ASSESSMENT DIAGNOSIS ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION

S> “Napansin ko yung Risk for infection related Open wound LTG: Independent: Goal met as
sugat ko sa binti, bigla to inadequate primary ↓ After 2 days of nursing 1. Observe and 1. With the onset of evidenced by the
report signs of infection the immune
nalang namamaga ata defenses secondary to Contact with intervention, the patient patient demonstrated
infection such as system is activated
namumula.” As broken skin integrity as contaminated soil or will demonstrate redness, warmth, and signs of infection techniques and
verbalized by the client. evidenced by: water infected by urine techniques and lifestyle discharge, and appear. lifestyles to prevent
increased body
 WBC result of 3.49 of rat to prevent or reduce risks for infection.
temperature.
O>  Wound on the right ↓ risks of infection.
 WBC result of leg Entry of Leptospira in 2. Note and report 2. Laboratory values
laboratory values are correlated with
3.49 the skin STG:
client's history and
 Wound on the ↓ After 4 hours of nursing physical examination
right leg Pathogens enters into intervention, the patient to provide a global
 Redness the bloodstream will verbalize different view of the client's
immune function and
 Swelling ↓ techniques in reducing nutritional status
Vital Signs: Leptospirosis or preventing risks of
 BP: 120/90mmHg ↓ infection. 3. Encourage a 3. Immune function
balanced diet, is affected by protein
 PR: 96bpm Decreased WBC
emphasizing proteins intake (especially
 RR: 25cpm ↓ to feed the immune arginine); the
system. balance between
 T: 36.9 °C RISK FOR
omega-6 and omega-
INFECTION
3 fatty acid intake;
and adequate
amounts of vitamins
A, C, and E and the
 minerals zinc and
iron.

4. Maintain or teach 4. Aseptic technique

asepsis for dressing decreases the
changes and wound changes of
care, peripheral IV transmitting or
and central venous spreading pathogens
management, and to the patient.
catheter care and
handling.

Dependent:
1. Assess home care 1. Used dressing
environment for materials may
appropriate disposal contain or be a
of used dressing primary medium for
materials. growth of pathogens.

2. Maintain the 2. Solutions exposed

cleanliness of all to contaminants
irrigation and provide a medium
cleansing solutions. for growth of
Change solutions pathogens.
when cleanliness has
not been
maintained—do not
wait to finish bottle.
3. Assess and teach 3. Knowledge of risk
clients about current factors promotes
medications and vigilance in
therapies that assessment, prompt
promote reporting, and early
susceptibility to treatment.
infection

Health teachings:
1. Refer client and
family to social
services and
community
resources to obtain
support in
maintaining a
lifestyle that
increases immune
function

2. Instruct client and

family about the
need for good
nutrition (especially
protein) and proper
rest to bolster
immune function.