Risk for infection

Assessment
Subjective:Hindi gumagalingang sugat ko (My wounds are not healing) As verbalized by the patient. Objective: Flushed appearance. Wound drainage. V/S taken as follows:T:37.4P:87 R:19BP: 120/90

Diagnosis
Risk for infection related to high glucose levels,

Planning
After 8 hours of nursing interventions, the patient will identify interventions to prevent or reduce risk of infection

Intervention Independent: Observe for signs of infection and inflammation.

Rationale Patient may be admitted with infection, which could have precipitated the ketoacidotic state, or may develop a nosocomial infection. Reduces the risk of crosscontamination High glucose in the blood creates an excellent medium for bacterial growth. ]

Evaluation After 8hours of nursing interventions, the patient was able to identify interventions to prevent or reduce risk of infection

Promote good hand washing by nurse and patient. Maintain aseptic technique for IV insertion procedure, administration of medications, and providing maintenance and site care. Rotate IV sites as indicated. Provide catheter or perineal care.

Minimizes the risk for infection.

Teach the female patient to clean from front to back after elimination. Provide conscientious skin care, gently massage bony areas. Keep the skin dry, linens dry and wrinkle free. Place in semi fowlers position.

Peripheral circulation maybe impaired placing patient at increased risk for skin irritation or breakdown and infection.

Facilitates lung expansion and reduces risk of aspiration.

Decrease susceptibility to infection. Encourage adequate dietary and fluid intake of 3000 ml per day. Collaborative: Obtain specimen for culture and sensitivities as indicated Identifies organisms so that most appropriate drug therapy can be instituted