You are the nurse caring for a 64-year-old male client who is postoperative day four on the medical-surgical unit after having an emergency right colectomy due to cancer. The client is NPO with a nasogastric (NG) tube to low intermittent suction (LIS). The client has a history of smoking and no other health problems.
Vital signs:
- Temperature: 99.2° F
- Heart rate: 91 beats/min
- Respirations: 20 breaths/minute
- O2 saturation: 93% on 2L oxygen via nasal cannula
- Blood pressure: 110/68 mm Hg
- Pain: “6/10”
Focused assessment findings:
- Alert and oriented to person, place, and time
- Moves all four extremities, refuses to ambulate
- Apical pulse is regular at 91 beats/minute
- Lungs diminished bilaterally in the bases
- Bowel sounds hypoactive, abdomen soft, tender in all four quadrants
- Midline abdominal incision well approximated with staples intact, no erythema, Penrose drain intact with scant serous drainage
- Right lower quadrant Jackson-Pratt drain with sutures intact, no erythema, 30 mL of serosanguineous drainage
Instructions
Using the information from the scenario, create a care plan using the attached template.
Student Name: __________________________
Date: ______________________
Client Gender: ____________ Client Age: ________
Client Diagnosis: __________________________________________________________________________________________________
| Assessment data for Nursing Diagnosis | Nursing Diagnosis (3) | Expected Outcomes with Indicators
(1 per Nursing Diagnosis) |
Nursing Interventions
(2 per Expected Outcome) |
Evidence-based Rationale for each Nursing Intervention (Cited/referenced) | Evaluation
(How do you know it worked?) |
Respond to this critical thinking question:
Describe evidence-based precautions to prevent this client from obtaining a nosocomial infection. Provide supporting rationales.
Support your response with evidence from credible sources.
Nosocomial infections, also known as healthcare-associated infections (HAIs), are infections that occur as a result of receiving medical care in a healthcare facility. In order to prevent the client from obtaining a nosocomial infection, the following evidence-based precautions should be taken:
- Hand hygiene: All healthcare providers should perform hand hygiene before and after any contact with the client, including after touching contaminated surfaces or objects in the client’s environment. This can be done using soap and water or an alcohol-based hand rub. Hand hygiene is the most effective way to prevent the transmission of HAIs.
- Standard precautions: Standard precautions are a set of infection prevention practices that apply to all clients regardless of their diagnosis or presumed infection status. Standard precautions include wearing personal protective equipment (PPE) such as gloves, gowns, and masks as needed; proper handling and disposal of contaminated items; and ensuring proper cleaning and disinfection of equipment and the environment.
- Use of antibiotics: The appropriate use of antibiotics can help prevent the development of HAIs, particularly in clients who have undergone surgery or have weakened immune systems. However, overuse or inappropriate use of antibiotics can lead to antibiotic resistance and increased risk of HAIs. Therefore, antibiotics should only be used when indicated and according to established protocols.
- Prevention of catheter-associated infections: Clients with indwelling urinary catheters are at increased risk of developing catheter-associated urinary tract infections (CAUTIs). To prevent CAUTIs, healthcare providers should ensure proper insertion and maintenance of the catheter, including using sterile technique for insertion, securing the catheter to prevent movement, and regularly cleaning and maintaining the catheter site.
- Prevention of surgical site infections: Clients who have undergone surgery are at increased risk of developing surgical site infections (SSIs). To prevent SSIs, healthcare providers should ensure proper sterile technique during surgery, proper skin preparation, and proper postoperative wound care, including regular monitoring for signs of infection.
Overall, preventing nosocomial infections requires a multifaceted approach that includes hand hygiene, standard precautions, appropriate use of antibiotics, and prevention of catheter-associated and surgical site infections. It is important for healthcare providers to follow established infection prevention protocols and guidelines to ensure the safety and well-being of clients.