Hyperthermia

Defining Characteristics

Hyperthermia is characterized by the following signs and symptoms:

 Body temperature above the normal range

 Hot, flushed skin
 Increased heart rate
 Increased respiratory rate
 Loss of appetite
 Malaise or weakness
 Seizures

Goals and Outcomes

The following are the common goals and expected outcomes for Hyperthermia:

 Patient maintains body temperature below 39° C (102.2° F).

 Patient maintains BP and HR within normal limits.

Nursing Assessment

Assessment is necessary in order to identify potential problems that may have lead
to Hyperthermia as well as name any episode that may occur during nursing care.

Assessment Rationales

Determination and management of the

Identify the triggering factors.
underlying cause are necessary to recovery.

HR and BP increase as hyperthermia progresses.

Monitor the patient’s HR, BP, and especially
Tympanic or rectal temperature gives a more
the tympanic or rectal temperature.
accurate indication of core temperature.
 Extremes of age or weight increase the risk for
Determine the patient’s age and weight.
the inability to control body temperature.

Fluid resuscitation may be required to

Monitor fluid intake and urine output. If the
correct dehydration. The patient who is
patient is unconscious, central venous
significantly dehydrated is no longer able to
pressure or pulmonary artery pressure should
sweat, which is necessary for evaporative
be measured to monitor fluid status.
cooling.

Review serum electrolytes, especially Sodium losses occur with profuse sweating and
serum sodium. accidental hyperthermia.

Nursing Interventions

The following are the therapeutic nursing interventions for Hyperthermia:

Interventions Rationales

Room temperature may be

accustomed to near normal body
Adjust and monitor environmental factors like room
temperature and blankets and linens
temperature and bed linens as indicated.
may be adjusted as indicated to
regulate temperature of the patient.

Exposing skin to room air decreases

Eliminate excess clothing and covers. warmth and increases evaporative
cooling.

Antipyretic medications lower body

temperature by blocking the
Give antipyretic medications as prescribed.
synthesis of prostaglandins that act
in the hypothalamus.

Hyperthermia increases the

Ready oxygen therapy for extreme cases.
metabolic demand for oxygen.

Provide chlorpromazine (Thorazine) Shivering increases the metabolic

and diazepam (Valium) when excessive shivering occurs. rate and body temperature.

Encourage ample fluid intake by mouth. If the patient is dehydrated or

diaphoretic, fluid loss contributes to
 fever.

Provide additional cooling mechanisms commensurate with the significance of temperature

elevation and related manifestations:

 Noninvasive: cooling mattress, cold packs

These measures help promote
applied to major blood vessels cooling and lower core temperature.

 Evaporative cooling: cool with a tepid bath; do

Alcohol cools the skin too rapidly,
not use alcohol causing shivering.

These invasive procedures are used

 Invasive: gastric lavage, peritoneal lavage,
to quickly lower core temperature.
cardiopulmonary bypass in an emergency These patients require
cardiopulmonary monitoring.
Cooling too quickly may cause
Modify cooling measures based on the patient’s physical shivering, which increases the use of
response. energy calories and increases the
metabolic rate to produce heat.
This is to ensure patient’s safety
Raise the side rails at all times. even without the presence
of seizure activity.
Intravenous normal saline solution
Start intravenous normal saline solutions or as indicated. replenishes fluid losses during
shivering chills.
Appropriate diet is necessary to
Provide high caloric diet or as indicated by the physician. meet the metabolic demand of the
patient.
Providing health teachings to the
Educate patient and family members about the signs and
patient and family aids in coping
symptoms of hyperthermia and help in identifying factors
with disease condition and could
related to occurrence of fever; discuss importance of
help prevent further complications
increased fluid intake to avoid dehydration.
of hyperthermia.
This organization provides
Refer at-risk individuals to the Malignant Hyperthermia information and additional resources
Association of the United States. for patients who have a history of
malignant hyperthermia.
Discuss the significance of informing future health care
Alternative anesthetic drugs or
providers of the malignant hyperthermia risk;
methods can be used for these
recommend a medical alert bracelet or similar
patients.
identification.

Defining Characteristics
Acute Pain is characterized by the following signs and symptoms:

 Patient complains of pain

 Appetite changes
 Self-focused
 Guarding behavior, protecting body part
 Intolerant (e.g., altered time perception, withdrawal from social or physical
contact)
 Facial mask of pain
 Autonomic responses (e.g., diaphoresis, an alteration in BP, HR, pupillary dilation;
alteration in RR; pallor; nausea)
 Change in muscle tone: lethargy or weakness; rigidity or tightness
 Relief or distraction behavior (e.g., pacing, seeking out other people or activities)
 Expressive behavior (e.g., restlessness, moaning, crying)
 Hopelessness
 Observed evidence of pain using standardized pain behavior checklist
 For those unable to communicate; refer to the appropriate assessment tool (e.g.,
Behavioral Pain Scale, Neonatal Infant Pain Scale, Pain Assessment Checklist for
Seniors with Limited Ability to Communicate)
 Positioning to avoid pain
 Protective gestures
 Proxy reporting pain and behavior/activity changes (e.g., family members,
caregivers)
 Self-report of intensity using standardized pain intensity scales (e.g., Wong-Baker
FACES scale, visual analogue scale, numeric rating scale)
 Self-report of pain characteristics (e.g., aching, burning, electric shock, pins and
needles, shooting, sore/tender, stabbing, throbbing) using standardized pain scales
(e.g., McGill Pain Questionnaire, Brief Pain Inventory)

Goals and Outcomes

The following are the common goals and expected outcomes for Acute Pain.

 Patient describes satisfactory pain control at a level less than 3 to 4 on a rating

scale of 0 to 10.
  Patient displays improved well-being such as baseline levels for pulse, BP,
respirations, and relaxed muscle tone or body posture.
 Patient uses pharmacological and nonpharmacological pain-relief strategies.
 Patient displays improvement in mood, coping.

Nursing Assessment

Proper assessment of Acute Pain is imperative for the development of an effective pain
management plan. Nurses play a crucial role in the assessment of pain, owing to the nature of
their relationship with patients.

