Nanda Books

Risk for Infection related to inadequate secondary defenses (decreased hemoglobin, leukopenia, or a decrease in granulocytes (inflammatory response depressed)).

Goal: Infection does not occur.
Expected outcomes:

• identify behaviors to prevent / reduce the risk of infection.
• improve wound healing, free purulent drainage or erythema, and fever.

Intervention and Rational:

1. Maintain strict aseptic technique on the procedure / treatment of wounds.
Rational: to reduce the risk of colonization / infection of bacterial

2. Increase good hand washing; by the care givers and patients.
Rational: to prevent cross contamination / bacterial colonization.

.3. Give skin care, oral and perianal carefully.
Rational: reducing the risk of damage to the skin / tissue and infection.

4. Increase enter adequate fluids.
Rational: to assist in the dilution secret breathing to ease spending and prevent stasis of body fluids such as respiratory and kidney.

5. Motivation changes in position / ambulation often, coughing and deep breathing exercises.
Rationale: increased pulmonary ventilation all segments and help mobilize secretions to prevent pneumonia.

6. Monitor body temperature. Note the chills and tachycardia with or without fever.
Rational: the process of inflammation / infection require evaluation / treatment.

7. Monitor / limit visitors. Provide insulation where possible.
Rational: limiting exposure to bacteria / infection. Protection of insulation required in aplastic anemia, when the immune response is very disturbed.

8. Observe erythema / wound fluid.
Rational: indicators of local infection. Note: the formation of pus may not exist when granulocytes depressed.

9. Take a specimen for culture / sensitivity as indicated (collaboration)
Rational: to distinguish the presence of infection, identify specific pathogens and influence the choice of treatment.

10. Leave a topical antiseptic; systemic antibiotics (collaboration).
Rational: may be used to reduce colonization or prophylactic treatment for local infection process.