Page 929 - Saunders Comprehensive Review For NCLEX-RN

From Perry S, Hockenberry M, Lowdermilk D, Wilson D: Maternal-child nursing care,
ed 4, St. Louis, 2010, Mosby.

Box 31-2
Protecting the Child from Infection

▪ Initiate protective isolation procedures.
▪ Maintain frequent and thorough hand washing.
▪ Maintain the child in a private room with high-efficiency particulate air filtration
or laminar air flow system if possible.
▪ Ensure that the child’s room is cleaned daily.
▪ Use strict aseptic technique for all nursing procedures.
▪ Limit the number of caregivers entering the child’s room, and ensure that
anyone entering the child’s room wears a mask.
▪ Keep supplies for the child separate from supplies for other children.
▪ Reduce exposure to environmental organisms by eliminating raw fruits and
vegetables from the diet, by not allowing fresh flowers in the child’s room, and
by not leaving standing water in the child’s room.
▪ Assist the child with daily bathing, using antimicrobial soap.
▪ Assist the child to perform oral hygiene frequently.
▪ Assess for signs and symptoms of infection.
▪ Monitor temperature, pulse, and blood pressure.
▪ Change wound dressings daily, and inspect wounds for redness, swelling, or
drainage.
▪ Assess urine for color and cloudiness.
▪ Assess the skin and oral mucous membranes for signs of infection.
▪ Auscultate lung sounds.

▪ Encourage the child to cough and deep-breathe.
▪ Monitor white blood cell and neutrophil counts.
▪ Notify the primary health care provider if signs of infection are present, and
prepare to obtain specimens for culture of open lesions, urine, and sputum.
▪ Initiate a bowel program to prevent constipation and rectal trauma.
▪ Avoid invasive procedures such as injections, rectal temperatures, and urinary
catheterization.
▪ Administer antibiotic, antifungal, and antiviral medications as prescribed.
▪ Administer granulocyte colony-stimulating factor as prescribed.
▪ Instruct parents to keep the child away from crowds and individuals with
infections.
▪ Instruct parents that the child should not receive immunization with a live virus
(measles, mumps, rubella, polio), because if the immune system is depressed,
the attenuated virus can result in a life-threatening infection; also, the child

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