CUES NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
S: “medyo Risk for infection Short term goal:  Monitored vital  Alteration from Goals met. At the
gangutngot ang related to At the end of 2 hours signs and assess normal values end of 2 hours, the
akng tahi dre sa inadequate of nursing symptoms of indicate signs patient was able to:
ubos ug tukar tukar primary defenses interventions, the infection of infection
pod ang kasakit,” as secondary to post patient will be able especially especially  “ang
verbalized by the surgical incision at to: temperature temperature gapamatuod na
patient the perineum naay inpeksyon
 state some  Conducted a  Aseptic and akong tahi
O: Patient reported symptoms of health teaching technique kay ang
pain scale of 5 out infection regarding the decreases the pagpanghupong,
of 10; surgical  identify ways to symptoms and changes of naay gagawas
incision at the reduce risks for ways to reduce transmitting or na tubig-tubig,
perineum due to infection risks of spreading gapanginit ang
natural  demonstrate infection. pathogens to panit palibot sa
spontaneous appropriate Maintained or the patient. akong samad,”
vaginal delivery; perineal care teach asepsis Interrupting as verbalized by
weak in for dressing the the patient
appearance Long term goal: changes and transmission of  identified ways
At the end of 1 week wound care. infection along to reduce risk
of nursing the chain of for infection
interventions, the infection is an such as using
patient will be able effective way aseptic
to: to prevent technique when
infection. changing wound
 remain free of dressings; intake
infection  Emphasized the  To promote of protein-rich
 exhibit evidence importance of cleanliness to and calorie-rich
of progressive proper perineal the perineal foods;
care (wash area increasing

DHANEANNE MARIE L. CHAN

 healing as hands before intake of fluid,
demonstrated starting and etc.
by clean, dry, perineal care,  demonstrated
absent edema, use warm water properly how to
and intact and clean do the perineal
episiotomy site washcloth care
moving from
front to back) At the end of 1 week,
the patient was able
 Encouraged  Helps support to:
intake of the immune
protein-rich system  remained free
(such as lean responsiveness. of infection
meat, eggs, throughout
chicken breast) shift, without
and calorie-rich any signs and
(such as symptoms of
avocado, dark infections
chocolate, eggs)  exhibited
foods. evidence of
progressive
 Encouraged  Fluids promote healing as
fluid intake of diluted urine demonstrated
2,000 to 3,000 and frequent by clean, dry,
mL of water per emptying of absent edema,
day. bladder – and intact
reducing the episiotomy site
stasis of urine,
in turn, reduces
risk for bladder
infection or

DHANEANNE MARIE L. CHAN

 urinary tract
infection.

 Emphasized  To prevent
necessity of drug resistance
taking
antibiotics as
ordered.

DHANEANNE MARIE L. CHAN