Assessment Explanation of the
Problem Objectives
May 14, 2009
Px> On the third day status
post appendectomy
S>”Masakit ang tiyan ko
kapag naglalakad” as
verbalized by the patient.
>Minimal pain reported
on the operative site.
O>
Fully awake, alert and
conversant
>With dry and intact
dressing, no discharges and
redness noted around the
operative site.
>Needs assistance in
doing ADLs such as
walking and toileting
>With difficulty in
turning on side to side
A >Risk for infection
related to tissue trauma
secondary to status post
appendectomy.
Goals and Nursing Interventions Rationale Evaluation
The patient’s risk LTO > After Dx >Monitored vital signs > Serves as baseline data, in Goal is met if:
for infection is the course of which significant changes could Within the duration of the shift the patient
very high since confinement, indicate imbalance in the will be able to identify 3 interventions to
she is the patient patient’s body prevent or reduce the risk for infection
experiencing an would be free After 30min of health teaching the patient
immunologic of infection. >Assessed signs of > to determine what will be able to identify at least 2
response against infection information to provide the importance of infection prevention.
what is causing STO > Within client and his significant others After the course of confinement, the
her pain. With this the duration of patient would be able to verbalize
as a fact the the shift the >Assessed general status > serves as a baseline data to understanding of this risk factor.
patient’s body’s patient will be determine if there is an
ability to react, or able to identify improvement on the patients Goal partially met if:
destroy harmful 3 interventions pain status Within the duration of the shift the patient
microorganisms is to prevent or will be able to identify 2 interventions to
being utilized, and reduce the risk >Assessed level of activity > to sustain activity level prevent or reduce the risk for infection
if it is for infection After 30min of health teaching the patient
unsuccessful it > After >Frequently checked >to prevent contamination of will be able to identify at least 1
would lead the 30min of health status of dressing the wound importance of infection prevention.
patient vulnerable teaching the After the course of confinement, the
to having these patient will be Tx> Practiced aseptic >to reduce likelihood of spread patient wouldn’t be able to verbalize
diseases. able to identify technique in giving of infections understanding of this risk factor.
at least 2 interventions.
importance of Goal not met if:
infection >Provided clean > keeping the environment of The patient’s condition worsened.
prevention. comfortable environment to the patient clean would
prevent the transmission of decrease the number of possible
infection. microorganisms that could
dwell in the area.
>Assisted patient in doing >to prevent overexertion
ADL such as ambulation and
toileting.
>Attended to the needs of >to sustain activity level
the patient.

Edx> Encouraged early > for mobilization of

ambulation, deep breathing, respiratory secretions
Coughing and position
change

>Encouraged patient to > to increase awareness on the

report any untoward signs easy spread of infection
and symptoms such as fever
and vomiting.

>Emphasized proper hand >Hand washing is the first line

washing techniques. defense against nosocomial
infections/ cross-contamination