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Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

 SUBJECTIVE Risk for infection related to Goal:  Assess for presence of  To determine the After the intervention, the
The client post- operative incision After the nursing host-specific factors possible risk factors client was able to:
verbalized “Ang sakit ng intervention, the client will that may affect and causative agents
immunity.  Verbalize
tahi ko pag naglalakad be able to identify the risk
tapos medyo nahihilo factors and causative agents  To look for signs and understanding of
ako kahit nakaupo” that are present  Conduct physical symptoms of a individual causative or
assessment for at-risk localized infection that risk factors
Pain Scale: 7/10 client could develop
Objectives:  Identify interventions
After the nursing  Demonstrate and  To have a first-line to prevent or reduce
 OBJECTIVE intervention, the client will inform client about defense against local risk of infection.
be able: proper hand hygiene. infections
Vital Signs  Achieve timely wound
BP: 160/90   Provide isolation (if  To avoid the healing; be free of
Temp: 37.1℃ To have an understanding needed), clean and contamination and the purulent
PR: 82 about infection control well-ventilated spread of infections. drainage/erythema
RR: 20 environment for the
 To gain knowledge client.
about infection control  To determine
and will be able to  Administer/monitor effectiveness of
perform proper medication regimen therapy or presence of
techniques of wound (antibacterial/antibiotic any adverse effects.
care. s such as cefuroxime.)
 Premature
 Be free from any signs,  Emphasize the discontinuation of
symptoms and risks of necessity of taking treatment when client
infection antivirals or begins to feel well may
antibiotics,as directed. result in return of
infection.
Inappropriate use can
lead to development of
drug resistant strains or
secondary infections.

Nursing Care Plan Name: Section: Date:

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