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The document appears to be a nursing assessment form for a patient who recently had surgery and is at risk for infection. It includes sections to document the patient's information, chief complaint, admitting diagnosis, and assessments of the problem. The nursing analysis identifies infection as the invasion of organisms into body tissues. The plan is to educate the patient on risk factors, signs of infection, and following the treatment regimen including handwashing and taking antibiotics as prescribed to prevent the spread of infection and treat any bacteria.

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177 views2 pages

Print 2

The document appears to be a nursing assessment form for a patient who recently had surgery and is at risk for infection. It includes sections to document the patient's information, chief complaint, admitting diagnosis, and assessments of the problem. The nursing analysis identifies infection as the invasion of organisms into body tissues. The plan is to educate the patient on risk factors, signs of infection, and following the treatment regimen including handwashing and taking antibiotics as prescribed to prevent the spread of infection and treat any bacteria.

Uploaded by

Void Less
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PHINMA University of Pangasinan

College of Health Sciences

Patient’s Initials: _____________ Age & Gender: ____________ Chief Complaint: __________________________________ Name of Student Nurse: ________________________
Birthday: _____________________________________________ Admitting Diagnosis:_______________________________ Level/block/group: ____________________________
Address: _____________________________________________ ________________________________________________ Hospital/area: ________________________________
_____________________________________________________ Date of Confinement: ______________________________ Clinical Instructor: ________________ Date: _______

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION


Infection is the invasion of an Short term:
organism's body tissues by After 30 minutes of Note risk factors for occurrence of to evaluate presence/ character
disease-causing agents, their nursing intervention, infection. of infection.
multiplication, and the reaction of the patient will
host tissues to verbalize
the infectious agents and the understanding of and
toxins they produce. willingness to follow Assess for any redness,swelling, To evaluate presence/ character
up prescribed increased temperature of skin of infection.
regimen. surrounding the wound and purulent
wound drainage

Advise patient to Perform Hand hygiene remains the


handwashing single most important factor in
preventing the spread of
infection.

Advis to take antibiotic medication as Antibiotics are medications


NURSING DIAGNOSIS prescribed by the Physician used to treat bacterial
infections
Risk for infection related
to Post op Surgery

ASSESSMENT EXPLANATION OF THE PROBLEM PLANNING INTERVENTIONS RATIONALE EVALUATION

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