Nursing Care Plan for infection risk status

<Definition>
Infection risk conditions include chronic disease, anticancer drug treatment, immune suppression by radiation therapy, steroid therapy, skin damage due to trauma or burns, and the presence of invasive tubes. The defense mechanism of the disease is weakened and it is easy to get infected. In addition to the above, in the case of children, the immature immune function weakens the defense mechanism of the host and adds a state of being susceptible to infection.

<Nursing care plan>

Target
Understand risk factors for infection and prevent infection
Nurses and caregivers can support and prevent infection

Observation plan
1. Vital signs
2. Dietary intake
3. Weight gain and loss
4. Nutritional status
5. Test data (WBC, granulocytes, CRP, Alb, TP, blood glucose, bacterial test, renal function, chest X-ray, etc.)
6. Presence or absence of respiratory infection (presence or absence of cough, wheezing, lung noise)
7. Presence or absence of aspiration
8. Abdominal symptoms (abdominal pain, diarrhea, vomiting, presence or absence of abdominal distension)
9. Urinary properties, urinary turbidity, frequent urination, presence or absence of pain during urination, presence or absence of pruritus in the genital area
10. Redness and cracks in the anus, presence of bleeding, presence of hemorrhoids, defecation status
11. Presence or absence of redness, rash and lymphadenopathy of the skin
12. Presence or absence of wound, if there is a wound, its condition (presence or absence of pain or exudate)
13. Condition of the insertion part of each tube (presence or absence of redness, exudate, bleeding, pain, odor)
14. If there are drains, the properties and amount of drainage from the drains
15. Treatment details and antibacterial drug usage and effects
16. Past infectious diseases and vaccination status
17. Presence or absence of infectious disease in family and friends
18. Presence or absence of contact with infected media
19. Behavior, facial expression, degree of liveliness
20. Understanding and implementation of infection prevention such as gargling, hand washing, and wearing a mask
21. Awareness and understanding of patients and families regarding illness and treatment

-Child-
1. Age, immune system, degree of mental development
2. How far can you do your daily life by yourself?
3. Parents’ attitudes and attitudes toward parenting

Care plan
1. Assess the cause of (potentially) infection
2. Thoroughly wash your hands, gargle, and wear a mask
3. Keep clean
4. Prevent aspiration by sitting or sitting half-sitting during meals and tube feeding
5. If you are at risk of pneumonia, encourage a cough that does not use energy
6. Perform postural changes to prevent pneumonia
7. Replace the gauze at the tracheostomy (each work zone, when contaminated)
8. When performing intratracheal suction, perform clean operation.
9. In principle, replace the untreated infusion within 72 to 96 hours (the tube used for administration of blood, blood products, and fat emulsion should be replaced within 24 hours after the infusion is completed).
10. Replacement date for catheters and tubes ( / ) Scheduled next replacement date ( / )
11. Disinfection of the central venous catheter and replacement of the dressing (day of the week) Replacement date ( / ) Next scheduled replacement date ( / )
12. If ADL is low due to fatigue, etc., help maintain cleanliness.
13. Control defecation (every other day, day of the week)
14. Administer antibiotics or antibiotics under the direction of your doctor
15. If you use a clean room or isolators, prepare the environment and take care according to the manual.
16. Biological foods are banned

-Child
1. If you cannot take preventive actions by yourself, your family or nurse will help you.
2. Use your favorite characters and things you are interested in so that you can take preventive actions against infection.
3. If you can take preventive actions against infection, praise what you have done and perform interventions to increase self-efficacy.

Education plan
1. Explain the causes and dangers of infectious diseases
2. Explain the need for infection prevention behavior
3. Explain how to prevent infection (washing hands, gargling, wearing a mask, places where you should go, places where you should not go, etc.)
4. Explain the need for visitation restrictions according to the patient’s condition and obtain cooperation
5. Explain the symptoms of infectious diseases at risk of getting sick
6. Explain that if you have any physical condition, tell the medical staff immediately.


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