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Subjective Data:: Assessme NT Diagnos IS Planning Intervention Rationale Evaluation

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Cuttie Anne Galang

The patient complained that their wound dressing had not been changed. A nursing assessment found signs of redness, swelling and facial grimacing from the wound. Vital signs showed an elevated temperature. The nursing plan was to practice good handwashing and wound care to reduce infection risk, inspect the wound daily for signs of infection, and cleanse the wound with antimicrobial solutions. The goal was timely wound healing without infection over 4 hours through these nursing interventions.

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Subjective Data:: Assessme NT Diagnos IS Planning Intervention Rationale Evaluation

Uploaded by

Cuttie Anne Galang
588 views1 page
The patient complained that their wound dressing had not been changed. A nursing assessment found signs of redness, swelling and facial grimacing from the wound. Vital signs showed an elevated temperature. The nursing plan was to practice good handwashing and wound care to reduce infection risk, inspect the wound daily for signs of infection, and cleanse the wound with antimicrobial solutions. The goal was timely wound healing without infection over 4 hours through these nursing interventions.

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RISK FOR INFECTION

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The patient complained that their wound dressing had not been changed. A nursing assessment found signs of redness, swelling and facial grimacing from the wound. Vital signs showed an elevated temperature. The nursing plan was to practice good handwashing and wound care to reduce infection risk, inspect the wound daily for signs of infection, and cleanse the wound with antimicrobial solutions. The goal was timely wound healing without infection over 4 hours through these nursing interventions.

Copyright:

© All Rights Reserved
Download as DOCX, PDF, TXT or read online from Scribd
Download as docx, pdf, or txt
588 views1 page

Subjective Data:: Assessme NT Diagnos IS Planning Intervention Rationale Evaluation

Uploaded by

Cuttie Anne Galang
The patient complained that their wound dressing had not been changed. A nursing assessment found signs of redness, swelling and facial grimacing from the wound. Vital signs showed an elevated temperature. The nursing plan was to practice good handwashing and wound care to reduce infection risk, inspect the wound daily for signs of infection, and cleanse the wound with antimicrobial solutions. The goal was timely wound healing without infection over 4 hours through these nursing interventions.

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ASSESSME DIAGNOS PLANNING INTERVENTION RATIONALE EVALUATION

NT IS
Subjective Risk for Within 2 Independent: •. Reduces risk After 4 hours of
data: infection hours of • Practice and of spread of nursing
“Hindi pa related to nursing instruct in bacteria. interventions the
napapalita surgical interventio good handwashing  patient’s Achieve
n yung incision ns the and aseptic wound timely wound
dressing ng patient’s care. healing; free of
sugat ko” pain will signs of
as be • Inspect incision • Provides for infection/inflammat
verbalized achieved and dressings. Note early detection ion.
by the timely characteristics of of developing
patient. wound drainage from infectious Goal Met
healing, wound (if process and
Objective free of inserted), presence monitors
data: signs of of erythema. resolution of
• Redness infection. preexisting
• Swelling peritonitis.
• Facial
Grimace
• Note onset of  •Suggestive of
Vital signs fever, chills, presence of
as follows: diaphoresis, infection or
PR- 96 changes in developing sep
BPM mentation, reports sis, abscess,
RR- 20 of increasing peritonitis.
BP- abdominal pain.
110/90
TEMP-
38.1 •Cleanse incisions • To reduce
and insertion sites infection and
using appropriate to prevent the
antimicropical growth of
topical or solution. bacteria

Dependent:
• Administer  • To prevent
medications as infection.
prescribed.

•Prepare and assist • May be
with incision and necessary to
drainage (I&D) if drain contents
indicated. of localized
abscess.

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