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    Potential NCP

    Uploaded by

    Kate Weygan

    Copyright:

    © All Rights Reserved
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    Potential NCP

    Uploaded by

    Kate Weygan
    50 views2 pages

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    50 views2 pages

    Potential NCP

    Uploaded by

    Kate Weygan

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Assessment Pathophysiology Goals Nursing Rationale Evaluation

    Interventions
    Subjective: JP drain removed STG: Dx: STG:
    N/A 1. Within 30 1. Noted risk -To evaluate -After 30 minutes of
    minutes of factors for presence or Nursing
    Nursing occurrence character of Interventions and
    Objective: Tissues takes time to Interventions, of infection. infection. Health Teachings,
    -JP drain recently heal the patient 2. Monitored -To establish baseline the patient is
    removed by doctor will verbalize vital signs. data. receptive to care and
    on duty understanding 3. Observed for -To evaluate management.
    -No pus, no redness, Insertion site and localized presence or
    no swelling on the JP exposed to air, willingness to signs of character of
    drain insertion site pathogens, etc. participate in infection on infection.
    -Afebrile treatment the insertion
    -Able to ambulate regimen. site.
    with assistance. Risk for Infection 2. Within 4 -After 4 hours of
    hours of Tx: Nursing
    Nursing 1. Maintained -To prevent further Interventions, the
    Interventions, aseptic complications and patient has
    Nursing Diagnosis: the patient technique the spread of demonstrated
    -Risk for Infection will while giving microorganisms. technique to
    demonstrate medications promote faster
    techniques and nursing healing.
    changes to interventions
    promote to the
    faster healing. patient.
    3. Within 4 2. Administered -To combat -After 4 hours of
    hours of medications pathogens that can Nursing
    Nursing such as cause infections. Interventions and
    Interventions antibiotics Health Teachings,
    and Health 3. Clustered -To establish timely the patient identified
    Teachings, the monitoring interventions. interventions to
    patient will care and prevent or reduce
    identify activities. risk of infection.
    interventions
    to prevent or Edx:
    reduce risk of 1. Instructed to -To prevent the
    infection. watcher to spread of germs that
    wash hands will contribute to the
    LTG: before and cause of infection. LTG:
    1. Within 3 days after -After days of
    of Nursing handling the Nursing
    Interventions patient. Interventions and
    and Health 2. Instructed to -Wearing of mask is a Health Teachings,
    Teachings, the wear mask at must in the hospital. the patient was free
    patient will be all times as of s/sx of infections
    free of signs per hospital’s and the insertion site
    and policy. is healing very well.
    symptoms r/t 3. Emphasized -To inform the client
    infection. necessity of the necessity of
    administering medications to help
    medications. in preventing
    infections.

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