Patient: Gozo, M.

Age: 31 years old Diagnosis: S/P Craniotomy Excision of Brain Tumor

Date
& Assessment Needs Nursing Diagnosis Objective Interventions Evaluation
Time
Nov Subjective: H Risk for infection After 8 hours 1. Monitor vital signs regularly. GOAL MET
16, “Mahadlok mi E related to s/p of nursing R: Changes in vital signs may indicate
2019 kay gikan sya A craniotomy excision of interventions, infection. After 8 hours
ug surgery, L brain tumor the patient of nursing
3:00 basig ma T will be able 2. Monitor the patient for any signs of interventions,
pm – infect.” As H R: Invasive procedures to: swelling, purulent discharge or presence the patient was
11:00 verbalized by such as surgery, of pain from wound. able to:
pm the father of P involves opening the - remain free R: These are the cardinal signs of infection.
the patient. E skin and leading a from any - remain free
R lesion thereafter. This infection from any
Objective: C makes the patient 3. Perform handwashing when dealing with infection
E vulnerable to pathogens patient.
- surgical P as the first barrier of R: Handwashing is an effective technique to
incision on T protection is prevent the spread of infection. Dry surfaces
frontal I compromised. are better in preventing transfer of
tempoparietal O microorganisms.
area of the N Source: Nicoll, D.,
head McPhee, S., Pignone,
- bleeding on A M. and Nicoll, D. 4. Wear gloves during any contact with
the site N (2014). Diagnostic mucus, blood, and other body fluids. Use
D tests. 13th ed. [New goggles when appropriate.
- Vital Signs York, N.Y.]: McGraw- R: It prevents the transfer of microorganisms
recorded at: H Hill Companies, p.185. that are already on the hands and to protect
Temp: 36.7c E the hands from becoming contaminated.
BP: 120/80 A
RR: 20bpm L 5. Encourage adequate rest.
PR: 78 T R: It can reduce stress and boost the immune
H system.
M 6. Provide a clean environment.
A R: A sanitized environment creates a colossal
N effect when preventing infection, as this
A reduces contamination to the patient, making
G it less likely for the patient to develop
E infection post procedure.
M
E 7. Teach S/O how to perform procedures at
N home, like dressing changes and assessing IV
T site for signs of infection.
R: Patient and caregivers need to master
P these skills to make sure that they can
A continue preventing risk of infection even if
T they are already discharged.
T
E 8. Routinely monitor the patient’s white
R blood cell count, serum protein, and serum
N albumin.
R: These laboratory values are closely linked
to the patient’s nutritional status and immune
function.

9. Administer medications as ordered.

R: Not completing or skipping the required
dose of antibiotics can encourage antibiotic
resistance.

10. Coordinate with a dietician to create a

meal plan suitable or the patient and his
nutritional needs.
R: Proper nutritious diet helps support the
immune system by delivering the necessary
nutrients needed by the body.