Assessment Nursing Goals/ Nursing Intervention Rationale Evaluation

Diagnosis Planning

Subjective cue: Risk for infection After a series Independent:

None related to tissue of nursing
trauma intervention, Monitor vital signs To assess baseline After the nursing
Objective: secondary to the client/ especially the data. intervention, the
surgery significant temperature. goal was met, the
Presence of other(s) client is free of
surgical Case should Monitor CBC To assess if infection as
incision in background: demonstrate especially WBC. infection occurs. evidenced by the
the left and techniques in client has no signs
right Modified radical reducing risk of infection. The
mastectomy of having Teach client/ To reduce/ correct SO(s) learns and
midclavicula
infection and SO(s) to have a existing risk factors. demonstrates
r line
client will be proper hygiene. properly cleaning
free of of incision.
infection.
Clean clients To reduce/ correct
Presence of Surgical wound
environment. existing risk factors.
two jackson
pratt
Clean incision
Proliferation of daily and prn with To reduce/ correct
bacteria appropriate existing risk factors.
solutions.

Change dressings
daily and prn. To reduce/ correct
Induce existing risk factors.
inflammation
Teach SO(s) the
 proper way of To reduce/ correct
cleaning incision. existing risk factors.

Collaborative:

Administer To reduce/ correct

cefuroxime and existing risk factors.
Infection clindamycin as
prescribed by the
physician.