Nursing Care Plan

Name of Patient: ________________________________________ Age: _____________________ Sex: ___________________ Occupation: _________________________________ Date of Admission: ___________________________ Status: _______________ Religion: _____________________ Needs / Nursing Diagnosis / Cues Patients Health Profile: _______________________________________________ _______________________________________________ _______________________________________________ Initial Complaint: _____________________________________________________ _____________________________________________________ Diagnosis/ Impression: ________________________________________________ Objectives Nursing Interventions Rationale Evaluation

Scientific Analysis

Physiologic Risk for infection related to break in skin integrity (surgical incision; JP drain) S: as verbalized by the patient O: Post surgical incision : Decreased RBC and hemoglobin count : Risk for nutritional imbalance

Postoperative wound infection is an infection in the tissues of the incision and operative area. It can occur from 1 day to many years after an operation but commonly occurs between the fifth and tenth days after surgery. Wound infection results from microbes flourishing in the surgical site because of poor preoperative preparation, wound contamination, poor antibiotic selection, or the inability of an immunocompromised patient to fight off infection. Contamination of the wound is present to some extent in all incisions. A setback in recovery such as malnutrition, cardiac failure, or decreased oxygen to the tissues will weaken the individual and allow the infection to take hold. Massanari, R. Michael, and Richard P. Wenzel. "Hospital Infection Control." Internal Medicine. 5th ed. St. 2004.

After 8 hours of student nurse client interaction, the client will be able to: Verbalize understanding about infection and its risks Identify interventions to prevent/reduce risk for infection Demonstrate techniques, lifestyle changes to promote safe environment Achieve timely wound healing

Monitor vital signs; assess for signs of infection (fever, chills, diaphoresis altered level of consciousness) Stress proper handwashing techniques to patient and significant others as well as all caregivers Cleanse incision and insertion sites daily with povidone-iodine or other appropriate solution and change dressings as needed or as indicated Administer/monitor medication regimen (antimicrobials, topical antibiotics) and note clients response Instruct client/SO in techniques to protect the integrity of skin, care of lesions, and prevention of spread of infection Emphasize necessity of taking antibiotic as directed

To assess and note presence of infection

Hand hygiene is the firstline defense against nosocomial infection/cross contamination To prevent microorganisms from entering the skin breakage and to promote hygiene To determine effectiveness of therapy / presence of side effects

To promote client/SO learning about prevention of infection

Premature discontinuation of treatment when client begins to feel well may

result in return of infection