Nursing Care Plans | 09/29/2011, 2:02 pm

9 Fracture Nursing Care Plans & Pathophysiology

9 Risk for Infection

Risk for infection occurs when a person is at risk for being invaded by pathogenic organisms. Transmission of an infectious agent from a source to a susceptible host occurs within an environment. Organisms live and multiply in a reservoir. The reservoir provides what the organisms needs for survival at a specific stage in its life cycle. In this case, the dressing and broken skin can be the reservoir that may lead to infection.

Assessment	Nursing Dx	Planning	NursingInterventions	Rationale	Expected Outcome
S > ØO > patient may manifest:

▪ increase in WBC count

▪ redness, swelling, purulent discharge at incision site

▪ hyperthermiaRisk for Infection r/t musculoskeletal impairmentShort Term:After 2 hours of nursing interventions, the patient will verbalize understanding of individual causative/risk factor.

Long Term:

After 1 day of nursing interventions, the patient will demonstrate techniques, lifestyle changes to promote safe environment.▪ Monitor temperature.▪ Assess incisions for redness, drainage, swelling, and increased pain.

▪ Instruct patient/caregiver to wash hands before contact with postoperative patient. Teach use of aseptic technique during dressing change, wound care, or handling or manipulating of tubes/drains.

▪ Instruct caregiver in administration of antibiotics and antipyretics as prescribed.▪ For the first 24 to 48 hours postoperatively, temperatures of up to 38.5 degrees Celsius are expected as a normal response to surgery. Beyond 48 hours, temperature should return to patient’s baseline.▪ Incisions that have been closed with sutures or staples should be free of redness, swelling, and drainage. Some incisional discomfort is expected. These incisions are usually kept covered by a large adhesive bandage for 24 to 48 hours; beyond 48 hours, there is no need for a dressing.

▪ Hand washing remains the most effective method of infection control.

▪ Reduce fever and risk of infectionPatient remains free of infection as evidenced by healing wound/incision that is free of redness, swelling, purulent discharge, and pain; and by normal temperature within 48 hours postoperatively.

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