Initial: Mr. X Age: 54 Years Old Room No.

V14 Chief Complaints: dizziness and vomitting

Date Admitted: 2/01/11 Admitting Diagnosis: CKD, AMI, Dm type 2

Attending Physician: Gomez, Hilario Abel B., MD Significant Medical and Nursing History: Sudden onset of dizziness and vomitting

Nursing Diagnosis: Goals: Nursing Orders/Interventions:
Risk for infection related to high Independent:
glucose levels, decreased leukocyte After 8 hours of nursing •Observe for signs of infection
function interventions, the patient and inflammation
will identify interventions
Subjective: to prevent or reduce risk of
“Wala na- ayo akong samad dong” As
infection.
verbalized by the patient.
•Promote good
hand washing
Objective: by nurse and
Flushed appearance. •Maintain aseptic technique for
IV insertion procedure,
Wound drainage. administration of medications,
and providing maintenance
V/S taken as follows: and site care.
T:37.4 •Provide catheter or perineal
P:87 R:19 care. Teach the female patient
BP: 140/60 to clean from front to back
after elimination.
•Encourage adequate dietary
and fluid intake of 3000 ml per
day.
Collaborative:
specimen for culture and
sensitivities as indicated.
Scientific rationale: Evaluation(Indicate the time the
outcome was met)
•Patient may be admitted with
infection, which could •After 8 hours of nursing interventions,
have precipitated the the patient was able to identify
ketoacidotic state, or may interventions to prevent or reduce risk of
develop a nosocomia. infection.
•Reduces the risk of cross
contamination.
•High glucose in the blood
creates an excellent medium
for bacterial growth.
•Minimizes the risk for
infection.
Decrease susceptibility to
infection.
Identifies specimen for
culture and
sensitivities as
indicated.

NURSING CARE PLAN

Clinical Dates: ______________________
Hospital Area: ______________________

Student’s Name: ____________________