Nursing Diagnosis: Nursing Care Plan for Shock

Sepsis, a severe systemic infection triggered by an extreme immune response, can rapidly progress to septic shock, a life-threatening condition characterized by organ failure and increased mortality. Early recognition and aggressive intervention are crucial in managing sepsis and preventing the onset of septic shock. Nurses across all healthcare settings, especially in critical care, play a pivotal role in the early detection, assessment, and management of sepsis and shock. Understanding the nuances of nursing diagnosis and nursing care plans for shock, particularly septic shock, is paramount for improving patient outcomes.

This article delves into the essential aspects of nursing care for patients at risk or experiencing shock secondary to sepsis. It provides a comprehensive overview of the nursing process, from initial assessment to detailed nursing interventions and care planning, focusing on the critical elements of shock management within the context of sepsis.

Nursing Process

Patients with sepsis and shock are typically managed in intensive care units (ICUs) due to the critical nature of their condition. However, nurses in all specialties must be adept at recognizing the subtle signs of sepsis and shock, as timely intervention is crucial for patient survival. Preventive measures, such as meticulous hand hygiene, adherence to personal protective equipment (PPE) protocols, diligent wound care practices, and the consistent use of sterile or aseptic techniques, are fundamental nursing responsibilities in minimizing infection risk and subsequent sepsis and shock.

Nursing Assessment

The cornerstone of effective nursing care is a thorough nursing assessment. This involves the systematic collection of physical, psychosocial, emotional, and diagnostic data. In the context of sepsis and shock, this assessment is particularly crucial for identifying early warning signs and guiding prompt interventions. This section will detail the subjective and objective data pertinent to patients at risk of or experiencing shock related to sepsis.

Review of Health History

1. Document General Sepsis Symptoms and Progression to Shock.

• Note any reported symptoms that may indicate sepsis, such as:
  • Fluctuating body temperature (increased or decreased)
  • Chills and rigors
  • Altered mental status, ranging from confusion to lethargy
  • Rapid respiratory rate (tachypnea)
  • Skin changes: flushed initially, progressing to cool and clammy
  • Hypotension, a key indicator of progressing shock

2. Identify Potential Sources of Sepsis and Risk of Shock. Pinpointing the source of infection is vital for targeted treatment. Sepsis, which can lead to shock, can originate from various infections, including:

• Respiratory infections, such as pneumonia
• Urinary tract infections (UTIs), including kidney and bladder infections
• Gastrointestinal infections
• Bloodstream infections (bacteremia)
• Infections associated with invasive devices (catheters, surgical sites)
• Infections of burns and wounds

3. Assess for Sepsis and Shock Risk Factors. Certain patient populations are at an increased risk of developing sepsis and subsequent shock. These risk factors include:

• Age extremes: Infants and adults over 65 years
• Compromised immune system due to conditions or treatments
• Presence of chronic comorbidities such as diabetes, kidney disease, or COPD
• Prolonged hospitalizations
• Indwelling invasive lines (central venous catheters, urinary catheters)
• Recent prolonged antibiotic use (within 90 days)
• Use of immunosuppressive medications (corticosteroids)

4. Review Medical History for Conditions Predisposing to Sepsis and Shock. A thorough medical history can reveal underlying conditions that increase susceptibility to infection and sepsis progression to shock:

• Pre-existing, undiagnosed, or untreated infections
• Immunocompromising conditions (cancer, HIV, autoimmune diseases)
• Chronic diseases (diabetes, COPD, heart failure)
• Recent surgical procedures, particularly those involving the abdomen or urinary tract
• Implanted medical devices (pacemakers, ports)
• History of organ transplant and associated complications

5. Medication Review: Immunosuppressants and Antibiotic Use. Medications can significantly impact infection risk and antibiotic resistance. Note:

• Current use of corticosteroids or other immunosuppressants, which can weaken the immune response.
• History of antibiotic use, as inappropriate or overuse of antibiotics can lead to drug-resistant infections, complicating sepsis and shock management.

