Nursing diagnosis: high risk for infection related to inadequate secondary defenses by immunosuppresion resulting from decreased immunoglobulins.
Expected outcomes: Absence of infection evidenced by temperature, white blood cell, urinalysis, cultures within normal ranges, breath sounds, urinary pattern, mucous membranes within baseline levels.
Nursing intervention and rationale:
I. Assess for:
- Temperature elevation above 101 degrees Celsius, chills, increased pulse above 100. Low grade temperature common following splenectomy for 7-10 days.
- Tachypnea, ronchi, crackles, cloudy foul smelling urine, urgency frequency, irritation ulcers of oral, vaginal or other mucosa; redness or drainage from wound or invasive sites. Indicates pneumococcal infection or overwhelming infection as phagocytic ability of spleen to destroy encapsulated organisms is lost.
- Hypotension, shock-like state. Indicates potential for meningeal infection.
- White blood cells increases, urine, blood and wound cultures and sensitivities. WBC of > 10,000 cu/mm positive cultures for infectious organisms.
- Immunoglobulins. IgM decreases, IgG ad IgA within normal ranges indicating deficiencies.
- Vital signs and temperature every four hours. Indicates presence of infection.
- Antibiotics specific to identified infectious agent. Acts to destroy microorganisms by inhibiting cell wall synthesis.
- Antipyretic (acetaminophen). Reduces fever by inhibiting heat-regulating center.
- Handwash techniques before giving care. Prevents cross-contamination.
- Aseptic technique for any invasive procedures. Prevents introduction of infectious agents.
- Adequate fluids, nutritional and activity support. Maintains support to prevent susceptibility to infection.
- Meticulous mouth and perineal care. Promotes comfort and care of suceptible mucosal areas