Care Plan for Infection

Category / Primary Body System

• Immune System / Infectious Disease

Problem

• Patient is at risk of complications due to infection.

Goal

• Patient's infections will resolve without complications for 90 days.

Plan/Approach

1. Precautionary Measures

   • Maintain appropriate precautions as indicated

2. Temperature Monitoring

   • Check temperature every shift (Q shift) while on antibiotics

3. Hydration and Nutrition

   • Encourage fluid intake if not contraindicated
   • Dietary consult as needed to ensure adequate nutrition

4. Activity Management

   • Encourage the patient to pace activities to conserve energy

5. Medication Management

   • Administer antibiotics as ordered

6. Patient and Family Education

   • Educate the patient and/or family about infection prevention and management as needed

Rationale

1. Precautionary Measures

   • Following appropriate precautions helps prevent the spread of infection and protects both the patient and healthcare providers.

2. Temperature Monitoring

   • Regular temperature checks allow for early detection of fever, indicating possible infection progression or complication, and prompt intervention.

3. Hydration and Nutrition

   • Adequate fluid intake supports overall health and aids in the recovery process. Proper nutrition boosts the immune system and helps the body fight infection.

4. Activity Management

   • Pacing activities helps conserve energy, allowing the body to focus on fighting the infection and recovering.

5. Medication Management

   • Timely and accurate administration of antibiotics ensures effective treatment of the infection, reducing the risk of complications.

6. Patient and Family Education

   • Educating the patient and family about infection helps them understand the importance of adherence to treatment and precautionary measures, improving outcomes and preventing recurrence.

Actions

1. Precautionary Measures

   • Implement and maintain standard and transmission-based precautions as required (e.g., hand hygiene, use of personal protective equipment).

2. Temperature Monitoring

   • Measure and document the patient's temperature every shift while on antibiotics.
   • Report any temperature spikes or signs of fever to the physician immediately.

3. Hydration and Nutrition

   • Encourage the patient to drink fluids regularly, unless contraindicated by medical conditions.
   • Arrange for a dietary consult to ensure the patient's nutritional needs are met and adjust the diet plan as necessary.

4. Activity Management

   • Advise the patient to rest and avoid strenuous activities.
   • Schedule periods of activity and rest to prevent fatigue.

5. Medication Management

   • Administer antibiotics as prescribed, adhering to the dosage and timing instructions.
   • Monitor the patient for any adverse reactions to medications and report them to the healthcare provider.

6. Patient and Family Education

   • Provide education on infection control practices, including hand hygiene, respiratory etiquette, and wound care.
   • Discuss the importance of completing the full course of antibiotics.
   • Offer educational materials and answer any questions the patient or family may have.