Physical Assessment

1. Vital Signs: Early Indicators of Sepsis and Shock. Vital sign monitoring is crucial for detecting early sepsis and shock. Initially, patients may exhibit:

• Hyperthermia (temperature >100.4°F or >38°C) or hypothermia (temperature <96.8°F or <36°C)
• Tachycardia (increased heart rate)
• Tachypnea (increased respiratory rate)
• Hypotension (low blood pressure) may be present early or develop as shock progresses.

2. Systemic Assessment: Monitoring for Organ Dysfunction in Severe Sepsis and Shock. Without prompt intervention, sepsis can evolve into severe sepsis and septic shock, characterized by organ dysfunction. Closely monitor for:

• Central Nervous System (CNS): Altered mental status, confusion, decreased level of consciousness.
• Respiratory System: Hypoxia, cough, chest pain, dyspnea, signs of acute respiratory distress syndrome (ARDS).
• Cardiovascular System: Decreased capillary refill time, tachycardia, hypotension, weak peripheral pulses.
• Gastrointestinal System: Ileus, abdominal distension, absent bowel sounds, potential for perforation or abscess, abdominal tenderness.
• Genitourinary System: Oliguria (decreased urine production) or anuria (absent urine production), indicating kidney hypoperfusion.
• Integumentary System: Initially flushed skin, progressing to cyanosis, pallor, or skin mottling, cool and clammy extremities.

3. Assess for Progression to Shock: Recognizing Septic Shock. Septic shock represents a critical stage where hypotension persists despite fluid resuscitation, leading to decreased organ perfusion. Signs include:

• Cool, clammy extremities
• Delayed capillary refill (>3 seconds)
• Thready, weak pulses
• Pale or mottled skin
• Diaphoresis (excessive sweating)
• Confusion, lethargy, or loss of consciousness
• Significantly decreased urine output

4. Intravenous Line Assessment: Infection Source. Inspect IV insertion sites for signs of localized infection and thrombophlebitis, such as:

• Swelling, redness, warmth, pain at the insertion site
• Purulent drainage
• Central venous lines are a significant risk factor for sepsis and bacteremia.

5. Wound and Incision Assessment: Identifying Infection. Assess wounds and surgical incisions for signs of infection, which can be a primary source of sepsis:

• Pain disproportionate to the wound
• Purulent discharge, foul odor
• Erythema (redness), warmth
• Swelling and induration
• Signs of cellulitis or abscess formation

Alt text: Nurse meticulously examines IV site for redness and swelling, key indicators of potential infection.

Diagnostic Procedures

1. Laboratory Studies for Sepsis and Shock Diagnosis. Laboratory tests are essential for confirming sepsis, identifying the causative organism, and assessing organ function:

• Complete Blood Count (CBC): May reveal leukocytosis (elevated WBC), leukopenia (decreased WBC in severe sepsis), neutrophilia, and thrombocytopenia (low platelet count).
• Kidney Function Tests (BUN, Creatinine): Elevated levels indicate impaired kidney perfusion and function.
• Blood and Site-Specific Cultures: Cultures from blood, urine, sputum, wound drainage, and IV sites to identify the causative pathogen and guide antibiotic therapy.
• Urinalysis and Culture: To investigate urinary tract infections as a potential source of sepsis.
• Biomarkers (Procalcitonin, Presepsin): Elevated levels support early sepsis diagnosis and can help differentiate sepsis from non-infectious inflammatory conditions.
• Lactate Levels: Elevated lactate (>2 mmol/L) indicates tissue hypoperfusion and anaerobic metabolism. Levels >4 mmol/L are strongly suggestive of septic shock.
• C-Reactive Protein (CRP): Elevated CRP is a marker of inflammation, expected to be high in sepsis.
• Coagulation Studies (INR, PTT): Elevated INR and PTT indicate coagulopathy and disseminated intravascular coagulation (DIC), a complication of severe sepsis.

