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  • NCP, Ent, Risk For Infection

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    Gale Dizon
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    The nursing assessment identified a patient at risk for infection due to immunosuppression and invasive surgery. The long term goal was for the patient to be free from signs of infection after 3 days. Nursing interventions included monitoring for signs of infection, maintaining sterile technique, providing rest and exercise, and educating on hand hygiene. The short term goal was for the patient to initiate interventions to reduce infection risk after 8 hours. Evaluation found the goals were met as the patient showed no infection signs and properly initiated hygiene.

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    Trachea Tube

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    Ncp, Ent, Risk for Infection

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    The nursing assessment identified a patient at risk for infection due to immunosuppression and invasive surgery. The long term goal was for the patient to be free from signs of infection after 3 days. Nursing interventions included monitoring for signs of infection, maintaining sterile technique, providing rest and exercise, and educating on hand hygiene. The short term goal was for the patient to initiate interventions to reduce infection risk after 8 hours. Evaluation found the goals were met as the patient showed no infection signs and properly initiated hygiene.

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    160 views1 page

    NCP, Ent, Risk For Infection

    Uploaded by

    Gale Dizon
    The nursing assessment identified a patient at risk for infection due to immunosuppression and invasive surgery. The long term goal was for the patient to be free from signs of infection after 3 days. Nursing interventions included monitoring for signs of infection, maintaining sterile technique, providing rest and exercise, and educating on hand hygiene. The short term goal was for the patient to initiate interventions to reduce infection risk after 8 hours. Evaluation found the goals were met as the patient showed no infection signs and properly initiated hygiene.

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    ASSESSMENT OBJECTIVE/GOAL NURSING INTERVENTION SCIENTIFIC RATIONALE EVALUATION

    Diagnostic (Dx):
    Subjective Data: Long Term Goal:  Assess and monitor for signs of  Early recognition of infection in After 3 days of NI the
    After 3 days of NI the patient infection various parts of the body enables the patient was free from
    will be free from any signs of initiation of early interventions to any signs of infection as
    infection as evidenced by prevent complications. evidenced by
    Objective Data: -VS and lab values within  Assess and evaluate signs of  Used to identify causative factors for -VS and lab values
     JP drain on left and right normal ranges infection through laboratory infections and appropriate therapy within normal ranges
    side of the neck - No inflammation or pus values and Vital signs. - No inflammation or
     Patent NGT tube formation at the wound area  Assess wound or surgical site for  Early recognition and intervention pus formation at the
     Secured trache tube signs of infection (inflammation, may prevent progression to more wound area
     Dry and intact dressing pus formation) serious situation or sepsis. LTG: fully met
     Vital Sign: Therapeutic (Tx):
    BP- 130/80  Provide adequate rest periods  Ensuring that the patient has
    PR- 80 but remain active adequate rest periods reduces the
    RR- 18 incidence of fatigue while adequate
    Temp.- 36.6  Maintain sterile technique in exercise can prevent the loss of After 8 hour of nursing
    Short Term Goal: changing dressing, suctioning, muscle function and support healthy intervention the client
    and cleaning of trache tube. immune function. was able to identify and
    After 8 hour of nursing  To prevent introducing bacteria. initiate interventions
    intervention the client will  Reposition frequently; keep that can help reduce the
    identify and initiate linens dry and wrinkle-free.  Reduces pressure and irritation to risk of infection as
    Nursing Diagnosis: Risk for interventions that can help tissues and may prevent skin evidenced by proper
    Infection r/t Immunosuppression reduce the risk of infection as Educative (Edx): breakdown hand hygiene and
    and invasive treatment procedures evidenced by proper hand  Promote good handwashing following infection
    secondary to post surgery of hygiene and following infection procedures by staff and visitors  Protects patient from sources of control measures.
    tongue mass, radical neck excision control measures. specially when handling the infection STG: fully met
    and insertion of trache tube. patient. Screen and limit visitors
    who may have infections.
     Emphasize personal hygiene,  Frequent hand washing limits
    specifically hand hygiene. potential sources of infection and
     Emphasize to the watcher or secondary overgrowth.
    patient to alert healthcare team  To provide immediate action and
    to signs of infection such as prevent complications.
    fever, cough, chills, sore throat
    or mouth sores.

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