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ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

 Risk for infection SHORT TERM  Note risk factors for  To assess SHORT TERM
OBJECTIVE related to invasion At the end of the shift occurrence of infection. causative/contributing At the end of the
 Prolonged admission in of pathogenic the parents of the client factors. shift, the client was
the hospital microorganism as will  Stress proper hand  Able to verbalize
manifested by  Verbalize hygiene.  To reduce/prevent and understand the
 Chronic disease exposure to understanding of cross contamination or causative factors and
causative factors individual  Stress proper use of spread of the infection. identify interventions
 Use of pharmaceutical causative/risk personal equipment. to prevent/reduce
agents - Prolonged admission factors. infection.
(immunosuppressant) in the hospital  Maintain sterile
 Identify interventions
- Iressa (gefitinib) technique in all the
250mg/tab 1 tab OD - Chronic disease to prevent/reduce LONG TERM
procedures for the
 Poor personal hygiene
the risk for infection After one week of
patient.
- Use of nursing intervention,
pharmaceutical LONG TERM  Teach the patient how  To promote wellness. the client
agents After one week of to maintain a clean  Outcome not yet
(immunosuppressant) nursing intervention, the environment. met (not yet
- Iressa (gefitinib) client will completing the time
250mg/tab 1 tab frame)
 Demonstrate
OD techniques, lifestyle
changes to promote
safe environment
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Objective: Impaired Short term goal:  Determine diagnosis  This will help the Short term goal:
 Client is on physical After 8 hours of that contributes to healthcare provider After 8 hours of nursing
traction mobility related nursing intervention immobility to determine what intervention the client
 Limited ability to to neuromuscular the client can  Note decreased kind of intervention was able to
perform impairment as demonstrate motor to be use demonstrate
gross/fine motor manifested by the techniques/behavior agility/essential  To lessen the techniques/behavior
skills presence of that enable tremor related to age tension to the that enable resumption
 Requires help traction. resumption of  Determine degree of exercise to be done of activities
from another activities immobility  Assessment on the
person for  Note emotional clients condition Long term goal:
assistance and Long term goal: /behavioral  Feelings of After 3 days of nursing
supervision After 3 days of nursing responses to problem frustrations/powerl intervention the client
 Client was intervention the client of immobility essness may impede was able to maintain or
diagnose with can maintain or  Provide safety attainment of goal increase strength and
idiopathic increase strength and measures as  To prevent further function of affected
scoliosis function of affected indicated by complication to the and/or compensatory
and/or compensatory individual situation, client body part
body part including  This enhances
environmental commitment to plan
management/ fall and optimizing the
prevention. outcomes
 Encourage the client’s
involvement in
decision as much as
possible

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