ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Infection After 5 days of nursing 1. Note risk for the occurrence of 1. To determine specific
related to intervention patient infection problem for specific
inadequate will be able to treat 2. Note signs and symptoms of intervention
Objective: secondary infection and decrease sepsis 2. To prevent complication
defenses as signs of infection 3. Monitor visitors 3. To prevent exposure of
> decrease evidence by 4. Provide Isolation the client
hemoglobin cough and 4. To prevent cross
>decrease fever 5. Maintain cleanliness of contamination
lymphocyte surroundings 5. Prevent further
>decrease RBC 6. Encourage the SO to change complication
>increase patient’s position frequently 6. For mobilization of
neutrophil 7. Maintain adequate hydration respiratory secretions
>increase 8. Discuss the SO of not taking 7. To prevent dehydration
monocyte antibiotics unless instructed 8. Inappropriate use of
>(+)cough by the heath care providers antibiotics can lead to
>Elevated body 9. Review the individual development of drug
temperature of nutritional needs & need rest resistant secondary
38.3 Celsius 10. Monitor medication regimen infection
9. To regain loss of energy
10. To prevent complication
from adverse reaction of
drugs
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Risk for After 8 hrs of nursing 1. Assess vital signs changes 1. Increase body
Objective: deficient intervention patient 2. Monitor skin turgor,moisture temperature will increase
volume deficit will be able to prevent mucous membrane metabolic ate & fluid loss
> Weakness noted related to fluid volume deficit 3. Note and reports nausea and through evaporation
>Irritability and increase vomiting 2. Indirect indicators of
restlessness noted digestive 4. Monitor intake and output adequacy of fluid volume
>mild diarrhea 2- motility 5. Encourage the SO to increase 3. Presence of this
3x a day fluid intake symptoms reduce oral
>good skin turgor 6. Discuss the So the risk factors intake
>moisten skin 7. Discuss the in how to measure 4. Provide appropriate fluid
intake and output volume replacement
8. Review appropriate 5. To prevent dehydration
medications 6. To prevent deficient
9. review laboratory data volume
10. Monitor medications 7. To easy get information
in monitoring I&O
8. To know appropriate
medications given
9. To determine fluid and
electrolyte imbalance
10. Reduce risk of
complication of adverse
reaction of drugs
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: ‘’ dili Risk for After 8 hrs of nursing 1. Monitor intake and 1. To obtain baseline data
kayo sya ganahan imbalance intervention, patient output of liquid
moinom ug tubig nutrition less will be able to 2. Schedule respiratory 2. Reduce effects of nausea
ug gatas’’, as than body demonstrate boost on treatments at least associated with these
verbalized by the requirements appetite to consume 1hr before meals treatments
SO. related to his normal range on 3. Auscultate bowel 3. Bowel sounds may be
decrease oral liquid and nutrition sounds diminished or absent of
intake. consumption 4. Provide small frequent the infectious process is
feeding sever or prolonged.
5. Evaluate general 4. Enhance intake though
Objective: nutrition state, obtain appetite may be slow to
baseline weight return
> Weakness noted 6. Encourage the SO to 5. Presence of chronic or
>Irritability and increase fluid intake financial limitations can
restlessness noted 7. Discuss the in how to be contribute to
measure intake and malnutrition
output 6. review laboratory data
8. Review appropriate 7. To easy get information
medications in monitoring I&O
9. review laboratory 8. To know appropriate
data medications given
10. review laboratory 9. To determine fluid and
data electrolyte imbalance
10. To prevent complication
from adverse reaction of
drugs
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Ineffective After 8 hrs of nursing 1. Monitor core 1. To prevent from seizure

thermoregulation intervention, patient temperature
Objective: increase body will be able to 2. Indicate needs for
temperature decrease body 2. Identify underlying cause prompt intervention
>Skin is warm to related to temperature within 3. To prevent dysrythmias
touch infection process normal of 37.5 degree
>Irritability as evidence by Celsius 3. Monitor heart rate and 4. Hyperventilation may
>restlessness temperature of rhythm initially be present
noted 38.3 degree 4. Motor respiration
>increase body Celsius
temperature of 5. Promote surface cooling 5. To decrease core
38.3 degree by means of undressing temperature
Celsius 6. Encourage he SO to
increase fluid intake 6. To prevent dehydration
7. Provide time for bed rest 7. To reduce metabolic
demands
8. Recommended high 8. To meet increase of
calorie diet metabolic demands
9. Promote client safety 9. To prevent from injury

10. Administer antipyretic/ 10. To control shivering and

analgesic as prescribed seizures