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NCP (Risk for Infection

)

ASSESSMENT

NURSING DIAGNOSIS

RATIONALE

DESIRED OUTCOME

NURSING INTERVENTION

JUSTIFICATION

EVALUATION

Abnormal Cues:  Abrasions on upper and lower extremities noted  Laceration on face  WBC increased with result of 17.1 10^9/L Risk Factors:  Trauma  Poor environmental sanitation Strengths:  Strong familial support

Risk for infection related to inadequate primary defenses (broken skin, traumatized tissue); trauma; tissue destruction Definition: At increased risk of being invaded by pathogenic organisms

Vehicular accident

Trauma on skin

After 16 hours of nursing intervention the client will be able to: 1. Verbalize understanding of individual/ causative risk factor

Independent: 1. Observe for localized signs of infection in wounds To assess the contributing or causative factors since impaired skin provides an entrance for microorganisms. Asepsis reduces or eliminates pathogens

After 16 hours of nursing intervention the client will be able to: 1. Goal met. The client verbalized “Dapat halongan ko ang akon na pilas-pilas na indi siya mahigkuan “ 2. Goal partially met. The client verbalized “ Dapat mag trapo ko sang akon pilas-pilas limpyo dapat na lampin ang gamiton. 3. Goal partially met. The client performs good skin hygiene such as hand

Broken Skin

Open Wound

Risk for Infection

2. Identify interventions to reduce infection

2. Maintain sterile technique for invasive procedures (e.g IV, urinary catheter)

Source:

Source: www.scribd.com

3. Demonstrate techniques, lifestyle changes to promote safe

3. Encourage early For mobilization of ambulation, deep respiratory breathing, secretions coughing, position changes

Administer medication regimen as indicated To reduce or correct existing factors Hand washing is a primary means of preventing transfer or organisms washing and the patient’s wife makes it a point to have his linen changed. Use standard precautions and good hand washing technique at all times Collaborative: 1.environment 4. .