Assessmen T Nursing Diagnosis Planning Interventions Rationale Evaluation

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Assessmen t

Nursing Diagnosis
Risk for infection related to high glucose levels

Planning
After 8 hours of nursing interventions, the patient will identify interventions to prevent or reduce risk of infection.

Interventions
Independent: -Observe for signs of infection and inflammation.

Rationale

Evaluation
After 8 hours of nursing intervention s, the patient was able to identify intervention s to prevent or reduce risk of infection.

Patient may be admitted with infection, which could have precipitated the ketoacidotic state, or may develop a nosocomial infection. -Reduces the risk of cross contamination -Peripheral circulation may be impaired, placing patient at increased risk for skin irritation or breakdown and infection -Identifies organisms so that most appropriate drug therapy can be instituted.

-Promote good handwashing by nurse and patient -Provide conscientious skin care, gently massage bony areas. Keep the skin dry, linens dry and wrinkle free. Collaborative: -Obtain specimen for culture and sensitivities as indicated.

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