Assessment 

Planning  Intervention  Rationale  Evaluation

Objective: Long Term Goal:   Assess for the  These factors Long Term
 Fatigue presence, existence, represent a break in Evaluation: 
 Fever After 8 hours of and history of the the body’s normal
 Chills and comprehensive nursing common causes of first line of defense After 8 hours of
sweats. intervention. infection and may indicate an nursing 
Subjective: infection. intervention, the
“I feel like I’m  Client will remain  Monitor Vital outcome goals for
always having a free of infection, as Signs  Vital signs the patient have
fever often.” evidenced by normal especially been met and the
vital signs and temperature can be patient condition
Nursing absence of signs and  Maintain strict a good indicator if improved.
Diagnosis symptoms of asepsis for dressing there is a presence
Risk for infection infection. changes, wound of infection.
related to  Client will maintain care, intravenous
Compromised or restore defenses. therapy, and  Aseptic technique
host defenses  Early recognition of catheter handling. decreases the
infection to allow for  Encourage sleep chances of
prompt treatment. and rest. transmitting or
 Patient will  Monitor white spreading pathogens
demonstrate a blood cell (WBC) to or between
meticulous hand count. patients.
washing technique.
 Adequate sleep is
an essential
modulator of
immune responses.

 An increasing WBC
count indicates the
body’s efforts to
combat pathogens.