Cues Nursing Background Goals and Objectives Nursing Interventions and Rationale Evaluation

Diagnosis Knowledge

Subjective: Risk for Risk for NOC: Knowledge: NIC: Infection Control After the Nursing
Infection Infection Infection Protection Intervention the patient
Objective: susceptible to was able:
● Emergency invasion of
CTT pathogenic Goal (Long Term):
insertion organisms at After the Nursing
and surgical site, Intervention the patient
Thoracotom which may will remain free of
y compromise infection, as evidenced
health. by normal vital signs and
(NANDA absence of signs and
15th, 2020) symptoms of infection.

Objectives (Short
Term):
After the nursing
intervention the patient
will be able to:

● Alleviate or ● 1. Perform proper infection ● Feel more safe at

reduce the control in the OR room such the end of the
problems related as: operation
with the
infection 1.1 Skin disinfection:
disinfecting and done in an
appropriate manner, letting the
 disinfectant air dry, soaked
cotton swabs, no infected
wounds preoperatively.
To remove skin
microorganisms at the site of
the incision and reduce the risk
of contamination of the
surgical site.

● 1.2 Aseptic technique:

Maintaining sterility, replacing
unsterile material, correct
implant handling, wiping off
blood from sterile= goods. To
prevent contamination in the
sterile field.

● 1.3 Draping: Maintaining the

sterile draping with no gaps,
leaving as little skin uncovered
as possible, using double layers
of draping.
To protect the surgical area
and transparent plastic film to
cover open wounds and
fastening the sterile draping
close to the surgical area in
order to leave as little as
possible of the patient's skin
uncovered.
 ● 1.4 Dressing: adhere draping
as soon as possible, dense, and
functional draping.
Applying the dressing in a
sterile manner, and applying
the dressing closely and tightly
against the skin with no
creases that could allow
bacteria to contaminate the
surgical wound.
● Maintain body
● Have adequate temperature of
thermoregulation 36.4- 37.5 degree
● 2. Normothermia: Monitor the celsius.
body temperature and warm
blankets, minimizing
temperature loss, keeping the
patient warm.
Nurses included heating
blankets, blankets that were
run through with a warm
airflow, preheated skin
disinfectant, covering the
patient's body with duvets, and
warm fluids. This was
described as a shared
responsibility, performed in
collaboration with the
registered nurse anesthetist in
the surgical team.
One study found that patients
who experienced mild
hypothermia during surgery
 were three times more likely to
have positive cultures from the
surgical site (The Association
of periOperative Registered
Nurses [AORN], 2011).
● Get tended to
● Be taken care of promptly when her
immediately if incision showed
there is signs of signs of infection.
infection.
● Examine skin for breaks or
irritation and signs of
infection.
Disruptions of skin integrity at
or near the operative site are
sources of contamination to the
incision. Careful shaving or
clipping as close as possible to
incision time will prevent skin
cuts or abrasions, which
provide potential entry for
bacteria. Note: AORN
recommendations state that
hair at the surgical site should
be left in place whenever
possible. If hair must be
removed, remove only the hair
at the surgical site (AORN,
2011).
● Adhere to ● To be free from
surgical care contaminated
policies and fluids and
procedures. ● Utilize Universal Precautions, materials as
contain contaminated fluids evidenced by
or materials to specific site in disposing them in
 accordance with
operating room suite, and the given protocol.
dispose of them according to
facility protocol.
Containment of blood and body
fluids, tissue, and materials in
contact with an infected wound
or client will prevent spread of
infection to environment and
other clients or personnel.