Client stated, “I am really tired lately and keep having
these pains come and go.”
Problem: Ineffective protection
Client will remain free of infection during the duration
of this hospital visit.
-Observe and report signs
of infection such as warmth, redness, discharge and increased body temperature. Surveillance for nosocomial infection
should include fever of unknown origin as the single most common and clinically
important finding for detecting infection
-Use strategies to prevent infection
transmission including washing hands before and after client contact and wearing
gloves during any contact with body fluids, and changing gloves in between contacts
of various systems (i.e. GU, oral mucosa, etc.).
Meticulous infection control precautions are required to prevent the transmission
of infectious organisms (Gould, 2004).
Evaluation of this goal is set for 22:00,[Month] 10, 2009.
Client was free of signs/symptoms of infectious processes throughout the
shift, some progress made.
-Observed client for signs and symptoms of infection including fever, warmth, redness,
and discharge. -Washed hands before
and after all client contact. Wore
gloves during all care that had potential for contact with body fluids and changed
them in between contact with body systems where body fluid could be transferred
to minimize risk of infection.
Client showed no signs of infection.
Some progress towards goal made. Continue
Evaluation of this goal set for [Month] 10, 2009 at 22:00.
related to a bleeding disorder , inadequate nutrition, extremes in age, impairment
of primary defenses and medical interventions
Client will state symptoms
of infection (fever, redness and/or warmth at IV site, burning around Foley catheter
site, warmth and/or redness or irritation at the colostomy site) of which to be
aware and monitor for by 13:00 on [Month] 3, 2009.
-Assess client’s current level of knowledge r/t infection
-Seek teachable moments to encourage health promotion. The provision of information should not
be restricted to just treatment information but also any information that prepares
the client to manage health-related issues (Timmons, et. al 2006)
-Teach client the signs and symptoms of infection both
generalized and local by invasive site (i.e. fever being generalized and localized
redness and irritation at the IV site).
Education programs based on empowerment, client participation, and adult learning
principles have demonstrated effectiveness (Kennedy, et. al, 2003).
Client stated the symptoms
of infection to monitor for at 11:15 on [Month]
10, 2009. Goal achieved.
At 11:00 on [Month] 3, 2009
assessed client’s current level of knowledge related to signs and symptoms of infection
of which she stated, “fevers, throwing up and not feeling good.”
Sought teachable moments to
encourage health promotion, provided education on nutrition and easy meals to freeze
and make at home.
Taught client the generalized
and localized signs and symptoms of infection to monitor for both within the hospital
and at home.