Nursing Diagnosis: Risk for infection related to the disease process

Cause analysis: Poor hygiene can lead to infection due to the accumulation of bacteria that can affect the wound by spreading of the some
microorganism that causes infection.
CUES
OBJECTIVES
NURSING INTERVENTIONS
RATIONALE
EVALUATION
Subjective:
Sakit kayo Zette mao
dili nako maayo ug
hugas akug lubot as
patient claimed.

Objective:
Poor hygiene
Unchanged
clothe
Unable to sit
Irritable
Pain scale 2/10

STO:
After 4 hours of nursing
intervention the patient
will gain knowledge in
infection control as
evidenced by discussing
the wound care.

LTO:
After 3 weeks of nursing
interventions, patient will
be able to verbalize
comfort as evidence by the
pain scale 4/10

Independent
1. Establish rapport
2. Teach patient to
wash hands often
especially before
meals and before
and after
administering selfcare
3. Discuss to patients
the following signs of
infection-redness
swelling increased
pain or purulent
drainage on the site
and fever
4. Demonstrate and
allow return
demonstration of
wound care
Collaborative:
1. Administer
prescribed meds

STO:
To gain trust and
cooperation of the patient
Hand washing reduces the
risks for infection
To impart to the patient
when the wound become
infected and when to
sought medical care
To know if the patient really
understand the principle of
proper wound care
To lessen infection and
prevent further spread of
the microorganism using
antibiotics

After 4 hours of nursing

intervention the patient gained
knowledge in infection control as
evidenced by discussing the
wound care.

LTO:
After 3 weeks of nursing
interventions, patient verbalized
comfort as evidence by the pain
scale 4/10

REF: SCRIBD.COM