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    1. The nurse assessed the patient for signs of local infection such as swelling, redness, pain, and loss of function around the gangrenous wound on their toe. 2. The nurse monitored the patient's vital signs and white blood cell count to check for indications of the body fighting infection. 3. The nurse ensured strict aseptic technique for wound care and procedures to decrease the chances of transmitting pathogens. 4. The nurse assessed the patient's nutritional status and educated them and their caregiver on appropriate infection prevention methods like cleaning and disinfection.

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    concept map NCP

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    1. The nurse assessed the patient for signs of local infection such as swelling, redness, pain, and loss of function around the gangrenous wound on their toe. 2. The nurse monitored the patient's vital signs and white blood cell count to check for indications of the body fighting infection. 3. The nurse ensured strict aseptic technique for wound care and procedures to decrease the chances of transmitting pathogens. 4. The nurse assessed the patient's nutritional status and educated them and their caregiver on appropriate infection prevention methods like cleaning and disinfection.

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    © All Rights Reserved
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    12 views1 page

    Concept Map NCP

    Uploaded by

    kuro hanabusa
    1. The nurse assessed the patient for signs of local infection such as swelling, redness, pain, and loss of function around the gangrenous wound on their toe. 2. The nurse monitored the patient's vital signs and white blood cell count to check for indications of the body fighting infection. 3. The nurse ensured strict aseptic technique for wound care and procedures to decrease the chances of transmitting pathogens. 4. The nurse assessed the patient's nutritional status and educated them and their caregiver on appropriate infection prevention methods like cleaning and disinfection.

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    of 1

    4.

    Assess and monitor


    Impaired for infection 3. Maintain strict asepsis for dressing nutritional status, weight,
    2. Monitor white blood cell changes, wound care, intravenous therapy, 5. Ensure that any materials
    related to gangrenous (WBC) count and vital signs. and catheter handling. Rationale: Aseptic
    history of weight loss, and
    used are properly
    serum albumin. Rationale:
    wound secondary to Rationale: An increasing WBC technique decreases the chances of Patients with poor
    disinfected or sterilized
    count indicates the body’s before use. Rationale: This
    diabetes mellitus type 2 efforts to combat pathogens
    transmitting or spreading pathogens to or
    between patients. Interrupting the chain of
    nutritional status may be
    reduces or eliminates germs.
    anergic or unable to muster
    and very low WBC count may infection (see image above) is an effective a cellular immune response
    indicate a severe risk for way to prevent the spread of infection.
    to pathogens making them
    infection. 6. Educate clients and SO
    susceptible to infection.
    about appropriate methods
    for cleaning, disinfecting, and
    1. Assess for the presence of
    sterilizing items. Rationale:
    local infectious processes in
    Knowledge of ways to reduce
    the skin or mucous
    or eliminate germs reduces
    membranes. Rationale: Signs
    the likelihood of transmission.
    and symptoms include
    localized swelling, localized 7. Demonstrate and allow
    redness, pain or tenderness,
    return demonstration of all
    loss of function in the affected high-risk procedures that the
    B area, palpable heat. Thus, patient and/or SO will do after
    there is a need to assess and
    discharge, such as dressing
    check for these signs and changes, peripheral or central
    symptoms to render IV site care, and so on.
    immediate interventions. Rationale: Patient and SO
    D need opportunities to master
    A new skills to reduce risk for
    infection.

    E
    C
    Subjective cues:

    “ning itom namani


    akong dako nga tudlo After 8 hours of nursing
    sa tiil” intervention the patient was able
    to recognize early signs of
    Objective cues: Within 8 hours of nursing infection and demonstrated
    intervention the patient will be techniques such as wound care to
    - gangrenous wound able to: recognize early signs of prevent infections.
    on the left great toe infection and demonstrate
    techniques such as hand Goal Met……………………………....
    - foul smell noted
    washing to prevent infections. ………………….KPJosol,FSUU/SN

    References: Doengenes, M., Moorhouse M.F., Murr, A. Nurse’s Pocket Guide (2017) edition 14 retrieved march 5, 2021

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