Assessment Rationales

Assess pain characteristics:

 Quality (e.g., burning,

sharp, shooting)
 Severity (scale of 0 or no
pain to 10 or most severe Assessment of pain experience is the first step in
planning pain management strategies. The most reliable
pain) source of information about the pain is the patient.
 Location (anatomical Descriptive scales such as a visual analogue can be
description) utilized to distinguish the degree of pain.
 Onset (gradual or sudden)
 Duration (how long;
intermittent or continuous)
 Precipitating or relieving
factors

Some people deny the existence of pain. Attention to

associated signs may help the nurse in evaluating pain.
Assess for signs and symptoms An increase in BP, HR, and temperature may be present
relating to pain. in a patient with acute pain. The patient’s skin may be
pale and cool to touch. Restlessness and inability to
concentrate are also some manifestations.
Such variables play a big role in modifying the patient’s
Assess to what degree cultural,
expression of pain. Some cultures simply express
environmental, intrapersonal, and
feelings, whereas others hold such expression.
intrapsychic factors may contribute to
Nevertheless, health care providers should not prejudge
pain or pain relief.
any patient response but rather evaluate the unique
 response of each individual.
Some patients may be satisfied when pain is no longer
massive; others will demand complete elimination of
Assess the patent’s anticipation for
pain. This influences the perceptions of the
pain relief.
effectiveness of the treatment of the treatment modality
and their eagerness to engage in further treatments.
Other patients may be overlooking of the effectiveness
of nonpharmacological methods and may be willing to
try them, either with or instead of traditional analgesic
Assess the patient’s willingness or medications. Often a combination of therapies (e.g.,
ability to explore a range of mild analgesics with distraction or heat) may be more
techniques aimed at controlling pain. effective. Some patients will feel uncomfortable
exploring alternative methods of pain relief. However,
patients need to be acquainted that there are other
approaches to manage pain.
PCA is the IV infusion of an opioid
(usually morphine or Demerol) through an infusion
pump that is controlled by the patient. This allows the
patient to manage pain relief within prescribed limits.
The criteria for implementing PCA include:

 No allergy to opioid analgesics

 No history of substance abuse
 No history of renal, hepatic, or respiratory
Assess the suitability of the patient as disease
a PCA candidate
 No history of major psychiatric disorder
 Clear sensorium
 Cooperative and motivated about use
 Manual dexterity

In the hospice or home setting, a nurse or caregiver may

be needed to assist the patient in managing the infusion.

If the patient is on PCA, assess the following:

If requests for medication are quite frequent, the
Weigh the amount of pain
patient’s dosage may need to be increased to promote
medication the patient is using to
pain relief. if requests are very low, the patient may
his or her reports of pain.
require further guidance to correctly use PCA.
Potential PCA complications such
as excessive sedation; respiratory
Early assessment of complication is required to prevent
distress; urinary retention; nausea
serious adverse reactions to opioid analgesics.
and vomiting; constipation; and IV
site pain, or swelling
 If the patient is receiving epidural analgesia, assess the following:
Tingling in the extremities, These symptoms may be indicators of an allergic
numbness, a metallic taste in response to the anesthesia agent or of incorrect catheter
the mouth placement.
Potential epidural analgesia
complications such as extreme Respiratory depression and intravascular infusion of
sedation, respiratory anesthesia (resulting from catheter migration) can be
distress, urinary retention, or potentially life threatening.
catheter migration
It is essential to assist patients express as factually as
possible (i.e., without the effect of mood, emotion,
or anxiety) the effect of pain relief measures.
Evaluate the patient’s response to pain
Inconsistencies between behavior or appearance and
and management strategies.
what the patient says about pain relief (or lack of it)
may be more a reflection of other methods the patient is
using to cope with the pain rather than pain relief itself.
The meaning of pain will directly determine the
Evaluate what the pain suggests to the patient’s response. Some patients, especially the dying,
patient. may consider that the “act of suffering” meets a
spiritual need.

Nursing Interventions

Nurses are not to judge whether the acute pain is real or not. As a nurse, we should spend
more time treating patients. The following are the therapeutic nursing interventions for Acute
Pain:

Interventions Rationales

Preventing the pain is one thing that a patient

Foresee the need for pain relief. experiencing it can consider. Early intervention may
decrease the total amount of analgesic required.

One’s perception of time may become distorted

during painful experiences. Pain can be aggravated
with anxiety and fear especially when pain is delayed.
Acknowledge reports of pain
An immediate response to reports of pain may
immediately.
decrease anxiety in the patient. Demonstrated concern
for the patient’s welfare and comfort fosters the
development of trusting relationship.

Get rid of additional stressors or sources Patients may experience an exaggeration in pain or a
of discomfort whenever possible. decreased ability to tolerate painful stimuli if
environmental, intrapersonal, or intrapsychic factors
 are further stressing them.

One’s experiences of pain may become exaggerated

Provide rest periods to promote relief, as a result of exhaustion. Pain may result in fatigue,
sleep, and relaxation. which may result in exaggerated pain. A peaceful and
quiet environment may facilitate rest.

Determine the appropriate pain relief Patients with acute pain should be given a nonopioid
method. analgesic around-the-clock unless contraindicated.

Pharmacological methods include the following:

Nonopioids (acetaminophen), a
nonselective NSAID, or a selective NSAIDs work in peripheral tissues. Some block the
synthesis of prostaglandins, which stimulate
NSAID (e.g., cyclooxygenase [COX]-2 nociceptors. They are effective in managing mild to
inhibitor) moderate pain.

Opioids may be administered orally, intravenously,

systemically by PCA systems, or epidurally (either by
Opioid analgesics bolus or continuous infusion). Intramuscular
injections are not reliably absorbed. Opioids are
indicated for severe pain, especially in the hospice or
home setting.
Local anesthetic agents Local anesthetics block pain transmission and are
used for pain in specific areas of nerve distribution.

Nonpharmacological methods include the following:

The aid of an imagined event or a mental picture
involves use of the five senses to divert oneself from
Cognitive-behavioral strategies as painful stimuli.
follows:
Increasing one’s concentration, these techniques help
 Imagery an individual decrease the pain experience. Breathing
 Distraction techniques modifications and nerve stimulations are some of the
 Relaxation exercises, methods.
biofeedback, breathing
exercises, music therapy The aim of these techniques is to lessen the stress,
tension, subsequently decreasing the pain.

Cutaneous stimulation as follows:

Massage of the affected area when A massage traps pain transmission, increases
suitable endorphin levels, and minimizes tissue edema. This
 method requires another person to perform the
massage.
TENS demands the application of two or four skin
Transcutaneous electrical nerve electrodes. Pain modulation happens through a mild
stimulation (TENS) units electrical current. The patient is able to control the
intensity and frequency of the electrical stimulation.
Heat decreases pain through improved blood blow to
the area and through reduction of pain reflexes. Cold
Hot or cold compress
lessens pain, inflammation, and muscle spasticity by
decreasing the release of pain-inducing chemicals and
regulating the conduction of pain impulses.
Provide analgesics as ordered, Effectiveness of pain medications must be evaluated
evaluating the effectiveness and individually because it is absorbed and metabolized
inspecting for any signs and symptoms differently by patients. Analgesics may cause mild to
of adverse effects. severe side effects.
Report to the physician when Patients who demand pain medications at more
interventions are unsuccessful and frequent intervals than prescribed may actually
ineffective. require higher doses or more potent analgesics.
Remind the patient that pain is limited
Patient may give up trying to cope with pain when he
and that there are other approaches to
or she perceives pain as everlasting and unresolvable.
minimizing pain.
If the patient is on PCA:
Restrict the use of an IV line for
PCA only; ask a pharmacist before
Unexpected IV incompatibilities may occur.
combining other drugs with opioids
being infused.
If the patient is receiving epidural analgesia:
Label all tubing (e.g., epidural
catheter, IV tubing to epidural
catheter) clearly to prevent the Improper use of an epidural catheter can result to
accidental administration of neurological injury or infection.
unseemly fluids or drugs into the
epidural space.
For the patient with PCA or epidural analgesia:
Place a “No additional analgesia”
This prevents inadvertent analgesic overdosing.
warning over the bed.
Keep Narcan or other opioid- These drugs reverse the opioid effect in case of
reversing agents readily available. respiratory depression.

