Cues/Needs Nursing Diagnosis

Goals and Objectives

Interventions Rationale Evaluation

Subjective:“Kagagaling lang nga anak ko sa sakit, tapos ngayon ngakasakit nanaman.” As verbalized by the patient’s mother

Objective:_Weakness_Pale looking_Clammy Skin_Sunken eyebags_Presence of illness

V/S P: 132 R:48 T: 37

Risk for infection After 6 hours of nursing intervention, the patient’s support familywill identify interventions to prevent/ reduce risk of infection as evidenced by positive feedbacks.

_Assess signs and symptoms of infection especially temperature

_Stress proper hand hygiene by all caregivers between therapies/clients

_Recommend routine body shower/scrubs when indicated

_Emphasize necessity of taking antivirals/antibiotics as directed

_Discuss importance of not taking antibiotics/using “leftover” drugs unless specifically instructed by healthcare provider

_Encourage patient and patient’s support family to consume nutirous foods and refrain from sedentary lifestyle

_Fever may indicate infection

_A first line defense against health care-associated infections

_To reduce bacterial colonization

_Premature dicontinuation of treatment when client begins to fell well may result in return of infection and potentiate drug-resistant strains

_Unappropriate use can lead to development of drug-resistant strains/secondary infections

_To boost immune system

After 6 hour of nursing intervention, the patient ‘s support familily identified intervetnions to prevent/reduce risk of infection as evidenced by poritive feedbacks. The mother stated that she would ensure to provide nutirous foods for the patient.

Goal Met