Rhea Mae V.

Valles
BSN-III
Pt. R.D. 3y/o

Assessment Diagnosis Planning Interventions Evaluation

Subjective: Risk for After the shift of Nsg. Action Rationale After the shift of
Patient denies infection related nursing 1. Adhere to 1. Established nursing
malaise. to post-operative interventions, facility mechanisms interventions, the
incision. the client will infection designed to client was
Objectives: maintain safe control, prevent maintaining safe
c complaint aseptic sterilization, infection. aseptic
of pain on environment. and aseptic 2. Prepackaged environment.
umbilical policies and items may
area, c pain procedures. appear to be
scale of 2-3, 2. Verify sterility sterile; however,
10 as the of all each item must
highest and manufacturers be scrutinized for
0 as the items. manufacturers
lowest 3. Review statement of
c facial laboratory sterility, breaks
grimacing studies for in packaging,
V/S taken possibility of environmental
as follow: systemic effect on
T: 35.8 infections. package, and
P: 94 4. Note risk delivery
R: 23 factors for techniques.
occurrence of 3. Increased WBC
infection in count may
the incision. indicate ongoing
5. Observed for infection, which
localized sign
 of infection at the operative
insertion sites procedure will
of invasive alleviate
lines, surgical 4. To help the
incisions or patient identify
wounds. the present risk
6. Make health factors that may
teachings add up to the
especially in infection.
identification 5. To evaluate if the
of character,
environmental presence and
risk factors condition of the
that could add present infection.
up on 6. To help the client
infection. modify/change/a
7. Administer void some of the
antibiotics as environmental
ordered by the factors present
physician which could
reduce the
incidence of
infection.
7. Antibiotics will
help kill and stop
the proliferation
and growth of
the bacteria
which could
cause infection.