ASSESSMENT NURSING DIAGNOSIS PLANNING/GOALS INTERVENTION EVALUATION

Subjective Cue: Risk for infection related to At the end of 5 days of nursing Monitor vital signs. Monitor the At the end of 5 days of nursing
“Hindi naman po siya failure to avoid pathogen interventions, the client will be patient’s temperature; the infection interventions, the client was able to:
nahihirapan huminga at wala secondary to exposure to able to: usually begins with a high temperature;
naman po siyang lagnat pero COVID-19. monitor the respiratory rate of the
nanlalanta po siya.” As Verbalize understanding of patient as shortness of breath is another Verbalize understanding of
verbalized by the client’s individual causative/risk common symptom. individual causative/risk factor(s).
significant other. Deficient knowledge related factor(s).
to unfamiliarity with disease Stress proper hand hygiene by all
transmission information. caregivers between therapies/ clients. A
first-line defense against healthcare- Identify interventions to
Identify interventions to associated infections (HAI). prevent/reduce risk of infection.
prevent/reduce risk of infection.
Objective Cue: Anxiety related to unknown Provide for respiratory isolation, as
Vital signs were taken as follow: etiology of the disease. indicated, Educate staff in infection
- BP:90/60 mmHg control procedures. Reduces risk of Keep the coronavirus infection from
- T:63.2°C Keep the coronavirus infection cross-contamination. Keep tissues at spreading to the patient's family,
- RR:20 cpm from spreading to the patient's the patient’s bedside; dispose community, and healthcare
- PR:70 bpm family, community, and secretions properly; instruct the patient professionals.
healthcare professionals. to cover mouth when coughing or
The client showed fatigue and sneezing; use masks, and advise those
presented with low blood entering the room to wear masks as As evidenced by normalization of
Pressure. well blood pressure and laboratory values.
The client also showed involvement
Changes in lab values Stress proper use of personal protective to nursing interventions and
equipment (PPE) by staff/visitors, as responded to teachings. All the
The client got positive on RT- dictated by agency policy. actions were performed.
PCR test.
Administer/monitor medication
Positive in fecal occult blood test regimen ( intravenous steroids, Therefore, the goals were met.
antibiotics, iron supplements and
X-ray result interpreted as vitamins ) and note client’s response to
pneumonia determine effectiveness of
therapy/presence of side effects.
With comorbidity
- Age Provide information/involve in
- History of present illness appropriate community and national
education programs to increase
awareness of and prevention of
communicable diseases.

Encourage adults to obtain/update