Imbalanced nutrition

 Loss of subcutaneous tissue

 Loss of weight or without adequate caloric intake
  Mental irritability or confusion
 Patient presents understanding of significance of nutrition to healing process and
general health.
 Patient or caregiver verbalizes and demonstrates selection of foods or meals that will
accomplish a termination of weight loss.
 Patient takes adequate amount of calories or nutrients.

Nursing Assessment

Routine assessment is needed in order to identify potential problems that may have lead
to Imbalanced Nutrition: Less Than Body Requirements as well as name any circumstance
that may transpire during nursing care.

Assessment Rationales

These anthropomorphic assessments are vital that they need

Note real, exact weight; do not
to be accurate. These will be used as basis for caloric and
estimate.
nutrient requirements.

Family members may provide more accurate details on the

Take a nutritional history with the
patient’s eating habits, especially if patient has altered
participation of significant others.
perception.

Several factors may affect the patient’s nutritional intake, so

it is vital to assess properly. Patients with dentition problems
Ascertain etiological factors for need referral to a dentist, whereas patients with memory
decreased nutritional intake. losses may need service like Meals on Wheels. Other
medications also have an effect on the appetite of the
patient.

Review laboratory values that Laboratory tests play a significant part in determining the
indicate well-being or patient’s nutritional status. An abnormal value in a single
deterioration. diagnostic study may have many possible causes.

 Serum albumin This determines degree of protein reduction (2.5 g/dl

signifies severe diminution; 3.8 to 4.5 g/dl is normal).
  Transferrin This is vital for iron transfer and typically decreases as
serum protein decreases.
 RBC and WBC counts These counts are frequently dropped in malnutrition,
revealing anemia, and reduced resistance to infection.
 Serum electrolyte
Potassium is typically elevated, and sodium is typically
values
lowered in malnutrition.

The patient encountering nutritional deficiencies may

resemble to be sluggish and fatigued. Other manifestations
include decreased attention span, confused, pale and dry
Look for physical signs of poor
skin, subcutaneous tissue loss, dull and brittle hair, and red,
nutritional intake.
swollen tongue and mucous membranes. Vital signs may
show tachycardia and elevated BP. Paresthesias may also be
present.
Various psychological, psychosocial, religious, and cultural
Note the patient’s perspective and
factors determine the type, amount, and appropriateness of
feeling toward eating and food.
food utilized.
Most adults find themselves “eating on the run” or relying
Evaluate the environment in massively on fast foods with lower nutritional components.
which eating happens. Older people living independently may not have the drive to
prepare a meal for themselves.
Link usual food intake to USDA The Food Guide Pyramid emphasizes the importance of
Food Pyramid, noting slighted or balanced eating. Omission of entire food groups increases
omitted food groups. risk of deficiencies.
Several factors may affect the patient’s nutritional intake, so
it is necessary to assess accurately. Cases of vitamin D
Assess patient’s ability to obtain
deficiency rickets have been reported among dark-skinned
and use essential nutrients.
infants and toddlers who were exclusively breast fed and
were not given supplemental vitamin D.
Strict vegetarians may be at particular risk for vitamin B12
If patient is a vegetarian, evaluate
and iron deficiencies. Proper care should be taken when
if obtaining sufficient amounts of
implementing vegetarian diets for pregnant women, infants,
vitamin B12 and iron.
children, and the elderly.

Nursing Interventions

This care plan addresses general concern related to nutritional deficits for the hospital or
home setting.

Interventions Rationales
 Experts like a dietician can determine nitrogen balance as
Ascertain healthy body weight for
a measure of the nutritional status of the patient. A
age and height. Refer to a dietitian
negative nitrogen balance may mean protein malnutrition.
for complete nutrition assessment
The dietician can also determine the patient’s daily
and methods for nutritional
requirements of specific nutrients to promote sufficient
support.
nutritional intake.

Set appropriate short-term and Patients may lose concern in addressing this dilemma
long-term goals. without realistic short-term goals.

A pleasing atmosphere helps in decreasing stress and is

Provide a pleasant environment.
more favorable to eating.

Elevating the head of bed 30 degrees aids in swallowing

Promote proper positioning.
and reduces risk for aspiration with eating.

Oral hygiene has a positive effect on appetite and on the

Provide good oral hygiene and
taste of food. Dentures need to be clean, fit comfortably,
dentition.
and be in the patient’s mouth to encourage eating.

If patient lacks strength, schedule Nursing assistance with activities of daily living (ADLs)
rest periods before meals and open will conserve the patient’s energy for activities the patient
packages and cut up food for values. Patients who take longer than one hour to complete
patient. a meal may require assistance.

Provide companionship during Attention to the social perspectives of eating is important

mealtime. in both hospital and home settings.

Consider the use of seasoning for

Seasoning may improve the flavor of the foods and attract
patients with changes in their sense
eating.
of taste; if not contraindicated.

Consider six small nutrient-dense Eating small, frequent meals lessens the feeling of fullness
meals instead of three larger meals and decreases the stimulus to vomit.
daily to lessen the feeling of
fullness.

For patients with physical

impairments, refer to an Special devices may be provided by an expert that can
occupational therapist for adaptive help patients feed themselves.
devices.

For patients with impaired

Adjustments of the thickness and consistency of foods to
swallowing, coordinate with a
improve nutritional intake may be provided by a speech
speech therapist for evaluation and
therapist.
instruction.

Determine time of day when the

Patients with liver disease often have their largest appetite
patient’s appetite is at peak. Offer
at breakfast time.
highest calorie meal at that time.

Encourage family members to

Patients with specific ethnic or religious preferences or
bring food from home to the
restrictions may not consider foods from the hospital.
hospital.

Offer high protein supplements

Such supplements can be used to increase calories and
based on individual needs and
protein without conflict with voluntary food intake.
capabilities.

Energy supplementation has been shown to produce

Offer liquid energy supplements. weight gain and reduce falls in frail elderly living in the
community.

Discourage caffeinated or These beverages will decrease hunger and lead to early
carbonated beverages. satiety.

Keep a high index of suspicion of

Impaired immunity is a critical adjunct factor in
malnutrition as a causative factor in
malnutrition-associated infections in all age groups.
infections.

Metabolism and utilization of nutrients are improved by

Encourage exercise.
activity.

Nutritional support may be recommended for patients who

Consider the possible need for
are unable to maintain nutritional intake by the oral route.
enteral or parenteral nutritional
If gastrointestinal tract is functioning well, enteral tube
support with the patient, family,
feedings are indicated. For those who cannot tolerate
 and caregiver, as appropriate. enteral feedings, parenteral nutrition is recommended.

Validate the patient’s feelings

regarding the impact of current Validation lets the patient know that the nurse has heard
lifestyle, finances, and and understands what was said, and it promotes the nurse-
transportation on ability to obtain patient relationship.
nutritious food.

