Problem

Nursing Diagnosis High risk for infection d/t inadequate primary defense as manifested by broken skin

Background Knowledge Trauma on skin at left anterior

Goal and Objectives After 2 hours of nursing intervention the patient will gain knowledge in infection control as evidenced by discussing the wound care.

Nursing Intervention

Rationale

Evaluation

Open wound

Independent 1. Establish rappoirt

Broken skin

Open wound

Risk for infection

2. Teach patient to wash hands often, especially before toileting, before meals and before and after administering self-care 3. Discuss to patients the following signs of infection redness, swelling, increased pain, or purulent drainage on the site and fever

To gain trust and cooperation of the patient Hand washing reduces the risks for infection

After 2 hours of nursing intervention the patient will be able to gain knowledge in infection control as evidenced by his discussion in wound care. Therefore, the goal was met

4. Demonstrate

and allow return demonstration of wound care

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