Assessment Diagnosis Planning Intervention Rationale Evaluation

Risk factors
Risk for Infection At the end of the INDEPENDENT: RATIONALE: Goal met. At the end
- Renal disease, related to alteration shift, the patient will of the shift, the
resulting to of immunity not manifest signs - Monitor A low-grade fever patient did not
depressed secondary to and symptoms of temperature and or increased pulse manifest signs and
immune system disease process infection such as an vital signs at least rate may indicate symptoms of
and leukocyte (Chronic Kidney elevation in body every 4 hours. an infection in the infection such as an
function Disease) temperature (38⁰C), immunosuppressed elevation in body
- Utilization of redness, and pallor. - Use standard client. temperature (38⁰C),
invasive devices precautions and redness, and pallor.
required for good hand Hand washing is a
hemodialysis washing primary means of
technique at all preventing the
times. transfer of
organisms. Clients
- Provide good who are on
respiratory hemodialysis have
hygiene including an increased risk
position changes, for Hepatitis B,
coughing and Hepatitis C, and
deep breathing. HIV infection.

- Restrict visits from These measures

obviously ill improve clearance
people. Teach the of respiratory
client and family secretions,
about the risk for reducing the risk
infection and for infection.
measures to
reduce the spread
of infection. The client’s
- Suction secretions resistance to
as necessary infection is
 impaired,
necessitating extra
DEPENDENT: caution in
preventing
- Monitor WBC and unnecessary
differential. exposures.

- Culture urine,
peritoneal dialysis
fluid, and other Secretions provide
drainage as good media for
indicated. microbial growth.

Increased WBCs
may indicate a
bacterial infection;
decreased WBCs
may indicate viral
infection. A shift in
the differential
showing more
immature WBC
(bands) in
circulation is
another indicator
of infection.

Culture is done to
verify the presence
of pathogens.