NURSING CARE PLAN

Clustered Nursing Nursing

Rationale
Cues Diagnosis
2/22/20 Risk for Risk of infection is
8:00 AM infection a nursing diagnosis which
is defined as "the state in
Subjective: which an individual is at
Verbalized risk to be invaded by
“sakit” an opportunistic or patho
genic agent
(virus, fungus, bacteria, p
Objective: rotozoa, or other parasite)
from endogenous or exog
lethargic and
fatigue; enous sources"
wheezing; (Carpenito, L J
(ed.). Nursing diagnosis:
forceful
breathing; application to clinical
shortness of practice, 9th ed.).
breath; pallor;
easy bruising; The risk of infection
decreased depends on a number of
RBC, WBC, endogenous sources.
HgB and Hct Skin damage from
incision as well as very
T-38.90 C,
young or old age can
BP-100/60 increase a patient's risk of
mmHG infection. Examples of
PR-140 bpm
risk factors includes
RR-57 bpm
decreased immune
system secondary to
disease,
compromised circulation  analgesic and
secondary to peripheral
vascular disease,
compromised skin 1. Reduced signs of
integrity secondary to facial grimacing and
surgery, or repeated grunting during labor
Outcome Criteria Rationale Evaluation
Interventions
2/22/20
9:30 AM
Independent:
1. Prevented/reduce Explained disease Provides emotional 1. Goal partially met.
d risk of infection course and treatment support, which can Instructions understood/
to parents reduce fear, lower followed by parents.
anxiety levels, and
help minimize pain
(Doenges, 2016).
Prevents cross
Emphasized to parents
the importance of contamination and
handwashing before reduces risk of
contact to patient infection (CDC,
2018)
Informed and
instructed to report Promotes
symptoms of infection participation in
such as fever, chills, decision making
coughs and sore throat process (Doenges,
2016).
Provided calm quiet
Promotes relaxation
environment for
and feeling of well-
adequate rest and
being and may
relaxation
reduce need for
anesthesia. Position
change can also
enhance circulation
and decrease
muscle tension
contact with contagious contractions after (Doenges, 2016).
agents nursing intervention.
(Spry, Cynthia. Essentials Although fever may
of Perioperative Nursing. accompany some
Jones & Bartlett. p. 80., Closely monitored forms of
2008.) temperature. chemotherapy,
progressive hyperth
ermia occurs in
some types of
infections, and
2. Must have
fever (unrelated to
performed deep-
drugs or blood
breathing exercises products) occurs in
properly after guiding most leukemia
and demonstration. patients.
Septicemia may
occur without fever.
References:
Doenges, M., et, al.
(2016). Nurse’s
pocket guide