DATE & TIME Septem ber 16, 2011 @ 8:00 AM

CUES Objective cues: -Hemoglobin: 106.0 g/dL (low) -Hematocrit: 0.31 (low) -WBC count: 10.93 x 10^3/uL (High) -Neutrophils: 84.6 (High) -Lymphocytes: 8 (Low) -Monocytes: 8 (Normal) -Eosinophil: 1 (Normal) Temporoparietal

NEED H E A L T H P E R C E P T I O N H

NURSING DIAGNOSIS Risk for Infection related to compromised host defenses and post-surgical incision

OBJECTIVE/ GOAL At the end of rendering 6 hours of nursing care, the patient will : - remain free from infection as evidenced by

NURSING INTERVENTIONS 1. Promote good hand washing by patient and staff. Reduces risk of cross-contamination. 2. Encourage to eat foods that are rich in protein and Vitamin C. Vitamin C is known to prevent infection; citrus fruits are rich in vitamin C. Protein is needed for tissue repair regeneration; meat products, nuts & legumes are rich sources of which. 3. Advice to have enough rest and sleep. -

EVALUATION Goal Met

At the end of rendering 6 hours of nursing care, the patient was able to: remain free from infection as evidenced by normal vital signs T: 37.3 RR: 22 cpm PR: 80 bpm - prevent

Immunosuppression due to decrease in hemoglobin, leukopenia, and suppress Inflammatory response gives a greater opportunity for pathogenic bacteria to invade and

normal vital signs This promotes healing by reducing basal metabolic rate & allowing oxygen & nutrients to be utilized for tissue growth, healing & regeneration. 4. Monitor vital signs. Fever with increased pulse and respirations is typical of increased metabolic rate resulting from inflammatory process, although sepsis can occur without a febrile response. 5. Discuss importance of not taking antibiotics unless specifically instructed by healthcare provider. Inappropriate use can lead to development of drugresistant strains/secondary infections.

- be able to prevent progression of illness

- be free from skin irritation

progression of disease - be free from skin irritation

Incision 2 inches incision of parietal part of the head

E A L T H M A N A G E M E N T

inoculate in a specific body part of a susceptible human body. Thus, leading to a further damage or infection. Post-surgery incision infection may occur with improper incision cleaning or loose dressings, that allow bacteria to

6. Provide meticulous skin, oral and perianal care. Reduces the risk of skin/tissue breakdown and infection. 7. Teach patients significant other on how to take antibiotics as prescribed. Most antibiotics work best when a constant blood level is maintained; a constant blood level is maintained when medications are taken as prescribed. The absorption of some antibiotics is hindered by certain foods; patient should be instructed accordingly. 8. Instruct client and family on appropriate aseptic practices to prevent infection. Instructing the client and family about the aseptic technique will help them become more knowledgeable and aware on the things that should be done in order to prevent infection. 9. Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake. Facilitates healing process and enhances natural resisitance. 10. Monitor WBC count. Rising WBC indicates bodys efforts to combat pathogens. Very low WBC indicates severe risk for infection because patient does not have sufficient WBCs to fight infection.

P A T

reach the incision site.

Source: Med-

T E R N

Surg Nursing, 10th ed. Brunner and Suddarth