Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide develop nursing diagnoses. When establishing nursing diagnoses around biological safety and infection, the nurse should consider the following possible diagnoses: • Contamination, risk for • Health behavior, risk prone • Infection, risk for • Injury, risk for • Knowledge deficit • Mobility, impaired • Pain, acute • Protection, impaired • Self-care deficit, bathing/hygiene • Self-neglect • Skin integrity, impaired or risk for impaired • Tissue integrity, impaired These diagnoses may be related to: • Chronic or acute disease processes • A breakdown in the patient's primary defenses that provides a portal of entry for a microorganism • Inadequate defenses provided by the patient's normal immune response, particularly any diseases or process that cause immunosuppression • Invasive procedures (tube or catheter insertion, surgery, etc.) that may involve a break in the skin or mucous membranes • Trauma • Environmental exposure to pathogens • Poor nutrition • Medications Planning The planning phase of the nursing process includes: • Prioritization of nursing diagnoses: Using the diagnoses from the analysis phase, the nurse and patient should establish the priority using Maslow's hierarchy and the patient's perception of his needs. • Establishing goals or expected outcomes: Goals or outcomes that might be appropriate are: o The patient will show no signs or symptoms of local or systemic infection. o The patient's vital signs will be within normal limits. o The patient will show no signs of skin breakdown. If skin breakdown exists, this goal might be changed to indicate that skin breakdown will be resolved. o The patient's hygiene practices will be maintained or improved. o Teaching and education goals should be appropriate to the patient's or caregivers' needs.

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