___College of Nursing____ Name of Patient: Perla Lopez Ferrer Chief Complaint: Abdominal pain Age: 68 y/o Sex: Female

Diagnosis/Impression: Ward/Area: ICU__ Hospital: _Luzon Medical Center__ December 07, 2011_

______________Date of Admission:

NURSIN CARE PLAN

ASSESMENT OBJECTIVE: (+)presence of wound V/S taken as follows: BP-120/70mmHg T-36.7C P-85bpm R-23cpm NURSING DIAGNOSIS Risk for infection related to increased environmental exposure to pathogens secondary to invasive procedure PLANNING After 8 hours of nursing interventions, the patient will achieve timely healing and free from further infection NURSING INTERVENTION INDEPENDENT: Provide isolation and monitor visitors as indicated. RATIONALE EVALUATION

Body substance isolation (BSI) should be used for all infectious patients. Reverse isolation/restriction on of visitors may be needed to protect the Immunosuppressed patient.

Wash hands before or after each care activity, even gloves are used. Limit use of invasive devices or procedure as possible.

After 8 hours of nursing interventions, the patient was able to achieve timely healing Reduces risk of cross contamination and free from because gloves may have noticeable defects, Further infection. get torn or damaged during use. Prevents spread of infection via airborne droplets.

Inspect wounds or site of invasive devices, May provide clue to portal entry, type of paying particular attention to parenteral lines. primary infecting organisms, as well as early identification secondary infection. Maintain sterile technique when changing dressings, suctioning or providing site care. Provide tepid sponge bath and avoid use of Prevents introduction of bacteria, reducing risk of nosocomial infection.

alcohol.

Used to reduce fever.

Observe for chills and profuse diaphoresis. Chills often precede temperature spikes in presence of generalized infection. Monitor for signs of deterioration of condition or failure to improve in therapy.

May reflect inappropriate antibiotic therapy or overgrowth of Secondary infections.

DEPENDENT: Administer antibiotics as prescribed. To prevent further spread of infection. COLLABORATIVE: Demonstrate to patients significant others the proper way of dressing changes and educate them about the her says to know the facts not the myths. Decreases further infection for the patient and prevent unnecessary self-medicating.