Once discharged, help the patient

and family identify area to change Change is difficult. Multiple changes may be
that will make the greatest overwhelming.
contribution to improved nutrition.

Adapt modification to their current Accepting the patient’s or family’s preferences shows
practices. respect for their culture.

efining Characteristics

Impaired Tissue Integrity is characterized by the following signs and symptoms:

 Affected area hot, tender to touch

 Damaged or destroyed tissue (e.g., cornea, mucous membranes, integumentary,
subcutaneous)
 Local pain
 Protectiveness toward site
 Skin and tissue color changes (red, purplish, black)
 Swelling around initial injury

Goals and Outcomes

The following are the common goals and expected outcomes for Impaired Tissue Integrity.

 Patient reports any altered sensation or pain at site of tissue impairment.

 Patient demonstrates understanding of plan to heal tissue and prevent injury.
 Patient describes measures to protect and heal the tissue, including wound care.
 Patient’s wound decreases in size and has increased granulation tissue.
Nursing Assessment

Assessment is required in order to recognize possible problems that may have lead
to Impaired Tissue Integrity as well as identify any episode that may transpire during nursing
care.

Assessment Rationales

Determine etiology (e.g., acute or

chronic wound, burn, Prior assessment of wound etiology is critical for proper
dermatological lesion, pressure identification of nursing interventions.
ulcer, leg ulcer).

Redness, swelling, pain, burning, and itching are indication

Assess site of impaired tissue
of inflammation and the body’s immune system response to
integrity and its condition.
localized tissue trauma.

These findings will give information on extent of injury.

Pale tissue color is a sign of decreased oxygenation. Odor
Assess characteristics of wound, may be a result of presence of infection on the site; it may
including color, size (length, also be coming from a necrotic tissue. Serous exudate from
width, depth), drainage, and odor. a wound is a normal part of inflammation and must be
differentiated from pus or purulent discharge, which is
present in infection.

Assess changes in body

Fever is a systemic manifestation of inflammation and may
temperature, specifically
indicate the presence of infection.
increased in body temperature.

Assess the patient’s level of Pain is part of the normal inflammatory process. The extent
distress. and depth of injury may affect pain sensations.

The patient who scratches the skin in attempts to alleviate

Know signs of itching and
extreme itching may open skin lesion and increase risk for
scratching.
infection.

Assess patient’s nutritional status;

refer for a nutritional consultation Inadequate nutritional intake places the patient at risk for
and/or institute dietary skin breakdown and compromises healing.
supplements.

Wound assessment is more reliable when classified in such

Classify pressure ulcers in the
manner according to the National Pressure Ulcer Advisory
 following manner: Panel.

Full-thickness skin loss involving damage to or necrosis of

 Stage III subcutaneous tissue that may extend down to but not
through underlying fascia; ulcer appears as a deep crater
with or without undermining of adjacent tissue
Full-thickness skin loss with extensive destruction; tissue
 Stage IV necrosis; or damage to muscle, bone, or supporting
structures (e.g., tendons, joint capsules)
Pay special attention to all high-
risk areas such as bony Systematic inspection can identify impending problems
prominences, skin folds, sacrum, early.
and heels.
Identify a plan for debridement if
necrotic tissue (eschar or slough) Healing does not transpire in the appearance of necrotic
is present and if compatible with tissue.
overall patient management goals.

Nursing Interventions

The following are the therapeutic nursing interventions for Impaired Tissue Integrity:

Interventions Rationales

Monitor site of impaired tissue integrity

at least once daily for color changes, Systematic inspection can identify impending
redness, swelling, warmth, pain, or other problems early.
signs of infection.

Monitor status of skin around wound.

Monitor patient’s skin care practices,
Individualize plan is necessary according to
noting type of soap or other cleansing
patient’s skin condition, needs, and preferences.
agents used, temperature of water, and
frequency of skin cleansing.

Each type of wound is best treated based on its

etiology. Skin wounds may be covered with wet or
dry dressings, topical creams or lubricants,
hydrocolloid dressings (e.g., DuoDerm) or vapor-
Provide tissue care as needed.
permeable membrane dressings such as Tegaderm.
An eye patch or hard, plastic shield for corneal
injury. The dressing replaces the protective function
of the injured tissue during the healing process.
Keep a sterile dressing technique during
This technique reduces the risk for infection.
wound care.

Premedicate for dressing changes as Manipulation of profound or extensive cuts or

necessary. injuries may be painful.

Wet thoroughly the dressings with Saturating dreesings will ease the removal by
sterile normal saline solution before loosening adherents and decreasing pain, especially
removal. with burns.

Monitor patient’s continence status and

minimize exposure of skin impairment
This is to prevent exposure to chemicals in urine and
site and other areas to moisture
stool that can strip or erode the skin.
from incontinence, perspiration, or
wound drainage.

If patient is incontinent, implement This is to prevent exposure to chemicals in urine and

an incontinence management plan. stool that can strip or erode the skin.

Wound infections may be managed well and more

Administer antibiotics as ordered. efficiently with topical agents, although
intravenous antibiotics may be indicated.

Tell patient to avoid rubbing and

Rubbing and scratching can cause further injury and
scratching. Provide gloves or clip the
delay healing.
nails if necessary.

Encourage a diet that meets nutritional A high-protein, high-calorie diet may be needed to
needs. promote healing.

Monitor for proper placement of tubes,

Mechanical damage to skin and tissues as a result of
catheters, and other devices. Assess skin
pressure, friction, or shear is often associated with
and tissue affected by the tape that
external devices.
secures these devices.

Check every 2 hours for proper

Mechanical damage to skin and tissues (pressure,
placement of foot boards, restraints,
friction, or shear) is often associated with external
traction, casts, or other devices, and
devices.
assess skin and tissue integrity.

For patients with limited mobility, use a

This is to identify patients at risk for immobility-
risk assessment tool to systematically
related skin breakdown.
assess immobility-related risk factors.

Do not position patient on site of This is to avoid adverse effects of external

 impaired tissue integrity. If ordered, turn mechanical forces (pressure, friction, and shear).
and position patient at least every 2
hours, and carefully transfer patient.

Maintain the head of the bed at the lowest

To reduce shear and friction.
degree of elevation possible.

Educate patient about proper nutrition,

The patient needs proper knowledge on his or her
hydration, and methods to maintain tissue
condition to prevent further tissue injury.
integrity.

Teach skin and wound assessment and

Early assessment and intervention help prevent the
ways to monitor for signs and symptoms
development of serious problems.
of infection, complications, and healing.

Instruct patient, significant others, and

family in proper care of the wound Accurate information increases the patient’s ability
including hand washing, wound to manage therapy independently and reduce risk for
cleansing, dressing changes, and infection.
application of topical medications).

Encourage use of pillows, foam wedges,

To prevent pressure injury.
and pressure-reducing devices.

Educate patient the need to notify

This is to prevent further complications.
physician or nurse.

