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Risk for Infection

Risk for Infection

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Published by Joevet T. Tadlas

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Published by: Joevet T. Tadlas on May 10, 2010
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01/04/2013

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Nursing Diagnosis: Infection, risk for further spread r/t presence of microorganism in the body and inadequate
primary and secondary
Cause analysis: A break in the body\u2019s primary or secondary defenses predisposes a pt to infection. When the body\u2019s immune
system becomes weak or is inadequate, pathogenic microorganisms cause infection (MSN by Neal, P. 135)
CUES
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION
Subjective

Pt verbalized,
\u201cnaghawuy akong
lawas ug kapoy
akong pamati.\u201d

Objective

\u2666Emaciated
\u2666Poor skin turgor
\u2666Fatigue
\u2666Muscle strength

4
\u2666Dirty nails and
toe nails
\u2666Body temp 39\u00baC
\u2666(7-18-2007)
STO

Within the shift, pt
will be able to
enumerate at least
2 ways of
preventing infection
such as proper
hand washing and
adequate nutrition.

LTO

Within 3 days of
duty, pt will not
manifest signs and
symptoms of
infection such as
elevated body
temperature and
other s/sx of
infection.

Assessment:

Asses and monitor
presence/absence/change
s in assessment findings
outlined above.

Independent:

Stressed the importance
of proper hand washing
techniques.

Maintained adequate
hydration, encouraged to
void, catheterize if
necessary.

Provided regular perineal
care.

Emphasized necessity of
taking antibiotics as
directed.

Provided personal
hygiene. Keep skin dry.
Regulate intake of fluids to
1L/day as ordered.
Provide oral hygiene as
needed.
In order to detect any change
in status.

A first-line defense against
nosocomial infections/ cross
contamination.

To avoid bladder distention.
Reduces risk for ascending
UTI.
To prevent discontinuation of
treatment.
To avoid skin breakdown and
prevent skin infection.
To promote urine flow.

To help minimize the risk of
oral contamination and
colonization to keep tissues
healthy and intact.

STE

The pt was able to
perform ways on
how to prevent
infection such as
proper hand
washing and by
having adequate
nutrition.
During the end of
shift, pt was febrile
with body temp of
39\u00baC.

LTE
Objective unmet, pt
died on the 3rd day.

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