Nursing Diagnosis: Risk for infection r/t loss of skin integrity; open surgical wound

! Long-Term Goal: The patient will show no signs of worsening infection !

Inter vention
1. Assess VS q4h (Independent)

Rationale
1. Measurement of vital signs provides data to determine a patients baseline. Vital signs are a quick and efcient way of monitoring a patients condition or identifying problems and evaluating his or her response to intervention. An alteration in vital signs signals a change in physiological function and the need for medical or nursing intervention (P&P, 441). 2. Signs and symptoms of infection include: redness, warmth, discharge, and increased body temperature. Change in mental status, fever, shaking, chills, and hypotension are indicators of sepsis (Ackley 481).

Outcome Criteria
1. Patient VS will remain stable throughout admission.

Evaluation
1. Met. Patients VS were checked q4h and remained stable throughout admission.

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2. Assess for S/S of infection q4h (Independent)

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2. Patient will show no signs of infection by discharge.

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2. Unmet. Ongoing. Patient went home with MRSA infection on antibiotics.

Nursing Diagnosis: Risk for infection r/t loss of skin integrity; open surgical wound

Long-Term Goal: The patient will show no signs of worsening infection Inter vention
3. Monitor lab values daily as ordered (Independent)

Rationale
3. While the white blood cell count may be in the normal range, an increased number of immature bands may be present. A neutropenic client with fever represents an absolute medical emergency (Ackley 481).

Outcome Criteria
3. Patient will have lab values WNL by discharge.

Evaluation
3. Unmet. Ongoing. Patient has an elevated WBC upon discharge.

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4. Assess skin for color, moisture, texture, and turgor q4h (Independent)

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4. Hospital-acquired pressure areas, skin tears, and infections are associated with pain, reduced mobility, increased risk of in-hospital complications, and increased health care costs (Ackley 481).

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4. Patients skin will be warm, pink, smooth, and elastic upon discharge.

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4. Unmet. Ongoing. Patient has erythema and induration on left buttock and labia upon discharge.

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Nursing Diagnosis: Risk for infection r/t loss of skin integrity; open surgical wound

! Long-Term Goal: The patient will show no signs of worsening infection !

Inter vention
5. Administer Cefazolin 160 mg IV q8h daily (Dependent)

Rationale
5. Cefazolin is used for treatment of infections due to susceptible organisms. It binds to bacterial cell wall membrane, causing cell death (Davis Drug Guide).

Outcome Criteria
5. Patient will exhibit a decrease in S/S of infection without adverse reactions to the medication.

Evaluation
5. Met. Patient exhibits a decrease in S/S of infection without any adverse reactions upon discharge.

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6. Administer Vancomycin 170 mg IV q6h (Dependent)

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6. Vancomycin is used for the treatment of potentially lifethreatening infections when less toxic anti-infectives are contraindicated. Particularly useful in staphylococcal infections. It binds to bacterial cell wall, resulting in cell death (Davis Drug Guide).

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6. Patient will exhibit decrease in S/S of infection without adverse reactions to the medication.

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6. Met. Patient exhibits a decrease in S/S of infection without any adverse reactions upon discharge.

7 . Administer Mupirocin 2% 1 application QID (Dependent)

7 . Mupirocin inhibits the bacterial protein synthesis of bacterial growth and reproduction (Davis Drug Guide).

7 . Patient will exhibit decrease in S/S of infection without adverse reactions to medication.

7 . Met. Patient exhibits a decrease in S/S of infection without any adverse reactions upon discharge.

Nursing Diagnosis: Risk for infection r/t loss of skin integrity; open surgical wound

! Long-Term Goal: The patient will show no signs of worsening infection !

Inter vention
8. Follow meticulous hand hygiene (Independent)

Rationale
8. Cross-transmission through transient hand carriage of a health care worker appeared to be the probable route of transmission (Ackley 483).

Outcome Criteria
8. Nurse will wash hands before entering a room and before exiting a room.

Evaluation
8. Met. Nurse washed her hands before entering and before exiting patients room.

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9. Monitor recurrent antibiotic use in children (Independent)

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9. Chronic antibiotic use in children may lead to the formation of resistant bacteria. Antibiotics in children can also lead to dehydration secondary to diarrhea (Ackley 483).

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9. Patient will show no adverse effects to antibiotic use throughout admission.

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9. Met. Patient showed no adverse effects to her antibiotic use throughout admission.

Nursing Diagnosis: Risk for infection r/t loss of skin integrity; open surgical wound

! Long-Term Goal: The patient will show no signs of worsening infection !

Inter vention
10. Teach caregiver importance of meticulous hand washing upon admission (Independent)

Rationale
10. Two thirds of wound infections occur after discharge. Using good hand hygiene practices is effective for preventing these infections (Ackley 484).

Outcome Criteria
10. Caregiver will demonstrate proper hand washing technique and verbalize understanding before discharge.

Evaluation
10. Unmet. Ongoing. Caregiver does not demonstrate an understanding of importance of meticulous hand washing by discharge.

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11. Teach caregiver to maintain strong infectionprevention policies at home (Independent)

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11. Strong guidelines are important to avoid infection in the home setting, especially addressing such issues as storage and use of irrigation solutions and supplies (Ackley 484).

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11. Caregiver will demonstrate understanding of infection-prevention policies before discharge.

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11. Unmet. Ongoing. Caregiver didnt understanding of the importance of infectionprevention by discharge.

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Nursing Diagnosis: Risk for infection r/t loss of skin integrity; open surgical wound

! Long-Term Goal: The patient will show no signs of worsening infection !

Inter vention
12. Teach caregiver how to care for penrose drain before discharge (Independent)

Rationale

Outcome Criteria

Evaluation
12. Unmet. Ongoing. Caregiver does not demonstrate or verbalize an understanding of penrose drain care by discharge.

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12. The health care provider 12. Caregiver will demonstrate inserts a drain into or near a understanding of penrose drain surgical wound if there is a large care before discharge. amount of drainage. Some drains are sutured in place. Exercise cau tion when changing the dressing around drains that are not sutured in place to prevent accidental removal (Potter 1190).

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Nursing Diagnosis: Risk for infection r/t loss of skin integrity; open surgical wound

! Long-Term Goal: The patient will show no signs of worsening infection !