Risk Factors

Various health problems and conditions can create a favorable environment that would
encourage the development of infections. Here are the common factors:

 Inadequate primary defenses (e.g., broken skin integrity, tissue damage).

 Insufficient knowledge to avoid exposure to pathogens.
 Compromised host defenses (e.g., cancer, immunosuppression, AIDS, diabetes
mellitus).
 Compromised circulation (e.g., obesity, lymphedema, peripheral vascular disease).
 A site for organism invasion (e.g., surgery, dialysis, invasive lines, intubation,
enteral feedings).
  Compromised host defenses (e.g.,radiation therapy, organ transplant, medication
therapy)
 Compromised host defenses
 Contact with contagious agents
 Increased vulnerability of infant (e.g., HIV-positive mother, lack of normal flora,
lack of maternal antibodies).
 Lack of immunization
 Multiple sex partners
 Chronic diseases
 Rupture of amniotic membranes

Goals and Outcomes

The patient should report risk factors associated with infection and precautions needed.

 Patient remains free of infection, as evidenced by normal vital signs and absence
of signs and symptoms of infection.
 Early recognition of infection to allow for prompt treatment.
 Patient will demonstrate meticulous hand washing technique.

Nursing Assessment

Assessment is paramount in identifying risk factors for Risk for Infection.

Assessment Rationales

Assess for the presence, existence

These represent a break in the body’s normal first line of
of, and history of risk factors
defense.
(mentioned above).

An increasing WBC count indicates the body’s efforts to

combat pathogens. Rates are as follows:
Monitor white blood cell (WBC)
count  Low: Below 4,500
 Normal: 4,500—11,000
 High: Above 11,000
 Very low WBC count may indicate a severe risk for
infection. In older patients, infection may be present
without an increased WBC count.

Assess and monitor nutritional Patients with poor nutritional status may be anergic or
status, weight, history of weight unable to muster a cellular immune response to pathogens
loss, and serum albumin. making them susceptible to infection.
Prolonged rupture of amniotic
For pregnant clients, assess the
membranes before delivery puts the mother and neonate at
intactness of amniotic membranes.
increased risk for infection.
Investigate the use of medications
Antineoplastic agents, corticosteroids, and so on, can
or treatment modalities that may
reduce immunity.
cause immunosuppression.
Assess immunization status and People with incomplete immunizations may not have
history. sufficient acquired active immunity.
Monitor the following signs of actual infection:
Redness, swelling,
increased pain, purulent
These are the classic signs of infection. Any suspicious
discharge from incisions,
drainage should be cultured; antibiotic therapy is
injury, and exit sites of tubes
determined by pathogens identified.
(IV tubings), drains, or
catheters.
Temperature of up to 38º C (100.4º F) 48 hours post-op is
usually related to surgical stress after 48 hours, temperature
Elevated temperature. of greater than 37.7º (99.8º F) may indicate infection; very
high temperature accompanied by sweating and chills may
indicate septicemia.
Yellow or yellow-green sputum is indicative of respiratory
Color of respiratory secretions.
infection.
Cloudy, turbid, foul-smelling urine with visible sediment is
Appearance of urine.
indicative of urinary tract or bladder infection.

Nursing Interventions

The following therapeutic nursing interventions can help reduce the Risk for Infection:

Interventions Rationales

Aseptic technique decreases the changes of

Maintain or teach asepsis for dressing
transmitting or spreading pathogens to the
changes and wound care, peripheral IV and
patient. Interrupting the transmission of infection
central venous management, and catheter
along the chain of infection is an effective way
care and handling. to prevent infection.

Wash hands and teach patient and SO to

wash hands before contact with patients and
between procedures with the patient.

Instances when to wash hands:

 Before putting on gloves and after

taking them off.
Friction and running water effectively remove
 Before and after touching a
microorganisms from hands. Washing between
patient, before handling an procedures reduces the risk of transmitting
invasive device (foley catheter, IV pathogens from one area of the body to another.
catheter, and so on) regardless of Wash hands with antiseptic soap and water for at
whether or not gloves are used. least 15 seconds followed by alcohol-based hand
 After contact with body fluids or rub. If hands were not in contact with anyone or
excretions, mucous membranes, anything in the room, use an alcohol-based hand
nonintact skin, or wound rub and rub until dry.
dressings.
 If moving from contaminated Plain soap is good at reducing bacterial counts
body site to another site during the but antimicrobial soap is better, and alcohol-
care of the same individual. based hand rubs are the best.
 After contact with inanimate
surfaces and objects in the
immediate vicinity of the patient.
 After removing sterile or
nonsterile gloves.
 Before handling medications or
preparing food.

Encourage intake of protein-rich and calorie- Helps support the immune system
rich foods. responsiveness.
Fluids promote diluted urine and frequent
Encourage fluid intake of 2,000 to 3,000 mL emptying of bladder – reducing the stasis
of water per day, unless contraindicated. of urine, in turn, reduces risk
for bladder infection or urinary tract infection.
Helps reduce stasis of secretions in the lungs and
Encourage coughing and deep breathing
the bronchial tree. When stasis occurs, pathogens
exercises; frequent position changes.
can cause upper respiratory tract infections
 and pneumonia.
Recommend the use of soft-bristled These may compromise the integrity of the
toothbrushes and stool softeners to protect mucous membranes and provide a port of entry
mucous membranes. for pathogens.
Restricting visitation reduces the transmission of
Limit visitors.
pathogens.
Provide surgical mask to visitors who are
coughing and provide an explanation why.
Instruct:

 Cover mouth and nose during

coughing or sneezing. Educating visitors on the importance of
 Use tissues to contain respiratory preventing droplet transmission from themselves
to others can help reduce the risk of infection.
secretions with an immediate
disposal to a no-touch receptacle;
wash hands with soap and water
afterward.

Place the patient in protective isolation if the Protective isolation is set when WBC counts
patient is at very high risk. indicate neutropenia (less than 500 mm3).
Initiate specific precautions for suspected agents; follow infection prevention according to
institution or CDC protocol.
Meningitis
Droplet, airborne precautions

Rubella Airborne precautions

MRSA Contact, droplet precautions
Tuberculosis Airborne precautions
Wear personal protective equipment (PPE):
Wear gloves when providing direct care; wash
Gloves hands with soap and water after properly
disposing of gloves.
Use masks, goggles, or face shields to protect the
mucous membrane of your eyes, mouth, and
nose during procedures and direct-care
Masks
activities (e.g., suctioning oral secretions) that
may generate splashes or sprays of blood, body
fluids, secretions, and excretions.
Wear a gown for direct contact with uncontained
secretions or excretions. Remove gown and
Gowns perform hand hygiene before leaving the
patient’s room or cubicle. Do not reuse gowns
even with the same individual.
 Teach the patient and/or SO to wash hands Patients and SO can spread infection from one
often, especially after toileting, before meals, part of the body to another –
and before and after administering self-care. handwashing reduces these risks.
Teach the patient the importance of avoiding Other people can spread infections or colds to a
contact with individuals who have infections susceptible patient through direct contact,
or colds. contaminated objects, or through air currents.
Demonstrate and allow return demonstration
of all high-risk procedures that the patient
Patient and SO need opportunities to master new
and/or SO will do after discharge, such as
skills to reduce risk for infection.
dressing changes, peripheral or central IV
site care, and so on.
Teach the patient, family, and caregivers, the Knowledge about isolation can help patients and
purpose and proper technique for family members cooperate with specific
maintaining isolation precautions.
Antibiotics work best when a constant blood
If infection occurs, teach the patient to level is maintained which is done when
take antibiotics as prescribed. Instruct patient medications are taken as prescribed. Not
to take the full course of antibiotics even if completing the prescribed antibiotic regimen can
symptoms improve or disappear. lead to drug resistance in the pathogen and
reactivation of symptoms.

