N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide 6.7 The Nursing Process and Biological Safety Assessment During the assessment phase of the nursing process, the nurse will inspect the patient for signs of infection or injury. • If the assessment is being done in the patient's home environment, the nurse will assess the environment to detect potential hazards within the context of the patient's abilities. • The patient's immunization status should be assessed to determine possible risks. • The patient's general hygiene practices and ability to maintain hygiene will be assessed. The nurse should also note the patient's basic hygiene during this visit (e.g., does the patient appear clean and well-kept, or is there a discernible body odor). • The patient's or caregiver's attitudes toward infection prevention strategies must be assessed. • During the exam, signs of localized infections (redness, swelling, draining, pain, or loss of movement) will be noted. • Signs of systemic infection (fever, nausea, vomiting, increased pulse, enlarged nodes, increased respiratory rate, and generalized malaise) will be noted. • Skin condition must be assessed, especially the back of the head, the back, buttocks, and heels for a non-ambulatory patient. Skin breakdown may begin in these areas. Any areas of redness or breakdown must be reported. • Range of motion (ROM) of all joints should be assessed as limitations may be indicative of infection. • Laboratory data that might be included in the assessment for infection include: o White blood cell count (WBC) may increase or decrease with infection o Erythrocyte sedimentation rate (ESR) may be elevated with infection o A pH higher than normal (alkalosis) of urine, gastric contents, or vaginal secretions may indicate the presence of pathogens o Positive cultures of wounds or body fluid (blood, urine, or sputum) indicate an infection is present. In the case of a positive culture, the lab will also run a sensitivity test that will determine what specific microorganism is causing the infection and what antibiotics will be effective against the pathogen Analysis and Diagnosis As the nurse conducts the assessment, the analysis of the data begins. During the analysis process, the nurse, patient, and other healthcare team members will collaborate to prioritize patient needs to develop nursing diagnoses. When establishing nursing diagnoses around biological safety and infection, the nurse should consider the following possible diagnoses: • Contamination, risk for • Health behavior, risk prone • Infection, risk for • Injury, risk for • Knowledge deficit • Mobility, impaired

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