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Patient: Roel Bael Age: 26 yrs.

old Status: MGH Date: 09/17/2010


Risk for Infection
ASSESSMENT NURSING INFERENCE PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Short-term Goal Short-term Goal
Subjective Cues: Risk for infection Entry of pathogens to the
r/t appendectomy appendectomy site Goal Met
↓ After 4 hours of nursing After 4 hours of nursing
 “Masakit and Infection
aking tahi, tapos interventions, the interventions, the
↓ patient will be: patient was:
parang and init.,” Release and activation of
as verbalized by Interleukin-1
the patient.  Able to  Give patient  To help the  Able to
↓ maintain tepid sponge bath body reduce the
Fever maintain
Objective Cues: temperature within temperature temperature within
normal range normal range
 Vital signs as of  Carefully  To properly
7:00 am monitor the patient know if there is  Vital signs as
temperature deviation in the
of 11 :00 am
patients
• T: 38.0 oC
temperature • T: 37.5 oC
• PR: 78 bpm • PR: 68 bpm
• RR: 19 cpm  To monitor • RR: 16 bpm
• BP: 110/70  Monitor and the present • BP: 100/60
document other vital health status of
signs the patient

 To
determine the
 Administer effectiveness of
medication regimen as the regimen
ordered by the
After 1 hour of nursing physician After 1 hour of nursing
interventions, the
interventions, the
patient will be:
patient was:

 Able to  To make an  Able to


identify and  Establish rapport efficient patient- identify
verbalize nurse interventions that
interventions that communication will reduce the risk
will reduce the risk for infection
for infection
 To prevent  The client
 Emphasize the infection verbalized that he
necessity of taking should take all his
antibiotics as directed medication and
by the physician clean the suture
 To promote wound in the
 Instruct client in the prevention of appendectomy site
techniques to care for infection to reduce and
lesion and prevention prevent infection
of spread of infection
Kirby R. Contaoi
PLM SN Batch 2012 Group F