Nanda Nursing Intervention for Infection

NANDA: Risk for Infection

Definition:

Circumstances where an individual is susceptible to the pathogenic and opportunistic agents (viruses, fungi, bacteria, protozoa, or other parasites) from external sources, the sources of exogenous and endogenous.

Expected outcomes are:

Individuals will:
  1. Techniques showed a very careful hand washing.
  2. Free of nosocomial infection during the hospitalization
  3. Demonstrate the ability of the risk factors associated with infection and make the proper precautions to prevent infection.

Nursing Intervention for Risk for Infection:

1. Identification of individuals at risk for nosocomial infection
  • Assessed against the predictor
    • Infection (pre-surgical)
    • Abdominal or thoracic surgery
    • Operating for more than 2 hours
    • Procedures genitouranius
    • Instrumentation (ventilator, suction, catheter, nebulizer, tracheostomy, invasive monitoring tool)
    • Anesthetics

  • Assess the factors that disrupt
    • Age younger than 1 year, or older than 65 years
    • Obesity
    • The conditions of the underlying disease (COPD, diabetes, cardiovascular disease)
    • Drug abuse
    • Nutritional Status
    • Smokers
2. Reduce the organisms enter the body
  • Wash hands carefully
  • Antiseptic techniques
  • Isolation
  • Diagnostic or therapeutic procedures that need
  • Reduction of microorganisms that can be transmitted through the air.
3. Protect the immune-deficient individuals
  • Instruct individuals to request to all visitors and personnel to wash their hands before approaching the individual.
  • Limit visitors when possible
  • Limit of invasive devices (IV, laboratory specimen) to the really need it.
  • Teach individuals and family members for signs and symptoms of infection.
4. Reduce the individual susceptibility to infection
  • Encourage and maintain caloric intake and protein in the diet.
  • Monitor the use or overuse of antimicrobial therapy.
  • Give antimicrobial therapy was prescribed in 15 minutes of scheduled time
  • Minimize the length of hospital stay.
5. Observed for clinical manifestations of infection (eg fever, cloudy urine, purulent drainage)

6. Instruct individuals and families to know the causes, risks of infection and transmission power.

7. Report of infectious diseases.

Source : http://nursesnanda.blogspot.com/2012/04/nursing-intervention-for-infection.html

Self-Care Deficit - Bathing / Hygiene

Self-Care Deficit - Bathing / Hygiene

Definition

Circumstances where individuals have failed to implement or complete ability bathing / hygiene activities.

Data:

Lack of ability to bathe themselves (including washing the whole body, combing hair, brushing teeth, doing skin care and nails as well as the use of makeup)
  • Can not or no desire to wash the body or body parts.
  • Can not use the source water.
  • Inability to feel the need for hygiene measures.
Lack of ability to wear his own clothes (including underwear routine or special clothing, not the clothes the night)
  • Failure of the ability to use or release of clothes.
  • Inability to fasten clothing.
  • Inability to dress themselves satisfactorily.
Expected outcomes are:

Individuals will
1. Identifying the love of self-care activities.
2. Demonstrated that optimal hygiene in care after assistance is given.
3. Participate in physical and or verbal self-care activities
  • Carry out the shower activity at its optimal level.
  • Reported satisfaction with the achievements despite the limitations.
  • Connecting a feeling of comfort and satisfaction with the cleanliness of the body.
  • Demonstrate ability to use adaptive assistive devices.
  • Describe the factors that cause of the lack of ability to bathe.

More :

Nursing Interventions for Self-Care Deficit - Bathing / Hygiene

Nursing Diagnosis and Interventions for Liver Abscess

Nursing Diagnosis for Liver Abscess - Nursing Interventions for Liver Abscess

Liver abscess is a relatively uncommon but life-threatening disorder that occurs when bacteria or protozoa destroy hepatic tissue. The damage produces a cavity, which fills with infectious organisms, liquefied hepatic cells, and leukocytes. Necrotic tissue then walls off the cavity from the rest of the liver.
A liver abscess occurs when bacteria or protozoa destroy hepatic tissue, producing a cavity, which fills with infectious organisms, liquefied liver cells, and leukocytes. Necrotic tissue then walls off the cavity from the rest of the liver. Liver abscess carries a mortality of 10% to 20%, despite treatment. Liver abscess affects both sexes and all age-groups, although it's slightly more prevalent in hospitalized children (because of a high rate of immunosuppression) and in females (most commonly those between ages 40 and 60).

Nursing Diagnosis for Liver Abscess
  1. Impaired Liver Function
  2. Acute pain
  3. Deficient knowledge (diagnosis and treatment)
  4. Imbalanced nutrition: Less than body requirements
  5. Risk for impaired skin integrity
  6. Risk for infection

Nursing Interventions for Liver Abscess

1. Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain. Environmental Management: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort

2. Teaching: Individual Planning, implementation, and evaluation of a teaching about Liver abscess. Learning Facilitation: Promoting the ability to process and comprehend information. Learning Readiness Enhancement: Improving the ability and willingness to receive information.

3. Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance: Facilitating gain of body weight

4. Skin Surveillance: Collection and analysis of patient data to maintain skin and mucous membrane integrity. Pressure Management: Minimizing pressure to body parts. Pressure Ulcer Prevention: Prevention of pressure ulcers for a patient at high risk for developing them

5. Infection Protection, Infection Control, Surveillance: Prevention and early detection of infection in a patient at risk. Minimizing the acquisition and transmission of infectious agents. Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making.

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