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Assessments to include for a patient with an infection:

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Subjective Data

What the patient SAYS

Signs and Symptoms.

Allergy history.

Adherence concerns.

Current Medication history.

Objective Data

What the nurse GATHERS

Vital signs.

Physical examination.

Lab work.

Imaging studies.

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Possible Nursing Diagnosis for a patient with an infection:

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1. Risk for infection

2. Ineffective health management

3. Risk for adverse drug reaction

4. Knowledge deficit

5. Imbalanced nutrition

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SMART goals for a patient with an infection.

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1. The patient will verbalize an understanding of their medication regimen, including drug names, dosages, and administration schedule, by the end of the teaching session.

2. The patient will demonstrate proper administration technique for their medications.

3. The patient will report a decrease in infection symptoms within 48–72 hours of starting antibiotic therapy.

4. The patient will remain free of adverse drug reactions or superinfections throughout the course of treatment.

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Nursing interventions for a patient with an infection.

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1. Medication administration: Administer antibiotics and antimycobacterials precisely as prescribed, considering timing relative to meals for optimal absorption.

2. Infection control: Implement appropriate isolation and airborne precautions for communicable diseases like TB. Use sterile technique for invasive procedures and proper hand hygiene.

3. Patient education: Provide thorough teaching on the medication regimen, including the importance of completing the entire course of therapy to prevent antimicrobial resistance. Explain potential side effects and when to notify the healthcare provider. For example, explain that rifampin, used for mycobacterial infections, can cause red-orange discoloration of body fluids.

4. Promoting adherence: For complex, long-term regimens, connect the patient with resources such as home healthcare nurses or directly observed therapy (DOT) programs to improve adherence.

5. Addressing side effects: Advise patients on how to manage common side effects, such as taking certain antibiotics with food to reduce gastrointestinal upset.

6. Hydration and nutrition: Encourage adequate fluid intake and small, frequent, high-calorie, and high-protein meals to combat malnutrition and aid recovery.

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Post-intervention assessments for a patient with an infection.

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1. Assess clinical improvement: Monitor for a decrease in infection signs and symptoms, such as reduced fever, pain, and improved vital signs. Document all findings.

2. Review lab values: Check follow-up lab tests, like white blood cell counts and repeated cultures, to ensure the infection is resolving. For mycobacterial infections, this includes monitoring sputum cultures to confirm eradication.

3. Monitor for adverse effects: Continuously assess for signs of adverse drug reactions, such as allergic reactions, liver or kidney toxicity, and superinfections like Clostridioides difficile (C. diff).

4. Assess for adherence: Confirm the patient's ability to consistently follow the prescribed medication schedule and identify any ongoing barriers.

5. Update the care plan: If goals are not met or new problems arise, the nurse revises the care plan and communicates findings to the interprofessional team.