Defining Characteristics

Deficient Knowledge is characterized by the following signs and symptoms:

 Verbalizing inaccurate information

 Exaggerated behaviors
 Inaccurate follow-through of instruction
 Inappropriate behaviors (e.g., agitated, apathetic, hysterical, hostile)
 Questioning members of health care team
 Incorrect task performance
 Expressing frustration or confusion when performing task

Goals and Outcomes

The following are the common goals and expected outcomes for Deficient Knowledge.

 Patient explains disease state, recognizes need for medications, and understands
treatments.
 Patient demonstrates how to incorporate new health regimen into lifestyle.
  Patient exhibits ability to deal with health situation and remain in control of life.
 Patient shows motivation to learn.
 Patient lists resources that can be used for more information or support after
discharge.
 Patient identifies learning needs.

Nursing Assessment

Assessment is required in order to recognize patient’s existing knowledge about the present
situation.

Assessment Rationales

Identify the learner: the patient, Some patients especially older adults or the terminally ill
family, significant other, or view themselves as dependent on the caregiver, therefore will
caregiver. not allow themselves to be part of the educational process.

Assess ability to learn or

Cognitive impairments must be recognized so an appropriate
perform desired health-related
teaching plan can be outlined.
care.

Learning requires energy. Patients must see a need or

Assess motivation and
purpose for learning. They also have the right to refuse
willingness of patient to learn.
educational services.

This is to know what needs to be discussed especially if the

Determine priority of learning
patient already has a background about the situation.
needs within the overall care
Knowing what to prioritize will help prevent wasting
plan.
valuable time.

Allow the patient to open up Older patients often share life experiences to each learning
about previous experience and session. They learn best when teaching builds on previous
health teaching. knowledge and experience.

Observe and note existing

Assessment provides an important starting point in education.
misconceptions regarding
Knowledge serves to correct faulty ideas.
material to be taught.

Acknowledgement of racial/ethnicity issues will enhance

Acknowledge racial/ethnic
communication, establish rapport, and promote treatment
differences at the onset of care.
outcomes.
 Identify cultural influences on Interventions need to be specific to each patient considering
health teaching. their individual differences and backgrounds.

Every individual has his or her learning style, which must be

Consider the patient’s learning a factor in planning an educational program. Some may
style, especially if the patient has prefer written materials over visual materials, while others
learned and retained new prefer group sessions over an individual instruction.
information in the past. Matching the learner’s preferred style with the educational
method will facilitate success in mastery of knowledge.

Self-efficacy refers to a person’s confidence in his or her own

Determine the patient’s self- ability to perform a behavior. A first step in teaching may be
efficacy to learn and apply new to foster increased self-efficacy in the learner’s ability to
knowledge. learn the desired information or skills. Some lifestyle
changes.

Assess barriers to learning (e.g.,

perceived change in lifestyle, The patient brings to the learning situation a unique
financial concerns, cultural personality, established social interaction patterns, cultural
patterns, lack of acceptance by norms and values, and environmental influences.
peers or coworkers).

Nursing Interventions

The following are the therapeutic nursing interventions for Deficient Knowledge.

Interventions Rationales

Based on Maslow’s theory, basic physiological

needs must be addressed before the patient
Render physical comfort for the patient. education. Ensuring physical comfort allows the
patient to concentrate on what is being discussed
or demonstrated.

Grant a calm and peaceful environment A calm environment allows the patient to
without interruption. concentrate and focus more completely.

Conveying respect is especially important when

Provide an atmosphere of respect,
providing education to patients with different
openness, trust, and collaboration.
values and beliefs about health and illness.

Include the patient in creating the teaching Goal setting allows the learner to know what will
plan, beginning with establishing be discussed and expected during the session.
objectives and goals for learning at the Adults tend to focus on here-and-now, problem-
beginning of the session. centered education.

Allowing the patient to identify the most

Consider what is important to the patient. significant content to be presented first is the most
effective.

Involve patient in writing specific

Patient involvement improves compliance with
outcomes for the teaching session, such as
health regimen and makes teaching and learning a
identifying what is most important to learn
partnership.
from their viewpoint and lifestyle.

Assessment assists the nurse in understanding how

Explore reactions and feelings about the learner may respond to the information and
changes. possibly how successful the patient may be with
the expected changes.

Patients know what difficulties will transpire in

Support self-directed, self-designed their own environments, and they must be
learning. encouraged to approach learning activities from
their priority needs.

This technique aids the learner make adjustments

Help patient in integrating information into
in daily life that will result in the desired change in
daily life.
behavior.

Give adequate time for integration that is in Informatiom that is in direct conflict with what is
direct conflict with existing values or already held to be true forces a reevaluation of the
beliefs. old material and is thus integrated more slowly.

Provide clear, thorough, and

Patients are better able to ask questions when they
understandable explanations and
have basic information about what to expect.
demonstrations.

Give information with the use of

media. Use visual aids like diagrams,
Different people take in information in different
pictures, videotapes, audiotapes, and
ways.
interactive Internet websites, such as
Nurseslabs.

Check the availability of supplies and Adequate preparation is especially important when
equipment. teaching in the home setting.

When presenting a material, start with the

This method allows the patient to understand new
basics or familiar, simple, and concrete
information to less familiar, complex ones. material in relation to familiar material.

Clearly focuses teaching allows the learner to

Focus teaching sessions on a single concept
concentrate more completely on material being
or idea.
discussed.

Learning requires energy, so shorter, well-paced

Pace the instruction and keep sessions
sessions reduce fatigue and allow the patient to
short.
absorb more completely.

In patients with low literacy skills, materials

When teaching, build on patient’s literacy
should be short and have culturally sensitive
skills.
illustrations.

Identify patient’s understanding of

Patients are expected to read and understand labels
common medical terminology, such as
on medicine containers, appointment slips, and
“empty stomach,” “emesis,” and
informed consents.
“palpation.”

Use the teach-back technique to determine

the patient’s understanding of what was
taught:

 The nurse gives information in a

caring manner, using plain
language.
 Ask the patient to explain in his
or her own words. The teach-back technique consists of specific steps
in a repetitive order to evaluate the recipient’s
 Rephrase the information if knowledge of the content discussed. Patients who
unable to repeat it accurately. are not able to do this method after multiple cycles
is considered cognitively impaired.
 Again ask the patient to teach-
back the information using his or
her own words until the nurse is
comfortable that is understood.
 If the patient still does not
understand, consider other
strategies.

