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NCP 3

The document outlines an assessment, plan, intervention, and evaluation for a patient presenting with fatigue, fever, chills, and sweats. The nursing diagnosis is risk for infection related to compromised host defenses. The plan is for the patient to remain free of infection as evidenced by normal vital signs and absence of signs and symptoms after 8 hours of interventions including strict asepsis, encouraging rest, and monitoring vital signs and white blood cell count to allow early recognition and treatment of potential infection.

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Abijah Leris Sarmiento
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37 views

NCP 3

The document outlines an assessment, plan, intervention, and evaluation for a patient presenting with fatigue, fever, chills, and sweats. The nursing diagnosis is risk for infection related to compromised host defenses. The plan is for the patient to remain free of infection as evidenced by normal vital signs and absence of signs and symptoms after 8 hours of interventions including strict asepsis, encouraging rest, and monitoring vital signs and white blood cell count to allow early recognition and treatment of potential infection.

Uploaded by

Abijah Leris Sarmiento
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Assessment 

Planning  Intervention  Rationale  Evaluation

Objective: Long Term Goal:   Assess for the  These factors Long Term
 Fatigue presence, existence, represent a break in Evaluation: 
 Fever After 8 hours of and history of the the body’s normal
 Chills and comprehensive nursing common causes of first line of defense After 8 hours of
sweats. intervention. infection and may indicate an nursing 
Subjective: infection. intervention, the
“I feel like I’m  Client will remain  Monitor Vital outcome goals for
always having a free of infection, as Signs  Vital signs the patient have
fever often.” evidenced by normal especially been met and the
vital signs and temperature can be patient condition
Nursing absence of signs and  Maintain strict a good indicator if improved.
Diagnosis symptoms of asepsis for dressing there is a presence
Risk for infection infection. changes, wound of infection.
related to  Client will maintain care, intravenous
Compromised or restore defenses. therapy, and  Aseptic technique
host defenses  Early recognition of catheter handling. decreases the
infection to allow for  Encourage sleep chances of
prompt treatment. and rest. transmitting or
 Patient will  Monitor white spreading pathogens
demonstrate a blood cell (WBC) to or between
meticulous hand count. patients.
washing technique.
 Adequate sleep is
an essential
modulator of
immune responses.

 An increasing WBC
count indicates the
body’s efforts to
combat pathogens.

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