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    Ineffective Protection

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    api-283822730
    The patient has multiple liver abscesses and a decreased ability to fight infection. Goals include remaining free of infection with healing wounds. Interventions include frequent assessment of vital signs, temperature, oxygen levels, white blood cell count, and surgical sites for signs of infection. The patient is educated on diet, hygiene, rest, and avoiding crowds/sick people to prevent further infection while antibiotics and medications are given to decrease inflammation and signs of infection.

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    Ineffective Protection

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    api-283822730
    834 views7 pages
    The patient has multiple liver abscesses and a decreased ability to fight infection. Goals include remaining free of infection with healing wounds. Interventions include frequent assessment of vital signs, temperature, oxygen levels, white blood cell count, and surgical sites for signs of infection. The patient is educated on diet, hygiene, rest, and avoiding crowds/sick people to prevent further infection while antibiotics and medications are given to decrease inflammation and signs of infection.

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    The patient has multiple liver abscesses and a decreased ability to fight infection. Goals include remaining free of infection with healing wounds. Interventions include frequent assessment of vital signs, temperature, oxygen levels, white blood cell count, and surgical sites for signs of infection. The patient is educated on diet, hygiene, rest, and avoiding crowds/sick people to prevent further infection while antibiotics and medications are given to decrease inflammation and signs of infection.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    834 views7 pages

    Ineffective Protection

    Uploaded by

    api-283822730
    The patient has multiple liver abscesses and a decreased ability to fight infection. Goals include remaining free of infection with healing wounds. Interventions include frequent assessment of vital signs, temperature, oxygen levels, white blood cell count, and surgical sites for signs of infection. The patient is educated on diet, hygiene, rest, and avoiding crowds/sick people to prevent further infection while antibiotics and medications are given to decrease inflammation and signs of infection.

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    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

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