs

Risk for Infection — Burns Nursing Care Plans

Nurseslabs — Sat, 31 Mar 2012 11:20:59 +0000

Nursing Diagnosis: Infection, risk for

Risk factors may include

Inadequate primary defenses: destruction of skin barrier, traumatized tissues
Inadequate secondary defenses: decreased Hb, suppressed inflammatory response
Environmental exposure, invasive procedures

Desired Outcomes

Achieve timely wound healing free of purulent exudate and be afebrile.

Nursing Interventions	Rationale
Implement appropriate isolation techniques as indicated	Dependent on type/extent of wounds and the choice of wound treatment (e.g., open versus closed), isolation may range from simple wound/skin to complete or reverse to reduce risk of cross-contamination and exposure to multiple bacterial flora.
Emphasize/model good handwashing technique for all individuals coming in contact with patient.	Prevents cross-contamination; reduces risk of acquired infection.
Use gowns, gloves, masks, and strict aseptic technique during direct wound care and provide sterile or freshly laundered bed linens/gowns.	Prevents exposure to infectious organisms.
Monitor/limit visitors, if necessary. If isolation is used, explain procedure to visitors. Supervise visitor adherence to protocol as indicated.	Prevents cross-contamination from visitors. Concern for risk of infection should be balanced against patient’s need for family support and socialization.
Shave/clip all hair from around burned areas to include a1-in border (excluding eyebrows). Shave facial hair (men) and shampoo head daily.	Opportunistic infections (e.g., yeast) frequently occur because of depression of the immune system and/or proliferation of normal body flora during systemic antibiotic therapy.
Examine unburned areas (such as groin, neck creases, mucous membranes) and vaginal discharge routinely.	Eyes may be swollen shut and/or become infected by drainage from surrounding burns. If lids are burned, eye covers may be needed to prevent corneal damage.
Provide special care for eyes, e.g., use eye covers and tear formulas as appropriate.	Prevents adherence to surface it may be touching and encourages proper healing.Note: Ear cartilage has limited circulation and is prone to pressure necrosis.
Prevent skin-to-skin surface contact (e.g., wrap each burned finger/toe separately; do not allow burned ear to touch scalp).	Identifies presence of healing (granulation tissue) and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury. Note: A strong sweet, musty smell at a graft site is indicative of Pseudomonas.
Examine wounds daily, note/document changes in appearance, odor, or quantity of drainage.	Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Note: Changes in sensorium, bowel habits, and respiratory rate usually precede fever and alteration of laboratory studies.
Monitor vital signs for fever, increased respiratory rate/depth in association with changes in sensorium, presence of diarrhea, decreased platelet count, and hyperglycemia with glycosuria.	Water softens and aids in removal of dressings and eschar (slough layer of dead skin or tissue). Sources vary as to whether bath or shower is best. Bath has advantage of water providing support for exercising extremities but may promote cross-contamination of wounds. Showering enhances wound inspection and prevents contamination from floating debris.
Remove dressings and cleanse burned areas in a hydrotherapy/whirlpool tub or in a shower stall with handheld shower head. Maintain temperature of water at100°F (37.8°C). Wash areas with a mild cleansing agent or surgical soap.	Early excision is known to reduce scarring and risk of infection, thereby facilitating healing.
Debride necrotic/loose tissue (including ruptured blisters) with scissors and forceps. Do not disturb intact blisters if they are smaller than 1–2 cm, do not interfere with joint function, and do not appear infected.	Promotes healing. Prevents autocontamination. Small, intact blisters help protect skin and increase rate of re-epithelialization unless the burn injury is the result of chemicals (in which case fluid contained in blisters may continue to cause tissue destruction).
Photograph wound initially and at periodic intervals.	Provides baseline and documentation of healing process.
Administer topical agents as indicated, e.g.: Silver sulfadiazine (Silvadene); Mafenide acetate (Sulfamylon); Silver nitrate; Bacitracin; Povidone-iodine (Betadine); Hydrogels, e.g., Transorb, Burnfree.	The following agents help control bacterial growth and prevent drying of wound, which can cause further tissue destruction. Broad-spectrum antimicrobial that is relatively painless but has intermediate, somewhat delayed eschar penetration. May cause rash or depression of WBCs. Antibiotic of choice with confirmed invasive burn-wound infection. Useful against Gram-negative/Gram-positive organisms. Causes burning/pain on application and for 30 min thereafter. Can cause rash, metabolic acidosis, and decreased Paco2. Effective against Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa, but has poor eschar penetration, is painful, and may cause electrolyte imbalance. Dressings must be constantly saturated. Product stains skin/surfaces black. Effective against Gram-positive organisms and is generally used for superficial and facial burns. Broad-spectrum antimicrobial, but is painful on application, may cause metabolic acidosis/increased iodine absorption, and damage fragile tissues. Useful for partial- and full-thickness burns; filling dead spaces, rehydrating dry wound beds, and promoting autolytic debridement. May be used when infection is present. Systemic antibiotics are given to control general infections identified by culture/sensitivity. Subeschar clysis has been found effective against pathogens in granulated tissues at the line of demarcation between viable/nonviable tissue, reducing risk of sepsis.
Administer other medications as appropriate, e.g.;Subeschar clysis/systemic antibiotics; Tetanus toxoid or clostridial antitoxin, as appropriate.	Tissue destruction/altered defense mechanisms increase risk of developing tetanus or gas gangrene, especially in deep burns such as those caused by electricity.
Place IV/invasive lines in nonburned area.	Decreased risk of infection at insertion site with possibility of progression to septicemia.
Obtain routine cultures and sensitivities of wounds/drainage.	Allows early recognition and specific treatment of wound infection.

