ASSESSMENT Nsg.

Diagnosis Planning Interventions Rationale Evaluation

2˚ Subjective • Risk for • After the shift,  Monitor vital » Serves as  GOAL MET
Data: infection r/t the the patients’ signs and record baseline data At the end of the
“Inoperahan siya presence of mother will be shift, the mother of
kahapon at ayon sa surgical incision able to  Observe for » To prevent the patient
kanyang doctor eh on the right demonstrate localized signs development of demonstrated
nilagyan daw nila side of the techniques to of infection at infection techniques to
ng butas ang ulo head promote safe the site of promote safety for
niya para environment for surgical incision her baby like by
mabawasan ang her baby with » To note any practicing hand
tubig doon”,as hydrocephalus.  Assess and drainage that washing before
stated by the document skin might contribute cuddling the baby
patients’ mother. condition around in having an and always makes
insertion of infection sure that side rails
shunt are always up.
Objective Data: » A first-line
 Stress proper defense against
hand hygiene to associated
• Presence of the patients’ infections
surgical caregivers and
incision on also the
the right side watchers
of the head » Wound dressings
are where
 Change surgical
microorganisms
wound dressing,
• v/s: live especially
as indicated,
when it wasn’t
using proper
changed for a
technique.
RR – long time

CR – » For safety
T˚ - purposes on
 Encourage
discharge
contacting
considerations
healthcare
provider for
prophylactic
therapy, as
indicated
 following
exposure to
individuals with
infectious
disease

ASSESSMENT Nsg. Diagnosis Planning Interventions Rationale Evaluation

2˚ Subjective
Data:
Objective Data: