Patient: Rivas, Flora Age: 46 years old Diagnosis: ESRD SEC TO DKD/HKD; S/P BKA/ DISLODGED IJ

Date
& Assessment Needs Nursing Diagnosis Objective Interventions Evaluation
Time
Nov Objective: H Risk for infection After 8 hours 1. Monitor vital signs regularly. GOAL MET
29, - Dislodged E related to dislodged of nursing R: Changes in vital signs may indicate
2019 Intrajugular A IJ line interventions, infection. After 8 hours
line L the patient of nursing
7:00 - Unchanged T R: Central venous will be able 2. Monitor the patient for any signs of interventions,
am – wound H access is commonly to: swelling, purulent discharge or the patient
3:00 dressing performed in the care presence of pain from site. was able to:
pm - bleeding on P of the critically-ill - remain free R: These are the cardinal signs of
the site E patient, for a number from any infection. - remain free
-S/P BKA R of indications. infection from any
- GCS 10 C However, this routine infection
(inability to E procedure has 3. Perform handwashing when dealing
perform P complications that with patient.
ADL’s that T every provider must R: Handwashing is an effective
concerns I recognize, consider, technique to prevent the spread of
hygiene) O and be able to infection. Dry surfaces are better in
- Weak in N manage—either preventing transfer of microorganisms.
appearance directly or with
- Low WBC A prompt specialty
count (2.38 x N assistance. These 4. Wear gloves during any contact with
103/uL D complications can be mucus, blood, and other body fluids.
-Immuno immediate or delayed Use goggles when appropriate.
compromised H in nature. Immediate R: It prevents the transfer of
(ESRD) E complications occur microorganisms that are already on the
- Limited A at the time of hands and to protect the hands from
sanitation L catheter insertion becoming contaminated.
access T and include vascular,
-Knowledge H cardiac, pulmonary, 5. Encourage adequate rest.
deficit and placement
regarding M complications.
avoidance of A Delayed
pathogens N complications include
A device dysfunction
- Vital Signs G and infection.
recorded at: E Peripherally inserted
Temp: 37.5 M central venous
BP: 100/80 E catheters have an
RR: 21 bpm N altered complication
PR: 86 T profile that clinicians
should consider
P when deciding on
A central venous
T access, but are still
T associated with the
E same spectrum of
R complications as
N centrally placed
catheter.
Source: McGee DC,
Gould MK.
Preventing
complications of
central venous
catheterization. N
Engl J Med.
2015;348:1123–33.
[PubMed] [Google
Scholar]
R: It can reduce stress and boost the
immune system.
6. Provide a clean environment.
R: A sanitized environment creates a
colossal effect when preventing
infection, as this reduces contamination
to the patient, making it less likely for
the patient to develop infection post
procedure.
7. Assist in performing ADL’s,
especially ones related to hygienic
measures.
R: To decrease the risk of contracting
pathogens and infection.
8. Maintain aseptic technique when
performing wound dressing.
R: Regular wound dressing promotes
fast healing and drying of wounds.
9. Educate S/O on signs of infection
and when to call for help.
R: Nurses are not round the clock
available for bedside care, hence, S/O’s
must watch out for any signs of
infection present and report
immediately to healthcare staff for
immediate managemen.t.
10. Teach S/O how to perform
procedures at home, like dressing
changes once discharged.
R: Patient and caregivers need to
master these skills to make sure that
they can continue preventing risk of
infection even if they are already
discharged.

11. Routinely monitor the patient’s white

blood cell count, serum protein, and
serum albumin.
R: These laboratory values are closely
linked to the patient’s nutritional status
and immune function.

12. Administer medications as ordered.

R: Not completing or skipping the
required dose of antibiotics can
encourage antibiotic resistance.

13. Coordinate with a dietician

prescribe proper NGT solution suitable
for the patient and her nutritional needs.
R: Proper nutritious diet helps support
the immune system by delivering the
necessary nutrients needed by the
body.