Risk for Infection NANDA Definition: At increased risk for being invaded by pathogenic organisms
Goal: Reduce infections, improve patient comfort.
Expected outcomes:
- Increased healing in time, free of purulent drainage or erythema, no fever.
- Stated understanding of the causes of individual / risk factors.
Nursing Interventions Risk for Infection for Peritonitis
Independent:
1. Note the example of individual risk factors abdominal trauma, acute appendicitis, peritoneal dialysis.
Rational: Affects choice of interventions
2. Assess vital signs with frequent, noted no improvement or continuing hypotension, decreased pulse pressure, tachycardia, fever, tachypnea.
Rationale: Signs of septic shock, endotoxin circulation causes vasodilation, loss of fluid from the circulation, and low cardiac output status.
3. Note the change in mental status (eg, confusion, fainting).
Rational: Hypoxaemia, hypotension, and acidosis can cause irregularities in mental status.
4. Note the color, temperature, humidity.
Rational: Warm, redness, dry skin is an early sign of septicemia. Further manifestations include cold, pale skin moist and cyanosis as a sign of shock.
5. Monitor urine output.
Rational: Oliguria occurred as a result of reduced renal perfusion, the toxin in the circulation affects the antibiotic.
6. Maintain strict aseptic technique in the treatment of abdominal drain, wound incision / open, and the invasive side.
Rationale: Prevent the spread and limit the spread of infectious organisms / cross contamination.
7. Observations on wound drainage.
Rationale: Provides information about the status of infection.
8. Maintain sterile technique when the patient is placed catheters, and catheter care provided / or perineal hygiene routine.
Rasonal: Preventing the spread, limiting the growth of bacteria in the urinary tract.
9. Supervise / limit visitors and staff as needed. Provide insulation protection when indicated.
Rational: Reduce the risk of exposure to / add a secondary infection in patients who experienced immune pressure.
Collaboration:
1. Take for example / watch the results of serial blood, urine, wound cultures.
Rationale: Identifying microorganisms and assist in assessing the effectiveness of antimicrobial program.
2. Assist in the peritoneal aspiration, if indicated.
Rational: Guide to drain fluids and to identify infectious organisms so that appropriate antibiotics but can be given.
3. Prepare for surgical intervention when indicated
Rationale: Treatment of choice (curative) in acute peritonitis or local, for example a local abscess drainage, peritoneal exudate throw, throw rupturapendiks / gall bladder, cope with perforated ulcer, or bowel resection.
