ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Independent:
Subjective: “Hindi Risk for infection related to After 8 hours of nursing • Observe for signs of After 8 hours of nursing
gumagaling ang sugat ko” high glucose levels, decreased interventions, the patient will infection and inflammation. interventions, the patient was
as verbalized by the patient. leukocyte function. identify interventions to • Promote good handwashing able to identify interventions
prevent or reduce risk of by nurse and patient. to prevent or reduce risk of
Objective: infection • Maintain aseptic technique infection.
• for IV insertion procedure,
Flushed appearance. administration of medications, >Goalmet
• and providing maintenance
Wound drainage. and site care. Rotate IV sites
• as indicated.
V/S taken as follows: T:37.4 •Provide catheter or perineal
P:87 R:19 BP: 120/90 care. Teach the female patient
to clean from front to back
after elimination.
•Provide conscientious skin
care,gently massage bony
areas.Keep the skin dry,linens
dry and wrinkle free.
• Place in semi – fowler’s
position.
• Encourage adequate dietary
and fluid intake of 3000 ml per
day. Collaborative:

Collaborative:
Obtain specimen for culture
and sensitivities as indicated.