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INEFFECTIVE BREATHING PATTERN Nursing Care Plan

Stuart, 23 years old, diagnosed with pneumonia 3 months ago. Because of having not enough money for hospitalization. His state got worse day...

RISK FOR INFECTION Nursing Care Plan

One of the best example of infection is the new coronavirus called COVID-19. Experts believe it was originated in a country of Asia. A lot of people died in this pandemic. Since the mode of transmission of this infection is from person to person, people are encourage to implement social distancing and stay at their home. It takes 7-14 days before you manifest symptoms, some are asymptomatic, and you can't see the virus with your naked eye so people are strictly washing their hands, using alcohol and even wearing mask to protect them and the others from infection.

Mrs. Bobin case of risk for infection is a different story. Mrs. Bobin is a 38 year old fire fighter officer who had recent surgical operation after she was been diagnosed with myoma. The doctor instructed her to take a leave for at least two months but she instead went to work after a week of home rest. Unfortunately, her surgical wound began to open again. Below is a sample of risk for infection nursing care plan of Mrs. Bobin.

Assessment:

Subjective: "Help! My entire surgical wound opens again." As verbalized by the patient.

Objectives:

- Vital signs is normal except slight increase in body temperature.
- Anxious
- Frightened
- Facial grimace
- Pain scale 2/10

Diagnosis:

Risk for infection related to a site for organism invasion secondary to surgical incision dehiscence or surgical wound reopen.

Planning:

After 4 hours of nursing intervention, the patient will understand the precautions needed to prevent infection. The patient will describe the methods of transmission of infection and will describe the influence of nutrition on prevention of infection.

Interventions:


- Consider those with the following factors at high risk for delayed wound healing; consider if Mrs. Bobin's malnourishment. Ask Mrs. Bobin if she use tobacco. Check Mrs. Bobin health history, if she had been diagnosed with anemia, diabetes, or cancer. Identify if she had undergone corticosteroid therapy.

- Use universal precautions to reduce patient's susceptibility to infection. Encourage and maintain caloric and protein intake in her diet (see Imbalanced Nutrition). Assess Mrs. Bobin, the patient, for adequate immunizations against childhood diseases, bacterial infections and other viral infections. Administer her with prescribed antimicrobial therapy within 15 minutes of schedule. Minimize the length of her stay in hospital. Observe for superinfection in Mrs. Bobin while receiving antimicrobial therapy.

- Reduce entry of organisms into the patient's surgical wound. Monitor temperature every 4 hours; notify physician if her temperature is greater than 100.8° F. Assess Mrs. Bobin's  wound site every 24 hours and during her dressing changes; document any abnormal findings. Evaluate all her abnormal laboratory findings, especially her culture/sensitivities and complete blood count (CBC). Assess nutritional status to provide adequate protein and caloric intake for healing. Evaluate all abnormal laboratory findings, especially cultures/sensitivities and CBC. Assess for abnormal signs and symptoms after any urologic procedure, including frequency, urgency, burning, abnormal color, and odor. Monitor patient's temperature at least every 24 hours for elevation; notify physician if her temperature is greater than 100.8° F. Encourage Mrs. Bobin to take fluids when appropriate. Use aseptic technique when emptying any urinary drainage device; keep bag off the floor, but below bladder or clamped during transport. Reassess need for indwelling urinary catheter daily. Assess all her invasive lines every 24 hours for redness, inflammation, drainage, and tenderness. Maintain aseptic technique for all invasive devices, changing sites, dressings, tubing, and solutions per policy schedule. Evaluate all abnormal laboratory findings, especially cultures/sensitivities and CBC. Assess client’s nutritional status. Evaluate risk for infection after any instrumentation of the respiratory tract for at least 48 hours after procedure. Monitor temperature at least every 8 hours and notify physician if greater than 100.8° F. Evaluate sputum characteristics for frequency, purulence, blood, and odor. Evaluate sputum and blood cultures, if done, for significant findings. Assess her lung sounds every 8 hours or as needed, If patient has abdominal/thoracic surgery, instruct her before surgery on importance of coughing, turning, and deep breathing. Prompt her to cough and deep breathe hourly. If Mrs. Bobin has had anesthesia, monitor for appropriate clearing of secretions in lung fields. Evaluate her need for suctioning if she cannot clear secretions adequately. Assess her for risk of aspiration, keeping head of bed elevated 30 degrees unless otherwise contraindicated. Ensure optimal pain management.

Evaluation:

After 4 hours of nursing intervention, the patient would understand the precautions needed to prevent infection. The patient would described the methods of transmission of infection and would described the influence of nutrition on prevention of infection.

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For more samples of nursing care plan you are free to check it out in our NCP LIST page.

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