BSN 2 Sec 3 Grp B

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM

Subjective: A 37 year old women STO: Dx: STO:

has been admitted
"Paano po ba ang due to salpingectomy Within 8 hours of  Assess for the  These represent a break (Goal Met)
tamang paglinis ng (Removal of one effective nursing presence, existence of, in the body’s normal first
sugat ang perineum interventions, the line of defense. Within 8 hours of
(unilateral) or and history of risk
ko? ". patient will be able to: effective nursing
two(bilateral) fallopian factors ( surgery)
interventions,
Objective: tubes.
a) Verbalize the patient will
understanding  Monitor vital signs  To serve as a baseline identify the risk
 Clean intact of the situation data. factors that are
Risk for Infection is
wound b) Identify the risk
present, Have
surgical defined as at factors that are
present partial
dressing and increased risk for being understanding
c) Have partial  These are cardinal signs
abdominal  Monitor the patient for any about infection
invaded by understanding for infection
binder about infection signs of swelling, purulent control
 Vaginal. pathogenic organisms. control discharge or presence of regarding
bleeding Infections occur when regarding pain from wounds, injuries , perineal and
noted. perineal and catheters or drains. wound care
the natural defense wound care.
Nursing Diagnosis: LTO:
mechanisms of an
Risk for infection as individual are Within 24-48 hours of
LTO:
manifested by effective nursing
inadequate to protect
deficient interventions, the Tx: (Goal Met)
knowledge in them. Organisms such patient will:
perineal and wound  Maintain aseptic  are to protect the Within 24-48
as bacterium, virus,
care. a) Patient remains technique when in patient from infection hours of
fungus, and other free of contact with the patient and to prevent the effective nursing
 infection, as spread of pathogens. interventions,
parasites invade
evidenced by the patient’s will
susceptible hosts normal vital remain free of
through inevitable signs and infections,
absence of  This promotes minimal demonstrate
injuries and exposures.
signs and  Performed perineal and interruption in sleep and ability to
People have wound care perform
symptoms of rest.
dedicated cells or hygenic
infection.  Keep area around wound  Wet area can lodge measures like
tissues that deal with b) Demonstrate clean and dry. area of bacteria proper
ability to
the threat of infection. handwashing,
perform
proper perineal
These are known as hygienic
Edx: care and
measures, like
the immune system. wound care.
proper
handwashing.  Teach the patient and/or  Patients and SO can
The human immune c) Show the SO(Significant Other) to spread infection from
capability to wash hands often, one part of the body to
system is crucial for
recognize especially after toileting, another – handwashing
survival in a world full symptoms of before meals, and before reduces these risks.
of potentially deadly infection and after administering
and harmful microbes, self-care.

and serious  Encourage intake of  Helps support the

immune system
impairment of this protein-rich and calorie-
rich foods. responsiveness.
system can predispose
to severe, even life-
 Demonstrate and allow  Patient and SO need
threatening, infections.
return demonstration of all opportunities to master
Organs and tissues
high-risk procedures that
involved in the
 the patient and/or SO will new skills to reduce risk
immune system
do after discharge, such as for infection.
include the thymus, dressing changes and
bone marrow, lymph wound care.

nodes, spleen,
appendix, tonsils, and
Peyer’s patches (in the
small intestine). If the
patient’s immune
system cannot battle
the invading
microorganism
sufficiently, an
infection occurs.
Breaks in
the integument,
mucous membranes,
soft tissues, or even
organs such as the
kidneys and lungs can
be sites for infections
after trauma, invasive
procedures, or
invasion of pathogens
through the
bloodstream
or lymphatic system.
And a common
means for infectious
diseases to spread is
through the direct
transfer of bacteria,
viruses or other germs
from one person to
another. This can
transpire via contact,
airborne, sexual
contact, or sharing of
IV drug paraphernalia.
Also, having
inadequate resources,
lack of knowledge,
and being
malnourished place
an individual at high
 risk of developing an
infection

ASSESSMENT:
1. Focus on your Nursing Diagnosis (Subjective and Objective cues should ALL be align with your problem)
2. Subjective data (preferably verbalization from the patient and must be in an open and close quotation otherwise if it is coming from the mother
or any significant other, it must be categorize as subjective data from a secondary source or an objective data [if it can be perceived by the
senses, verified by another person observing the same patient, and tested against accepted standards or norms] from a secondary source).
3. Objective data (start with the most obvious observation that is related to your nursing diagnosis to the less obvious, followed by abnormal vital
signs that are related to your problem and any laboratory results that are relevant to your problem)
4. For Nursing Diagnosis, use the 3-Part Statement: PES Format (Problem + Etiology + Signs and Symptoms) Three parts are joined together by
“related to” or “associated with” and “as manifested by” or “as evidenced by”
EXPLANATION OF THE PROBLEM:
1. Should be in paragraph form, it’s just like doing your pathophysiology but explaining in detail how the problem arise in relation to your objective
data and other signs and symptoms manifested by the patient that are related to your problem.
2. DO NOT FORGET to indicate your source as a basis in coming up with your explanation of the problem.
OBJECTIVES:
1. Must follow the concept of SMART (Specific, Measurable, Attainable, Realistic and Time bound).
2. STO (Short Term Goal). In theory it covers your acute care (till 6 months). But for our requirement we measure our STO within the shift (0 – 8 hours).
A better parameter would be using ranges of time depending on the planned activities.
 3. LTO (Long Term Goal). In theory it covers your chronic care (6 months and above). But for our requirement we measure our LTO within the first day
to the third day or one rotation (24 – 72 hours). A better parameter would be using ranges of time depending on the planned activities.
NURSING INTERVENTION:
1. Dx (diagnostics) should be based on your SUBJECTIVE and OBJECTIVE DATA.
2. Tx (therapeutics) should be arrange as ICDS (Independent nursing function, Collaborative [other health-care professional aside from the
physician], Dependent nursing function [physician/doctor], Supportive [Significant others, clergy/priest, and non-health care professional]
3. Edx (educative) should be based on the most needed by the patient that is relevant to the nursing diagnosis. (you can also base it on your STO
and LTO if there are educative goal)
RATIONALE:
1. It must be aligned with your nursing intervention and relevant to the case of you patient.
2. For the administration of medication, your rationale should be the indication of the drug in relation with the patient’s case.
EVALUATION/ EXPECTED OUTCOMES:
1. Evaluation for ACTUAL PROBLEM and your NURSING INTERVENTION should be past tense.
2. EXPECTED OUTCOME for POTENTIAL PROBLEM and your NURSING INTERVENTION should be future tense.
3. Should evaluate (GOAL MET, GOAL NOT MET or GOAL PARTIALLY MET) accurately and should be supported by results from your STO and LTO.
4. For expected outcomes (GOAL MET IF, GOAL NOT MET IF or GOAL PARTIALLY MET IF), and give parameters for the IF.
5. Should discuss or make recommendation/s for goal not met and partially met.

Always remember that NURSING PROCESS is SYSTEMATIC, PATIENT-CENTERED, GOAL-ORIENTED AND DYNAMIC.