ASSESSMENT OBJECTIVE/GOAL NURSING INTERVENTION SCIENTIFIC RATIONALE EVALUATION

Diagnostic (Dx):
Subjective Data: Long Term Goal:  Assess and monitor for signs of  Early recognition of infection in After 3 days of NI the
After 3 days of NI the patient infection various parts of the body enables the patient was free from
will be free from any signs of initiation of early interventions to any signs of infection as
infection as evidenced by prevent complications. evidenced by
Objective Data: -VS and lab values within  Assess and evaluate signs of  Used to identify causative factors for -VS and lab values
 JP drain on left and right normal ranges infection through laboratory infections and appropriate therapy within normal ranges
side of the neck - No inflammation or pus values and Vital signs. - No inflammation or
 Patent NGT tube formation at the wound area  Assess wound or surgical site for  Early recognition and intervention pus formation at the
 Secured trache tube signs of infection (inflammation, may prevent progression to more wound area
 Dry and intact dressing pus formation) serious situation or sepsis. LTG: fully met
 Vital Sign: Therapeutic (Tx):
BP- 130/80  Provide adequate rest periods  Ensuring that the patient has
PR- 80 but remain active adequate rest periods reduces the
RR- 18 incidence of fatigue while adequate
Temp.- 36.6  Maintain sterile technique in exercise can prevent the loss of After 8 hour of nursing
Short Term Goal: changing dressing, suctioning, muscle function and support healthy intervention the client
and cleaning of trache tube. immune function. was able to identify and
After 8 hour of nursing  To prevent introducing bacteria. initiate interventions
intervention the client will  Reposition frequently; keep that can help reduce the
identify and initiate linens dry and wrinkle-free.  Reduces pressure and irritation to risk of infection as
Nursing Diagnosis: Risk for interventions that can help tissues and may prevent skin evidenced by proper
Infection r/t Immunosuppression reduce the risk of infection as Educative (Edx): breakdown hand hygiene and
and invasive treatment procedures evidenced by proper hand  Promote good handwashing following infection
secondary to post surgery of hygiene and following infection procedures by staff and visitors  Protects patient from sources of control measures.
tongue mass, radical neck excision control measures. specially when handling the infection STG: fully met
and insertion of trache tube. patient. Screen and limit visitors
who may have infections.
 Emphasize personal hygiene,  Frequent hand washing limits
specifically hand hygiene. potential sources of infection and
 Emphasize to the watcher or secondary overgrowth.
patient to alert healthcare team  To provide immediate action and
to signs of infection such as prevent complications.
fever, cough, chills, sore throat
or mouth sores.