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NCP of Non Healing Woound Final

The nursing diagnosis is risk for infection for a patient with a wound showing signs of drainage and elevated temperature. Interventions include observing for signs of infection, promoting hand washing, maintaining asepsis, placing the patient in semi-Fowler's position, and obtaining cultures if needed. The expected outcome is that after 8 hours the patient can identify ways to prevent or reduce infection risk.

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Juko Fernandez
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81 views

NCP of Non Healing Woound Final

The nursing diagnosis is risk for infection for a patient with a wound showing signs of drainage and elevated temperature. Interventions include observing for signs of infection, promoting hand washing, maintaining asepsis, placing the patient in semi-Fowler's position, and obtaining cultures if needed. The expected outcome is that after 8 hours the patient can identify ways to prevent or reduce infection risk.

Uploaded by

Juko Fernandez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Juco Fernandez, NR-41 (GROUP 2)

Nursing Diagnosis: Risk for Infection


Inference: Pancreas ->
if untreated.
ASSESSMENT
Subj. Cues:
Matagal
gumaling yung
sugat ko as
verbalized by the
patient.
Obj. Cues:
Flushed
Appearanc
e
Wound
Drainage
V/S:
T: 37.4
P:87
R:21
BP:13/90

Insulin -> Body tissue becomes resistant ->

Expected
Outcome
After 8 hours
of nursing
interventions
the patient will
identify
interventions
to prevent or
reduce risk of
infection

Intervention
Independent:
Observe for signs of
infection and
inflammation

Dependent:
Promote good hand
washing by nurse
and patient
Maintain aseptic
technique for IV
insertion procedure,
administration of
meds and providing
maintenance site
care.

blood glucose -> Number of complications


Rationale

Patient may be
admitted w/
infection, which
could have
precipitated the
ketoacidosis state or
may develop a
nosocomial
infection.

Reduces the risk of


cross contamination.

High glucose in the


blood creates an
excellent medium
for bacterial growth.

Facilitates lung
expansion and

Place semi-fowlers
position

Collaborative:

Evaluation
After 8 hours of
nursing interventions,
the patient was able to
identify interventions
to prevent or reduce
risk of infection.

Obtain specimen for


culture and
sensitives as
indicated

reduces risk of
aspiration

Identifies organisms
so that most
appropriate drug
therapy can be
instituted.

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