Juco Fernandez, NR-41 (GROUP 2)

Nursing Diagnosis: Risk for Infection

Inference: Pancreas ->
if untreated.
ASSESSMENT
Subj. Cues:
Matagal
gumaling yung
sugat ko as
verbalized by the
patient.
Obj. Cues:
Flushed
Appearanc
e
Wound
Drainage
V/S:
T: 37.4
P:87
R:21
BP:13/90

Insulin -> Body tissue becomes resistant ->

Expected
Outcome
After 8 hours
of nursing
interventions
the patient will
identify
interventions
to prevent or
reduce risk of
infection

Intervention
Independent:
Observe for signs of
infection and
inflammation

Dependent:
Promote good hand
washing by nurse
and patient
Maintain aseptic
technique for IV
insertion procedure,
administration of
meds and providing
maintenance site
care.

blood glucose -> Number of complications

Rationale

Patient may be
admitted w/
infection, which
could have
precipitated the
ketoacidosis state or
may develop a
nosocomial
infection.

Reduces the risk of

cross contamination.

High glucose in the

blood creates an
excellent medium
for bacterial growth.

Facilitates lung
expansion and

Place semi-fowlers
position

Collaborative:

Evaluation
After 8 hours of
nursing interventions,
the patient was able to
identify interventions
to prevent or reduce
risk of infection.

Obtain specimen for

culture and
sensitives as
indicated

reduces risk of
aspiration

Identifies organisms
so that most
appropriate drug
therapy can be
instituted.