ASSESSMENT EXPLANATION OF THE OBJECTIVES INTERVENTION RATIONALE EVALUATION

PROBLEM
SUBJECTIVE: Risk for infection as define by STO: Dx: STO:
“He can’t sleep, he NANDA is the vulnerable to After 2 hours of nursing > Assess and Monitor v/s > To know potential fatal GOAL MET IF, patient
always cries because he invasion and multiplication of intervention, patient will closely, especially during complication that may was able to:
has DOB” as verbalized pathogenic organisms, which able to: initiation of therapy. occur. > verbalize
by the mother may compromise health. understanding of
>verbalize understanding > Assess depth/rate of > Tachypnea, shallow individual causative or
As for the condition of the of individual causative or respiration and chest respiration, and risk factors of the
client, his lungs are filled from risk factors of the movement asymmetric chest significant others
secretions. significant others movement are frequently >demonstrate different
presented because of ways to prevent the
OBJECTIVE: Possible Pneumonia bacteria >demonstrate different discomfort of the moving infection such as:
> Irritability are invading his lung ways to prevent the chest wall and/or fluid in  Monitored
>wheezing and crackles parenchyma and suspected infection such as: the lungs visitors as
>Poor appetite bronchial breathing on the right  Monitored visitors > Assess for presence of suggested by
>Cannot breastfeed side thus, producing as suggested by host-specific factors that the health
properly inflammatory process. These the health affect immunity: provider
>T: 37.7-38.1 responses lead to filling of the provider  Frequent
>RR: 63 bpm showing alveolar sacs with exudates  Frequent position  Presence of > The client may have a position
tachypnea which then lead to changes underlying disease disease that directly changes
>PR: 163 bpm consolidation.  Covering of mouth impacts the immune  Covering of
>O2sat: 88 % by the family system or may be mouth by the
But it is a risk diagnosis because whenever they weakened by prolonged family
it is not evidenced by signs and cough disease conditions whenever they
symptoms , as the problem has  Certain treatment > The client in acute cough
NURSING DIAGNOSIS: not occurred; rather, settings/modalities care/critical care setting
Risk for Infection related nursing interventions are and/or on mechanical GOAL PARTIALLY MET
to excessive mucus as directed at prevention. ventilation may have a IF, patient was able to:
evidence by wheezing LTO: prolonged exposure to risk >verbalize
and crackles sec. to After 3 days of nursing factors for infection, understanding of
PCAP-C MR intervention, patient will: including problems with individual causative or
breathing and circulation, risk factors of the
-manifest absence of gastrointestinal (GI) significant others but
infection motility disorders, and doesn’t demonstrate
use of analgesics and different ways to
- free from any signs and sedatives, causing a higher prevent the infection
symptoms of infections as rate of acquired infections.
manifested by absence of  Nutritional status > Malnutrition weakens the GOAL NOT MET IF,
fever. immune system; and patient was not able to:
elevated serum glucose > verbalize
-able to finish all levels that provide growth understanding of
medications as prescribed media for individual causative or
Pathogen risk factors of the
  Certain medications > Steroids and significant others
chemotherapeutic agents > demonstrate different
Directly affect the immune ways to prevent the
system. Long-term or infection such as:
improper antibiotic  Monitored
treatment can disrupt the visitors as
body’s normal flora and suggested by
result in increased the health
susceptibility to antibiotic- provider
resistant organisms.  Frequent
position
Tx: changes
>Provide clean, well- > To reduce/correct  Covering of
ventilated environment existing risk factors mouth by the
(may require turning off family
central air-conditioning and whenever they
opening window for good cough
Ventilation ; room with
negative air pressure, etc.). LTO:
> Provide for isolation, as > This reduces the risk of GOAL MET IF, patient
indicated (e.g., contact, cross-contamination was able to:
droplet, and airborne > manifest absence of
precautions). Educate staff infection
in infection control > have free from any
procedures. signs and symptoms of
> Instruct the S.O > To promote safety infections as manifested
concerning about the disposal of secretions and by absence of fever.
disposition of secretions to assess for the resolution > finish all medications
and report changes in of pneumonia or as prescribed
color, amount and odor of development of secondary
secretions infection. GOAL PARTIALLY MET
> Administer/monitor > to determine IF, patient was able to:
medication regimen and effectiveness of therapy or > manifest absence of
note the client’s response presence of side effects infection but still has
medications to be taken
as prescribed.
Edx:
> Emphasize the necessity > Premature GOAL NOT MET IF,
of taking antivirals or discontinuation of patient was not able to:
antibiotics, as Directed treatment when client > manifest absence of
(e.g., dosage and length of begins to feel well infection
therapy). may result in return of > have free from any
infection and potentiation signs and symptoms of
of drug resistant strain. infections.
> Discuss the importance of > Inappropriate use can > finish all medications
not taking antibiotics or lead to development of as prescribed
using “leftover” drugs drug resistant strains or
unless specifically secondary infections
instructed by healthcare
provider.
> Provide information and > To increase awareness of
involve the client in and prevention of
appropriate community communicable diseases.
and national education
programs
> Discuss the importance of > To promote wellness
seeking the healthcare
providers if problems in
health occurs.