Risk for Infection

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Risk for infection related
Goal: Independent Goal:
- Fever to UTI secondary to
After 8 hours of nursing  Establish rapport  to obtain After 8 hours of nursing
- Lower back fever intervention the patient patient’s trust intervention the patient
pain will be able to identify and cooperation will be able to identify
- Pain in interventions to interventions to
prevent/reduce the risk  Take and record  To obtain prevent/reduce the risk
urinating for of infection vital signs baseline data of infection
1 week
 Encourage  facilitates
Objective: expression of grieving the loss Objective:
After 4 hours of nursing feelings and After 4 hours of nursing
intervention the patient anxieties intervention the patient
will be able to: will be able to:
 Promote good  Reduces risk of
 Establish good hand washing by cross-  Establish good
working staff and patient. contamination. working
relationship with relationship with
health care health care
providers  Encourage to  to prevent providers
increase fluid dehydration
intake-increase to boost immune
 Have knowledge Vit. C in the diet- system and  Have knowledge
and awareness increase CHON promote collagen and awareness
about his intake if not formation-for about his
condition and the contraindicated tissue repair condition and the
disease process disease process
  Provide  Peripheral
conscientious skin circulation maybe
 Practice proper care, gently impaired placing  Practice proper
hand washing massage bony areas. patient at increased hand washing
Keep the skin dry, risk for skin
linens dry and irritation or
wrinkle free. breakdown and
 Know infection.  Know
interventions to interventions to
facilitate early  Place in semi  Facilitates lung facilitate early
recognition of – fowler’s expansion and recognition of
infection position. reduces risk of infection
aspiration.

 These measures
 Encourage reduce stasis of
coughing and secretions in the
deep breathing; lungs and
consider use of bronchial tree.
incentive When stasis
spirometer. occurs, pathogens
can cause upper
respiratory
infections,
including
pneumonia.
  To promote pt’s
 Provide a safe comfort
and quiet
environment
 To meet the
 Take Due meds body’s
on time requirements

Collaborative  Identifies organisms

 Obtain specimen for so that most
culture and appropriate drug
sensitivities as therapy can be
indicated instituted.

 Early treatment
 Administer may help prevent
antibiotics as sepsis.
appropriate.
Pain

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Acute pain related to Independent:

- Fever biological factors such as After 8 hours of nursing  Assess pain,  Provides
interventions, the noting location, information to After 8 hours of nursing
- Lower back trauma or activity of
patient’s pain intensity (scale of aid in interventions, the
pain disease process will be 0 – 10), duration. determining patient’s pain
- Pain in relieved or choice or will be
controlled. effectiveness of relieved or
urinating for interventions. controlled.
1 week
 Encourage  Increased
increased fluid hydration
intake. flushes bacteria
and toxins.

 Investigate report  Urinary

of bladder retention may
fullness. develop,
causing tissue
distention (
bladder or
kidney), and
potentiates risk
for further
infection.

 Observe for  Accumulation of

changes in uremic waste
mental status, and electrolyte
 behavior or level imbalances
of consciousness. may be toxic to
the CNS.

 Provide comfort  Promotes

measure like relaxation,
back rub, helping refocuses
patient assume attention, and
position of may enhance
comfort. Suggest coping abilities.
use of relaxation
technique and
deep breathing
exercises.

 Encourage use of  Promotes

sitz baths, warm muscle
soaks to the relaxation.
perineum.

Collaborative:  Reduces
 Administer bacteria present
antibacterial as in urinary tract
prescribed. and those
introduced by
drainage
system
Fever

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Hyperthermia related to

- Fever the infectious process After 2 hours of INDEPENDENT: After 2 hours of

comprehensive nursing  Provide tepid sponge  Enhances heat loss by comprehensive nursing
- Lower back secondary to UTI
intervention, the patient bath. evaporation & intervention, the patient
pain temperature will lower
conduction. will:
- Pain in  Assess fluid loss &  Increases metabolic  Maintain normal
down to normal levels:
facilitate oral intake. rate & diaphoresis. temperature of 37.5°C
urinating for T: 36.5°C – 37.5°C  Promote bed rest.  Reduces body heat  Be free of dehydration
1 week production.  Maintain vital signs at
 Provide cool  Dissipates heat by normal levels
circulating air using a convection.  Be alert and
fan.  Increases comfort. responsive
 Assist patient in  Be comfortable in bed.
changing into dry  Prevents herpetic
clothing. lesions of the mouth.
 Provide oral hygiene.  Notes progress &
changes of condition.
 Monitor vital signs.
 Prevents dehydration.
DEPENDENT:
 Maintain IV fluids as  Reduces fever.
ordered by physician.
 Administer anti-  Treats underlying
pyretic as ordered. cause.
 Administer antibiotic
as ordered.

COLLABORATIVE:  Indicates presence of

  Monitor hematologic infection &
test & other pertinent dehydration.
lab records.
 Discuss condition of  Ensures continuous
the patient with other intervention.
members of the health
care team.

Impaired Urinary Elimination

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Impaired Urinary ◈After 4 hours of
- Fever Short Term Goal Independent ◈ Provides basis for nursing
Elimination further assessment & intervention, the
- Lower back pain ◈ Assessed patency
- Pain in urinating related to mechanical ◈ After 4 hours of of foley catheter. action. goal is met through
for 1 week nursing exhibition of adequate
obstruction of the intervention, ◈ Used asepsis and ◈ Prevents or urinary output and
normal urine hand hygiene in reduces risk of patent drainage system
bladder or other urinary
elimination and output providing care and contamination of
tract structure will be maintained. manipulating the foley catheter.
urinary drainage
system.
◈ Assessed color, ◈ Provides
volume, odor and information about
components of adequacy of urine
urine. output, condition and
patency of foley
catheter and debris in
urine.
Dependent
◈ Administered IV
fluids such as PNSS ◈ By regulating the
on fast drip as amount of sodium,
prescribed. the kidney can
regulate the volume of
body fluids.