Assessment, Nursing Diagnosis, Interventions, Implementationa and Evaluation
Assessment
Nurses assess the following matters:
1 Status defense mechanisms
The primary defense is not adequacy (skin / mucosal damage, tissue trauma, obstruction of lymph flow, peristaltic disorders, decreased mobility).
Secondary defense is not adequacy (decrease in Hb, WBC suppression, suppression of the inflammatory response, leukopenia).
2 Vulnerability client
Signs and symptoms of infection can be either local or systemic infection. Nurses need to examine the sign that appears on the client.
4 Laboratory data
The nurse examines the client's laboratory results.
Nursing Diagnosis related to Infection
Interventions
The general objective:
Prevention of exposure to infectious organisms.
Monitor and reduce the spread of infection.
Maintain resistance to infection.
Clients and families learn about infection control.
Implementation
Control of infectious agents:
Reservoir control
Infection control:
Evaluation
Assessment
Nurses assess the following matters:
1 Status defense mechanisms
The primary defense is not adequacy (skin / mucosal damage, tissue trauma, obstruction of lymph flow, peristaltic disorders, decreased mobility).
Secondary defense is not adequacy (decrease in Hb, WBC suppression, suppression of the inflammatory response, leukopenia).
2 Vulnerability client
- Age : Babies have a weak defense against infection, at birth have antibodies from the mother, while the immune system is still immature. As the child grows, the more mature the immune system, but the baby is still susceptible to the organism causes fever, intestinal infections, and other infectious diseases (mumps and measles). Early adult immune system has given the defense the bacteria invade. In old age, because the function and decreased organ, the immune system is also changing.
- Nutritional status : Reduction of the intake of protein and other nutrients such as carbohydrates and cause a decrease in the body's defenses. Nurses assess the dietary intake of the client and the client's ability to consume food (there is no interruption in the process of swallowing or digestive system).
- Stress : The body responds to emotional or physical stess through the general adaptation syndrome. If stess continues, causing high levels of cortisone yan decreased immune system.
- Heredity : Certain hereditary disorders interfere with an individual's defense against infection.
- Disease process : Clients who are sick in the immune system, especially the risk of infection. Clients who are experiencing complex illness (complications) higher risk of infection.
- Medical therapy : Some drugs and medical therapies affect the immune system. Nurses need to assess the client's drugs consumed.
Signs and symptoms of infection can be either local or systemic infection. Nurses need to examine the sign that appears on the client.
4 Laboratory data
The nurse examines the client's laboratory results.
Nursing Diagnosis related to Infection
- Risk for infection r / t impaired immunity.
- Risk for infection r / t tissue damage.
- Risk for injury r / t impaired immunity.
- Impaired skin integrity r / t interruption of circulation
- Imbalanced nutrition less than body requirements r / t poor dietary habits that
- Imbalanced nutrition less than body requirements r / t GI dysfunction.
Interventions
The general objective:
Prevention of exposure to infectious organisms.
Monitor and reduce the spread of infection.
Maintain resistance to infection.
Clients and families learn about infection control.
Implementation
- Prevention of disease (destroying the reservoir of infection, control the exit and entrance portals, avoiding the transmission of action, preventing bacteria find a place to grow).
- Measures of acute treatment (administration of appropriate antibiotics in the treatment and other measures).
Control of infectious agents:
- Cleaning. Throw out all foreign material such as dirt and organic material of an object.
- Disinfection. A process to destroy bacteria, but the spores
- Sterilization. Destruction and destruction of all microorganisms, including spores.
Reservoir control
- Bathe regularly.
- Changing bandages wet or dirty.
- Contaminated objects, discarded at the right place.
- Contaminated needles, discarded at the right place.
- Surgical wounds treated correctly.
- Nursing bottle and bag drainage.
- Keep the solution in a bottle.
Infection control:
- Wash hands.
- Avoiding the use of the same tool in some patients.
- Avoid touching dirty objects nurse's uniform.
- Instruct visitors to wash their hands before visiting a client.
- Familiarize client to wash hands.
- Maintaining the integrity of the skin and mucous membranes.
- Skin is kept moist.
- Setting position.
- Perform oral hygiene.
- Be careful within taking care of the wound.
- Be careful in removing medical devices disposable.
- Isolation.
- Maintain nutritional status.
- Maintain personal hygiene.
- Provide social support to clients who were isolated.
- Protective environment.
- Gown.
- Mask.
- Gloves.
- Protective goggles.
- Collection of specimens.
- Goods or linen wrap.
Evaluation
- Evaluation of the action / implementation has been done, if the action can not resolve the problem then forwarded nursing actions, if the problem is resolved, the action was stopped.
- For example, do not forget to wash your hands before and after examining patients. Not use the tool in a row in some patients without first properly cleaned after use on a patient. Bathing and cleaning the patient should not be considered routine work that must be completed as soon as possible, but should be done with full responsibility for the safety of the patient against the threat of nosocomial infections.
- To participate prevent fungal and bacterial resistance to antibiotics, use of antibiotics in a responsible manner, ie only against susceptible bacteria and fungi, and in sufficient quantity and under the supervision of a physician.
