Nursing Care Plan (NCP) for Infection
Included In This Lesson
Study Tools For Nursing Care Plan (NCP) for Infection
Outline
Objective: Nursing Care Plan for Infection
What is an Infection?
An infection happens when germs like bacteria, viruses, fungi, or parasites enter your body and start to multiply. It’s like having tiny invaders that can cause harm.
How Do Infections Happen?
Germs can enter your body through cuts in the skin, through your mouth, nose, or eyes, or they can be spread by other people, animals, or contaminated objects.
Types of Infections:
Bacterial Infections: Caused by bacteria, these can lead to illnesses like strep throat or urinary tract infections.
Viral Infections: Caused by viruses, common examples include the flu or the common cold.
Fungal Infections: These can affect your skin, nails, or lungs.
Parasitic Infections: Caused by parasites, like tapeworms or malaria.
Symptoms of Infections:
- Fever, chills, coughing, sneezing, or feeling tired.
- Redness, swelling, or pain, especially around a cut or wound.
- Sometimes, nausea, vomiting, or diarrhea.
By the end of this lesson, you will be able to:
- Define and recognize the signs and symptoms of infection.
- Identify common clinical manifestations and understand the varying presentations of infections in different body systems.
- Conduct a thorough nursing assessment for patients with suspected or confirmed infections.
- Systematically collect patient data, including vital signs, medical history, and physical assessments relevant to infection.
- Analyze the pathophysiology of infections, including the body’s immune response.
- Understand the mechanisms of infection, the role of microorganisms, and the body’s defense mechanisms against infections.
- Develop individualized nursing care plans for patients with infections.
- Formulate evidence-based care plans incorporating infection control measures, medication administration, and patient education.
- Implement and evaluate nursing interventions for managing infections.
- Apply infection prevention strategies, administer prescribed antibiotics, and assess the effectiveness of interventions in controlling and resolving infections.
Pathophysiology for Nursing Care Plan for Infection
- Invaders on the Scene:
- Picture bacteria as stealthy infiltrators, viruses as cunning hijackers, and fungi as silent intruders. These microorganisms enter the body, aiming to set the stage for their survival.
- The Battle Begins:
- As the invaders breach the body’s defenses, the immune system springs into action. It’s like an epic battle scene, with immune cells as valiant warriors fighting to protect their homeland.
- Inflammatory Symphony:
- Now, envision inflammation as a symphony of redness, swelling, heat, and pain. This orchestrated response is the body’s way of isolating and neutralizing the threat, like the grand crescendo in our drama.
- Cellular Defenders:
- Specialized cells, like macrophages and neutrophils, act as the superheroes of our story. They engulf and digest the invaders, maintaining order in the microscopic battlefield.
- Immune Memory:
- The immune system is no one-hit wonder. It learns from each encounter, creating a memory bank of invaders. This way, the body can mount a faster and more efficient response if the same actors return for an encore.
- Tissue Repair:
- As the battle subsides, imagine a scene of repair. Just like a skilled production crew, the body’s mechanisms restore damaged tissues, ensuring that the aftermath of the battle is healed and balanced.
Etiology for Nursing Care Plan for Infection
- Microbial Culprits:
- Bacteria, viruses, fungi, and parasites act as the primary instigators, infiltrating the body to initiate infections.
- Portals of Entry and Compromised Defenses:
- Infections seize opportunities through various entry points, such as the respiratory tract or breaks in the skin. Compromised defenses, like chronic conditions or immunocompromised states, create vulnerabilities.
- Person-to-Person Transmission and Environmental Factors:
- Infections spread through person-to-person contact, utilizing modes like respiratory droplets. Environmental factors, including contaminated surfaces and vectors, contribute to the transmission and persistence of infectious agents.
Desired Outcome for Nursing Care Plan for Infection
- Infection Eradication:
- Successfully eliminate the infectious agent, leading to the resolution of clinical signs and symptoms, normalization of vital signs, and a negative trend in laboratory markers.
- Symptom Relief:
- Alleviate the patient’s symptoms associated with the infection, such as pain, fever, and discomfort, promoting overall comfort and well-being.
- Prevention of Complications:
- Prevent the development of complications related to the infection, including the spread of infection to other body systems or the progression to severe systemic conditions.
- Patient Education and Prevention Strategies:
- Educate the patient on infection prevention strategies, including proper hand hygiene, adherence to prescribed medications, and awareness of signs indicating potential recurrence or worsening of the infection. Empower the patient to actively participate in their care and prevent future infections.
