Page 641 - Cardiac Nursing

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C HAPTER 2 5 / Cardiac Surgery 617
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Nursing Care Plan 25-1 (c (continued) ) )
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Nursing Diagnosis 2 ➧ Potential for infection related to immunosuppression manifested by a temperature 37.5 C, a
rising white blood cell count, or a change in pulmonary secretions.
Nursing Goal 1 ➧ To prevent conditions and situations that predispose the patient to increased risk of infection.
Outcome Criteria ➧ 1. Patient will maintain a temperature, 37 C.
2. Patient will maintain a white blood cell count between 5,000 and 10,000.
3. Patient will have normal breath sounds without cough and a clear chest radiograph.
NURSING INTERVENTIONS RATIONALE
1. Maintain protective protocols and monitor protective 1. Poor technique may put the patient at risk for infection by
technique of all visitors and staff entering the patient’s organisms carried in the room from the outside
room. environment.
2. Restrict plants, flowers, and unpeeled fruit from the room. 2. Plants, flowers, and unpeeled fruit, such as oranges, may
harbor fungus and put the patient at risk for fungal infection.
3. Teach each patient technique for wearing mask when leav- 3. It is important for the patient to begin to assume responsi-
ing the room. Explain rationale. (May not be required in all bility for health maintenance. The hospital environment is
institutions.). contaminated with multiple organisms and potentially re-
sistant strains that may jeopardize the patient not knowl-
edgeable in precautionary techniques.
4. Monitor visitors and personnel for signs of infection and 4. Some visitors and personnel may be unaware of the poten-
decline entry into room. tial threat of a seemingly benign infection. Viral infections
such as herpes simplex or colds, or infected cuts and
other skin lesions, are of particular concern.
5. Change all wound, CVP insertion site, and pacemaker wire 5. Conscientious attention to potential ports of entry
exit site dressings daily. Use absolute sterile technique. reduces the potential for wound, systemic, or pacemaker
wire-borne infection.
6. Change all intravenous solutions, tubings, stopcocks, and 6. Intravenous lines that are frequently accessed for
any heparin-locked lines daily. (Individual program guide- specimens and medications increase risk of introducing
lines may vary from 24 to 48 hours.) organisms into the bloodstream.
7. Monitor patient technique of self-administration of antibi- 7. The patient is at risk for opportunistic oral infection, and
otic and antifungal mouthwashes. Ensure that care must be taken to ensure that medications are used
mouthwashes are swished throughout the mouth, are al- appropriately. Mouthwashes should be allowed to linger
lowed to linger, and are taken after meals. Teach patient and not be followed by eating, drinking, or other rinsing,
not to perform toothbrushing or eat immediately after the which reduce mouthwash effectiveness.
administration of mouthwashes.
8. Notify physician if white blood cell count falls below 5,000. 8. Patient is at greatest risk for infection during augmented
immunosuppression and any time the white blood cell
count falls below target suppression level. A fall in this
count indicates a need for adjustment of dosage.
9. Provide aggressive pulmonary care, including inspirome- 9. Atelectasis is a risk after surgery, and its development in-
ters, deep breathing, coughing, and early mobility to pre- creases the risk of pulmonary infection.
vent atelectasis.
Nursing Goal 2 ➧ To detect early manifestations of infection to ensure prompt medical attention and
intervention
Outcome Criteria ➧ 1. Patient will have negative cultures 7 days after course of antimicrobial therapy.
2. Patient will have a white blood cell count between 5,000 and 10,000 after antimicrobial
therapy.
3. Patient’s temperature will return to less than 37 C after antimicrobial therapy.
NURSING INTERVENTIONS RATIONALE
1. Obtain weekly urine, sputum, and viral cultures as 1. Absolute vigilance in monitoring for infection and identi-
ordered. Ensure that daily white blood cell counts and fying organisms is crucial to successful, early treatment
chest radiographs are obtained. of infection.
2. Auscultate breath sounds every 4 hours. Document and 2–4. Nurses are often the first to identify changes in pul-
immediately report changes in secretions or aeration. monary status. The lungs are a likely site of infection,
3. Monitor for and report any productive or nonproductive and prompt medical evaluation is important. Cultures are
cough. necessary to identify appropriate antimicrobial therapy.
(care plan continues on page 618)