N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide ©2017 Achieve Test Prep Page 68 of 204 Vital signs: temperature, pulse, respiration, B/P, and O2saturations o Neurological assessment and level of consciousness o Check breath sounds o Skin assessment for abscesses o Check stools for diarrhea • Assess surgical wounds for drainage and erythema • Review laboratory and radiology reports o CBC with differential o Blood cultures x3 o Wound and sputum cultures o Urine and stool cultures o Chest x-ray Nursing diagnosis for nosocomial infections: • Risk for altered body temperature, secondary to sepsis • Impaired gas exchange related to pneumonia • Risk for altered nutritional status and less than body requirements related to GI complaints • Risk for altered mental status related to infectious process • Knowledge deficit related to disease, risk of hospitalization, treatment, and prevention Nursing interventions for nosocomial infections: • Monitor vital signs, level of consciousness, and healing of wounds closely • Give medications as ordered by MD; antipyretics, analgesics, antibiotics, antiemetic medications, and antidiarrheal medications • Encourage increased fluids • Give IV fluids as ordered by MD • Check 02 saturations • Give oxygen as ordered by MD if necessary • If patient has septic shock, give IV fluids, vasopressors, and monitor cardiac status in ICU • Daily weights • Encourage calorie dense foods • Patient and family teaching on strict hygiene standards while hospitalized; encourage visitors with illness to stay home; encourage visitors to use hand sanitizer Nursing assessment for nosocomial infections: • Head to toe general assessment o