RISK FACTORS DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

- Renal disease, Risk for Infection At the end of the shift, INDEPENDENT: RATIONALE: Goal met. At the end
resulting to related to alteration of the patient will not of the shift, the
depressed immunity secondary to manifest signs and - Monitor temperature A low-grade fever or patient did not
immune disease process symptoms of infection and vital signs at least increased pulse rate may manifest signs and
system and (Chronic Kidney such as an elevation in every 4 hours. indicate an infection in symptoms of infection
leukocyte Disease) body temperature the immunosuppressed such as an elevation in
function (38⁰C), redness, and client. body temperature
- Utilization of pallor. (38⁰C), redness, and
invasive - Use standard Hand washing is a pallor.
devices precautions and good primary means of
required for hand washing preventing the transfer
hemodialysis technique at all times. of organisms. Clients
- Presence of who are on hemodialysis
contraptions have an increased risk for
e.g. Hepatitis B, Hepatitis C,
endotracheal and HIV infection.
tube,
indwelling - Provide good These measures improve
Foley catheter respiratory hygiene clearance of respiratory
- Presence of including position secretions, reducing the
respiratory and changes, coughing and risk for infection.
oral secretions deep breathing.
s/t disease and
mechanical - Restrict visits from The client’s resistance to
ventilation obviously ill people. infection is impaired,
Teach the client and necessitating extra
family about the risk caution in preventing
for infection and unnecessary exposures.
measures to reduce
the spread of infection.

- Suction secretions as Secretions provide good

necessary media for microbial
growth.

BAUTISTA, Jesther Rowen, SN IV

 DEPENDENT:

- Monitor WBC and Increased WBCs may

differential. indicate a bacterial
infection; decreased
WBCs may indicate viral
infection. A shift in the
differential showing
more immature WBC
(bands) in circulation is
another indicator of
infection.
- Culture urine,
peritoneal dialysis Culture is done to verify
fluid, and other the presence of
drainage as indicated. pathogens.

BAUTISTA, Jesther Rowen, SN IV