this is a sample nursing care plan for nursing students about risk for infection during surgery

1. Roet . Mila
Gop 3 BN 3A
NURSING
CARE
PLAN
(Risk for Infection)

2. ASSESSMENT CUES
Name
Edcel C. Dado
Age
44 y/o
Gender
Male
Patient’s residual limb has
a non-healing wound
Patient is post-surgical
and in fair condition
Surgery
Above elbow amputation (right arm)
OBJECTIVE
Patient has DM 2
01
SUBJECTIVE

3. NURSING DIAGNOSIS
Risk for infection related to traumatized skin tissues post amputation.
02

4. BACKGROUND KNOWLEDGE
03
The human skin is a natural barrier against infection. Even with many
precautions and protocols to prevent infection in place, any surgery that
causes a break in the skin can lead to an infection. In medical terms, they
are called surgical site infections (SSIs) because they occur on the part of
the body where the surgery took place. The chances of developing an
SSI are about 1% to 3% for surgery patients.
Surgical site infection after amputation is common and can increase
patient morbidity, leading to negative effects on healing, phantom pain
and time to prosthetic fitting. Risk factors for a stump infection include
diabetes mellitus, old age and smoking, which are all common
denominators amongst the amputee population. Besides wound care,
antibiotics serve as first-line medications in the prevention of SSI.

5. PLANNING
Short-Term Goals
Stay afebrile Be free of purulent drainage and erythema
04
Achieve stable vital signs
Regain strength and energy
after surgery
Follow and participate in the
prescribed treatment regimen

6. PLANNING
Long-Term Goals
Verbalize appropriate home-care
measures in taking care of the residual
limb
04
Experience gradual and complete
wound healing within four to
eight weeks post-surgery
Prevent stump infection for
fourteen days until hospital
discharge
Eventually cope and recover from
experienced limb loss and be able to
continue daily life activities in the
absence of the right forearm

7. Vital signs establish baseline data
about patient’s overall function
and wellbeing. Temperature
elevation and tachycardia may
reflect developing sepsis.
NURSING
INTERVENTION
Monitored vital signs regularly,
especially temperature and heart
rate.
?
RATIONALE
05 06

8. To prevent introduction of bacteria
on the stump.
NURSING
INTERVENTION
Maintained aseptic technique
when performing wound care and
in applying and changing
dressings.
?
RATIONALE
05 06

9. Dressing the stump according to
surgeon’s order allows the wound to
heal effectively and shapes the
residual limb for prosthesis. Usually,
elastic bandage is used to hold the
dressing in place. Also, when
drainage starts to ooze from the
dressing, it needs to be changed.
NURSING
INTERVENTION
Referred to surgeon’s order on
what dressing to use, how often
it should be changed and how it
should be done properly.
?
RATIONALE
05 06

10. Early detection of developing
infection provides an
opportunity for timely
intervention and prevention of
more serious complications.
NURSING
INTERVENTION
Inspected the wound and the
used dressings; noted for
characteristics of damage.
?
RATIONALE
05 06

11. Antibiotics are prophylactic
medications used after limb
amputations in the goal of
preventing stump infection.
NURSING
INTERVENTION
Administer antibiotics as
ordered.
?
RATIONALE
05 06

12. Wound and drainage cultures and
sensitivities identify the presence of
specific microorganisms such as
bacteria that can cause infection;
hence, the appropriate treatment will
follow. CBC results suggest a
bacterial infection if the white blood
cell and neutrophil counts are high.
NURSING
INTERVENTION
Obtained wound and drainage
cultures and sensitivities and
other laboratory tests such as
CBC as appropriate.
?
RATIONALE
05 06

13. Drinking water promotes hydration which
speeds up the healing process by aiding in
the transport of cell-repairing nutrients to
the amputated area. A diet filled with
nutritious foods such as fruits and
vegetables reduce inflammation and
promote the production of WBCs which
strengthens the immune system and fuels
the body’s recovery to a performed
operation.
NURSING
INTERVENTION
Advised the patient to maintain
adequate fluid intake and a
well-balanced diet.
?
RATIONALE
05 06

14. Encourages the patient and the
family to participate in measures
that will promote wound healing
and avoid ones that may
exacerbate the risk of infection.
NURSING
INTERVENTION
Informed the patient and the
family about the signs and
stages of wound healing and
when to expect total healing.
?
RATIONALE
05 06

15. After fourteen days of hospital stay,
the stump will still need an allotted
recovery time of four to eight weeks.
Hence, proper homecare is essential
to ensure and quicken the healing
process. The do’s and don’ts must be
followed to prevent infection from
stopping the healing process.
Educated the patient and the family about
essential homecare measures including the
do’s and don’ts for wound care and
prevention of infection (making use of warm
water and mild soap and sterile dressing,
avoiding perfumed lotions or
alcohol-containing substances, washing
anything that comes in contact with the skin).
Stressed the importance of handwashing
before and after wound care.
NURSING
INTERVENTION
?
RATIONALE
05 06

16. CREDITS: This presentation template was created by Slidesgo,
including icons by Flaticon, infographics & images by Freepik
EVALUATION
07
The patient maintained normal vital signs as
evidenced by:
T = 36.5 C PR = 90 bpm
RR = 18 bpm BP = 110/70 mmHg
The patient did not experience purulent
drainage and erythema.

17. CREDITS: This presentation template was created by Slidesgo,
including icons by Flaticon, infographics & images by Freepik
EVALUATION
07
The patient regained his strength and energy
after surgery.
The patient was free of stump infection for
fourteen days until discharge.
The patient followed and participated in his
treatment regimen.

18. CREDITS: This presentation template was created by Slidesgo,
including icons by Flaticon, infographics & images by Freepik
EVALUATION
07
The patient verbalized various home-care
measures for taking care of his residual right arm
and committed to these measures for gradual
recovery and complete wound healing.
The patient demonstrated effective coping
mechanisms after experienced limb loss and
showed desire to continue daily life activities
despite such loss.

19. THANK
YOU!

20. REFERENCES
Matt Vera (2021). 4 Amputation Nursing Care Plans.
Retrieved from
https://nurseslabs.com/4-amputation-nursing-care-plans/2/