Chapter 1



Chapter 10

Sample Nursing Care Plan

The Client At Risk For Infection

Mr. Filar, a 38-year-old homeless person, was struck and dragged by a speeding car as he crossed the street. He was taken to the hospital by ambulance. His left leg is broken, and there are lacerations and abrasions on his right side, arm, and leg. The left leg is in a cast and the lacerations have been sutured. Mr. Filar is very thin and says that he has not eaten for 2 days.

Nursing Diagnosis 1 Infection, Risk for, related to inadequate primary defenses as evidenced by lacerations and abrasions

Planning/Goals Nursing Rationale Evaluation

Intervention Antimicrobial soap Mr. Filar has redness around

Mr. Filar will not Thoroughly wash is more effective one laceration.

have developed an hands using antimi- in reducing

infection in the crobial soap before microorganisms on

lacerations and and after caring hands.

abrasions at for Mr.Filar.

discharge. Prevents introduction

Use sterile technique of microorganisms

when caring for into lacerations and

lacerations and abrasions.

abrasions.

Promotes healing of

Apply antibiotic abrasions.

ointment on

abrasions as ordered. Removes any drain-

age that may harbor

Keep bed linens microorganisms.

clean and dry.

Prevents or cures

Administer oral infection.

antibiotics, as

ordered.

Nursing Diagnosis 2 Pain, related to physical injury as evidenced by facial grimacing

Planning/Goals Nursing Rationale Evaluation

Interventions

Mr. Filar will exper- Use pain scale to det- Provides objective Mr. Filar states that he is

ience increased ermine level of measure of pain. Experiencing less discomfort

comfort and will discomfort. by 16 hours but that he still

verbalize that Reduces pain and desires pain medication.

pain is under Assist client to a swelling by increas-

control within 24 position of comfort ing blood return to

hours. and elevate extrem- the heart.

ities.

Provides comfort.

Administer analge-

sics as ordered.

Nursing Diagnosis 3 Nutrition, Altered, Less than Body Requirements, related to economic factors as evidenced by extreme thinness and not having eaten for 2 days

Planning/Goals Nursing Rationale Evaluation

Interventions

Mr. Filar will eat Assist Mr. Filar to Wound healing Mr. Filar eats both

balanced meals select foods high depends on the everything on his meal

while hospitalized. in protein, vitamins availability of trays and the between

A and C, calcium, protein, vitamins, meal snacks.

zinc, and copper. and minerals.

Provide between Snacks will increase

meal snacks, espec- overall caloric intake;

ially milk, or milk increased protein will

products. promote wound healing;

increased calcium will

promote bone healing.

From While, L. (2001). Foundations of Nursing: Caring For the Whole Person.

Albany, NY: Delmar Learning.

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