Nursing

Assessment Planning Intervention Rationale Evaluation

Diagnoses
Subjective: Risk for After 8 hours of Maintain strict aseptic to reduce the risk of After 8 hours of
“kakaanak ko pa Infection nursing technique on the colonization / nursing
lang nung isang related to intervention the procedure / infection of bacterial. intervention, goal
araw, Cesarian ako” inadequate patient’s will treatment of wounds. was partially met as
as verbalized by the secondary identify behaviors evidenced by the
patient. defenses of to prevent or to patient able to
decreased reduce the risk of verbalize
Objective: hemoglobin infection. understanding of
- (+) surgical Increase good hand to prevent cross health teachings
incision washing; by the care contamination / provided to prevent
-decreased Hgb = givers and patients. bacterial spread of infection.
103.0 colonization.
- decreased Hct
=0.31 Give skin care, oral reducing the risk of
- decreased MCH = and perianal damage to the skin /
26.8 carefully. tissue and infection.
- decreased MCV =
81.3
- increased RBW = Increase enter to assist in the
20 adequate fluids. dilution secret
- increased breathing to ease
Neutrophils = 78.8 spending and
prevent stasis of
body fluids such as
respiratory and
kidney.
Motivation changes in increased pulmonary
position / ambulation ventilation all
often, coughing and segments and help
deep breathing mobilize secretions
exercises. to prevent
pneumonia.

Monitor body the process of

temperature. Note inflammation /
the chills and infection require
tachycardia with or evaluation /
without fever. treatment.
Administer topical may be used to
antiseptic and reduce colonization
systemic antibiotics or prophylactic
as ordered treatment for local
infection process