Updated Care Plan for Infection

Updated Care Plan for Infection

Category / Primary Body System:

Infection Control / Immune System

Problem:

The patient is at risk of complications due to infection.

Goal:

The patient's infection will resolve without complications within 90 days.

Plan/Approach:

1. Infection Precautions:

   • Step: Maintain precautions as indicated (e.g., contact, droplet, airborne).
   • Rationale: Proper precautions prevent the spread of infection and protect both the patient and others.
   • Actions: Follow standard and transmission-based precautions as per infection control guidelines. Use appropriate personal protective equipment (PPE) and ensure all staff and visitors adhere to these precautions.

2. Temperature Monitoring:

   • Step: Check the patient’s temperature every shift while on antibiotics.
   • Rationale: Monitoring temperature helps detect fever, which is a common sign of infection, and assesses the effectiveness of antibiotic treatment.
   • Actions: Measure and record the patient’s temperature every shift, report any persistent fever or significant changes to the healthcare provider, and adjust the care plan as needed.

3. Fluid Intake:

   • Step: Encourage fluid intake if not contraindicated.
   • Rationale: Adequate hydration supports the immune system and helps in the recovery process.
   • Actions: Offer a variety of fluids throughout the day, track daily fluid intake, and ensure the patient remains hydrated. Adjust fluid intake based on the patient’s condition and any contraindications.

4. Energy Conservation:

   • Step: Encourage the patient to pace activities to conserve energy.
   • Rationale: Conserving energy helps the body focus on fighting the infection and promotes recovery.
   • Actions: Assist the patient in planning and spacing out activities, encourage rest periods, and educate the patient on the importance of conserving energy.

5. Antibiotic Administration:

   • Step: Administer antibiotics as ordered.
   • Rationale: Proper administration of antibiotics is essential for treating the infection effectively.
   • Actions: Administer prescribed antibiotics on schedule, monitor for efficacy and side effects, and document administration and patient response. Report any adverse reactions to the healthcare provider.

6. Patient and Family Education:

   • Step: Provide education about the infection and its management as needed.
   • Rationale: Education ensures that the patient and family understand the infection, treatment plan, and necessary precautions to prevent further complications.
   • Actions: Offer educational materials and one-on-one teaching sessions about the nature of the infection, treatment regimen, and hygiene practices. Encourage questions and provide clear, supportive answers.

7. Dietary Consultation:

   • Step: Arrange for a dietary consultation as needed.
   • Rationale: Proper nutrition supports the immune system and overall recovery.
   • Actions: Consult with a dietitian to develop a balanced diet plan that meets the patient’s nutritional needs. Ensure the patient follows dietary recommendations and monitor nutritional intake.