Subjective Data
- Diarrhea
- Fatigue
- Muscle aches
- Coughing
- Pain
- Chills
- Sore throat
Objective Data
- Fever
- Tachycardia
- BP changes
- Elevated WBC count
- Redness/swelling/heat/drainage from the wound
Nursing Assessment for Nursing Care Plan for Infection
Patient Information:
- Demographic Data: Age, gender, occupation.
- Medical History: Chronic illnesses (especially those impacting the immune system), recent surgeries, immunization status.
- Presenting Complaint: Details on the infection – onset, duration, specific symptoms.
Infection-Specific Assessment:
- Signs and Symptoms: Document specific signs of infection such as fever, chills, malaise, fatigue, localized redness, swelling, and pain.
- Site of Infection: Identify the location (e.g., respiratory, urinary, wound).
- Onset and Duration: Note when symptoms started and any changes.
- Predisposing Factors: Assess for factors increasing infection risk (e.g., immunosuppression, recent hospitalization, invasive procedures).
- Recent Travel or Exposure: Inquire about recent travel or exposure to infectious agents.
Vital Signs:
- Temperature: Note any fever or subnormal temperatures.
- Heart Rate: Assess for tachycardia, which can be indicative of systemic infection.
- Respiratory Rate: Look for signs of respiratory distress or increased rate.
- Blood Pressure: Monitor for fluctuations, especially hypotension.
Skin and Wound Assessment:
- Skin Integrity: Inspect for localized redness, warmth, or other signs of infection.
- Wound Assessment: If applicable, assess for signs of infection (e.g., purulent drainage, increased redness, swelling).
Laboratory and Diagnostic Tests:
- Complete Blood Count (CBC): Check for elevated white blood cell count.
- Cultures: Identify causative organisms and sensitivity to antibiotics.
- Inflammatory Markers: Assess CRP or ESR levels.
Patient Education:
- Understanding of Infection: Assess knowledge and understanding of the infection, its mode of transmission, and preventive measures.
- Medication Understanding: Evaluate understanding of prescribed antibiotics, including dose, frequency, and potential side effects.
- Hygiene Practices: Assess knowledge of proper hand hygiene and wound care.
Psychosocial Assessment:
- Emotional Well-being: Evaluate the patient’s emotional response to the infection.
- Support System: Identify available support from family or caregivers.
Nursing Interventions for Nursing Care Plan for Infection
Nursing Intervention (ADPIE) | Rationale |
General head-to-toe assessment | noting color, moisture, swelling, drainage, and injuries can show signs of infection |
Assess the patient’s immune history/medication history | lab values- (WBC, serum protein, serum albumin)- are closely linked to the patient’s nutritional status and immune function.
Medications (corticosteroids and antineoplastic agents)- suppress the immune system which increases infection risk for patients |
Assess VS | get baseline vitals and note if the patient has a fever, tachycardia, or changes in blood pressure depending on the extent of the infection |
Obtain diagnostics/Labs (blood tests, urine sample, throat swabs, stool samples, x-rays) as ordered | these tests can determine the particular microbe that is causing the illness and better tailor the physician for a treatment plan |
Administer medications (antibiotics, antivirals, antifungals, antipyretics, anti-inflammatories, anti-parasitics) | depending on the cause of infection will depend on the type of medication therapy given |
Use of proper hand hygiene (washing hands, using hand sanitizer, wiping down surface areas) | helps in preventing the spread of the infection |
Encourage fluid intake, well-balanced diet/rest | fluids help aid in rehydrating a patient and fluid loss during a fever.
Balanced diet-omega 3’s, omega 6’s, protein, vitamins A, C, and E, zinc, and iron (immune support) Rest reduces stress and helps boost the immune system and able to fight off infection |
Implement isolation precautions as ordered | To prevent the spread of infection to other patients and the healthcare provider |
Comfort measures as indicated (local application of ice, pain control, environmental temperature, appropriate clothing, changing sheets if sweating, etc.) | Symptoms of infection can be uncomfortable and distressing. Taking measures to keep the patient comfortable can promote rest and healing. |
Evaluation of Nursing Care Plan for Infection
- Clinical Stability:
- Assess if the patient remains afebrile and if vital signs are within the normal range, indicating resolution of systemic infection.
- Local Symptom Improvement:
- Evaluate changes in localized signs and symptoms (e.g., reduced redness, swelling, and pain), reflecting effective localized treatment.
- Laboratory Parameters:
- Review follow-up laboratory values (e.g., white blood cell count) to determine if they have normalized.
- Patient Education Understanding:
- Assess the patient and/or caregiver’s understanding of infection prevention measures, including hand hygiene, wound care, and medication adherence.
