Assessment Nursing Planning Intervention Rationale Evaluation

diagnosis
Risk for Short term Establish rapport To establish
Obj: infection, risk goal: on client trust and
Not factor may After 8 hours cooperation
applicable include of nursing on the client.
promise of traumatized intervention Monitor vital
sign and tissue and the patient sign To obtain the
symptoms tissue will prevent baseline data
established distraction and reduced
an actual compromised risk spread of
diagnosis. immune infection. Note risk factor
response for occurrence of Understanding
invasive infection (e.g) of how the
procedural Long term compromised infection
increased goal: post skin develop
environmental integrity,
exposure. After 24 environmental
hours of exposure.
nursing
intervention Observe for
the patient localized sign of
will infection at To have
understanding incision of necessary
of the invasive line, information
individual suture, surgical about the case
causative risk incision and of the client
factor. wound

Note sign and For

symptoms of documentation
sepsis(systematic
infection)

Change dressing To reduced

as needed infection

Provide To help
medication reduction of
regimen as pain
prescribed by the
doctor
Promote To prevent
adequate bed rest fatigue

Placed the It will help the

patient in a client feel
comport position comfortable

Keep Compromised
environment may reduced
allergens free irritation and
severity of
infection

Health teaching The client

needs health
information to
participate
effectively in
her own care
and to optimal
health outside
the hospital.