Chapter 10 Sample Nursing Care Plan The Client At Risk For Infection Mr.

Filar, a 38-year-old homeless person, was struck and dragged by a speeding car as he crossed the street. He was taken to the hospital by ambulance. His left leg is broken, and there are lacerations and abrasions on his right side, arm, and leg. The left leg is in a cast and the lacerations have been sutured. Mr. Filar is very thin and says that he has not eaten for 2 days. Nursing Diagnosis 1 Infection, Risk for, related to inadequate primary defenses as evidenced by lacerations and abrasions Planning/Goals Mr. Filar will not have developed an infection in the lacerations and abrasions at discharge. Nursing Intervention Thoroughly wash hands using antimicrobial soap before and after caring for Mr.Filar. Rationale Antimicrobial soap is more effective in reducing microorganisms on hands. Evaluation Mr. Filar has redness around one laceration.

Prevents introduction Use sterile technique of microorganisms when caring for into lacerations and lacerations and abrasions. abrasions. Promotes healing of Apply antibiotic abrasions. ointment on abrasions as ordered. Removes any drainage that may harbor Keep bed linens microorganisms. clean and dry. Prevents or cures Administer oral infection. antibiotics, as ordered.

Nursing Diagnosis 2 Pain, related to physical injury as evidenced by facial grimacing Planning/Goals Nursing Rationale Interventions Mr. Filar will exper- Use pain scale to det- Provides objective ience increased ermine level of measure of pain. Evaluation Mr. Filar states that he is Experiencing less discomfort

comfort and will verbalize that pain is under control within 24 hours.

discomfort. Assist client to a position of comfort and elevate extremities. Administer analgesics as ordered. Reduces pain and swelling by increasing blood return to the heart. Provides comfort.

by 16 hours but that he still desires pain medication.

Nursing Diagnosis 3 Nutrition, Altered, Less than Body Requirements, related to economic factors as evidenced by extreme thinness and not having eaten for 2 days Planning/Goals Mr. Filar will eat balanced meals while hospitalized. Nursing Interventions Assist Mr. Filar to select foods high in protein, vitamins A and C, calcium, zinc, and copper. Provide between meal snacks, especially milk, or milk products. Rationale Wound healing depends on the availability of protein, vitamins, and minerals. Evaluation Mr. Filar eats both everything on his meal trays and the between meal snacks.

Snacks will increase overall caloric intake; increased protein will promote wound healing; increased calcium will promote bone healing.

From While, L. (2001). Foundations of Nursing: Caring For the Whole Person. Albany, NY: Delmar Learning.