Provide preadmission self-instruction Providing patients with preadmission information

materials to prepare patient for about exercises has been shown to increase
postoperative exercises. positive feelings and the ability to perform
 prescribed exercises.
Questions facilitate open communication between
Encourage questions patient and health care professionals and allow
verification of understanding of given information.
Immediate feedback allows the learner to make
Provide immediate feedback on
corrections rather than practicing the skill
performance.
wrongly.
Repeated practice allows patient gain confidence
Allow repetition of the information or skill.
in self-care ability.
A positive approach by the patient will help him or
Render positive, constructive reinforcement
her feel good about learning accomplishments,
of learning
gain confidence, and maintain self-esteem.
Incorporate rewards into learning process. Rewards help to make learning fun and exciting.
Documentation allows additional teaching to be
Note progress of teaching and learning.
based on what the learner has completed.
Learning occurs through imitation, so persons who
are currently involved in lifestyle changes can help
Help patient identify community resources
the learner anticipate adjustment issues.
for continuing information and support.
Community resources can offer financial and
educational support.
Approach individuals of color with respect, Instances of disrespect and lack of caring have
warmth, and professional courtesy. special significance for individuals of color.

Nursing Diagnosis for chickenpox

Hyperthermia Evidenced by :

 Temperature over 37.8 C (100 F) orally, or 38.8 C (101 F) rectally.

 Malaise/weakness
 Loss of appetite
 Tachycardia
 Shivering/goose pimples
 Dehydration
 Flushed skin/li>
 Warm to touch
 Increased respiratory rate
Goal : The patient will : Maintian normal body temperature.

Nursing Interventions :

 Administer antipyretics per physician's order.

 Remove excess clothing or blankets.
 Assess possible etiology of increased temperature.
 Encourage fluids when indicated.
 Assess temperature q ___ hours.
 Provide air condition/fan if appropriate.
Nursing Interventions : Impaired Skin Integrity

1. Encourage clients to avoid all forms of friction (touched, scratched by hand) on the skin.
Rational: Preventing the spread of bacteria that can worsen the infection in the skin lesions.

2. Instruct the patient to be able to treat the skin with a clean and correct.
Rational: the right skin care reduces the risk of accumulation of dirt on the skin.

3. Motivation of patients to keep taking the drugs and foods that contain enough nutrients.
Rational: To expedite the healing process.

4. Observations of erythema and palpated for warmth around the area.

Rational: The warmth is a sign of infection.

5. Collaboration of topical antibiotics.

Rational: To inhibit the growth of bacteria.

Disturbed Body Image

1. Encourage clients to express their feelings and perceptions about the effects of the disease.
Rational: By expressing feelings, can reduce the psychological burden.

2. Encourage individuals to ask the problem, management, development and health prognosis.
Rational: To assess patients' knowledge level and can provide new inputsthat are beneficial to
recovery

3. Provide reliable information and confirmed the information given.

Rational: Increasing patient knowledge, so that a healthy behavior and prevent the development of
more severe disease.

4. Encourage you to share with the people about the values and things that are important to them
Rational: By expressing, sharing, can reduce the psychological burden.

Deficient Knowledge

NOC
 Knowledge of: Diet
 Disease Process
 Energy Conservation
 Health Behaviors
 Health Resources
 Infection Control
 Medication
 Personal Safety
 Prescribed Activity
 Substance Use Control
 Treatment Procedure(s)
 Treatment Regimen

Client Outcomes
 Explains disease state, recognizes need for medications, understands treatments
 Explains how to incorporate new health regimen into lifestyle
 States an ability to deal with health situation and remain in control of life
 Demonstrates how to perform procedure(s) satisfactorily
 Lists resources that can be used for more information or support after discharge

NIC

 Teaching: Disease Process

 Teaching: Individual
 Teaching: Infant Care
Risk for Infection
Intervention:

Independent:

 Monitor vital signs noticed fever, chills, sweating, mental changes, increased abdominal pain.
 Do a good hand washing and aseptic wound care. Provide complete care.
 See incision and bandage. Write down the characteristics and wound drainage / drain (if
included), the erythema.
 Provide appropriate information, be honest with the patient / parent close.
 5. Knowledge deficit related to Varicella Zoster disease process and
management: This diagnosis may be one of the most important nursing diagnoses
related to chickenpox infections. There is great value in teaching and understanding
the importance of vaccines to prevent and lesson chickenpox infections and the
seriousness of chickenpox infection complications. Below is the care plan for a nurse
addressing knowledge deficits related to the chickenpox infection.


Nursing Related to: Plan and Outcome:
Diagnosis: interventions:
Knowledge Varicella Zoster 1. Educate 1. Parents will
deficit disease process parents about the articulate the
– prevention, importance and importance of
management, safety of the the Varicella
and Varicella Zoster Zoster vaccine,
complications. vaccine. See and children will
reference 1 below receive the
for vaccine vaccination.
information.

2. Provide a
variety of 2.
instructions Patients/family
(verbal, written, will describe
online, etc.) about how to prevent
preventing the the spread of the
spread of the infection and
infection and how how to manage
to treat side uncomfortable
effects of the side effects at
 chickenpox home.
infection (itching,
fever, etc.). See
reference 2 below
for information
about preventing
the spread of
infection. See
previous blog
posts for how to
manage
symptoms.

3. Teach patients
and family about
disease
complications, 3.
what serious Patients/family
signs to will state the
recognize, and warning signs
when to come in for potential
for medical complications
evaluation. See and will seek
reference 3 for medical
information about attention if
disease experiences
complications. signs or
symptoms of
serious
complications.
RUBELLA

 Inadequate primary defenses (e.g., broken skin integrity, tissue

damage).
 Insufficient knowledge to avoid exposure to pathogens.
 Compromised host defenses (e.g., cancer,
immunosuppression, AIDS, diabetes mellitus).
 Compromised circulation (e.g., obesity, lymphedema, peripheral
vascular disease).
 A site for organism invasion (e.g., surgery, dialysis, invasive lines,
intubation, enteral feedings).
 Compromised host defenses (e.g.,radiation therapy, organ
transplant, medication therapy)
 Compromised host defenses
 Contact with contagious agents
  Increased vulnerability of infant (e.g., HIV-positive mother, lack of
normal flora, lack of maternal antibodies).
 Lack of immunization
 Multiple sex partners
 Chronic diseases

The patient should report risk factors associated with infection and
precautions needed.

 Patient remains free of infection, as evidenced by normal vital signs

and absence of signs and symptoms of infection.
 Early recognition of infection to allow for prompt treatment.
 Patient will demonstrate meticulous hand washing technique.

Nursing Assessment

Assessment is paramount in identifying risk factors for Risk for Infection.

Assessment Rationales

Assess for the presence,

existence of, and history of These represent a break in the body’s normal
risk factors (mentioned first line of defense.
above).

