Assessment Diagnosis Planning Intervention Evaluation

Subjective High risk for After 2 hours Independent After 2 hours

“Kaaopera infection r/t of ♥ Establish of
lang sakanya”, inadequate nursing rapport nursing
as verbalized primary intervention ♥ Teach intervention
by the defense as the patient to the patient
patient’s manifested by patient’s wash hands relatives was
mother. broken skin relatives will often, able to gain
gain especially knowledge in
Objective: knowledge in before infection
♥ Surgical infection toileting, control as
incision control before evidenced by
with suture. as evidenced meals and his
♥ No wound by before and discussion in
dressing. discussing the after wound
♥ (+) wound care. administeri care.
abdominal ng self-care Therefore, the
distention ♥ Discuss to goal was met
patients the
following
signs of
infection
-redness,
swelling,
increased
pain, or
purulent
drainage on
the site and
fever
♥ Demonstrat
e and allow
return
demonstrati
on of
wound care

Dependent
♥ Give anti
bacterial or
antibiotic
as
prescribed
by the
physician
Assessment Diagnosis Planning Intervention Evaluation
Subjective: Ineffective After 1 hour of Independent After 1 hour of
♥ “Miss oka coping to Nursing ♥ Monitor Nursing
lang ba inadequate Intervention vital sign Intervention
siya? opportunity to the patient especially the patient
Parang prepare for together with the RR together with
hirap stressor aeb his relative will ♥ Monitor O2 his relative
siyang post be able to: saturation. was able to:
huminga extubation. ♥ Assess the ♥ Teach ♥ Assess the
nung current patient on current
tinanggal situation breathing situation
yung ET accurately. properly. accurately.
niya”, as ♥ Identify ♥ Place on a ♥ Identify
verbalized ineffective semifowler ineffective
by the copig position. copig
patient’s behaviours ♥ Provide a behaviours
mother. and comfortable and
consequenc environmen consequenc
Objective: es. t. es.
♥ Post ♥ Verbalize ♥ Avoid ♥ Verbalize
extubated awareness stressors. awareness
@ 4:00pm of own Dependent of own
♥ Use of coping ♥ Carry put coping
accessory abilities. doctor’s abilities.
muscle. order for
♥ RR=32 the patient.