Bai Rahaaf M.

Lumanggal
Bachelor of Science in Nursing- 3B

ASSESSMENT NURSING PLANNING NURSING INTERVENTION EVALUATION

DIAGNOSIS

Patient’s Name:
Kim Corbilla After 8 hours of Nursing Independent: After 8 hours of nursing
intervention: intervention:
Subjective: Risk for infection related ❖ Observe infection and
Chief complaint :Infected to high glucose levels. ● The patient will inflammation. ● The patient
wound. demonstrate Rationale: demonstrates adequate
adequate hydration Patients may be admitted hydration.
Objective: ● The patient will with infection and inflammation ● The patient identifies
Amputated 2nd digit of left identify interventions which may worsen the interventions to reduce
food. to reduce risk of conduction of the patient. risk of infections.
infection.
V/S taken as follows: ❖ Teach and promote good
BP: 120/80 hygiene.
T: 36 Rationale:
RR: 19BPM Reduced risk of cross
Pr: 78 bpm contamination.
02SAT: 95%
❖ Promote health teaching
on taking medications
and ways to decrease
the risk of infection.

Rationale:
Provides knowledge and
understanding for patients.
 ❖ Keep foot elevated
Rationale: To decrease
swelling.

Dependent:

Administer antibiotics as
prescribed.
Rationale: It may help prevent
sepsis