RISK FOR INFECTIONRISK FOR INFECTIONBY: Michelle Ann B. Tarrobago, St. N. BY: Michelle Ann B. Tarrobago, St. N.

Date Cues Need

JULY 25,

2013

@

7:00 AM

Objective:

S/P Debridement of infected wound

@ left foot

WBC count of 20.4

Glycosated hemoglobin

Bacteria (820) in urine

Yeast infection in urine

Vital signs as follows: Temp: 35.5°CPR: 79 bpm

CR: 81 bpm

RR: 20 cpm

BP: 110/70 mmHg

HEALTH

PERCEPTION

– HEALTH

MANAGEMEN

T PATTERN

Nursing Diagnosis

Risk for infection related to tissue destruction as evidenced by

left diabetic foot

Rationale:Foot infections are common in patients with diabetes and are associated with high morbidity and risk of lower extremity amputation. In patients with diabetes, any foot infection is potentially serious. Diabetic foot infections range in severity from superficial paronychia to deep infection involving bone. Types of infection include cellulitis, myositis, abscesses, necrotizing fasciitis, septic arthritis, tendinitis, and osteomyelitis. Foot infections are among the most common and serious complications of diabetes mellitus. They are associated with increased frequency and length of hospitalization and risk of lower extremity amputation. Foot ulceration and infection are the leading risk factors for amputation. Prevention and prompt diagnosis and treatment are necessary to prevent morbidity, especially amputation.

Objectives of Care

Within my 8 hours span of nursing care, my patient

will be able to remain free from infection as

evidenced by:a)Demonstration of various techniques in order to

avoid infection like proper hand washing;b)Verbalization comprehension on the importance of

avoiding the spread of organisms;c)WBC within normal range (N: 5.0 – 10.0 x 10

^g/L);d)Maintain normal vital signs.

Nursing Interventions

1. Observe for signs of infection and inflammation—fever, flushed appearance, wound

drainage, purulent sputum, and cloudy urine.

Rationale: Client may be admitted with infection, which could have precipitated the ketoacidotic

state, or may develop a nosocomial infection.

2. Promote good hand washing by staff, student nurses, relatives/watcher and client.

Rationale: Reduces risk of cross-contamination.

3. Maintain aseptic technique for IV insertion procedure, administration of medications, and

providing site care. Rotate IV sites, as indicated.

Rationale: High glucose in the blood creates an excellent medium for bacterial growth.

4. Teach the client to clean the vagina from front to back after elimination.

Rationale: Minimizes risk of UTI. Note: Elderly female diabetic clients are especially prone to

UTIs and vaginal yeast infections. Many UTIs are asymptomatic, possibly related to neurogenic

bladder.

5. Provide conscientious skin care, gently massage bony areas, keep the skin dry, and keep

linens dry and wrinkle-free.

Rationale: Peripheral circulation may be impaired, placing client at increased risk for skin

irritation and breakdown and infection.

Nursing Interventions

6. Inspect client’s feet, noting presence of ulcers or infected ingrown toenails, or other

problems requiring medical or nursing intervention.

Rationale: Foot injuries and impaired circulation are associated with many complications in

diabetics, including cellulitis and amputations. Note: Cellulitis can precipitate episode of DKA.

7. Auscultate breath sounds.

Rationale: Rhonchi indicate accumulation of secretions possibly related to pneumonia or

bronchitis that may have precipitated the DKA.

8. Place in semi-Fowler’s position.

Rationale: Facilitates lung expansion and reduces risk of aspiration.

9. Reposition and encourage coughing and deep breathing if client is alert and cooperative.

Otherwise, suction airway, using sterile technique, as needed.

Rationale: Aids in ventilating all lung areas and mobilizing secretions. Prevents stasis of

secretions with increased risk of infection.

10. Provide tissues and trash bag in a convenient location for sputum and other secretions.

Instruct client in proper handling of secretions.

Rationale: Minimizes spread of infection.

Evaluation

June 25, 2013

@ 3 PM

GOAL PARTIALLY MET

After my 8 hours span of nursing care, my patient was able to remain free from

infection as evidenced by:a) Demonstration of various techniques in order to avoid infection like proper hand

washing, cleaning the vagina from front to back, keeping the skin dry, etc.b) “kailangan talaga malinis para hindi mainpeksyon ang aking sugat sa paa, diabetic

pa naman ako” as verbalized by the patient;c) WBC count of 14.4 (N: 5.0 – 10.0 x 10 ^g/L)d) Maintain normal vital signs

Temp: 35.4°C RR: 22 cpmPR: 78 bpm BP: 110/80 mmHg

CR: 80 bpm

Michelle Ann B. Tarrobago, St. N.