Nurse's Pocket Guide

measures to prevent pneumonia, wound/dressing care, avoidance
of others with infection).
• Review use of prophylactic antibiotics if appropriate (e.g.,
prior to dental work for clients with history of rheumatic
fever/valvular heart disease).
• Encourage contacting healthcare provider for prophylactic
therapy, as indicated, following exposure to individuals with
infectious disease (e.g., tuberculosis, hepatitis, influenza).
• Identify resources available to the individual (e.g., substance
abuse/rehabilitation or needle exchange program, as appropriate;
available/free condoms, etc.).
• Refer to NDs readiness for enhanced Immunization; risk for
Disuse Syndrome; impaired Home Maintenance; ineffective
Health Maintenance.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Individual risk factors that are present including recent/current
antibiotic therapy.
• Wound and/or insertion sites, character of drainage/body
secretions.
• Signs/symptoms of infectious process
PLANNING
• Plan of care/interventions and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Discharge needs/referrals and who is responsible for actions
to be taken.
• Specific referrals made.
SAMPLE NURSING OUTCOMES & INTERVENTIONS
CLASSIFICATIONS (NOC/NIC)
NOC—Immune Status
NIC—Infection Protection
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 413
risk for INFECTION