CUES NSG. DX.

SCIENTIFIC RATIONALE OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE Risk for Persons at risk for infection are those After 8hours of INDEPENDENT
infection r/t whose natural defense mechanisms are Nurse-patient
- presence of Inadequate inadequate to protect them from the interaction, the
lacerated wounds primary inevitable injuries and exposures that client will be able Assess for presence, This will help you Plan
on the face. defenses: occur throughout the course of living. to: existence of, and history for further interventions.
broken skin, Infections occur when an organism of risk factors .
- attachment of injured (e.g., bacterium, virus, fungus, or other
CTT tissue, body parasite) invades a susceptible host. a. Client will remain
fluid stasis Breaks in the integument, the body’s free of infection, as
- untidy first line of defense, and/or the mucous evidenced by temp
environment membranes allow invasion by < 38C Monitor for signs and fever above 37.7° C
pathogens. If the host’s (patient’s) symptoms of infection. (99.8° F) suggests
- still for immune system cannot combat the (Redness, swelling, infection; fever spikes
Laboratory Work invading organism adequately, an b. Client will show increased pain,and that occur and subside
– ups infection occurs. Open wounds, no signs and Elevated temperature, are indicative of wound
traumatic or surgical, can be sites for symptoms of Color of respiratory infection; very high
- on O2 inhalation infection; soft tissues (cells, fat, muscle) infection secretions and fever accompanied by
and organs (kidneys, lungs) can also be Appearance of urine) sweating and chills may
- V/S sites for infection either after trauma, indicate septicemia.
BP: 90/70 invasive procedures, or by invasion of Yellow or yellow-green
T: 36.8 pathogens carried through the sputum is indicative of
P: 80 bloodstream or lymphatic system. respiratory infection.
RR: 24 Infections can be transmitted, either by loudy, foul-smelling
contact or through airborne urine with visible
“ wa pa siya'y transmission, sexual contact, or sharing sediment is indicative of
kaon ky ingin man of intravenous (IV) drug paraphernalia. urinary tract or bladder
sa ako nga kuhaan Being malnourished, having inadequate infection.
pa siya ug dugo resources for sanitary living conditions,
pero wa pa man and lacking knowledge about disease
karon. “ as transmission place individuals at risk
verbalized by SO for infection. Health care workers, to
protect themselves and others from
disease transmission, must understand
 how to take precautions to prevent
transmission. Because identification of
infected individuals is not always
apparent, standard precautions Assess for nutritional Patients with poor
recommended by the Centers for status. nutritional status may be
Disease Control and Prevention (CDC) anergic, or unable to
are widely practiced. muster a cellular
immune response to
pathogens and are
therefore more
susceptible to infection.

Stress proper hand Friction and running

washing technique by water effectively remove
all caregivers between microorganisms from
therapies. hands. Washing between
procedures reduces the
risk of transmitting
pathogens from one area
of the body to another

this maintains optimal

Encourage intake of
nutritional status.
protein- and calorie-rich
foods.
Encourage fluid intake Fluids promote diluted
urine and frequent
emptying of bladder;
reducing stasis of urine,
in turn, reduces risk of
bladder infection or
urinary tract infection
(UTI).

These measures reduce

Encourage coughing and stasis of secretions in the
deep breathing lungs and bronchial tree.
When stasis occurs,
pathogens can cause
upper respiratory
infections, including
pneumonia.

COLLABORATIVE

Administer Both Bactericidal and

antimicrobial Bacteriostatic: they
(antibiotic) drugs as interfere with the cell –
ordered. wall building ability of
the bacteria, they
prevent the bacteria
form synthesizing the
framework of their cell
walls.