Selected Nursing Diagnosis; risk for infection r/t open wound AEB destruction of skin layers

Goal/Outcome Criteria; ST: client and family will demonstrate appropriate care of infection prone sites within 48 hours of instruction
LT: client will remain free from symptoms of infection during contact with health care providers and throughout stay of the hospital

Assessment Data Cluster
Subjective Symptoms:
54-year-old
History of L4-L5 paraplegic
Supportive family
Admitted for chronic sacral
wound
Objective Signs:
Alert and oriented
Nursing Interventions
Assessment Interventions:
Observe and report as redness,
warmth, discharge, and
increased body temperature.
Monitor client’s vitamin D
level.
Rationale (Include Source) Goal Evaluation
Change in mental status, fever,
shaking, chills, and
hypotension are indicators of
sepsis. (Ackley et al, 2017, p ST: goal met. Client was able to
547) demonstrate appropriate care of
Vitamin D deficiency has been infection prone sites within the
correlated with increased risk desired time.
and greater severity of
infection, particularly of the
respiratory tract. Vitamin D
influences the body’s immune
system by influencing the
production of endogenous
antimicrobial peptides and LT: goal met. Client remained
regulating the inflammatory free of any symptoms
cascade. (Ackley et al, 2017, p associated with an infection.
548)

Therapeutic Interventions: Skin and soft tissue infections

Use sterile technique where
there is loss of skin integrity.
arise when skin integrity is
broken by treatments with
trauma, surgery, burns and so
forth. (Ackley et al, 2017, p
549)

Revised 8/6/2008
 Recommend responsible use of
antibiotics; use antibiotics
sparingly.
Teaching Interventions:
Teach the client and family the
importance of hand hygiene in
preventing postoperative
infections.
Educate the client and the
caregiver regarding local
wound care and allow for a
return demonstration.
Revised 8/6/2008
Use and misuse of antibiotics
diminishes their therapeutic
benefit and facilitates the
development of MDROs and C.
difficile-associated disease and
increases health care costs.
Antibiotic stewardship is
essential in reducing current
and future resistance in
bacteria. (Ackley et al, 2017, p
549)
Two-thirds of wound infections
occur after discharge. Using
good hand hygiene practices is
effective in preventing these
infections. (Ackley et al, 2017,
p 550)
Promotion of wound healing is
a nursing priority. Specific
wound care regimens
administered depend on the
type, size, and location of the
wound and overall treatment
goals. (Ackley et al, 2017, p
550)