2. Imaging Scans to Identify Infection Source. Imaging can help locate the source of infection, especially in cases of pneumonia, abdominal infections, or soft tissue infections:

• Chest X-ray: To rule out pneumonia.
• Chest CT Scan: More detailed evaluation of the lungs.
• Abdominal Ultrasound: Initial imaging for abdominal infections, gallbladder disease.
• Abdominal CT Scan or MRI: Detailed imaging of abdominal organs, abscesses, and inflammation.
• Site-Specific Soft Tissue Imaging (Ultrasound, CT, MRI): To evaluate localized infections, abscesses in skin, muscle, or joints.
• Contrast-Enhanced CT or MRI of Brain/Neck: To investigate CNS infections, meningitis, or neck infections.

3. Invasive Diagnostic Procedures. Invasive procedures may be necessary to obtain samples for diagnosis in certain cases:

• Thoracentesis: To obtain pleural fluid for analysis in suspected pleural infections.
• Paracentesis: To obtain ascitic fluid for analysis in suspected peritonitis.
• Drainage of Fluid Accumulations and Abscesses: Surgical or percutaneous drainage for culture and source control.
• Bronchoscopy with Lavage: To obtain lower respiratory tract samples for culture in pneumonia.

Nursing Interventions

Effective nursing interventions are crucial for patient recovery from sepsis and shock. These interventions are aimed at supporting vital functions, eradicating the infection, and preventing further complications.

1. Prepare for Hospital and ICU Admission. Patients with sepsis and shock require intensive monitoring and treatment in a hospital setting, typically in the ICU, due to the potential for rapid deterioration.

2. Initiate Antibiotic Therapy Promptly. Administer broad-spectrum antibiotics as soon as sepsis is suspected, ideally within one hour of recognition. Once culture results are available, antibiotics may be narrowed to target the specific pathogen.

3. Fluid Volume Resuscitation: Addressing Hypovolemia in Shock. Aggressive fluid resuscitation is a cornerstone of shock management in sepsis. Administer at least 30 mL/kg of crystalloid fluids in the first three hours to improve preload and cardiac output, aiming to maintain adequate perfusion pressure.

4. Vasopressor Administration: Managing Hypotension in Septic Shock. If hypotension persists despite adequate fluid resuscitation, administer vasopressors (e.g., norepinephrine) to induce vasoconstriction and increase blood pressure and tissue perfusion.

5. Patient Positioning: Optimizing Respiratory Function. Position the patient in semi-Fowler’s or high-Fowler’s position to improve lung expansion and reduce the risk of pneumonia. Prone positioning may be indicated in sepsis-induced ARDS to improve oxygenation.

6. Invasive Hemodynamic Monitoring. Initiate invasive arterial monitoring to continuously and accurately monitor hemodynamics and blood pressure, guiding fluid and vasopressor therapy. Central venous catheters are essential for CVP monitoring and medication administration.

7. Oxygen Therapy and Mechanical Ventilation. Administer supplemental oxygen to patients with hypoxia. Patients with respiratory failure may require intubation and mechanical ventilation to support oxygenation and ventilation.

8. Insulin Administration: Managing Hyperglycemia. Sepsis-induced stress hyperglycemia is common. Administer insulin to maintain blood glucose levels between 140-180 mg/dL, as per guidelines, to prevent complications associated with hyperglycemia.

9. Prepare for Potential Surgical Source Control. In some cases, surgical intervention may be necessary to remove the source of infection, such as draining abscesses or debriding necrotic tissue.

10. Remove Potentially Infected Intravascular Devices. Promptly remove any intravascular access devices (central lines, peripheral IVs) that are suspected as the source of sepsis to prevent ongoing infection.

11. Implement Strict Hygiene Practices. Meticulous hand hygiene is paramount to prevent healthcare-associated infections and cross-transmission. Provide bed baths and perform aseptic cleaning of catheters and IV hubs according to hospital protocols. Ensure regular disinfection of patient care equipment.

