Name: Vince John B.

Sevilla NCP CONFERENCE N-31

ASSESSMENT NURSING OBJECTIVES/EVAL NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOS UATION CRITERIA
IS
Independent: Independent: Short Term: after 8 hours
S: Risk for Short term: Within 8 1. Assess the general condition of the patient 1. To note any alterations regarding the of nursing interventions,
infection r/t hours of nursing 2. Focused assessment on abdomen . patient’s condition and to identify the the patient was able to
tissue interventions the 3. Observe for localize sign of infection. prioritized problem. identify ways to prevent
destruction patient will be able 4. Review of lab studies. 2. To have a thorough assessment on following or reduce risk of
O: secondary identify ways to 5. Assess for use of medication that may cause areas in the lower abdomen. infection
to inguinal prevent or reduce risk immunosuppression. 3. To know where the microorganism may enter - Goal met
-with 4 days hernia of infection and create infection. Long Term: after 3 days
incision site at repair 6. Monitor temperature of pt. 4. Very low WBC count may indicate a severe of nursing interventions,
inguinal area. Long term: Within 3 7. Assist with measures to facilitate gas exchange. risk for infection. the patient was able to be
days of nursing (positioning Semi-fowlers) 5. Antineoplastic agents, corticosteroids, and so free from developing an
-warm upper interventions the
lower on, can reduce immunity infection throughout her
patient will be able to 8. Demonstrate Coughing exercise such as direct or 6. Hyperthermia indicates present of infection. hospitalization
extremities be free from controlled coughing through splinting. 7. To promote comfort when standing , sitting - Goal met
developing an 9. Demonstrate Breathing Exercise such Inspiratory, and lying.
-WBC 11.5
infection throughout Diaphragmatic, Pursed Lip Breathing. 8. The most convenient way to remove most
increased
his hospitalization 10. Demonstrated proper hand washing to patient and secretions is coughing.
-Neutrophils SO 9. Deep breathing, on the other hand, promotes
9.87 increased 11. Maintain adequate hydration, stand, or sit to void if oxygenation before controlled coughing.
necessary 10. To prevent such infections.
-unchanged 12. Provide a clean and well ventilated environment 11. To eliminate toxic substances from our body,
dressing 4 days so they can be excreted through urine and/or
Health Teachings: sweat.
12. To minimize the possibility of infection
13. Advise adequate rest periods 13. Pulse oximetry values are used to assess the
14. Emphasize constant and proper personal care patient’s need for oxygen and administer
15. Encourage intake of foods rich in protein and supplemental oxygen as prescribed
vitamin C. Health Teachings:
16. Encourage patient adequate fluid intake 14. To promote healing and restoration of energy
17. Encourage Patient to limit visitor 15. Patients and SO can spread infection from
18. Teach the patient or SO the importance of avoiding one part of the body to another –
contact with individuals who have infection or colds. handwashing reduces these risks.
19. Teach patient to avoid touching the incision site. 16. Helps support the immune system
20. Instructed pt to avoid wetting the dressing. responsiveness.
21. teach the patient to take antibiotics as prescribed. 17. Fluids promote diluted urine and frequent
Dependent: emptying of bladder – reducing the stasis of
22. Administer antibiotics, as indicated urine, in turn, reduces risk for bladder
infection or urinary tract infection.
18. Restricting visitation reduces the
transmission of pathogens.
 19. To prevent entry of microorganism
20. Wet areas causes the microorganism
multiply fast
21. To provide information about nebulizing
22. Antibiotics work best when a constant blood
level is maintained which is done when
medications are taken as prescribed.
Dependent:
23. Antibiotics hinder or kill susceptible
bacterias
Collaborative:
24. For curative measres