An increasing WBC count indicates the body’s

efforts to combat pathogens. Rates are as
follows:

 Low: Below 4,500

Monitor white blood cell  Normal: 4,500—11,000
(WBC) count
 High: Above 11,000

Very low WBC count may indicate a severe risk

for infection. In older patients, infection may be
present without an increased WBC count.
Assess and monitor Patients with poor nutritional status may be
nutritional status, weight, anergic or unable to muster a cellular immune
history of weight loss, and response to pathogens making them susceptible
serum albumin. to infection.

For pregnant clients, assess Prolonged rupture of amniotic

the intactness of amniotic membranes before delivery puts the mother and
membranes. neonate at increased risk for infection.

Investigate the use of

medications or treatment Antineoplastic agents, corticosteroids, and so on,
modalities that may cause can reduce immunity.
immunosuppression.

Assess immunization status People with incomplete immunizations may not

and history. have sufficient acquired active immunity.

Monitor the following signs of actual infection:

Redness, swelling,
increased pain, purulent These are the classic signs of infection. Any
discharge from incisions, suspicious drainage should be
injury, and exit sites of cultured; antibiotic therapy is determined by
tubes (IV tubings), pathogens identified.
drains, or catheters.

Temperature of up to 38º C (100.4º F) 48 hours

post-op is usually related to surgical stress after
48 hours, temperature of greater than 37.7º
Elevated temperature.
(99.8º F) may indicate infection; very high
temperature accompanied by sweating and chills
may indicate septicemia.

Color of respiratory Yellow or yellow-green sputum is indicative of

secretions. respiratory infection.

Cloudy, turbid, foul-smelling urine with visible

Appearance of urine. sediment is indicative of urinary tract
or bladder infection.

Nursing Interventions
The following therapeutic nursing interventions can help reduce the Risk for
Infection:

Interventions Rationales

Aseptic technique decreases the changes

Maintain or teach asepsis for
of transmitting or spreading pathogens
dressing changes and wound care,
to the patient. Interrupting the
peripheral IV and central venous
transmission of infection along the chain
management, and catheter care and
of infection is an effective way to
handling.
prevent infection.

Wash hands and teach patient and

SO to wash hands before contact
with patients and between
procedures with the patient.

Friction and running water effectively

Instances when to wash hands: remove microorganisms from hands.
Washing between procedures reduces
 Before putting on gloves the risk of transmitting pathogens from
one area of the body to another.
and after taking them off.
 Before and after touching a Wash hands with antiseptic soap and
patient, before handling an water for at least 15 seconds followed
invasive device (foley by alcohol-based hand rub. If hands
catheter, IV catheter, and were not in contact with anyone or
so on) regardless of anything in the room, use an alcohol-
whether or not gloves are based hand rub and rub until dry.
used.
 After contact with body Plain soap is good at reducing bacterial
fluids or excretions, mucous counts but antimicrobial soap is better,
membranes, nonintact skin, and alcohol-based hand rubs are the
or wound dressings. best.
 If moving from
contaminated body site to
another site during the care
of the same individual.
 After contact with inanimate
 surfaces and objects in the
immediate vicinity of the
patient.
 After removing sterile or
nonsterile gloves.
 Before handling medications
or preparing food.

Encourage intake of protein-rich and Helps support the immune system

calorie-rich foods. responsiveness.

Fluids promote diluted urine and

Encourage fluid intake of 2,000 to frequent emptying of bladder – reducing
3,000 mL of water per day, unless the stasis of urine, in turn, reduces risk
contraindicated. for bladder infection or urinary tract
infection.

Helps reduce stasis of secretions in

Encourage coughing and deep the lungs and the bronchial tree. When
breathing exercises; frequent stasis occurs, pathogens can cause
position changes. upper respiratory tract infections
and pneumonia.

Recommend the use of soft-bristled These may compromise the integrity of

toothbrushes and stool softeners to the mucous membranes and provide a
protect mucous membranes. port of entry for pathogens.

Restricting visitation reduces the

Limit visitors.
transmission of pathogens.

Provide surgical mask to visitors who

are coughing and provide
an explanation why. Instruct:
Educating visitors on the importance of
 Cover mouth and nose preventing droplet transmission from
during coughing or themselves to others can help reduce
the risk of infection.
sneezing.
 Use tissues to contain
respiratory secretions with
an immediate disposal to a
 no-touch receptacle; wash
hands with soap and water
afterward.

Place the patient in protective Protective isolation is set when WBC

isolation if the patient is at very high counts indicate neutropenia (less than
risk. 500 mm3).

Initiate specific precautions for suspected agents; follow infection

prevention according to institution or CDC protocol.

Meningitis Droplet, airborne precautions

Rubella Airborne precautions

MRSA Contact, droplet precautions

Tuberculosis Airborne precautions

Wear personal protective equipment (PPE):

Wear gloves when providing direct care;

Gloves wash hands with soap and water after
properly disposing of gloves.

Use masks, goggles, or face shields to

protect the mucous membrane of your
eyes, mouth, and nose during
procedures and direct-care
Masks
activities (e.g., suctioning oral
secretions) that may generate splashes
or sprays of blood, body fluids,
secretions, and excretions.

Wear a gown for direct contact with

uncontained secretions or excretions.
Remove gown and perform hand
Gowns
hygiene before leaving the patient’s
room or cubicle. Do not reuse gowns
even with the same individual.

Teach the patient and/or SO to wash Patients and SO can spread infection
hands often, especially after from one part of the body to another –
toileting, before meals, and before handwashing reduces these risks.
and after administering self-care.

Other people can spread infections or

Teach the patient the importance of
colds to a susceptible patient through
avoiding contact with individuals who
direct contact, contaminated objects, or
have infections or colds.
through air currents.

Demonstrate and allow return

demonstration of all high-risk
Patient and SO need opportunities to
procedures that the patient and/or
master new skills to reduce risk for
SO will do after discharge, such as
infection.
dressing changes, peripheral or
central IV site care, and so on.

Teach the patient, family, and Knowledge about isolation can help
caregivers, the purpose and proper patients and family members cooperate
technique for maintaining isolation with specific precautions.

Antibiotics work best when a constant

If infection occurs, teach the patient blood level is maintained which is done
to take antibiotics as prescribed. when medications are taken as
Instruct patient to take the full prescribed. Not completing the
course of antibiotics even if prescribed antibiotic regimen can lead to
symptoms improve or disappear. drug resistance in the pathogen and
reactivation of symptoms.

MUMPS:
mbalanced nutrition less than body requirements related to inability to ingest adequate nutrients
due to infectious conditions.
Goal: Demonstrate an increase in body weight reached the expected range.
Expected outcomes: body weight returned to normal ranges.
Interventions and Rational :
1. Give eat soft foods little by little and little extra, right. Avoid acidic foods.
Rational: The food is hard, is not able to be chewed by patients parotitis. Acidic foods, adding a
sense of discomfort in patients with parotitis.
2. Give liquid diet or food tube / hyperalimentation when needed.
Rational: When caloric intake fails to meet the metabolic needs, nutritional support can be used
to prevent malnutrition.
3. Give the drink a little by little but often.
Rational: Moisten the mucous membranes of the mouth are less wet because it is rarely used.