12. Implement Transmission-Based Precautions. Institute septic isolation and transmission-based precautions to minimize the risk of cross-infection to other patients, healthcare workers, and visitors. Protective isolation may be necessary for severely immunocompromised patients.

13. Use Appropriate Personal Protective Equipment (PPE). Healthcare workers should consistently use appropriate PPE (gloves, gowns, masks, eye protection) to protect themselves and patients from infection transmission.

14. Initiate Enteral Nutrition Early. Start enteral nutrition within 24-48 hours if the patient can tolerate it. If enteral nutrition is contraindicated, initiate parenteral nutrition to provide adequate calories and protein, supporting the patient’s metabolic needs and immune function.

Nursing Care Plans

Once nursing diagnoses are identified for patients with sepsis and shock, nursing care plans are essential for prioritizing assessments and interventions to achieve both short-term and long-term goals. The following are examples of nursing care plans relevant to patients experiencing shock in the context of sepsis.

Decreased Cardiac Output related to Septic Shock

Septic shock, characterized by severe sepsis and hypoperfusion, profoundly impacts circulatory function, leading to decreased cardiac output.

Nursing Diagnosis: Decreased Cardiac Output

Related Factors:

• Altered hemodynamic parameters due to sepsis
• Impaired myocardial contractility (septic cardiomyopathy)
• Impaired myocardial circulation
• Loss of vascular tone and systemic vasodilation
• Hypovolemia due to fluid shifts and capillary leak

Evidenced By:

• Tachycardia
• Hypotension (MAP <65 mmHg)
• Elevated or decreased Central Venous Pressure (CVP), depending on stage of shock and fluid status
• Cyanosis, Pallor
• Prolonged capillary refill time (>3 seconds)
• Oliguria or anuria
• Altered level of consciousness, confusion, restlessness
• Cold, clammy skin
• Decreased peripheral pulses, weak or thready pulses
• Cardiac dysrhythmias
• Presence of murmurs (less common, but possible in septic cardiomyopathy)

Expected Outcomes:

• Patient will demonstrate adequate cardiac output as evidenced by:
  • Hemodynamic stability:
    • Blood pressure within acceptable parameters (e.g., systolic BP >90 mmHg or MAP >65 mmHg)
    • Heart rate 60-100 beats per minute (or within patient’s baseline)
    • Central venous pressure (CVP) within target range (e.g., 8-12 mmHg, or as prescribed)
    • Mean arterial pressure (MAP) ≥65 mmHg
  • Adequate tissue perfusion:
    • Urine output ≥0.5 mL/kg/hour
    • Improved level of consciousness and mental status
    • Warm and dry skin, normal capillary refill
    • Strong peripheral pulses
  • Absence of cardiac dysrhythmias

Nursing Assessments:

1. Monitor for Signs and Symptoms of Cardiac and Circulatory Compromise in Shock. Hypotension, tachycardia, tachypnea, weak peripheral pulses, altered mental status, and decreased urine output are critical indicators of decreased cardiac output in septic shock.

2. Hemodynamic Monitoring: CVP, Arterial Blood Pressure.

• Continuously monitor arterial blood pressure for hypotension. Assess trends and response to interventions.
• CVP monitoring provides insights into right ventricular preload and fluid volume status. Interpret CVP in conjunction with other hemodynamic parameters.

3. Laboratory Data: Cardiac Markers, Ejection Fraction. Sepsis-induced cardiomyopathy can significantly impair cardiac function.

• Monitor cardiac biomarkers (troponin, BNP, NT-proBNP). Elevated troponins may indicate myocardial injury. Elevated BNP/NT-proBNP can correlate with disease severity and cardiac dysfunction.
• Assess echocardiogram results for ejection fraction (EF). Decreased EF is an indicator of septic cardiomyopathy and impaired contractility.

Nursing Interventions:

1. Aggressive Fluid Resuscitation as Prescribed. Fluid resuscitation is essential to address hypovolemia and improve preload. Administer crystalloids (normal saline, lactated Ringer’s) as per physician orders, closely monitoring for fluid overload, especially in patients with septic cardiomyopathy.

2. Administer Vasopressors and Inotropes as Prescribed.

• Vasopressors (norepinephrine, vasopressin) are crucial to counteract vasodilation and maintain blood pressure in septic shock. Titrate vasopressors to achieve target MAP.
• Inotropes (dobutamine) may be prescribed to improve myocardial contractility in patients with septic cardiomyopathy and persistent low cardiac output despite adequate preload and afterload management.

3. Anticipate and Prepare for Advanced Hemodynamic Support. In severe cases of septic shock and septic cardiomyopathy, advanced therapies may be necessary.

• Prepare for potential insertion of an intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD) to support cardiac output if pharmacologic interventions are insufficient.
• Extracorporeal membrane oxygenation (ECMO) may be considered in refractory septic shock with severe cardiac and/or respiratory failure.

4. Optimize Oxygen Delivery. Ensure adequate oxygenation to support myocardial function and tissue perfusion. Maintain SpO2 as per orders. Provide supplemental oxygen via nasal cannula, high-flow mask, or mechanical ventilation as needed.

Alt text: ICU ventilator settings being adjusted by healthcare provider, critical for respiratory support in shock patients.

Hyperthermia related to Systemic Infection

Hyperthermia is a common physiological response to infection and inflammation in sepsis. However, extreme and prolonged hyperthermia can be detrimental.

Nursing Diagnosis: Hyperthermia

Related Factors:

• Dehydration, contributing to impaired thermoregulation
• Increased metabolic rate associated with sepsis and hyperdynamic state
• Inflammatory process and release of pyrogens

Evidenced By:

• Elevated body temperature above the normal range (e.g., >100.4°F or >38°C)
• Flushed skin, warm to touch
• Tachypnea, increased respiratory rate
• Tachycardia, increased heart rate
• Confusion, irritability, restlessness
• Potential for seizures, especially in children or with rapid temperature rise

Expected Outcomes:

• Patient will achieve and maintain body temperature within normal limits (97.6°F-99.6°F or 36.4°C-37.6°C).
• Underlying infection will be effectively treated to resolve the cause of hyperthermia.

Nursing Assessments:

1. Accurate Temperature Measurement: Rectal Temperature. Rectal temperature measurement provides the most accurate assessment of core body temperature, especially in critically ill patients.

2. Neurological Status Assessment. Uncontrolled hyperthermia can lead to neurological damage. Monitor for changes in level of consciousness (LOC), confusion, seizures, or other neurological deficits.

Nursing Interventions:

1. Environmental Cooling Measures. Create a cool environment to promote heat dissipation. Reduce room temperature, remove excessive blankets, and ensure lightweight, breathable clothing.

2. Cooling Blanket Application. Utilize a cooling blanket to reduce surface body temperature. Closely monitor the patient for shivering, which can paradoxically increase body temperature. Manage shivering with medications as ordered.

3. Antipyretic Medication Administration. Administer antipyretics (acetaminophen, ibuprofen) as prescribed to reduce fever. Monitor effectiveness and administer around the clock or as needed.

4. Physical Cooling Methods: Cool Rags, Tepid Baths. Apply cool, damp cloths to areas with high blood flow (groin, axillae). Provide tepid sponge baths to enhance heat loss through evaporation. Avoid cold water baths, which can induce shivering.

Ineffective Protection related to Immunosuppression and Systemic Infection

Patients with sepsis and shock are inherently in a state of ineffective protection due to the overwhelming systemic infection and often underlying immunosuppression.

Nursing Diagnosis: Ineffective Protection

Related Factors:

• Infectious process and systemic inflammatory response
• Immunosuppression (disease-related, medication-induced)
• Abnormal blood profiles (leukopenia, neutropenia)
• Poor nutritional status, malnutrition
• Medication regimen (immunosuppressants, chemotherapy)
• Extremes of age (infancy, older adulthood)

Evidenced By:

• Change in level of consciousness, lethargy, confusion
• Insomnia, fatigue, weakness
• Immobility, impaired physical function
• Poor ability to handle stress, anxiety, irritability
• Presence of open wounds, pressure ulcers, or invasive lines

Expected Outcomes:

• Patient will remain free from new infections during hospitalization.
• Patient will demonstrate improved nutritional intake to support immune function.
• Patient will verbalize understanding of measures to enhance immune system protection.

