University:
West Coast University
Course:
NURS 100 | Fundamentals of Nursing
Academic year:

2022
Views:

104

Pages:

1
Author:

do3ran7ut

Name: Date: 1/18/2022 Goal met Partially met If goal was met, monitor patient for any significant changes. If goal was partially met, continue enforcing nursing interventions till patient's goals are sufficient. Patient goals CONCEPT CARE MAP Pathophysiology Medical Diagnosis Gram-positive coccus that prevent the neutrophil migration to the site of infection, prevent phagocytosis, and prevent killing of foreign cells Methicillin-Resistant Staphylococcus Aureus (MRSA) Caused by neutropenia or neutrophil dysfunction Nursing Diagnosis Risk for infection r/t inadequate primary defenses / L Ensure isolation and contact transmission precautions Cefoxitin disk diffusion test Encourage strict hand hygiene Enforce strict use of personal protective equipment Ensure a clean environment Prevent the spread of infection Isolating the patient and keeping door closed will limit contact and limit spread of infection Anti-PBP2a monoclonal antibodies Assessment Skin infection noted on right side of neck, bump is red, swollen, and warm to touch. Pt states pain 7/10. Purulent drainage present. Temperature 101.7F. BP 135/89 P 98 RR 15. Nursing Interventions Number one way to prevent spread of infection Ensure isolation and contact transmission precautions Will protect patient and caregiver from infection risk Perform hand hygiene Using appropriate disinfecting solutions will ensure a clean environment Checking lab results, temperature every shift will identify signs fo infections Complications Skin infections: swelling, warmth, redness, and pain Blood and deep tissue infection (fever, chills, malaise, dizziness, confusion, muscle pain, swelling, tenderness) Use proper PPE Clean environment often Ensured isolation and contact transmission precautions Decontaminate patient equipment Encouraged strict hand hygiene Monitor signs of infection Ensured clean environment Enforces PPE use Prevented spread of infection