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Potential

Assessment Diagnosis Inference Planning Intervention rationale evaluation

Subjective: Risk for Sepsis is a Within 8 Independent: Within 8 hours


”walang gana dumede infection clinical term hours of -provide -Body substance of nursing
ang anak ko” as related to used to nursing isolation and isolation (BSI) intervention
verbalized by the compromised describe interventions, monitor should be used for the patient was
patient. immune symptomatic the patient visitors as all infections was achieve
system bacteremia, will achieve indicated patients. Reverse timely healing
Objective: with or timely isolation restrict and free from
- increase body without organ healing and on of visitors may infection. Goal
temperature dysfunction. free from be needed to met.
-flushed skin Sustained further protect the
-increased respiratory bacteremia, infection immunosuppessed
rate may result in a patient.
-v/s taken as follows: sustained
T-37.7 febrile -wash hands -reduces risk of
P- 130 response that before or after cross
Rr- 45 may be each care contamination
associated activity, even because gloves
with organ gloves are may have
dysfunction. used. noticeable defects
Septecemia get form or
refers to the damaged during
active uses.
multiplications
-prevents spread
of bacteria in -limit use of
of infection via
the invasive airborne droplets
bloodstream device or
that results in procedure as
an possible.
Actual
Assessment Diagnosis Inference Planning Intervention Rationale evaluation

Objective: Diarrhea related Diarrhea is Within 8 hours Independent: Within 8 hours of


-hyperactive to increase the condition of nursing -note client’s -diarrhea in nursing intervention the
bowel sounds secretion of of having intervention the age infant /young child patient’s fluid volume
-3x loose of fluid by the three or more patient’s fluid and older or secretion was decreased
liquid /day intestinal loose or liquid secretion will debilitated client as evidenced by decrease
mucosa bowel decrease, liquid can cause loose of liquid.
secondary to movements loose will also complications of
infection. per day. It is a be decreased. dehydration and
common electrolyte in
cause of death balances.
in developing
countries and -auscultate
the second results of -for presence,
most common laboratory location and
cause of testing. characteristics of
infant deaths bowel sounds.
worldwide.
The loss of -review result
fluids through of laboratory -for acute diarrhea,
diarrhea can testing. chronic diarrhea
cause testing may include
dehydration upper and lower
and gastrointestinal
electrolyte structures, stool
imbalances. In examination for
2009 diarrhea parasites.
was estimated -restrict solid
to have food intake as -to allow for bowel
caused 1.1 indicated. rest/reduced
million deaths intestinal workload.
in people aged -provide for
5 and over changes in -to avoid
and 1.5 dietary intake foods/substances
million deaths that precipitate
in children diarrhea
under the age -assess for/
of 5. remove fecal -where impaction
impaction, may be
especially in an accompanied by
elderly client. diarrhea.

-assess for
presence of -indicating
postural dehydration
hypotension,
tachycardia,
skin hydration/
turgor, and
condition of
mucous
membranes.

Collaborative:
-administer
antidiarrheal -to decrease
medications, as gastrointestinal
indicated. motility and
immune fluid
losses.
-administer
medication as -to treat infections
ordered. process, decrease
motility, and absorb
water.
Actual

Assessment Diagnosis Inference Planning Intervention Rationale evaluation

subjective: Ineffective airway Sepsis is a Within 8 hours of Independent: Within 8 hours of


clearance related potentially nursing intervention nursing intervention
“hirap huminga to excessive dangerous or the patient’s -monitor -indications of the patient’s sputum
ang anak ko” as sputum secretions life-threatening sputum secretions reparations and respiratory secretions was
verbalized by secondary to medical will decreased and breathe sounds, distress and decreased.
the patient. infection. condition, breathing pattern noting rate and accumulation of Respiratory rate
found in will be normal. sounds. secretions. was 60cpm.
Objective: association with Goal was met.
a known or -evaluate client’s -to determine
-Cyanosis suspected cough/gag ability to protect
-changes in infection reflexes and own airway.
respiratory rate (usually but not swallowing
and rhythm. limited to ability
bacteria) whose
-v/s results: signs and
RR- 35 symptoms -position head -To open or
CR- 75 fulfill at least appropriately for maintain open
two of the age/condition. airway in at- rest
following or compromised
criteria of a individual.
systemic
inflammatory
response -elevate head of -to take advantage
syndrome bed/change of gravity
(SIRS): position every 2 decreasing
hours and prn. pressure on the
diaphragm and
enhancing
drainage of
ventilation to
different
segments.

-encourage deep -to maximize


breathing and effort
coughing exercise
s, splint chest or
incision.
Collaborative:

-obtain sputum -To verify


specimen appropriateness
preferably before of therapy
antimicrobial
therapy is
initiated.

-determine that -for treatment of


client has obstructive sleep
equipment and is apnea, when
informed in use indicated of
of nocturnal generalized
continuous infection.
positive airway
pressure (CPAP)

-monitor of signs -may reflect


of deterioration of inappropriate
condition or antibiotic therapy
failure to improve or overgrowth of
in therapy. secondary
infections.