Nursing Assessments:

1. Continuous Monitoring for Sepsis and Shock Progression. Vigilantly monitor for signs of worsening sepsis or shock: changes in mental status, persistent hypotension, ongoing fever or hypothermia, persistent tachycardia, chills, and skin changes.

2. White Blood Cell Count and Differential Monitoring. Monitor WBC count and differential. Leukocytosis is typical of infection, but leukopenia can occur in severe sepsis. Assess neutrophil count for neutropenia, increasing infection risk. Monitor bandemia (increased immature neutrophils) as a sign of ongoing infection.

3. Risk Factor Assessment for Ineffective Protection. Identify and document patient-specific risk factors that compromise protection: immunosuppressive conditions, medications, malnutrition, immobility, presence of wounds or invasive lines.

Nursing Interventions:

1. Promote Rest and Energy Conservation. Ensure adequate rest and minimize energy expenditure to support cellular repair and immune function. Cluster nursing care activities to allow for uninterrupted rest periods.

2. Minimize Invasive Procedures. Limit invasive procedures (catheterizations, injections, rectal procedures) whenever possible to reduce the risk of introducing pathogens. Use aseptic technique meticulously when invasive procedures are necessary.

3. Nutritional Support: High-Protein, Nutrient-Rich Diet. Encourage a high-protein, nutrient-rich diet to support immune function and tissue repair. Consult with a dietitian for nutritional assessment and recommendations. Consider oral nutritional supplements or enteral/parenteral nutrition if indicated.

4. Patient and Family Education on Infection Control. Educate the patient and family/caregivers about infection control measures, particularly hand hygiene. Emphasize the importance of frequent and proper handwashing techniques to prevent infection transmission.

Risk for Deficient Fluid Volume related to Vasodilation and Capillary Leak in Septic Shock

Septic shock is characterized by significant fluid shifts and vasodilation, leading to a high risk of deficient fluid volume and hypovolemic shock.

Nursing Diagnosis: Risk for Deficient Fluid Volume

Related Factors:

• Systemic vasodilation, leading to decreased preload and hypotension
• Increased capillary permeability and capillary leak, resulting in fluid shifts from intravascular to interstitial space
• Third spacing of fluids

Evidenced By:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are focused on prevention.

Expected Outcome:

• Patient will maintain adequate circulatory volume as evidenced by stable vital signs, adequate urine output, and balanced fluid status.

Nursing Assessments:

1. Monitor for Early Signs of Fluid Volume Deficit. Assess for early indicators of hypovolemia and shock: rapid drop in blood pressure, tachycardia, fever, signs of dehydration (poor skin turgor, dry mucous membranes), decreased urine output.

2. Intake and Output and Daily Weight Monitoring. Strictly monitor and record all fluid intake (oral, intravenous) and output (urine, drains, emesis). Monitor daily weights for trends in fluid balance. A sudden weight gain may indicate fluid retention and third spacing.

3. Assess for Edema: Third Spacing. Assess for peripheral edema (extremities, sacrum) as a sign of fluid shifting into the interstitial space. Monitor for signs of pulmonary edema (crackles, dyspnea) as a complication of fluid overload or cardiac dysfunction.

4. Review Laboratory Values: Hemoglobin, Hematocrit, Renal Function. Monitor hemoglobin and hematocrit levels for trends. Elevated hematocrit may indicate hemoconcentration due to fluid volume deficit. Monitor BUN and creatinine for signs of acute kidney injury (AKI) related to hypoperfusion. Monitor urine specific gravity; high specific gravity may indicate dehydration.

