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.