One of the best examples
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 encouraged 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 are 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 super infection 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.
For more samples of nursing care plan you are free to check it out in our NCP LIST page.
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