Nursing Process Worksheet

Nursing Diagnosis: Risk of infection related to IV device

Long Term Goal: Patient will remain free from infection during hospitalization

Outcome Criteria: Interventions: Scientific Rationale: Evaluation:

1. Patients PICC site will 1. RN will assess PICC 1. Phlebitis is inflammation of the vein that 1. Met
remain free of insertion site Q shift. can occur due to infection. Redness, heat,
erythema, edema, swelling or drainage are the common
phlebitis or drainage signs/symptoms of infection. Early
during hospitalization. recognition of local infection and treatment
are important to prevent bacteria from
2. RN will assess VS Q Shift. entering bloodstream and causing sepsis. 2. Met
2. Patients vital signs will (P&P p. 909-910)
remain within normal 2. Vital signs are important to note when any
limits during inflammation is present. With infection,
hospitalization. temperature rises, pulse and respirations
may increase. Early detection of infection is
3. RN will assess WBC as important to initiate appropriate treatment, 3. Met
ordered. ie. Drug therapy or rest. (P&P p176)
3. Patients WBC will 3. WBC count will in increased in acute
remain within normal infections. Sepsis or viral infections will
limits during cause a decrease in WBC count. Lab values
4. Partially met-
hospitalization. (5,000- are not enough to detect infection; RN
4. RN will assess dressing Q insertion site
10,000) should assess for other clinical signs &
shift. had dried
symptoms. (Potter & Perry p.406)
4. A sterile dressing reduces the entrance of blood,
bacteria. Dressing change increases risk of changed by
4. Patients dressing will
catheter displacement and is performed VAT team.
remain clean, dry and
intact during only if dressing is compromised. Moisture is
hospitalization. a medium of bacterial growth and renders
the dressing contaminated. Loose dressing 5. Met
5. VAT (vascular access
increases risk for bacterial contamination or
team) change dressing
venipuncture site. (P&P p.934)
using sterile procedure.
5. Contaminated hands of healthcare workers
5. Patients dressing will be are a primary source of infection
changed Q7 days and transmission in health care settings. Sterile
PRN if soiled, per policy. technique reduces the number of organisms
present. Sterile procedure also prevents
transfer of potentially harmful organisms.
(P&P p.410)