CUES RISK FACTORS: Non-modifiable: 1. Age (51 years old) Modifiable: 1.

immunosuppression and inadequate secondary defences - Leukocyt e count = 2.70 (normal 4.5x109/ L) - Granuloc yte count = 2.70 (normal 0.5000.750) - Lymphoc ytes=0.47 (normal range: 0.2000.350) Monocyt es=0.09 (normal range:0.0 20-0.060)

NSG DIAGNOSIS

RATIONALE

OBJECTIVES/ GOALS

NSG. INTERVENTIONS

RATIONALE

EVALUATION GOALS PARTIALLY MET

Risk for infection

Even though an infectious disease is said to be After 2 days of nursing INDEPENDENT cause by an etiologic (causal) interventions the client will agent, infection results from be able to: 1. Assess vital signs. interactions among a variety of 1. Demonstrate (BP changes, factors related to agent, host and reduction of Temperature environment. Susceptibility to modifiable risk elevated, infection is influence by an factors for infection respiratory rate anatomic and physiological such as increase and pulse defenses sometimes called lines environment, rate increase). of defenses. The hosts first-line malnutrition, of defenses are external and up knowledge, 2. Assess for local or to bar invasion by pathogens. immunosupression systemic signs of The second line of defense (the and skin conditions. infection (e.g, inflammatory process) and the fever, chills, third line (the immune response) malaise, swelling share several physiologic 2. Identify and and pain) components. These include the demonstrate lymphatic system, techniques/lifestyle 3. Instruct patient to leukocytes(WBCs), and a changes to promote report signs and multitude of proteins and safe environment symptoms of enzymes. and prevent infection infection(e.g, wash immediately (e.g. Reference: hands before and fever, chills and after eating and pain). th Medical Surgical Nursing 8 when in contact Edition Vol.1. Black and with infected Hokanson-Hawks p 326 persons, perineal 4. Assisted patient to care, mouth care, perform proper proper cooking of handwashing, and food, boiling water) discussed its importance.

1. Provides baseline data. Elevated temperature may indicate infection. 2. Early assessment facilitates effective treatment. Early assessment prevents further complications facilitates prompt treatment Meticulous hand washing is a priority in both the hospital and the outpatient or home setting to prevent transmission of pathogens.

After 2 days of nursing interventions, the client: Demonstrated slight reduction of modifiable risk factors for infection as evidence by: -increased in: a. leukocytes (2.90 X 109/L) b. Granulocytes (0.51 X 109/L) c. Lymphocytes (0.47) d. Monocytes (0.07); -slight increased in weight= 53.2 kg; -he identified and demonstrated lifestyle techniques to prevent infection such as participating in handwashing, doing perineal and mouth care, consuming nutritious and adequately cooked food. -he verbalized Tikang yana hihimuon ko ha akon makakaya na sundon an imo mga ginyakan para maibanan an

3.

4.

- Low hgb

5. Provide / instruct cleaning the environment (home

5. The environment is a source of