Nursing Diagnosis: Ineffective Protection r/t decreased ability to fight infection AEB multiple liver abscesses
Long Term Goal: Pt will remain free of further infection, wounds will heal
OUTCOME CRITERIA
Pt temp will be 97.0-99.4F
as assessed q4h
INTERVENTIONS
Assess temperature
q4h
Pt O2 sat will remain
above 95% as assessed
q4h
Assess Oxygen
saturation levels q4h
RATIONALE
Fever is usually in initial indication
that an infection is present. The
release of cytokines works to
increase core temperature which
can help to kill microorganisms
unable to survive at a higher temp.
This is a defense mechanism
indicating systemic infection. These
messenger cells also cause
manifestations of inflammation.
Infection may also lower
temperature; therefore it must be
monitored closely for abnormalities.
Oxygen is needed for the body to
maintain optimal health. If O2 sats
stay above 95% that means that
diffusion is occurring properly.
Tissues require adequate oxygen to
perfuse and antibodies in the blood
are able to reach and fight infection.
Systemic infection can cause acute
inflammation and swelling in the
lungs making it harder to breathe,
and causing oxygen levels to drop
which could possible lead to sepsis.
Initially the patient may
hyperventilate as a compensatory
mechanism, resulting in respiratory
alkalosis which can then lead to
ARDS or even death.
EVALUATION
Met: Pt maintained
a temp WNL
throughout the shift
Met: Pt O2 sat
remained at 97% or
above
Pt will have WBC between
4.5-13k as assessed per
MD order
Monitor CBC as ordered
by MD
Pt PICC insertion site, JP
drains, and abdominal
ins=cision will show no
increase in redness,
swelling, drainage or
irritation as assessed q4h
and prn
Assess PICC insertion
site, JP drains, and
abdominal incision q4h
and prn
A normal WBC count is 4.5-13k (per
Upstate lab). Any value above or
below that range is an indication of
infection (high or low value) or a
severe decrease in WBC with a high
risk for infection (low value).
Monitoring is especially important
for this patient due to his inability to
fight off infection.
If bacteria start to grow in or around
a device insertion site or surgical
incision , they can easily enter the
blood and cause a serious infection.
This can lead to a condition called
sepsis , which occurs when bacteria
overwhelm the body. Having
devices inserted and surgical
incisions for a prolonged period of
time increases the risk for infection.
Inflammation is a protective vascular
reaction that delivers fluid, blood,
and nutrients to the infected area.
Heat, pain, and tenderness are
localized signs of infection while
increased temp indicates systemic
infection.
Met: Pts last CBC
on 3/20 showed
WBC levels at 11.5k
Met: Site showed no
signs of infection
and Pt denied pain
Pts VS will remain within
normal ranges of (HR 60100, R 12-20, BP 90/60128/88) as assessed q4h
Monitor VS q4h
Pt will verbalize 3 foods to
eat and 3 foods to avoid as
assessed qshift
Teach regarding a diet
TID
Routinely monitoring vital signs
(Temp, Pulse, BP, Resp) can both
provide a baseline for 'normal'
values for the patient but also can
be an indication that a medical
intervention may be needed. Often
times during an active infection, the
body is put under stress and is
working overtime to combat the
pathogen. If a patient becomes has
a systemic infection they will likely
have low blood pressure leading to
poor circulation and lack of perfusion
of vital tissues and organs. This
condition is termed shock and is
sometimes referred to as septic
shock, when an infection is the
cause of shock. This condition can
develop either as a result of the
body's own defense system or from
toxic substances made by the
infecting agent such as a bacteria,
virus, or fungus. Pulse will often
increase with infection and
respirations can be increased or
decreased.
Following a neutropenic diet will help
by decreasing the amount of
infection causing organisms that
may be consumed. Items such as
raw foods, fruits and vegetables that
cannot be peeled, vegetable
sprouts, certain cheeses, and
processed foods must be avoided.
Fruits that can be peeled are
acceptable to be eaten as well as
Met: Pts VS
remained WNL
throughout the shift
Partially Met: Pt
verbalized 3 foods
to eat, but couldnt
identify 3 foods to
avoid
Pt will verbalize
importance of adequate
periods of rest q4h
Encourage rest periods
q4h
Pt will have scant, thin,
serous drain output as
assessed q4h
Assess JP drain output
q4h
Pt will verbalize the
importance of proper
hygiene and bathing for
prevention of infection
every day
Encourage proper
hygiene and bathing
every day
cottage cheese and well cooked
meats. Food for this patient should
never be microwaved due to the
uneven cooking.
Frequent periods of rest can help the
body to recover faster by decreasing
the metabolic demand on the body.
It would be important for this reason
that he takes advantage of the
opportunity to rest often. He is
currently fatigued and has difficulty
with more strenuous activities such
as walking.
