NURSING CARE PLAN

Assessment Analysis
Subjective: Nanghihinatal agaakokadala san as verbalized by the client. Mahiluhinnga din ako e as verbalized by the client, Objective: Pale skin Fatigue Increased respiratory rate RR: 28 Laboratory results: Hemoglobin: 81 Hematocrit: 0.25 WBC: 23.1 x10 g/l Sepsis is a clinical term used to describe symptomatic bacteremia, with or without organ dysfunction. Sustained bacteremia, in contrast to transient bacteremia, may result in a sustained febrile response that may be associated with organ dysfunction. Septicemia refers to the active multiplication of bacteria in the bloodstream that

Diagnosis
Risk for infection related to compromised immune.

Planning
Goal: After 8 hours of nursing intervention the infection must be eliminated or controlled. Objectives: After 1 hour of nursing intervention the client will able to: y Understand the risk of infection Determine the techniques to reduce the risk of infection

Intervention
Independent: Provide isolation or monitor visitors as indicated.

Rationale

Evaluation
Infection was eliminated or controlled. Client able to understand risk of infection. Client able to determine the techniques to reduce the risk of infection.

Body substance isolation (BSI) should be used for all infectious patients. Wound/linen isolation and hand washing may be all that is required for draining wounds. Patients with diseases transmitted through air may also need airborne and droplet precautions. Reverse isolation/restriction of visitors may be needed to protect the immunosuppressed patient. Reduces risk of crosscontamination because gloves may have unnoticeable defects, get torn or damaged during use. Good pulmonary toilet may reduce respiratorycompromis

Wash hands with antimicrobial soap/ after each care activity, even if gloves are used.

Encourage/provide frequent position changes, deep-

Salud, Rausan J. BSN216/ Group 64

Ms. Liza Villacorte Clinical Insrtuctor

NURSING CARE PLAN

results in an overwhelming infection. breathing/coughing exercises. Encourage patient to cover mouth and nose with tissue during coughs/sneezes. Wear mask when providing direct care as appropriate. Dispose of soiled dressings/materials in double bag. e. Prevents spread of infection via airborne droplets.

Reduces contamination/soilage of area; limits spread of airborne organisms. To increase awareness and to minimize spread of infection.

Instruct the client in techniques in prevention of spread of infection.

Collaborative: Obtain specimens of urine, blood, sputum, wound, invasive lines/tubes as indicated for Gram stain, culture, and sensitivity. Monitor laboratory studies, e.g., WBC count with Salud, Rausan J. BSN216/ Group 64

Identification of portal of entry and organism causing the septicemia is crucial to effective treatment.

The normal ratio of neutrophils to total WBCs is at least Ms. Liza Villacorte Clinical Insrtuctor

NURSING CARE PLAN

neutrophil and band counts. 50%; however, when WBC count is markedly decreased, calculating the absolute neutrophil count is more pertinent to evaluating immune status.

Reference: http://www.scribd.com/d oc/ 9658938/ Sepsis-Septicemia

Salud, Rausan J. BSN216/ Group 64

Ms. Liza Villacorte Clinical Insrtuctor