PHINMA University of Pangasinan

College of Health Sciences

Patient’s Initials: JM Age & Gender: 31, Female
Birthday: March 2, 1990
Address: Caranglaan district, Dagupan city, Pangasinan
Chief Complaint: I feel really weak Name of Student Nurse: FERRER, GIENELLE SJ
Admitting Diagnosis: Post-Operatively due to surgery Level/block/group: 2BSN2
Date of Confinement: March 18, 2021 Hospital/area: Recovery room
Clinical Instructor: SIR JESUS RABE
Date: March 18, 2021

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Wounds involving injury to soft  
‘’ Kaninang umaga lang tissue can vary from minor tears Short-Term Goal:  Assess signs and symptoms  Fever may indicate Goal met:
ako naoperahan’’; as to severe crushing injuries. The Within the shift, of infection especially infection Patient was free
verbalized by the decision to suture a wound patient will temperature. from any signs
patient. depends on the nature of the be able to identify and symptoms
of infections as
Objecti
wound the time since the injury ways
was sustained the degree to reduce risk for  Monitor vital signs  To monitor if there manifested by
of contamination. infection. are any changes or absence of fever.
abnormalities.
ve Long-Term Goal: At
the end of hospitali  Emphasize hand washing  It serves as a first line
techniques
cues:
zation, patient will of defense against
not manifest any si infection.
gns

Patient’
 Maintain aseptic technique  Regular wound
and symptoms of in
when changing dressing promotes
fection
dressing/caring wounds fast healing and

s vital  Keep area around wound 

drying wounds.

Wet area can lodge

signs is
clean area of bacteria
 Emphasized necessity of  Premature
closely
taking antibiotics as discontinuation of
ordered treatment, when
patient begins to feel

monitor
well may result in
return of infection.

ed,
 Provide a quiet  To minimizes stress
environment that patient is
experiencing

patient
is in a
supine
positio
n, the
abdome
n is
expose
d
Objecti
ve
cues:
Patient’
s vital
signs is
closely
monitor
ed,
patient
is in a
supine
positio
n, the
abdome
n is
sUB
Objective:
Weak in appearance

Clean and intact

abdominal dressing

NURSING DIAGNOSIS
 Risk for
infection related to
post-surgical incision
8. Maka a NCP, base on priority problem Post-Operatively.