ASSESSMENT NURSING BACKGROUND GOALS AND INTERVENTIONS and EVALUATION

DIAGNOSIS KNOWLEDGE OBJECTIVES RATIONALE

Objective: Risk for infection Risk for Infection NOC: Infection Status, NIC: Infection Control,
related to invasive refers to vulnerability Wound Healing: Incision Site Care, Health
> OPERATIVE procedures to invasion and Primary Intention, Education
PROCEDURE DONE: secondary to multiplication of Immune Status
CTT insertion (R), Pneumonia (severe) pathogenic organisms,
Right lateral with Pleural which may
Thoracotomy under Effusion, compromise health. GOAL: GOALS:
VATS, Open Empyema Thoracis (NANDA) The patient is free of After 24 hours of
Deloculation, infectious processes such nursing interventions,
Decortication under as an elevated the client was able to:
General anesthesia VATS thoracotomy, temperature, or drainage Exhibit free of
through endotracheal open deloculation, and from surgical sites or infectious processes
tube. decortication access sites as evidenced by vital
procedures. VATS signs within normal
(video-assisted range and lack of
thoracoscopic surgery) evidence of infection
is a minimally invasive such as swelling,
surgical procedure redness, and purulent
used to identify and drainage from non-
manage chest intact areas of the
problems. According to skin.
research, Open
thoracotomy and
decortication is the OBJECTIVES:
standard treatment for OBJECTIVES:
both early and chronic
empyema. However, After 2 hours of nursing The client was able
these types of invasive interventions, the client The nurse will: to:
procedures are will be able to:
associated with a
significant risk of A. Maintained strict asepsis
A. Recognize and A. Recognized
postoperative for dressing changes,
verbalize signs and
infections. wound care, and
and symptoms of verbalized
infection. intravenous therapy. signs and
Aseptic technique decreases symptoms of
the chances of transmitting or
spreading pathogens to or
 between patients. infection.
Interrupting the chain of
infection is an effective way
to prevent the spread of
infection.

A.1 Ensured that any articles

used are properly disinfected
or sterilized before use.
This reduces or eliminates
germs.

B. Demonstrate B. Washed hands or B. Demonstrated

meticulous performed hand appropriate ways
measures to hygiene before having to prevent
prevent infection. contact with the client. infection as
Also, impart these evidenced by
duties to the client and demonstration of
their SO and know the handwashing
instances when to technique,
perform hand hygiene wound/dressing
or “5 moments for changes, and right
hand hygiene”: disinfecting of
materials used.
1. Before touching a patient.
2. Before clean or aseptic
procedure (wound dressing,
starting an IV, etc.).
3. After body fluid exposure
risk
4. After touching a patient
5. After touching the patient’s
surroundings.
Friction and running water
effectively remove
microorganisms from hands.
Washing between procedures
 reduces the risk of
transmitting pathogens from
one area of the body to
another.

B.1 Educated the client and

SO about appropriate
cleaning, disinfecting, and
sterilizing items.
Knowledge of ways to reduce
or eliminate germs reduces
the likelihood of
transmission.

B.2 Demonstrated and

allowed return demonstration
of all high-risk procedures
that the patient and/or SO will
do after discharge, such as
dressing changes, peripheral
or central IV site care, and so
on.
The client and SO need
opportunities to master new
skills to reduce susceptibility
to infection.

C. Monitored the client for

C. Manifest no signs any signs of swelling, C. Manifested no
and symptoms of purulent discharge, or signs and
infection and presence of pain from symptoms of any
maintain wounds, injuries, catheters, or infection as
temperature drains. evidenced by vital
within normal These are the classic signs of signs within
limits. infection. normal limits.

C.1 Regularly monitored the

 client’s temperature.
Fever is often the first sign of
an infection. A temperature
of up to 38º C (100.4º F) 48
hours post-op is usually
related to surgical stress
after 48 hours. A temperature
of greater than 37.7º (99.8º
F) may indicate infection; a
very high temperature
accompanied by sweating
and chills may indicate
septicemia.

C. 2 Routinely monitored the

client’s white blood cell
count, serum protein, and
serum albumin.
These laboratory values are
closely linked to the patient’s
nutritional status and
immune function.

D. Encouraged intake of
D. Obtain adequate protein-rich and calorie-rich D. Obtained adequate
nutrition to foods and encouraged a nutrition to promote
strengthen immunity balanced diet. immunity and
and faster healing. Proper nutrition and a healing.
balanced diet support the
immune systems’
responsiveness and enhance
the health of all the body’s
tissues. Adequate nutrition
enables the body to maintain
and rebuild tissues and helps
keep the immune system
functioning well.
 E. Assisted the client to learn
E. Exhibit stress- stress-reducing techniques.
reducing techniques Excessive stress predisposes
that alleviate stress the client to infection.
and provide comfort.
E.1 Helped the client change
positions frequently.
It prevents stasis of
secretions and pathogens in
the lungs and bronchial tree.
E. Exhibited stress-
reducing techniques
(e.g., deep breathing,
getting adequate
sleep, listening to
soothing music) and
frequent changing of
position.

F. Adhere to prescribed F. Administered (as

medications. prescribed) and monitored F. Adhered with the
medication regimen (e.g., proper take of
antimicrobials) and noted the medication.
client’s response.
To determine effectiveness of
therapy or presence of side
effects.