Minimize patient's risk of infection by: - washing hands before and after providing care. Hand washing is the single best way to avoid spreading pathogens.
- wearing gloves to maintain asepsis when providing direct care. Gloves offer protection when handling wound dressings or carrying out various treatments.
- Identify risk factors predisposing patient to infection. A complete nursing assessment allows development of an individualized care plan.
Follow the facility's infection control policy to minimize the risk of nosocomial infection.- Maintain standard precautions. Wear gloves if you might come into contact with the patient's blood and body secretions. Standard precautions protect you and the patient from the transfer of microorganisms.
- Monitor temperature at least every 4 hours, and record on graph paper. Report elevations immediately. Sustained temperature elevation after surgery may signal onset of pulmonary complications, wound infection or dehiscence, urinary tract infection, or thrombophlebitis.
- Monitor WBC count, as ordered. Report elevations or depressions. Elevated total WBC count indicates infection. Markedly decreased WBC count may indicate decreased production resulting from extreme debilitation or severe lack of vitamins and amino acids. Any damage to bone marrow may suppress WBC formation.
- Culture urine, respiratory secretions, wound drainage, or blood according to facility policy and physician's order. This identifies pathogens and guides antibiotic therapy.
- Help patient wash hands before and after meals and after using bathroom, bedpan, or urinal. Hand washing prevents spread of pathogens to other objects and food.
Assist patient when necessary to ensure that perianal area is clean after elimination. Cleaning perineal area by wiping from area of least contamination (urinary meatus) to area of most contamination (anus) helps prevent genitourinary infections.- Instruct patient to report incidents of loose stools or diarrhea. Inform physician immediately. Diarrhea or loose stools may indicate need to discontinue or change antibiotic therapy. It may also indicate need to test for Clostridium difficile.
- Offer oral hygiene to patient every 4 hours to prevent colonization of bacteria and reduce risk of descending infection. Disease and malnutrition may reduce moisture in mucous membranes of mouth and lips.
- Use strict sterile technique when performing invasive procedures, such as urinary catheterization or IV line insertion, to minimize the risk of introducing pathogens into the body.
- Use strict sterile technique when suctioning lower airway, inserting indwelling urinary catheters, inserting IV catheters, and providing wound care to avoid spreading pathogens.
- Change IV tubing, and give site care every 24 to 48 hours or as facility policy dictates to help keep pathogens from entering body.
- Rotate IV sites every 48 to 72 hours or as facility policy dictates to reduce chances of infection at individual sites.
- Have patient cough and deep breathe every 4 hours after surgery to help remove secretions and prevent pulmonary complications.
- Provide tissues and disposal bags for expectorated sputum. Convenient disposal encourages expectoration; sanitary disposal reduces spread of infection.
- Help patient turn every 2 hours. Provide skin care, particularly over bony prominences, to help prevent venous stasis and skin breakdown.
- Use sterile water for humidification or nebulization of oxygen. This prevents drying and irritation of respiratory mucosa, impaired ciliary action, and thickening of secretions within respiratory tract.
- Encourage fluid intake of 3,000 to 4,000 mL daily unless contraindicated to help thin mucus secretions.
- Ensure adequate nutritional intake. Offer high-protein supplements unless contraindicated. This helps stabilize weight, improves muscle tone and mass, and aids wound healing.
- Arrange for protective isolation if patient has compromised immune system. Monitor flow and number of visitors. These measures protect patient from pathogens in environment.
- Administer topical, oral, and parenteral antibiotics as ordered to eradicate pathogenic organisms.
- Teach patient about:
- Good hand washing technique.
- Factors that increase infection risk.
- Signs and symptoms of infection. These measures allow patient to participate in care and help patient modify lifestyle to maintain optimum health.
Suggested NIC Interventions
Incision Site Care; Infection Control; Infection Protection; Teaching: Nutrition Therapy; Procedure/Treatment; Wound Care |