- Absence of Recurrence:
- Determine if there has been any recurrence of infection within the specified follow-up period.
References
https://www.cdc.gov/infectioncontrol/spread/index.html
https://www.mayoclinic.org/diseases-conditions/infectious-diseases/symptoms-causes/syc-20351173
Example Nursing Diagnosis For Nursing Care Plan (NCP) for Infection
- Risk for Infection: Patients with infections are at risk of complications. This diagnosis emphasizes the potential for infection and the need for preventive measures.
- Altered Comfort: Infections often lead to discomfort and pain. This diagnosis focuses on comfort measures and symptom management.
- Ineffective Coping: Dealing with an infection can be emotionally challenging. This diagnosis addresses the patient’s coping abilities.
Transcript
Hi everyone. Today, we are going to be putting together a nursing care plan for infection. Let’s get started. First, we’re going to go over the pathophysiology. So an infection it’s a disease caused by microorganisms that infect the tissue. Some nursing considerations. You want to make sure you’re doing a full head to toe assessment, vital signs, diagnostic tests, administering medications, proper hand hygiene, and a well balanced diet and rest. Some desired outcomes: the patient’s going to remain free from infection and demonstrate proper hand hygiene.
So we’re going to go over our care plan here. We’re going to make sure we’re going to go over some of that subjective data and some objective data. So what are we going to see with the patient that has an infection? So some subjective data that you are going to see, or what they’re going to talk about are some possible aches, coughing, and sore throat. Some objective: there’ll be a fever, tachycardia, and BP changes. Some other things that you’ll see, they may complain of some diarrhea, fatigue, pain, chills. There could be an elevated white blood cell count for infection, redness and swelling, heat, and drainage from the wound. It depends on the type of infection as far as what you’ll see. So one of the first things that we’re going to do is a full on head to toe assessment. So you’re going to be noting any color changes, moisture, swelling, any drainage coming from anywhere. Injuries can show any sort of signs of infection. Another intervention that we’re going to be doing. We want to assess the patient’s immune history and medication history; that can be cancer or any sort of autoimmune disorder. Medications. There are certain medications that suppress the immune system, such as corticosteroids and antineoplastic agents. Another intervention we want to do, we want to make sure we’re assessing the vital signs. So we’re going to be seeing anything from fever, elevated heart rate, and any changes in blood pressure. Typically those are elevated. We’re going to do some diagnostic tests and some lab tests. So we’re going to be checking some blood work and then the white blood cell count. We’re possibly going to be doing throat swabs, maybe a stool sample, urine sample; anything that will help determine the cause of the infection, and dependent on what comes through, will depend on what the physician does for a treatment plan. Another intervention that we’re going to be doing is to give medications. Depending on what the infection is will depend on getting antibiotics, antivirals, antifungals, and anti parasitics. So it just depends on the cause of the infection for the type of medication we’ll be giving to the patient. Another invention we’re going to be doing. We want to make sure that they are doing proper hand hygiene. So you want to make sure that you’re washing your hands and using hand sanitizer and wiping down any surface areas. This all helps with preventing the spread of infection. You also want to make sure we’re encouraging fluid intake, eating a well-balanced diet, and plenty of rest. Fluids will help with rehydrating the patient. Usually when they have a fever with a balanced diet, you want to make sure that they have some omega threes. So omega sixes, protein, vitamin A, C, and E, zinc, and iron, which all help support the immune system. Rest is going to help reduce stress and helps boost your immune system to be able to fight off the infection. Right?
We’re going to go on to key points here. So an infection is a disease caused by microorganisms that infect the tissues. Organisms that can cause infection are viruses, bacteria, fungi, and parasites. Some subjective and objective data that you’ll see in these patients. They’ll complain of fatigue, coughing, pain, sore throat, fever, tachycardia, elevated white blood cells, redness, swelling, drainage from the wound, muscle aches. Again, depending on what the infection is, will depend on what you’ll see in the patient. You want to do a full assessment, do some diagnostic tests or labs. So make sure you’re doing that full head to toe assessment, check in their past medical history, medications, check their vitals, do some blood tests, urine samples, stool sample, or throat swab, give certain medications, and diet. So you want to give antibiotics, antivirals, antifungals, anti parasitics, just depending on the cause of the infection. You want to promote fluid intake and make sure they have a very well balanced diet and are getting plenty of rest. You want to make sure that they’re trying to get over this infection as quickly as they’re able to. And there you have it with the care plan you guys.
Awesome. We love you guys. Go out, be your best self today and as always happy nursing.