Assessment:

Objective Data:

1. Monitor vital signs, paying attention to any signs of fever (elevated temperature), increased heart rate, or abnormal respiratory rate.
2. Assess the patient’s skin for signs of infection, such as redness, swelling, warmth, or purulent drainage at wound sites.
3. Evaluate laboratory results, including complete blood count (CBC) with differential, C-reactive protein (CRP), and blood cultures, to identify potential infection.
4. Observe for any invasive devices, such as intravenous catheters or urinary catheters, and assess the insertion sites for signs of infection.

Subjective Data:

1. Interview the patient about any recent surgeries, invasive procedures, or prolonged hospital stays.
2. Inquire about the presence of symptoms such as pain, discomfort, or changes in urinary or bowel habits that may indicate infection.
3. Obtain a thorough medical history, including any chronic illnesses, immunocompromised conditions, or recent antibiotic use.

Diagnosis:

• Risk for Infection related to compromised skin integrity, invasive procedures, or immunocompromised state.

Planning:

• The patient will remain free from infection during the hospital stay, as evidenced by normal vital signs, absence of systemic signs of infection, and intact skin.

Interventions:

1. Hand Hygiene:
   • Emphasize and ensure proper hand hygiene practices for healthcare providers, visitors, and the patient.
   • Educate the patient on the importance of handwashing and provide alcohol-based hand sanitizer for regular use.
2. Aseptic Technique:
   • Utilize aseptic technique during all invasive procedures, wound care, and the insertion of any indwelling devices.
   • Train healthcare providers on the correct application of sterile procedures to minimize the risk of contamination.
3. Monitor and Maintain Skin Integrity:
   • Conduct regular skin assessments, especially in areas prone to breakdown, such as pressure points or surgical incisions.
   • Implement preventive measures, including the use of pressure-relieving devices and moisture control.
4. Administer Prophylactic Antibiotics:
   • Administer prophylactic antibiotics as prescribed before invasive procedures or surgeries.
   • Follow institutional guidelines for antibiotic selection, dosage, and timing to maximize effectiveness.
5. Catheter Care and Removal:
   • Implement proper urinary catheter care to prevent catheter-associated urinary tract infections (CAUTIs).
   • Assess the necessity of catheters regularly and remove them promptly when no longer needed to reduce infection risk.
6. Promote Respiratory Hygiene:
   • Educate the patient on respiratory hygiene practices, including cough etiquette and the use of tissues or masks when appropriate.
   • Implement isolation precautions when necessary for patients with known or suspected infectious diseases.
7. Environmental Cleaning:
   • Ensure routine environmental cleaning of patient rooms, equipment, and high-touch surfaces.
   • Educate housekeeping staff on infection control protocols and the proper use of disinfectants.
8. Monitor and Control Device-Related Infections:
   • Regularly assess and care for indwelling devices such as central lines, peripheral IVs, or urinary catheters.
   • Strictly adhere to sterile techniques during device insertion and follow established protocols for maintenance.
9. Education and Communication:
   • Educate the patient and family about signs and symptoms of infection, the importance of reporting any changes promptly, and the prescribed antibiotic regimen if applicable.
   • Foster open communication among healthcare providers to ensure effective collaboration in infection prevention.

Evaluation:

• Monitor vital signs and assess for any signs of infection regularly.
• Review laboratory results for indications of infection or changes in inflammatory markers.
• Assess the patient’s skin integrity and note any improvements or deterioration.
• Evaluate the patient’s understanding and adherence to infection control measures.
• Adjust the care plan based on ongoing assessments and address any emerging infection risks promptly.