Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more ➡
Download
Standard view
Full view
of .
Add note
Save to My Library
Sync to mobile
Look up keyword
Like this
6Activity
×
0 of .
Results for:
No results containing your search query
P. 1
NCP - Risk for Infection

NCP - Risk for Infection

Ratings: (0)|Views: 1,143|Likes:
Published by linnaroueyak

More info:

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

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, DOC, TXT or read online from Scribd
See More
See less

01/09/2014

pdf

text

original

 
NURSING CARE PLANPROBLEMEXPLANATION OFTHE PROBLEMOBJECTIVENURSINGINTERVENTIONRATIONALEEVALUATION
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
2.
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
2.
determinepatient’s abilityto performindependentinterventionstogether with hersignificant others
3.
determining theblood supply forproperoxygenation of the tissues whichwould aide in theprogress ohealing of theaffected tissue
Criteria
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
Result
 
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
5.
verbalizefeelings ounderstanding,recovery andcomfort
4.
assesschanges owound site fordepth, width,color, smell,location,temperature,texture, anddischarges
5.
obtain specifictissue or fluidspecimen fromthe woundTx :
1.
clean thewound every shiftor as requiredusing povidoneiodine
4.
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
4.
promotesfaster woundhealing andprovide thepatient adequatesource of energyfor recovery
5.
promote bettercirculation atbody parts andpreventexcessive tissuepressure thuspromoting fasterwound healingand recovery

You're Reading a Free Preview

Download
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->