Nursing Care Plan for Risk for Infection

Nursing Care Plan

Medical Diagnoses: Risk for Infection

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Nurse noted in shift change report about the pt’s pressure ulcer.

Objective

Documented pressure ulcer of 2X3 inches, 1 inch in depth, with clear, non-odorous drainage

Problem

Risk for infection

Long Term:

Pt will demonstrate appropriate hygienic measures such as hand washing, oral care, and perineal care by discharge.

*Teach the importance of appropriate hand hygiene

Rationale: “Meticulous infection control precautions are required to prevent infection, with particular attention to hand hygiene” (Ackley & Ladwig, 2008, p. 496).

ü

R/T

Stage II pressure ulcer on coccyx

Short Term:

Pt will remain free from symptoms of infection throughout this shift, by 1900.

*Observe and report any signs of infection such as redness, warmth, and discharge.

Rationale: “Prospective surveillance study for nosocomial infection on hematology” (Ackley & Ladwig, 2008, p. 495).

*Use careful sterile technique when there is a loss of skin integrity.

Rationale: “Extensive literature search revealed that sterile gloves should be used for postoperative wound dressing changes” (Ackley & Ladwig, 2008, p. 497).

AEB

N/A

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*I = Implementation. Check those interventions/actions/orders that were implemented.

References

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8^th ed.). St. Louis: Mosby Elsevier.

Return to Table of Contents

Assessment	Nursing DX/Clinical Problem	Client Goals/Desired Outcomes/Objectives	Nursing Interventions/Actions/Orders and Rationale	*I	Evaluation
					Goals	Interventions
Subjective Nurse noted in shift change report about the pt’s pressure ulcer. Objective Documented pressure ulcer of 2X3 inches, 1 inch in depth, with clear, non-odorous drainage	Problem Risk for infection	Long Term: Pt will demonstrate appropriate hygienic measures such as hand washing, oral care, and perineal care by discharge.	*Teach the importance of appropriate hand hygiene Rationale: “Meticulous infection control precautions are required to prevent infection, with particular attention to hand hygiene” (Ackley & Ladwig, 2008, p. 496).	ü
	R/T Stage II pressure ulcer on coccyx	Short Term: Pt will remain free from symptoms of infection throughout this shift, by 1900.	Observe and report any signs of infection such as redness, warmth, and discharge. Rationale: “Prospective surveillance study for nosocomial infection on hematology” (Ackley & Ladwig, 2008, p. 495). Use careful sterile technique when there is a loss of skin integrity. Rationale: “Extensive literature search revealed that sterile gloves should be used for postoperative wound dressing changes” (Ackley & Ladwig, 2008, p. 497).
	AEB N/A