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NCP - Risk for Infection

NCP - Risk for Infection

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Published by linnaroueyak

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Published by: linnaroueyak on Jun 20, 2011
Copyright:Attribution Non-commercial


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Status post VPshuntingIncision at right subcoastal areaS “dalawa yungsugat niya sa ulo,linagyan daw ng tubopara maalis yungtubig sa loob medyo namamaganga ata ehasverbalized bypatient’s significantothersO incision site atright subcoastal areaof head.- patient is lying onblanket from theirhouse- presence of thickterminal hair aroundincision sites- inflammation atright side of head- rubor and calloraround the woundedpart- WBC count is belowThe patient isscheduled for VPshunting due toincreased intracranialpressure anddiagnosis odestructivehydrocephalusmeasuring 2.1 x 1.7x 1.8 cm which aresecondary topituitary adenomaThe patient isscheduled for VPshunting wherein theexcess CSF isremoved to decreaseintracranial pressure.There are twoincision sites done atthe patient’s head(right subcoastalarea). Excesscerebrospinal fluid isdrained for palliativereasons.A break in the firstline of defense by thebody, the skin, wouldLTO : after 3 days of Nursing Interventionthe client will be ableto prevent the riskfor infectionSTO :After 8 hours onursing intervention,the client with thehelp of the significantothers will be ableto:1.performindependentlyproper woundcare2.take infoods/diet thatwould promotefaster woundhealing3.identifyinterventions thatcould prevent orreduce the riskfor infection4.achieve timelywound healing,free from signs of infectionDx :1.monitor vitalsigns
Assess thepatient’sknowledge aboutcondition. Inaddition, thesignificant othersknowledge sincethe patient maybe unable to dosuch because of neurologicdisturbances3.assessadequacy oblood supply andinnervations of the affectedtissueDx :1.this woulddetermine ithere has beensystemicinfectionoccurring insidethe body
determinepatient’s abilityto performindependentinterventionstogether with hersignificant others
determining theblood supply forproperoxygenation of the tissues whichwould aide in theprogress ohealing of theaffected tissue
After 3days oNursingInterventionthe client wasable to preventthe risk forinfectionThe client withthe help of thesignificantothers wasable to:
performindependently properwound care
take infoods/dietthat wouldpromotefasterwoundhealing
identifyinterventions thatcouldprevent or
normal at 4.2 G/L(ref. value 5.0-10.0 G/L)- patient is havingand IVF side drip of PLNSS 500ml +tramadol x 24 hoursA – Risk for Infectionrelated to break inthe skin integrity(right subcoastalarea of head)secondary to statuspost VP shuntpromote the entranceof microorganismswhich can causeinfection at woundsite or even sepsisthrough the body’sblood circulation if not treated properly
verbalizefeelings ounderstanding,recovery andcomfort
assesschanges owound site fordepth, width,color, smell,location,temperature,texture, anddischarges
obtain specifictissue or fluidspecimen fromthe woundTx :
clean thewound every shiftor as requiredusing povidoneiodine
Providescomparativebaseline forfutureassessment andpromote timelynursingintervention andrevision of careplan. It alsodetermines therisk or degree of infection of thewound5.determine isthere is infectionand provideinformationabout nursinginterventions tobe planned andperformedTx :1.promotesfaster woundhealing andprevent infectionat the wound site2.preventaccumulation of reduce therisk forinfection
achievetimelywoundhealing,free fromsigns oinfection
verbalize feelingsof understanding,recoveryandcomfort
2.changedressings asneeded orrequired3.maintainadequatehydration byproper regulationof IVF and givingfluids asindicated4.provide goodnutrition bygiving diet rich inprotein andcalories, andvitamins and/orminerals5.promote earlymobility byproviding positionchanges, activeor passiveexercises andassistiveexudates andproliferation of microorganismson the dressing,preventingfurther infection3.preventdehydration andprovideelectrolytes andminerals neededby the body torecover
promotesfaster woundhealing andprovide thepatient adequatesource of energyfor recovery
promote bettercirculation atbody parts andpreventexcessive tissuepressure thuspromoting fasterwound healingand recovery

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