Tuesday, September 23, 2014

Risk for Infection - NCP for Anemia

Nursing Care Plan for Anemia

Nursing Diagnosis : Risk for Infection

Definition : Increased risk of entry of pathogenic organisms.

Risk factors :
  • Invasive procedures.
  • Insufficient awareness to avoid exposure to pathogens.
  • Trauma.
  • Tissue damage and increased environmental exposure.
  • Rupture of amniotic membranes.
  • Pharmaceutical agents (immunosuppressants).
  • Malnutrition.
  • Increased exposure to environmental pathogens.
  • Imonusupresi.
  • Imum ketidakadekuatan made.
  • Inadequate secondary defenses (decreased hemoglobin , Leukopenia , suppression of inflammatory response).
  • Inadequate primary defenses (broken skin, traumatized tissue, decrease in ciliary, static body fluids, secretions changes in pH, changes in peristalsis).
  • Chronic disease.
Goal : increase the client 's immune status .

Outcomes :
  • Free from signs and symptoms of infection.
  • Demonstrated ability to prevent infection.
  • The number of leukocytes within normal limits.
  • Demonstrate healthy behavior.

NIC :

Infection Control
  • Clean up the environment after use for other patients.
  • Maintain isolation techniques.
  • Limit visitors when necessary.
  • Instruct visitors to wash their hands when leaving the visit and after visiting a patient.
  • Use antimicrobial soap for hand washing.
  • Wash hands before and after each nursing action.
  • Use suit , gloves as protective gear.
  • Maintain aseptic environment during the installation of equipment.
  • Change the location of the peripheral IV and central line and dressing in accordance with the general instructions.
  • Use intermittent catheters to decrease bladder infection.
  • Increase the intake of nutrients.
  • Provide antibiotic therapy if necessary.
Infection Protection
  • Monitor signs and symptoms of systemic and local infections.
  • Monitor granulocyte count, WBC.
  • Monitor susceptibility to infection.
  • Limit visitors.
  • Filter visitors to infectious diseases.
  • Partahankan aspesis technique in patients who are at risk.
  • Maintain isolation techniques if necessary.
  • Give the skin of the treatment area epidema.
  • Inspection of skin and mucous membranes of the redness, heat, drainage.
  • Inspection of the condition of the wound / incision surgery.
  • Encourage enter adequate nutrition.
  • Encourage fluid intake.
  • Instruct the break.
  • Instruct the patient to take antibiotics as prescribed.
  • Teach the patient and family the signs and symptoms of infection.
  • Teach how to avoid infection.
  • Report suspicion of infection.
  • Report positive cultures.

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