7/29/2019 NCP QMMC
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Assessment Diagnosis Interventions Rationale Evaluation
Subjective:
Kaninang umaga lang
ako naoperahan; as
verbalized by the patient.
Objective:
T-36.3C
Weak in
appearance
Clean and
intact abdominal
dressing
Risk for infection
related to
post operative incision
Inference:
Wounds involving
injury to soft tissue can
vary from minor tears to
severe crushing injuries.
The decision to suture a
wound depends on the
nature of the wound the
time since the injury
was sustained the
degree of
contamination.
Reference:
Brunner & Suddarths
Textbook of Medical-
Surgical Nursing 11th edition
by Smeltzer, Bare, Hinkle,
Cheever
STG: After 2-4 hours of
nursing intervention, the
patient will be able to:
Identify ways to
reduce risk for
infection.
Have partial
understanding about
infection control
LTG: After 2-3 days of
nursing intervention, the
patient was able to :
Clients full
knowledge in
identifying the risk
factors of the
infection
Be free from any
signs and symptoms
of related to infection
1. Promote good hand
washing by patient and
staff.
2. Encourage to eat foods
that are rich in protein
and Vitamin C.
3. Advice to have enough
rest and sleep.
4. Monitor vital signs.
5. Discuss importance of
not taking antibiotics
unless specifically
instructed by healthcare
provider.
6. Provide meticulous skin,
oral and perianal care.
Reduces risk of cross-
contamination
Vitamin C is known to
prevent infection;. Protein is
needed for tissue repair
regeneration; meat products,nuts & legumes are rich
sources of which.
This promotes healing by
reducing basal metabolic rate
& allowing oxygen &
nutrients to be utilized for
tissue growth, healing &
regeneration.
Fever with increased
pulse and respirations istypical of increased
metabolic rate resulting from
inflammatory process,
although sepsis can occur
without a febrile response.
Inappropriate use can
lead to development of drug-
resistant strains/secondary
infections.
Reduces the risk of
skin/tissue breakdown and
infection.
Most antibiotics work best
After 2-4 hours of nursi
intervention, the patient
was able to identify way
to reduce risk for
infection and had partia
understanding aboutinfection control. The
goal was fully met.
After 2-3 days of nursin
intervention, the patientwas able to have full
knowledge in identifyin
the risk factors of the
infection and became fr
in any signs and
symptoms related to
infection. The goal was
fully met.
Nursing Care Plan
