Sharwen Romero 2011 BSN215 Group60B

FEU-NRMF CCU JESUS CASPILLO ARI RIGHT CORONA RADIATA CUES OBJECTIVE: Presence of wound in the lips Increase WBC Temperature of 39.1 degree Celsius Respiratory rate of 36 cpm Blood pressure of 150/80 mmHg NURSING DIAGNOSIS Risk for infection related to inadequate primary defenses ANALYS IS NURSING CARE PLAN GOALS AND NURSING OBJECTIVES INTERVENTION GOAL: RATIONALE

September 20, C.I. Edsel Cortez

EVALUATIO N Patients WBC are within the normal range. All areas are without signs of infection. The patients vital sig are within normal range.

After 8 hour of nursing intervention, the patients risk for being invaded by pathogenic organisms will be decreased.

Monitor white blood count (WBC).

Normal WBC is 4-11 mm3. Rising WBC indicates the bodys attempt to combat pathogens. Redness, swelling, increased pain, or purulent drainage is suspicious of infection and should be cultured.

OBJECTIVES: After a 4 hour nursing intervention the client will have normal vital signs. After 4 hour nursing intervention, the client will achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile

Monitor incisions, injured sites and exit sites of tubes, drains and catheters for signs of infection. Maintain strict aseptic technique with all dressing changes; tubes, drains and catheter care; and venous access devices. Administer and teach the use of antimicrobial drugs as ordered.

Strict asepsis is necessary to prevent crosscontamination and nosocomial infections.

All agents are either toxic to the pathogens or retard the pathogens growth. Ideally medications should be selected based on a culture from the infected area. A broad-spectrum agent may be started until culture reports are

available.