Risk for Infection — Burns Nursing Care Plans Original source at: Nurseslabs

Risk for Infection — Appendectomy Nursing Care Plans

Nurseslabs — Sat, 31 Mar 2012 02:44:10 +0000

Nursing Diagnosis: Infection, risk for

Risk factors may include

Inadequate primary defenses; perforation/rupture of the appendix; peritonitis; abscess formation
Invasive procedures, surgical incision

Desired Outcomes

Achieve timely wound healing; free of signs of infection/inflammation, purulent drainage, erythema, and fever.

Nursing Priorities

Prevent complications.
Promote comfort.
Provide information about surgical procedure/prognosis, treatment needs, and potential complications.

Discharge Goals

Complications prevented/minimized.
Pain alleviated/controlled.
Surgical procedure/prognosis, therapeutic regimen, and possible complications understood.
Plan in place to meet needs after discharge.

Nursing Interventions	Rationale
Practice/instruct in good handwashing and aseptic wound care. Encourage/provide perineal care.	Reduces risk of spread of bacteria.
Inspect incision and dressings. Note characteristics of drainage from wound/drains (if inserted), presence of erythema.	Provides for early detection of developing infectious process, and/or monitors resolution of preexisting peritonitis.
Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in mentation, reports of increasing abdominal pain.	Suggestive of presence of infection/developing sepsis, abscess, peritonitis.
Obtain drainage specimens if indicated.	Gram’s stain, culture, and sensitivity testing isuseful in identifying causative organism and choice of therapy.
Administer antibiotics as appropriate.	Antibiotics given before appendectomy are primarily for prophylaxis of wound infection and are not continued postoperatively. Therapeutic antibiotics are administered if the appendix is ruptured/abscessed or peritonitis has developed.
Prepare for/assist with incision and drainage (I&D) if indicated.	May be necessary to drain contents of localized abscess.

Risk for Infection — Appendectomy Nursing Care Plans Original source at: Nurseslabs

Risk for Infection — Pneumonia Nursing Care Plans

Nurseslabs — Tue, 27 Mar 2012 13:21:50 +0000

Nursing Diagnosis: Risk for [Spread] of Infection

Risk factors may include

Inadequate primary defenses (decreased ciliary action, stasis of respiratory secretions)
Inadequate secondary defenses (presence of existing infection, immunosuppression), chronic disease, malnutrition

Desired Outcomes

Achieve timely resolution of current infection without complications.
Identify interventions to prevent/reduce risk/spread of/secondary infection.

