PHINMA University of Pangasinan

College of Health Sciences

Patient’s Initials: _____________ Age & Gender: ____________ Chief Complaint: __________________________________ Name of Student Nurse: ________________________
Birthday: _____________________________________________ Admitting Diagnosis:_______________________________ Level/block/group: ____________________________
Address: _____________________________________________ ________________________________________________ Hospital/area: ________________________________
_____________________________________________________ Date of Confinement: ______________________________ Clinical Instructor: ________________ Date: _______

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Infection is the invasion of an
organism's body tissues by
disease-causing agents, their
multiplication, and the reaction of
host tissues to
the infectious agents and the
toxins they produce.
Short term:
After 30 minutes of Note risk factors for occurrence of to evaluate presence/ character
nursing intervention, infection. of infection.
the patient will
verbalize
understanding of and
willingness to follow Assess for any redness,swelling, To evaluate presence/ character
up prescribed increased temperature of skin of infection.
regimen. surrounding the wound and purulent
wound drainage

Advise patient to Perform Hand hygiene remains the

handwashing single most important factor in
preventing the spread of
infection.

Advis to take antibiotic medication as Antibiotics are medications

NURSING DIAGNOSIS prescribed by the Physician used to treat bacterial
infections
Risk for infection related
to Post op Surgery

ASSESSMENT EXPLANATION OF THE PROBLEM PLANNING INTERVENTIONS RATIONALE EVALUATION