Far East ern University

Institute of Nursing
 
Nursing Care Plan
 
Cues Nursing Scientific Goal and Interventions Rationale Evaluation
Diagnosis Analysis Objectives
           
Subjective:  Risk or  An infection Goal: after the 8     After the ___
   The client infection is a host hours shift, the     shift, the
verbalized: related to organism’s client will be able     client was
  tissue response to a to demonstrate     able to
  destruction pathogen, or techniques with     demonstrate
Objective: – chest-tube disease- assistance on  Minimize  Hand techniques
 Foul thoracotomy causing lifestyle changes patient’s risk washing is with
odor (CTT) substance. It particularly of infection the single assistance on
 Bad results when maintaining by washing best way to bed bath and
breath tissue- personal hygiene. hands before avoid sponge bath,
??????????? Risk for destroying   and after spreading oral hygiene
infection microorganism Objectives: providing pathogens. and use of
related to enter and care. materials to
external multiply in the  After 20 maintain a
factors????? body. Some mins of  Wearing daily hygienic
infections take interventio gloves to habit.
the form of n the maintain
minor patient is asepsis when
illnesses, such able to providing  Gloves offer
as colds and properly direct care. protection
ear infections. wash his when
Others results hands handling
as life wound
threatening  After 20 dressings or
condition mins of carrying out
called sepsis, interventio  Culture various
which causes n the urine, treatments
widespread patient’s respiratory
vasodilation respiratory secreations,
and multiple – secreations wound
organ are clear drainage, or  This
dysfunction and blood identifies
(MODS). odorless. according to pathogens
Infection facility and guides
occurs when  After the policy and antibiotic
the body’s interventio physicians theraphy.
defense n the order.  
mechanism patient is  
break down. able to  
Infection state the  
results when a risks for  Help patient  
pathogen infection. wash hands  
enters the before and  
body through after meals  
direct contact, and after  
inahalation,   using the
ingestion, or   bathroom,  Hand
an insect bite.   bedpan, or washing
  urinal. prevents
  spread of
  pathogens to
  other objects
   Instruct and food.
  patient to
  report
  incidents of
  loose stools
  and diarrhea.
  Inform
  physician
  immediately.
   Loose stools
  or diarrhea
   Offer oral may indicate
  hygiene to the need to
  patient every discontinue
  4 hours or change
  antibiotic
  theraphy.

 Use strict
aseptic
technique
when  To prevent
suctioning the
the lower colonization
airway, of bacteria
inserting and reduce
indwelling the risk
urinary
catheters,
and
providing
wound care  To avoid
to avoid spreading of
spreading pathogens.
pathogens.
 Have patient
cough and
deep-breathe
every 4
hours after
surgery.

 To help
remove
secretions
 Use sterile and prevent
water for pulmonary
humidificatio complication
n or s.
nebulization
of oxygen.
  Educate the
patient
regarding:
-good hand
washing
-factors that  This prevents
increase drying and
infection risk irritation of
-infection signs respiratory
and symptoms. mucosa, and
  thickening of
  secretions
  within
respiratory
  tract.
 
 
 
   These
  measures
  allow patient
to participate
in care and
help patient
modify
lifestyle to
maintain
optimum
health level.