Nursing Interventions	Rationale
Monitor vital signs closely, especially during initiation of therapy.	During this period of time, potentially fatal complications (hypotension/shock) may develop.
Instruct patient concerning the disposition of secretions (e.g., raising and expectorating versus swallowing) and reporting changes in color, amount, odor of secretions.	Although patient may find expectoration offensive and attempt to limit or avoid it, it is essential that sputum be disposed of in a safe manner. Changes in characteristics of sputum reflect resolution of pneumonia or development of secondary infection.
Demonstrate/encourage good handwashing technique.	Effective means of reducing spread or acquisition of infection.
Change position frequently and provide good pulmonary toilet.	Promotes expectoration, clearing of infection.
Limit visitors as indicated.	Reduces likelihood of exposure to other infectious pathogens.
Institute isolation precautions as individually appropriate.	Dependent on type of infection, response to antibiotics, patient’s general health, and development of complications, isolation techniques may be desired to prevent spread/protect patient from other infectious processes.
Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake.	Facilitates healing process and enhances natural resistance.
Monitor effectiveness of antimicrobial therapy.	Signs of improvement in condition should occur within 24–48 hr.
Investigate sudden changes/deterioration in condition, such as increasing chest pain, extra heart sounds, altered sensorium, recurring fever, changes in sputum characteristics.	Delayed recovery or increase in severity of symptoms suggests resistance to antibiotics or secondary infection. Complications affecting any/all organ systems include lung abscess/empyema, bacteremia, pericarditis/endocarditis, meningitis/encephalitis, and superinfections.
Prepare for/assist with diagnostic studies as indicated.	Fiberoptic bronchoscopy (FOB) may be done in patients who do not respond rapidly (within 1–3 days) to antimicrobial therapy to clarify diagnosis and therapy needs.

Risk for Infection — Pneumonia Nursing Care Plans Original source at: Nurseslabs

Risk for Infection — Diabetes Mellitus Nursing Care Plans

Nurseslabs — Mon, 26 Mar 2012 13:25:58 +0000

Nursing Diagnosis: Risk for Infection

Risk factors may include:

High glucose levels, decreased leukocyte function, alterations in circulation
Preexisting respiratory infection, or UTI

Desired Outcomes:

Identify interventions to prevent/reduce risk of infection.
Demonstrate techniques, lifestyle changes to prevent development of infection.

Nursing Interventions	Rationale
Observe for signs of infection and inflammation, e.g., fever, flushed appearance, wound drainage, purulent sputum, cloudy urine.	Patient may be admitted with infection, which could have precipitated the ketoacidotic state, or may develop a nosocomial infection.
Promote good handwashing by staff and patient.	Reduces risk of cross-contamination.
Maintain aseptic technique for IV insertion procedure, administration of medications, and providing maintenance/site care. Rotate IV sites as indicated.	High glucose in the blood creates an excellent medium for bacterial growth.
Provide catheter/perineal care. Teach the female patient to clean from front to back after elimination	Minimizes risk of UTI. Comatose patient may be at particular risk if urinary retention occurred before hospitalization. Note: Elderly female diabetic patients are especially prone to urinary tract/vaginal yeast infections.
Provide conscientious skin care; gently massage bony areas. Keep the skin dry, linens dry and wrinkle-free.	Peripheral circulation may be impaired, placing patient at increased risk for skin irritation/breakdown and infection.
Auscultate breath sounds.	Rhonchi indicate accumulation of secretions possibly related to pneumonia/bronchitis (may have precipitated the DKA). Pulmonary congestion/edema (crackles) may result from rapid fluid replacement/HF.
Place in semi-Fowler’s position.	Facilitates lung expansion; reduces risk of aspiration.
Reposition and encourage coughing/deep breathing if patient is alert and cooperative. Otherwise, suction airway, using sterile technique, as needed.	Aids in ventilating all lung areas and mobilizing secretions. Prevents stasis of secretions with increased risk of infection.
Provide tissues and trash bag in a convenient location for sputum and other secretions. Instruct patient in proper handling of secretions.	Minimizes spread of infection.
Encourage/assist with oral hygiene.	Reduces risk of oral/gum disease.
Encourage adequate dietary and fluid intake (approximately3000 mL/day if not contraindicated by cardiac or renal dysfunction), including 8 oz of cranberry juice per day as appropriate.	Decreases susceptibility to infection. Increased urinary flow prevents stasis and aids in maintaining urine pH/acidity, reducing bacteria growth and flushing organisms out of system. Note: Use of cranberry juice can help prevent bacteria from adhering to the bladder wall, reducing the risk of recurrent UTI.
Administer antibiotics as appropriate.	Early treatment may help prevent sepsis.

