Nursing Care Plan


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Medical Diagnoses: Risk for Infection

   

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

 

Nurse noted in shift change report about the pt’s pressure ulcer.

 

 

 

 

Objective

   

Documented pressure ulcer of 2X3 inches, 1 inch in depth, with clear, non-odorous drainage

 

   

Problem

   

Risk for infection

   

   

 

  

Long Term:

 

Pt will demonstrate appropriate hygienic measures such as hand washing, oral care, and perineal care by discharge.

 

   

*Teach the importance of appropriate hand hygiene

   

Rationale: “Meticulous infection control precautions are required to prevent infection, with particular attention to hand hygiene” (Ackley & Ladwig, 2008, p. 496).

 

   

   

   

   

   

ü     

 

 

 

 

 

   

   

R/T

 

Stage II pressure ulcer on coccyx

 

 

 

 

 

Short Term:

 

Pt will remain free from symptoms of infection throughout this shift, by 1900.

 

*Observe and report any signs of infection such as redness, warmth, and discharge.

 

Rationale: “Prospective surveillance study for nosocomial infection on hematology” (Ackley & Ladwig, 2008, p. 495).

 

*Use careful sterile technique when there is a loss of skin integrity.

 

Rationale: “Extensive literature search revealed that sterile gloves should be used for postoperative wound dressing changes” (Ackley & Ladwig, 2008, p. 497).

 

 

 

 

 

 

 

 

 

AEB

 

N/A

 

 

 

 

 

 

 

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*I = Implementation.  Check those interventions/actions/orders that were implemented.

 

 

References

 

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.



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