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