Date Cues Nsg Dx Scientific basis Goal of care Nsg intervention Rationale Evaluation

03/3/2 ROS RIsk for DEFINITION OF THE After 8 hours of INDEPENDENT After 8 hours of
1 Immune infection NSG. DIAGNOSIS nurse-client >Determine blood >Unstable blood glucose nurse-client
system: related to interaction, the glucose stability levels contribute to interaction, the
decreased decreased Vulnerable to invasion client will be able delayed wound healing. client was able to:
leukocyte leukocyte and multiplication of to:
function function pathogenic organisms, >Assess for necrotic >Necrotic tissues signify -Verbalize some
which may compromise -Verbalize tissues around the poor blood flow and in of the risk factors
ASSESSMENT health. understanding of client’s wound severe cases, would that contributes to
Subjective: identified risk need amputation delayed wound
“Kini akong PATHOPHYSIOLOGY factors healing
mga samad BASIS >Educate patient about >To ensure good blood
dugay jud Infection occurs when >Verbalize the importance of flow around the wound -Verbalize
maayo an organism is able to understanding of adhering to prescribed understanding of
kasagaran colonize an organism the importance diabetic treatment the importance of
kining sa tiil and is able to multiply of adhering to religiously taking
semana nani. within a host. An prescribed >Educate client about >Proper wound care medications to
Ngolngol pud infection causing treatment proper wound care contributes to the prevent further
siya usahay” microorganism must prevention of wound infection
have virulence, be -Identifies infection
Objective: transmitted from its important -Verbalize
-Pain scale of reservoir, and gain interventions in DEPENDENT methods of
5/10 entry into the reducing risk for >Administer antibiotics >Early treatment may proper wound
-Temperature of susceptible host. infection as prescribed help in preventing the care
37.7 °C development of infection
RATIONALE -obtain timely on the site of wound. -Adhere to
When the immune would healing prescribed
system is alerted that free from >Clean and change >To prevent development treatment to avoid
an invader entered the purulent wound dressings as of infections associated discharges and
body, cytokines send discharges and indicated with poor wound care necrosis in would
message to phagocytes necrosis hygiene
to attack the infection.
Lymphocytes and other
white blood cells also
begin to attack the
microorganism. The
result of this activity of
ten results in a fever
and causes the blood
vessels to enlarge in
order to increase the
amount of blood
containing phagocytes
and lymphocytes to the
site of infection