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UNIVERSITY OF SOUTH ALABAMA

COLLEGE OF NURSING Student Name: Teokie King


Childbearing/Childrearing
ASSESSMENTS NURSING DIAGNOSIS NURSING INTERVENTIONS EVIDENCE SUPORTING IMPLEMENTATION EVALUATION
(Subjective/Objective Data NANDA diagnosis? Related Note Frequency. PRACTICE (Rationale) Explain how interventions State outcome
pertinent to this nursing factors noted? Evidence if an (Cite source: Author & Page #) were met or not met (and achievement in
diagnosis) “actual” problem? *3 ACTION based interventions List full reference separately. why) Behavioral terms. Note:
Continue
Change (specify),
Discontinue POC
1) Maintain 1) After 48hrs 1) Intervention A) Goal met
Subjective: Risk for infection r/t C- temperature less temperature > 99.8 met pt. continue
section incision and than or equal to suggest fever r/t temperature POC.
“It’s kind of red on the
inadequate secondary 98.7 incision site (Ricci remained B) Goal met
outside of my cut.”
defenses i.e.) decreased 2) Teach the patient & Kyle, pg. 487). under 98.7. continue
H&H the importance of 2) Family members or 2) Met. Patient POC.
“My staples are sticking
together with burning avoiding contact visitors can spread understands C) Goal met
drainage.” with those who are infections through that good continue
OUTCOME STATEMENTS infected or have cold or cough. hand POC.
Measurable? Realistic? Time
“No severe pain but still element noted? Pertinent to colds. (Ricci & Kyle, pg. hygiene and
sore.” diagnosis? 3) Teach patient to 487). the threat
GOAL & Objectives TCDB. 3) Encourage TCDB to infected
avoid retaining people have
Objective: Pt. will remain free of secretions, on her.
23 year old Female infection by 10/26 by 1-9pm infections, 3) Met. Patient
BP: 116/70 clinical shift a.e.b. aspirations and carried out
P:82
pneumonia (Pan, instructions
Repeat C-section A) Normal VS & BP: pg.424). TCDB and
Redness outside of incision less than or equal to educated
Staples sticking to other 125/85. why this
staples with drainage B) Absence of purulent procedure is
H&H: 8.8, 26.9% drainage or done post-
erythema from op.
incision q 8hrs
throughout hospital
stay.
C) Identify
interventions to
prevent risk for
infection.

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