Scribd
Upload
23 views2 pages

Cues Nursing Diagnosis Scientific Basis Goal & Outcome Criteria Nursing Actions & Nursing Orders Rationale of Nursing Orders

The patient is at risk for infection related to a recent surgical incision. Vital signs were within normal limits and the dressing was dry and intact. The nursing diagnosis is risk for infection. The goal is for the patient to identify signs of infection within 24 hours. Nursing actions include teaching hand washing, wound care, proper nutrition, exercise and rest. Orders include monitoring medications and administering antibiotics or immunizations as needed to prevent infection and promote healing.

Uploaded by

Alexis Tillano
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
23 views2 pages

Cues Nursing Diagnosis Scientific Basis Goal & Outcome Criteria Nursing Actions & Nursing Orders Rationale of Nursing Orders

The patient is at risk for infection related to a recent surgical incision. Vital signs were within normal limits and the dressing was dry and intact. The nursing diagnosis is risk for infection. The goal is for the patient to identify signs of infection within 24 hours. Nursing actions include teaching hand washing, wound care, proper nutrition, exercise and rest. Orders include monitoring medications and administering antibiotics or immunizations as needed to prevent infection and promote healing.

Uploaded by

Alexis Tillano
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

CUES

NURSING
DIAGNOSIS

SCIENTIFIC
BASIS

GOAL &
OUTCOME
CRITERIA

NURSING
ACTIONS &
NURSING
ORDERS

RATIONALE
OF NURSING
ORDERS
SUBJECTIVE:
>none

OBJECTIVE:
>Vital signs
taken as follow:
>BP:
110/80mmHg
>T: 36.5
o
C
>PR: 82 bpm
>RR: 18 cpm

>Dressing dry
and intact.


Risk for
infection related
to surgical
incision.
Wounds
involving injury
to soft tissue can
vary from minor
tears to severe
crushing
injuries. The
decision to
suture a wound
depends on the
nature of the
wound the time
since the injury
was sustained
the degree of
contamination.

(NANDA
BOOK, 2009 pg.
307)
GOAL:
After 24 hours of
nursing
intervention, the
patient would be
able to identify
signs of
infection and
report them to
health care
provider
accordingly.

OUTCOME
CRITERIA:
1.) The client
would be able to
verbalize
understanding of
individual
causative/risk
factor(s).

2.)Identify
interventions to
prevent/reduce
risk of infection.

INDEPENDENT:
>Stress proper hand
washing techniques
by all caregivers
between therapies.

>Inspect dressing
and perform wound
care.


>Provide isolation as
indicated.


>Review individual
nutritional need,
appropriate exercise
program, and need
for rest.


DEPENDENT:
> Monitor
medication regimen
and note client's
response.


>A first-line
defense against
nosocomial
infections.

>moist from
drainage can be
a source of
infection.

>Reduces risk of
cross-
contamination.

>To promote
wellness






>To reduce
existing risk
factors.


3.) Demonstrate
techniques,
lifestyle changes
to promote safe
environment.

4.) Achieve
timely healing.

5.) Be free of
purulent
drainage or
erythema; be
afebrile.
COLLABORATIVE:
>Administer
prophylactic
antibiotics and
immunizations as
indicated.

>To prevent
infection from
occurring.

(NANDA
BOOK, 2009
pp.307-309)

You might also like