Nursing Interventions:

1. Administer Intravenous Fluids as Ordered. Administer crystalloid solutions (normal saline, lactated Ringer’s) as the primary fluid for resuscitation in septic shock. Colloids (albumin) may be used in conjunction with crystalloids in some cases, but crystalloids are the initial fluid of choice.

2. Administer Vasopressors as Prescribed. Vasopressors (norepinephrine, dopamine) are crucial for restoring and maintaining blood pressure in septic shock, especially when hypotension persists despite fluid resuscitation. Titrate vasopressors to achieve target MAP.

3. Monitor Circulatory and Renal Function Closely. Continuously monitor heart rate, blood pressure, MAP, CVP, and urine output to assess circulatory and renal function. Monitor pulse oximetry and arterial blood gases to assess respiratory function and oxygenation. Assess for signs of acute kidney injury (decreased urine output, elevated creatinine).

Risk for Infection related to Immunosuppression and Invasive Procedures

Patients in the ICU, particularly those with sepsis and shock, are at high risk for developing new infections due to immunosuppression, invasive procedures, and exposure to a hospital environment.

Nursing Diagnosis: Risk for Infection

Related Factors:

• Immunosuppression associated with sepsis, underlying conditions, and treatments
• Multiple chronic comorbidities increasing susceptibility to infection
• Compromised skin or tissue integrity (wounds, pressure ulcers, invasive lines)
• Malnutrition, impaired immune function
• Untreated or worsening infections (pneumonia, UTI, cellulitis)
• Invasive procedures and devices (catheters, ventilators)

Evidenced By:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are focused on prevention.

Expected Outcomes:

• Patient will remain free of new infections during hospitalization, as evidenced by normal vital signs and white blood cell count within normal limits.
• Patient will demonstrate improvement in wound healing without signs of infection (redness, drainage, odor).
• Patient will identify and implement interventions to prevent or reduce the risk of infection.

Nursing Assessments:

1. Monitor for Signs and Symptoms of Infection. Vigilantly monitor for signs of new infections: fever, new onset of hypothermia, tachycardia, tachypnea, chills, altered mental status, localized signs of infection (wound drainage, redness, warmth, swelling).

2. Monitor Laboratory Values: White Blood Cell Count, Inflammatory Markers. Monitor WBC count for leukocytosis or leukopenia. Monitor inflammatory markers (CRP, procalcitonin) for elevation, which may indicate infection. Monitor lactate levels for trends, as increasing lactate can indicate worsening sepsis or new infection.

3. Obtain Specimens for Culture as Indicated. Obtain cultures (blood, urine, sputum, wound drainage, catheter tips) as ordered to identify potential new infections and guide antibiotic therapy. Obtain cultures prior to initiating or changing antibiotic therapy.

Nursing Interventions:

1. Administer Anti-infective Medications as Prescribed. Administer prophylactic antibiotics as ordered for specific high-risk situations (e.g., pre-operatively). Administer broad-spectrum antibiotics promptly for suspected infections, and adjust to narrow-spectrum antibiotics based on culture and sensitivity results.

2. Implement Meticulous Hand Hygiene. Ensure strict adherence to hand hygiene protocols by all healthcare providers, patients, and visitors. Promote handwashing with soap and water or use of alcohol-based hand sanitizer before and after patient contact, and after contact with potentially contaminated materials.

3. Discontinue Unnecessary Invasive Lines and Devices. Regularly assess the necessity of all invasive lines (IV catheters, urinary catheters, central lines, drains, endotracheal tubes). Discontinue lines and devices as soon as they are no longer clinically indicated to reduce infection risk.

4. Promote Skin Integrity and Wound Care. Implement measures to prevent skin breakdown, especially in immobile patients. Turn and reposition patients every 2 hours. Assist with ambulation as tolerated. Ensure meticulous wound care for any existing wounds, pressure ulcers, or surgical incisions. Use appropriate dressings and aseptic technique for wound care.

Alt text: Nurse demonstrating thorough handwashing technique at hospital sink, emphasizing infection prevention.