Sample Care Plan Template (Page 42 of 51) in pdf

Sample Care Plan Template Page 42

Nursing Diagnosis and Priority # 3:

Risk for infection R/T malnutrition, decreased hemoglobin, decrease in ciliary action, increased environmental exposure to pathogens

AEB increased temperature of 100.4, H & H of 9.0 & 27.9, nutritional deficiencies of folic acid & thiamine, ventilated, recovering for

pneumonia, and invasive medical lines (A-line, foley catheter, CVP).

General Goal:

The patient will not develop Ventilator Assisted Pneumonia (VAP) while intubated under my nursing care.

Outcome Objective(s): (use SMART format)

1. The patient will not develop signs of infection such as a temperature above 100 F, warmth, redness, or discharge during the nursing

shift.

2. The nurse will perform appropriate hand hygiene and where gloves when administering patient care during the nursing shift to help

prevent the development of infection.

3. The nurse will perform the patients oral care q2hrs during the shift and daily care routines (bathing, pericare, hair, and nail) qshift to

help prevent infection by decrease bacteria on patient skin and in oral cavity.

Patient Responses

Interventions with time frames/frequency

Rationale (for each intervention)

(subjective/objective data)

1) Elevation of the patient’s head of bed at

1) The patient was position with the head of bed

1) The patient tolerated the head of

at 30-45 degrees during the nursing shift to

30-45 degrees is one of the strategies

bed elevated at 30 degrees during

prevent gastric reflux of organisms into the lung

implemented to prevent VAP (Hunter,

the nursing shift. He had no adverse

(Ackley & Ladwig, 2011).

2006).

physiological changes to the

position while being on the

2) Drain collected fluid from condensation out of

2) This intervention lowers the risk for

ventilator.

ventilation tubing qShift (Ackley & Ladwig,

infection because it decreases the inhalation

2011).

of potentially contaminated water droplets

2) The patient tolerated the

(Burns, 2005).

intervention and experienced no

3) Auscultate patient’s lungs for adventitious

desaturation below 95% while

sounds q4hrs.

3) Assessing for adventitious lung sounds

touching and draining the ventilator

associated with VAP is one of strategies to

tubing.

prevent healthcare acquired infections

3) The patient’s lung sounds were

(Hunter, 2006).

assessed q4hrs and not adventitious

lung sounds were auscultated.

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12/17/2012

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Sample Care Plan Template Page 42

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