Risk for Infection — Diabetes Mellitus Nursing Care Plans Original source at: Nurseslabs

Risk for Infection — Cancer Nursing Care Plans

Nurseslabs — Mon, 26 Mar 2012 12:45:33 +0000

Nursing Diagnosis: Risk for Infection

Risk factors may include

Inadequate secondary defenses and immunosuppression, e.g., bone marrow suppression (dose-limiting side effect of both chemotherapy and radiation).
Malnutrition, chronic disease process
Invasive procedures

Desired Outcomes

Remain afebrile and achieve timely healing as appropriate.
Identify and participate in interventions to prevent/reduce risk of infection.

Nursing Interventions	Rationale
Promote good handwashing procedures by staff and visitors. Screen/limit visitors who may have infections. Place in reverse isolation as indicated.	Protects patient from sources of infection, such as visitors and staff who may have an upper respiratory infection (URI).
Emphasize personal hygiene.	Limits potential sources of infection and/or secondary overgrowth.
Monitor temperature.	Temperature elevation may occur (if not masked by corticosteroids or anti-inflammatory drugs) because of various factors, e.g., chemotherapy side effects, disease process, or infection. Early identification of infectious process enables appropriate therapy to be started promptly.
Assess all systems (e.g., skin, respiratory, genitourinary) for signs/symptoms of infection on a continual basis.	Early recognition and intervention may prevent progression to more serious situation/sepsis.
Reposition frequently; keep linens dry and wrinkle-free.	Reduces pressure and irritation to tissues and may prevent skin breakdown (potential site for bacterial growth).
Promote adequate rest/exercise periods.	Limits fatigue, yet encourages sufficient movement to prevent stasis complications, e.g., pneumonia, decubitus, and thrombus formation.
Stress importance of good oral hygiene.	Development of stomatitis increases risk of infection/ secondary overgrowth.
Avoid/limit invasive procedures. Adhere to aseptic techniques.	Reduces risk of contamination, limits portal of entry for infectious agents.
Monitor CBC with differential WBC and granulocyte count, and platelets as indicated.	Bone marrow activity may be inhibited by effects of chemotherapy, the disease state, or radiation therapy. Monitoring status of myelosuppression is important for preventing further complications (e.g., infection, anemia, or hemorrhage) and scheduling drug delivery.
Obtain cultures as indicated.	Identifies causative organism(s) and appropriate therapy.
Administer antibiotics as indicated.	May be used to treat identified infection or given prophylactically in immunocompromised patient.

Risk for Infection — Cancer Nursing Care Plans Original source at: Nurseslabs

Peritonitis Nursing Management

Nurseslabs — Tue, 13 Mar 2012 10:00:24 +0000

Peritonitis, inﬂammation of the peritoneum, is usually the result of bacterial infection, with the organisms coming from disease of the GI tract, or, in women, the internal reproductive organs. It can also result from external sources, such as injury or trauma or an inﬂammation from an extraperitoneal organ, such as the kidney.