When infection is present edema
results due to the inflammatory
response and increased capillary
permeability. The drainage output
can give an indication as to the state
of infection. Thick tenacious
drainage that is white colored
indicates active infection. As a
wound heals drainage should trend
from thick, tenacious, and white to
thin, serous, and scant.
Bacteria normally live on the skin.
Since the catheter is inserted
through your skin, these bacteria will
sometimes track along the outside
of the catheter. From the catheter,
Met: Pt takes naps
and rests frequently
during the day
Met: Drain output
was less than 30mL,
thin, and serous for
all 3 drains
Met: Pt verbalized
importance of
bathing to reduce
risk of infection
Pt abdomen will have BSx4
and be free from pain,
tenderness, masses, and
distention as assessed
q4h
Assess abdomen q4h
The pt will verbalize
importance of hand
hygiene and demonstrate
qshift
Teach the pt proper
hand hygiene prior
qshift
they can get into your bloodstream.
The patient should bathe regularly
to avoid a pathogenic invasion.
Although the PICC dressing will be
covered while bathing, the patient
should take extra care to clean
around the dressing while avoiding
saturating it.
The abdomen should be flat or
slightly round, soft, non tender, and
free of masses or pain. BS should be
present in all quadrants. Any
deviation from normal should be
noted and investigated. Masses or
tenderness indicate active
inflammation and possible infection.
Distention or an absence of BS
signals a decrease in motility or
possible ileus.
Hand washing is the single most
effective way of preventing the
spread of infection in healthcare.
Good hand washing is done to
greatly reduce dirt, skin oil, and
transient microorganisms. It is also
done to decrease the microbial
count as much as possible and
inhibit the rapid rebound growth of
microorganisms. If soap and water is
not available, persons handling the
PICC should make all efforts to clean
the hands as best as possible or use
a waterless alcohol-based agent.
Hands should be washed for at least
15 seconds while being sure to scrub
under the fingernails and in between
Partially Met: Patient
reported slight
tenderness to
abdominal area in
RLQ where drains
were present
Partially Met: Pt
verbalized
understanding, but
did not wash his
hands before eating
fingers.
Intake will be at least
2000mL/day and output
will be within 200mL of
intake as assessed qshift
Assess I&O qshift
Pt will verbalize
understanding of
completing follow up
appointments qshift
Teach importance of
follow up care qshift
Pt will verbalize
understanding of avoiding
crowds and sick people
qshift
Teach Pt to avoid
crowds and sick people
qshift
Pt will show decreased
signs of infection (pain,
redness, tenderness,
decreased drain output,
temp 97.0-99.4) qshift
Administer Oxacilin 2g
in sterile water IV q6h
Monitoring of I&O can give an
indication as to a patients fluid
status. Infection requires more fluids
than normal. Maintaining hydration
also keeps the urine diluted and
promotes frequent emptying of the
bladder which reduces urine stasis
and helps prevent UTI. A patient that
is hypovolemic is also at an
increased risk to falls due to a
decrease in perfusion to the brain
and a potential for syncopal
episodes.
Due to this patients diagnosis, it is
critical that he be checked often by
his doctor and that follow up visits
be kept. The MD can monitor his
Everyone in a large crowd has
millions of organisms on them that
could cause a serious infection in
this patient. He should avoid being
in contact with a large number of
people at all times due to his
inability to ward off infection. He
should also avoid people that are
already sick because they have an
active infection that could easily be
transferred to him.
Oxacillin is a penicillinase resistant
penicillin antibiotic. It is used to
prevent or ward off infection. It
works by binding to the bacterial cell
wall, which leads to cell death. It is
Met: Pt drank
approximately
900mL by 1pm and
had output of
700mL
Met: Pt verbalized
understanding of
frequent checkups
and follow up
appointments
Met: Pt verbalized
understanding
Met: Pt showed no
increased signs of
infection besides
minor tenderness
surrounding one
Pt will have normal
temperature (97.0-99.4)
and be free from pain
Administer
acetaminophen 650mg
PO q4h PRN
Pt will have decreased
inflammation and
tenderness in abdomen
with decreasing drain
output as assessed q4h
Administer prednisone
50mg PO every day
not inactivated by penicillinase
bacterial enzymes.
Acetaminophen is an antipyretic and
NSAID. It is used to decrease pain
and reduce fever. It works by
inhibiting prostaglandin synthesis
that moderate pain and fever.
drain site
Prednisone is a steroid antiinflammatory medication. It
suppresses the normal immune
response which includes
inflammation and edema. In
conjunction with antibiotics it helps
promote quicker healing with a
decrease in tenderness and edema
with numerous other metabolic
changes such as increase in
appetite.
Partially Met: Pt had
mild tenderness
upon palpitation in
RLQ. There was no
inflammation or
swelling. Drainage
was thin, scant, and
clear.
Met: Pt remained
afebrile and denied
pain throughout the
shift
