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NURSING CARE PLAN

Nursing Diagnosis/Focus: Risk for infection related to increased environmental exposure invasive procedure
Scientific Analysis: Wounds involving injury to soft tissue can vary from minor tears to severe crushing injuries. The decision to suture a
wound depends on the nature of the wound time since the injury was sustained the degree of contamination.
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
08/30/17 Short Term Goal Independent 8/30/17
2:00 PM 2:30 PM
After 30 minutes to one 1. Assessed patients vital 1. For baseline data. Also, Short Term Goal:
Subjective Cues hour of Nursing signs. changes in vital signs indicate Goal Met.
wa paman ni nailisan Intervention, patient presence of discomfort. - Okay naman
akong dressing, nya murag must have: Maam.tawha
puno na nga baho Identified 2. Demonstrate and 2. Hand washing is the first-line y na akong
gamay., as verbalized behaviors and emphasize importance of of defense against infection and pagbati
practices to proper hand-washing cross-contamination. Maam., as
Objective Cues prevent and techniques by client and verbalized.
- T = 37.2 oC reduce the risk of caregivers. - Verbalized
- One day post-op infection 3. Frequent assessment of understandin
- Slightly weak in 3. Inspect all incisions and incisions and puncture sites g and
appearances puncture sites. Evaluate promotes early identification of demonstrated
- Slightly soaked After 3 days of Nursing healing progress onset of infection and prompt on how to
abdominal Intervention (09/02/17), intervention. prevent
dressing patient must have: further
- WBC: Achieved timely infections.
16.49 10^3/L wound healing 4. Provide meticulous care 4. Minimizes potential for - Wound
(normal range: Free from signs of of invasive lines, incisions, bacteria to reduce exposure and dressing
4.8-10.8 infection, and wounds. Remove risk of infection. changed.
10^3/L) inflammation, and invasive devices as soon as
purulent drainage possible. Long Term Goal:
5. Mobilizes respiratory - Goal partially
5. Encourage deep secretions and reduces risk of met.
breathing and coughing respiratory problems. Evaluation
exercises. date on
6. Meticulous oral hygiene 09/02/17.
reduces the risk for opportunistic
infections
NURSING CARE PLAN
Nursing Diagnosis/Focus: Risk for infection related to increased environmental exposure invasive procedure
Scientific Analysis: Wounds involving injury to soft tissue can vary from minor tears to severe crushing injuries. The decision to suture a
wound depends on the nature of the wound time since the injury was sustained the degree of contamination.
6. Provide or assist with in clients who are on antibiotic
frequent oral hygiene. therapy or who are
immunocompromised.

7. Temperature elevation and


tachycardia may reflect
7. encourafe frequent developing sepsis.
position changes amd being
out of bed or early
ambulation, as tolerated. 8. Elevated WBC count signals
inflammation or infection.
8. Monitor laboratory tests, However, reduced WBC levels
such as WBC count and may result from severe
blood glucose. immunosuppression and viral
infection. Note: Use of some
medications such as
corticosteroids increases risk of
insulin resistance. Tight glucose
control is required to reduce risk
of deep wound infections during
the postoperative period.

9. Antibiotics may be used to


9. Administer antibiotics, as treat infections; however, they
prescribed. must
be closely monitored for side
effects and drug interaction
with cyclosporine and other
immunosuppressants
NURSING CARE PLAN
Nursing Diagnosis/Focus: Risk for infection related to increased environmental exposure invasive procedure
Scientific Analysis: Wounds involving injury to soft tissue can vary from minor tears to severe crushing injuries. The decision to suture a
wound depends on the nature of the wound time since the injury was sustained the degree of contamination.