What did the nursing orders for a patient with a bacterial infection likely include?

Nursing Orders for Bacterial Infection Management

Nursing orders for a patient with bacterial infection should include immediate vital sign monitoring (within 30 minutes of fever recognition), focused clinical assessment, specimen collection for culture before antibiotic administration, and implementation of infection control measures including isolation precautions and prevention of secondary complications. 1

Immediate Assessment and Monitoring

• Obtain complete vital signs within 30 minutes of recognizing fever or suspected infection, including temperature, pulse, blood pressure, and respiratory rate (respiratory rate >25 breaths/min has 90% sensitivity for pneumonia). 1
• Monitor temperature using oral method (single reading ≥100°F or repeated readings ≥99°F) or rectal method (≥99.5°F), or document temperature increase ≥2°F above baseline. 2
• Assess for hemodynamic instability through blood pressure and pulse monitoring to identify early sepsis. 1
• Document mental status changes, as altered consciousness, new confusion, decreased mobility, and reduced food intake are key infection indicators in elderly patients. 2, 1

Focused Clinical Examination Orders

• Perform respiratory assessment including auscultation and observation for increased work of breathing, as pneumonia accounts for 15-25% of stroke-associated deaths and is the most common serious infection. 2, 1
• Examine all indwelling devices (urinary catheters, IV lines, feeding tubes) as catheters confer a 39-fold increased risk of bacteremia. 1
• Inspect skin including sacral, perineal, and perirectal areas for breakdown, erythema, or purulence. 1
• Assess oropharynx and conjunctiva for signs of localized infection. 1
• Evaluate hydration status through skin turgor, mucous membranes, and urine output. 1

Specimen Collection and Laboratory Orders

• Obtain site-specific cultures before initiating antibiotics: blood cultures for fever without clear source, urine culture for UTI symptoms, sputum/respiratory cultures if obtainable for suspected pneumonia. 1
• Order complete blood count with manual differential to evaluate band forms (elevated band count >1,500/mm³ has highest likelihood ratio for bacterial infection). 1
• Obtain chest radiograph when pneumonia is suspected or fever lacks a clear source. 1
• Collect specimens using proper technique: swab sloughy areas for wound cultures, midstream clean-catch or catheter specimen for urine. 3

Infection Control and Isolation Measures

• Implement barrier nursing techniques immediately to reduce nosocomial transmission, including gown and glove use for all patient contact. 3
• Position patient in semi-recumbent position (head of bed elevated) to prevent aspiration pneumonia. 2
• Maintain strict hand hygiene protocols before and after all patient contact. 2
• Cohort infected patients when possible, physically separating them from non-infected residents. 2
• Ensure proper use of personal protective equipment (PPE) including masks, gowns, gloves, and eye protection as indicated. 2

Airway and Respiratory Management

• Position airway appropriately and suction carefully if increased intracranial pressure is present. 2
• Provide pulmonary care including deep breathing exercises and incentive spirometry. 2
• Monitor oxygen saturation continuously and administer supplemental oxygen to maintain SpO2 >92%. 2
• Implement early mobility protocols as soon as hemodynamically stable to prevent atelectasis and pneumonia. 2

Catheter and Elimination Management

• Remove indwelling urinary catheters as soon as medically feasible, as routine use is not recommended due to infection risk (15-60% of stroke patients develop UTI). 2
• Transition to intermittent catheterization every 4-6 hours if bladder retraining needed. 2
• Use external catheters or incontinence products as alternatives to indwelling catheters. 2
• Monitor for urinary retention and assess for UTI if mental status changes occur without other explanation. 2
• Implement bowel program using stool softeners, laxatives, and enemas to prevent constipation. 2

Nutrition and Hydration Orders

• Maintain euvolemia using isotonic intravenous normal saline for hypovolemia treatment; volume expanders for hemodilution are not recommended. 2
• Initiate nasoenteric feeding within 24 hours for patients unable to safely swallow (preferred over PEG tube for first 2-3 weeks). 2
• Verify feeding tube placement by radiographic methods before initiating feeds. 2
• Provide antiemetic medications promptly for nausea/vomiting to prevent aspiration pneumonia. 2
• Monitor intake and output closely, documenting fluid balance every shift. 2

Oral Hygiene and Aspiration Prevention

• Provide oral hygiene at least 3 times daily and immediately after meals to reduce aspiration pneumonia risk. 2
• Use chlorhexidine or diluted antimicrobial solutions for oral care. 2
• Keep head of bed elevated 30-45 degrees during and for 30 minutes after feeding. 2
• Assess swallowing function before oral intake; nothing by mouth until swallow evaluation completed. 2

Venous Thromboembolism Prophylaxis

• Apply intermittent pneumatic compression devices for immobile patients to reduce VTE risk and possibly death. 2
• Administer pharmacologic anticoagulation as ordered (provides superior VTE prophylaxis in acute ischemic stroke). 2
• Do not use antiembolic stockings routinely as they are not recommended. 2
• Assess lower extremities daily for signs of DVT (warmth, swelling, tenderness). 2

Pressure Injury Prevention

• Place high-risk patients on high-specification foam mattress to prevent pressure ulcer development. 2, 3
• Reposition patient every 2 hours, documenting position changes. 2, 3
• Perform thorough skin examination focusing on sacrum, ischia, heels, and bony prominences. 3
• Measure and document any lesions in centimeters, noting size, depth, and characteristics. 3
• Assess for signs of infection in existing wounds (warmth, purulence, odor). 3

Antibiotic Administration Orders

• Administer antibiotics targeting relevant pathogens within 1 hour of sepsis recognition after cultures obtained. 2
• Use "stat" orders or include minimal time elements in antimicrobial orders to prevent delays. 2
• Establish vascular access promptly; consider intraosseous access if IV access difficult. 2
• For patients with suspected pneumonia, sepsis, or UTI, initiate antibiotics immediately after clinical examination and culture collection. 2, 1
• Monitor for antibiotic-related adverse effects including diarrhea, rash, and allergic reactions. 4

Documentation and Communication

• Document all vital signs, assessment findings, and interventions in real-time to facilitate physician communication. 2, 1
• Report fever, mental status changes, or clinical deterioration to physician immediately. 2
• Notify infection control practitioner and medical director if outbreak suspected (multiple residents with similar symptoms). 1
• Record response to interventions including temperature trends, symptom resolution, and functional status. 2

Common Pitfalls to Avoid

• Never administer antibiotics without clinical examination (17% of residents historically received antibiotics without assessment). 1
• Do not obtain surveillance cultures in asymptomatic patients, as this drives unnecessary antibiotic use. 5
• Avoid treating positive urine cultures without localizing urinary symptoms, as bacteriuria is common in catheterized patients. 5
• Do not delay antibiotic administration for diagnostic procedures in hemodynamically unstable patients. 2
• Never use prophylactic antibiotics to prevent recurrent infections, as this increases resistance without proven benefit. 5