Assessment Nursing Diagnosis Planning Nursing Intervention Evaluation

Ist Day of Hospital- Risk for infection re- Short Term: Independent: After effective nursing in-
ization: lated to elevated After 8 hours of nursing tervention the short term
July 12, 2022 body temperature intervention patient will • Monitor vital signs. Note presence goals aremet.
be able to: of chills, fever, malaise, changes in
Shift/Time: mentation. Short Term:
7:00 am - 4:00 pm • gain knowledge in in- • Perform Tepid Sponge Bath After 8 hours of nursing
Subjective Data: fection control • If patient feels cold, provide blan- intervention patient was
“Para akong nilala- • Subside body temper- ket. able to:
gat” as verbalized by ature • Promote a well-ventilated area to
the patient. patient. • gain knowledge in infec-
Long Term: • Inspect the skin for pre-existing ir- tion control
Method Used: Inter- After 6-8 weeks of nurs- ritation or breaks in continuity. • subside body tempera-
view ing intervention the pa- • Assess pin sites and skin areas, ture
tient will achieve bone noting reports of increased pain,
healing. burning sensation, presence of
Objective Data: edema, erythema, foul odor, or
Vs as follows: drainage.
T: 38.6 • Line perineal cast edges with plas-
RR: 26 bpm tic wrap.
PR: 115 bpm Damp, soiled casts can promote
BP: 110/90 mmHg the growth of bacteria.

- Weak in appear-
Collaborative:
ance
- Diaphoresis Refer to medical technologist for
- Chills laboratory tests

Method Used: Ob-

Dependent:
servation and taking
vital signs. Administer prescribed medications.
2nd Day of Hospital-
ization:
July 13, 2022

Shift/Time:
7:00 am - 4:00 pm
Subjective Data:
“Para akong nilala-
gat” as verbalized by
the patient.

Method Used: Inter-

view

Objective Data:
Vs as follows:
T: 38.6
RR: 26 bpm
PR: 115 bpm
BP: 110/90 mmHg

- Weak in appear-
ance
- Diaphoresis
- Chills

Method Used: Ob-

servation and taking
vital signs.