Pathophysiology

Peritonitis is caused by leakage of contents from abdominal organs into the abdominal cavity, usually as a result of inﬂammation, infection, ischemia, trauma, or tumor perforation. The most common bacteria implicated are Escherichia coli, and Klebsiella, Proteus, and Pseudomonas species. Other common causes are appendicitis, perforated ulcer, diverticulitis, and bowel perforation. Peritonitis may also be associated with abdominal surgical procedures and peritoneal dialysis. Sepsis is the major cause of death from peritonitis (shock, from sepsis or hypovolemia). Intestinal obstruction from bowel adhesions may develop.

Clinical Manifestations

Diffuse pain becomes constant, localized, and more intense near site of the process.
Pain is aggravated by movement.
Affected area of the abdomen becomes extremely tender and distended, and muscles become rigid.
Rebound tenderness and paralytic ileus may be present.
Anorexia, nausea, and vomiting occur and peristalsis is diminished.
Temperature and pulse increase; hypotension may develop.

Assessment and Diagnostic Methods

Leukocytes (elevated) and serum electrolytes (altered potassium, sodium and chloride)
Abdominal x-rays, ultrasound, CT scan, MRI, and peri-toneal aspiration with culture and sensitivity studies

Nursing Diagnosis

Risk for Infection [Septicemia]
Deficient Fluid Volume
Acute Pain
Risk for Imbalanced Nutrition: Less than Body Requirements
Anxiety/Fear
Deficient Knowledge

Medical Management

Fluid, colloid, and electrolyte replacement with an isotonic solution is the major focus of medical management.
Analgesics are administered for pain; antiemetics are administered for nausea and vomiting.
Intestinal intubation and suction are used to relieve abdominal distention.
Oxygen therapy by nasal cannula or mask is instituted to improve ventilatory function.
Occasionally, airway intubation and ventilatory assistance are required.
Massive antibiotic therapy may be instituted (sepsis is the major cause of death).
Surgical objectives include removal of infected material; surgery is directed toward excision (appendix), resection (intestine), repair (perforation), or drainage (abscess).

Nursing Management

Monitor the patient’s blood pressure by arterial line if shock is present.
Monitor central venous or pulmonary artery pressures and urine output frequently.
Provide ongoing assessment of pain, GI function, and ﬂuid and electrolyte balance.
Assess nature of pain, location in the abdomen, and shifts of pain and location.
Administer analgesic medication and position for comfort (eg, on side with knees ﬂexed to decrease tension on abdominal organs).
Record intake and output and CVP and/or pulmonary artery pressures.
Administer and monitor IV ﬂuids closely; nasogastric intubation may be necessary.
Observe for decrease in temperature and pulse rate, softening of the abdomen, return of peristaltic sounds, and passage of ﬂatus and bowel movements, which indicate peritonitis is subsiding.
Increase food and oral ﬂuids gradually, and decrease parenteral ﬂuid intake when peritonitis subsides.
Observe and record character of drainage from postoperative wound drains if inserted; take care to avoid dislodging drains.
Postoperatively, prepare patient and family for discharge; teach care of incision and drains if still in place at discharge.
Refer for home care if necessary.

Peritonitis Nursing Management Original source at: Nurseslabs

Risk for Infection — AIDS Nursing Care Plan

Nurseslabs — Wed, 29 Feb 2012 16:48:50 +0000

Acquired immunodeficiency syndrome (AIDS) is the final result of infection with a retrovirus, the human immunodeficiency virus (HIV).

Nursing Diagnosis:

Risk for Infection

Risk factors may include

Inadequate primary defenses: broken skin, traumatized tissue, stasis of body fluids
Depression of the immune system, chronic disease, malnutrition; use of antimicrobial agents
Environmental exposure, invasive techniques

Possibly evidenced by:

[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes:

Achieve timely healing of wounds/lesions.
Be afebrile and free of purulent drainage/secretions and other signs of infectious conditions.
Identify/participate in behaviors to reduce risk of infection.

