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Saturday, 12 January 2013

Risk for Infection Care Plan COPD



Risk for Infection NANDA Definition: At increased risk for being invaded by pathogenic organisms

COPD or Chronic obstructive pulmonary disease is one of the most common lung diseases. It makes it difficult to breathe. There are two main forms of COPD:
  • Chronic bronchitis, which involves a long-term cough with mucus
  • Emphysema, which involves destruction of the lungs over time
  • Most people with COPD have a combination of both conditions.

Symptoms
  • Cough, with or without mucus
  • Fatigue
  • Many respiratory infections
  • Shortness of breath (dyspnea) that gets worse with mild activity
  • Trouble catching one's breath
  • Wheezing

The diagnosis of COPD requires lung function tests. Important management strategies are smoking cessation, vaccinations, rehabilitation, and drug therapy (often using inhalers). Some patients go on to require long-term oxygen therapy or lung transplantation.


Risk factors may include :
  • Inadequate acquired immunity (tissue destruction, increased environmental exposure)
  • Inadequate primary defenses (decreased ciliary action, stasis of secretions)
  • Malnutrition
  • Chronic disease process

Outcomes :
  • Remains free from symptoms of infection
  • States symptoms of infection of which to be aware
  • Demonstrates appropriate care of infection-prone site
  • Maintains white blood cell count and differential within normal limits
  • Demonstrates appropriate hygienic measures such as hand washing, oral care, and perineal care

Nursing Care Plan for COPD - Nursing Diagnosis : Risk for Infection

Interventions and Rationale :

1. Monitor temperature
R : Fever may be present because of infection and/or dehydration.

2. Observe color, character, odor of sputum.
R : Odorous, yellow, or greenish secretions suggest the presence of pulmonary infection.

3. Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake.
R : These activities promote mobilization and expectoration of secretions to reduce risk of developing pulmonary infection.

4. Encourage balance between activity and rest.
R : Reduces oxygen consumption/demand imbalance, and improves patient’s resistance to infection, promoting healing.

5. Monitor visitors; provide masks as indicated.
R : Reduces potential for exposure to infectious illnesses, e.g., upper respiratory infection (URI).

6. Obtain sputum specimen by deep coughing or suctioning for Gram’s stain, culture/sensitivity.
R : Done to identify causative organism and susceptibility to various antimicrobials.

7. Discuss need for adequate nutritional intake.
R : Malnutrition can affect general well-being and lower resistance to infection

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