Nursing Diagnosis: risk for infection r/t multiple invasive medical devices Long Term Goal: Patient will

remain free from infection Outcome Criteria 1. Patient insertion site will be asymptomatic for len t! of stay. Intervention 1. .ssess I//PICC line insertion site 0s!ift and PR1. Scientific Rationale Evaluation

1. %!e skin is t!e 1. 2et# I/ access body's first line of site remained defense a ainst asymptomatic. infection. .ny break in skin inte rity s!ould be observed for S/S of infection. ". 4ealt!#care ac5uired $%I's account for up to ,+6 of all 4.I3 and a si nificant number of t!ese are associated wit! t!e use of urinary cat!eters. &. Elevated ()C count can indicate infection. ,. 7ever is often t!e first si n of infection. *. 8ab cultures s!ow w!et!er or not t!e body fluid contains bacteria3 indicatin infection. -. .ntibiotics !ave bactericidal action a ainst susceptible bacteria. ". 2et# Patient did not ac5uire a $%I w!ile in !ospital.

". Patient will be free from cat!eter# associated $%I for len t! of stay.

". Perform cat!eter care 0s!ift and PR1.

&. Patient's ()C count will remain *# 1+. ,. Patient's temperature will remain below 1++ for len t! of stay. *. Patient's lab cultures will s!ow no bacterial rowt! for len t! of stay. -. Patient will !ave decreased ()C count after administration of antibiotics.

&. 2onitor ()C count. ,. 2onitor temperature 0,!rs.

&. $nmet# Patient's ()C count was elevated at 1,.&. ,. $nmet# Patient !ad a temp of 1++.9 1 !r. %ylenol administered. *. 2et# Patient's blood cultures s!owed no rowt!.

*. .ssess wound3 blood3 and urine cultures.

-. .dminister antibiotics as ordered.

-. 2et# Patient ()C count decreased to :.*.