AIDS Nursing Care Plan: Risk for Infection

Nursing Interventions	Rationale
Assess patient knowledge and ability to maintain opportunistic infection prophylactic regimen.	Multiple medication regimen is difficult to maintain over a long period of time. Patients may adjust medication regimen based on side effects experienced, contributing to inadequate prophylaxis, active disease, and resistance.
Wash hands before and after all care contacts. Instruct patient/SO to wash hands as indicated.	Reduces risk of cross-contamination.
Provide a clean, well-ventilated environment. Screen visitors/staff for signs of infection and maintain isolation precautions as indicated.	Reduces number of pathogens presented to the immune system and reduces possibility of patient contracting a nosocomial infection.
Discuss extent and rationale for isolation precautions and maintenance of personal hygiene.	Promotes cooperation with regimen and may lessen feelings of isolation.
Monitor vital signs, including temperature.	Provides information for baseline data; frequent temperature elevations/onset of new fever indicates that the body is responding to a new infectious process or that medications are not effectively controlling noncurable infections.
Assess respiratory rate/depth; note dry spasmodic cough on deep inspiration, changes in characteristics of sputum, and presence of wheezes/rhonchi. Initiate respiratory isolation when etiology of productive cough is unknown.	Respiratory congestion/distress may indicate developing PCP (the most common opportunistic disease); however, TB is on the rise and other fungal, viral, and bacterial infections may occur that compromise the respiratory system. Note: CMV and PCP can reside together in the lungs and, if treatment is not effective for PCP, the addition of CMV therapy may be effective.
Investigate reports of headache, stiff neck, altered vision. Note changes in mentation and behavior. Monitor for nuchal rigidity/seizure activity.	Neurological abnormalities are common and may be related to HIV or secondary infections. Symptoms may vary from subtle changes in mood/sensorium (personality changes or depression) to hallucinations, memory loss, severe dementias, seizures, and loss of vision. CNS infections (encephalitis is the most common) may be caused by protozoal and helminthic organisms or fungus.
Examine skin/oral mucous membranes for white patches or lesions. (Refer to ND: Skin Integrity, impaired, actual and/or risk for, and ND: Oral Mucous Membrane, impaired.)	Oral candidiasis, KS, herpes, CMV, and cryptococcosis are common opportunistic diseases affecting the cutaneous membranes.
Clean patient’s nails frequently. File, rather than cut, and avoid trimming cuticles.	Reduces risk of transmission of pathogens through breaks in skin. Note: Fungal infections along the nail plate are common.
Monitor reports of heartburn, dysphagia, retrosternal pain on swallowing, increased abdominal cramping, profuse diarrhea.	Esophagitis may occur secondary to oral candidiasis, CMV, or herpes. Cryptosporidiosis is a parasitic infection responsible for watery diarrhea (often more than 15L/day).
Inspect wounds/site of invasive devices, noting signs of local inflammation/infection.	Early identification/treatment of secondary infection may prevent sepsis.
Wear gloves and gowns during direct contact with secretions/excretions or any time there is a break in skin of caregiver’s hands. Wear mask and protective eyewear to protect nose, mouth, and eyes from secretions during procedures (e.g., suctioning) or when splattering of blood may occur.	Use of masks, gowns, and gloves is required by Occupational Safety and Health Administration (OSHA, 1992) for direct contact with body fluids, e.g., sputum, blood/blood products, semen, vaginal secretions.
Dispose of needles/sharps in rigid, puncture-resistant containers.	Prevents accidental inoculation of caregivers. Use of needle cutters and recapping is not to be practiced. Note: Accidental needlesticks should be reported immediately, with follow-up evaluations done per protocol.
Label blood bags, body fluid containers, soiled dressings/ linens, and package appropriately for disposal per isolation protocol.	Prevents cross-contamination and alerts appropriate personnel/departments to exercise specific hazardous materials procedures.
Clean up spills of body fluids/blood with bleach solution (1:10); add bleach to laundry.	Kills HIV and controls other microorganisms on surfaces.

Risk for Infection — AIDS Nursing Care Plan Original source at: Nurseslabs