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RISK Time

Cues

Need

FOR

Nursing Diagnosis

Objective of Care Within 8 hours span of care my patient will be able to be free from infection as manifested by: a.) Vital signs maintained within normal range T=35.6c36.7c CR=7080pbm PR=7080bpm RR=1624cpm BP=110/70130/90 b.) Verbalize understandi ng about prevention of infection. c.) Identify interventions to prevent/redu ce risk of infection.

Nursing Intervention 1. Assess causative or contributing factors such as underlying illness. Client may have disease that directly impacts immune system (e.g., cancer, AIDS, autoimmune disorder) or may be weakened by any disease Condition.

Evaluation

O: August Leukocytes: 19, 2.9 10^9L 2010 (Low) @ 3:00 p.m.

H E A L T Neutrophils: H 0.53 (low) P E Lymphocytes: R 0.38 (High) C E Monocytes: P 0.07 (High) T I Hematocrit: O 0.13 (Low) N Vital Signs: H T-35.7 E Cr- 65bpm A Pr-72bpm L Rr-22cpm T Bp-120/60 H M A N A G E M E N T P A T T E R

Risk for infection related to decrease WBC count secondary to anemia. decreased WBC places individuals at risk for infection . they protect against foreign materials and infections. They are divided into two categories s uch as granulocytes and agranulocytes. The granulocytes include neutrophils, eosinophils and basophils. Lymphocytes and monocytes are the agranulocytes. The normal count of WBC is 400010000mm3. These cells offer

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August 19, 2010 @ 11 PM GOAL MET At the end of my 8 hours span of care my patient was able to be free from infection as manifested by: a.) Temperature is within the normal range(36.3) b.) Dapat na diay ko mag bantay, 2. Assess presence or kay kabalo na absence of immunity. ko naa nay Natural immunity problema may be acquired as a akoang lawas result of development sa pag protekta of antibodies to a sa akoang specific agent following lawas tungod sa infection, preventing akoang sakit. recurrence of specific As verbalized Disease. by patient. c.) Patient wash his 3. Note onset of fever, hand before chills, diaphoresis, and and after eating. altered level of And change his consciousness. clothes Signs and everyday for symptoms of sepsis proper hygiene (systemic infection), requiring intensive medical treatment and acquisition of appropriate tissue/fluid specimens for observation and culture and sensitivities 4.Maintain fluid and