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nursing
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COLLEGE OF NURSING
COLLEGE OF NURSING
Foundation University
Dumaguete City
CUES/EVIDENCES
NURSING DIAGNOSIS
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION
Subjective:
Objective:
(+) presence of wound
V/S taken as follows:
Temp:
RR:
PR:
BP:
Risk for infection related to wound secondary to fracture
At the end of the 6hr nurse-patient interaction and intervention the patient will:
Identify interventions to prevent/reduce risk of infection
Achieve timely wound healing; be free of purulent drainage or erythema;
Be afebrile as evidenced by the normal V/S.
>Note risk factor for occurrence of infection
>Observe for localized signs of infection
.
>Stress proper hand-hygiene by all caregivers bet. Therapies/clients.
>Recommend routine or body shower/scrub when indicated
>Change surgical or other wound dressings, as indicated, using proper technique for changing or disposing of contaminated materials
>Review individual nutritional needs,
>To assess causative/ contributing factors
>To assess for infected sites
>A first line defense against healthcare-associated infections
>To reduce bacterial colonization
>To prevent infection
>To promote wellness.
After 6hr nurse-patient interaction and intervention the patient has :
identified interventions to prevent/reduce risk of infection
Achieved timely wound healing; be free of purulent drainage or erythema;
Been afebrile as evidenced by the normal V/S.
NURSING CARE PLA