Assessment: Subjective Cues: Objective cues:

NURSING DIAGNOSIS Risk for infection related to open wound.

Planning Short term: After 8 hours of nursing intervention the patient is less risk for infection. Long term: After 3 days the patient is able to do own wound care, knows more when it comes to preventive measures to infection and manifesting good/better wound healing.

Nursing Intervention Perform daily wound care. Note risk factors of occurrenc e of infection Observe for localized signs of infection at wounds Give daily meds.

Rationale To clean the wound and to avoid infection. To evaluate the presence of infection. To evaluate the presence of infection

Evaluation After 8 hours of nursing intervention the client is less at risk for infection and more knowledgeable in wound care and more aware when it comes to infection.

To improve condition and wound healing. For the patient to be able to continue wound care at home.

Let the client/ clients friends or relative to observe and participate in doing wound care. Brief the client more about how to prevent further infection. (E.g. good hygiene, clean environme nt & etc.).

For the patient to avoid and to do certain things to avoid infection and to promote fast/good/be tter wound healing.