A client with a venous ulcer, which has not responded to intravenous vancomycin treatment and is discharging pus, has been admitted with a potential infection of Vancomycin-Resistant Enterococci (VRE). Which nursing interventions should be included in the care plan? Select all that apply.
A.
Monitor the client’s white blood cell count.
B.
Implement contact precautions for staff and visitors.
C.
Use standard precautions and wear a mask.
D.
Explain the purpose of a low bacteria diet.
E.
Send wound drainage for culture and sensitivity.
The Correct answer and Explanation is:
For a client with a venous ulcer potentially infected with Vancomycin-Resistant Enterococci (VRE), the appropriate nursing interventions from the options provided would be:
A. Monitor the client’s white blood cell count.
B. Implement contact precautions for staff and visitors.
E. Send wound drainage for culture and sensitivity.
Explanation
A. Monitor the client’s white blood cell count.
Monitoring the white blood cell (WBC) count is essential in assessing the client’s immune response and detecting signs of infection. An elevated WBC count can indicate the presence of an infection, which is particularly crucial in a patient suspected of having a VRE infection, as it helps in determining the severity of the infection and guiding treatment decisions.
B. Implement contact precautions for staff and visitors.
Given that the client has a potential VRE infection, it is critical to implement contact precautions to prevent the spread of this multidrug-resistant organism. Contact precautions involve using gloves and gowns when entering the client’s room and ensuring that any equipment used for the client is either disposable or properly disinfected before being used for other patients. This intervention helps protect both the healthcare team and other patients from potential cross-contamination.
C. Use standard precautions and wear a mask.
While standard precautions are essential in all healthcare settings, wearing a mask is not specifically required for VRE unless there is a risk of respiratory droplet transmission, which is not typically the case with VRE infections. Therefore, this option is not necessary.
D. Explain the purpose of a low bacteria diet.
A low bacteria diet is typically recommended for immunocompromised patients to minimize the risk of infections from food sources; however, it is not specifically indicated in the context of managing a VRE infection.
E. Send wound drainage for culture and sensitivity.
Obtaining a culture and sensitivity test from the wound drainage is crucial for identifying the specific organism and determining the most effective antibiotic treatment. This step is vital, especially since the current treatment with vancomycin has not been effective.
In summary, the selected interventions focus on monitoring the infection, implementing necessary precautions to prevent its spread, and obtaining relevant microbiological data to guide further treatment.