Assessment Nursing Diagnosis Goals and Objective Nursing Interventions Rationale Evaluation

Subjective: "Hindi Risk for infection After 8 hours of nursing Observe for signs of infection and Patient may be admitted with infection, After 8 hours of nursing
gumagaling ang sugat related to high glucose interventions, the inflammation. which could have precipitated the intervention s, the patient
ko" verbalized by the levels, decreased patient will identity ketoacidotic state, or may develop a was able to identify
patient. leukocyte function interventions to prevent nosocomial infection. intervention s to prevent or
or reduce risk of reduce risk of infection
infection.
Promote good handwashing by
Objective: Reduces the risk of cross contamination.
nurse and patient.
Flushed appearance.

Wound drainage High glucose in the blood creates an

Maintain aseptic technique for IV
excellent medium for bacterial growth
insertion procedure, administration
of medications, and providing
maintenance and site care. Rotate IV
sites as indicated.

Minimizes the risk for infection.

Provide catheter or perineal care
Teach the female patient to clean
from front to back after elimination.

Provide conscientious skin care,

gently massage bony areas. Keep Peripheral circulation may be impaired,
the skin dry linens dry and wrinkle patient placing at increased risk for skin
tree. irritation or breakdown and infection.

Place in semi fowler's position. Facilitates lung expansion and reduces

risk of aspiration.

Decrease susceptiblity to Infection

Encourage adequate dietary and
fluid intake of 3000 ml per day.