ASSESSMENT

DIAGNOSIS

SCIENTIFIC

OBJECTIVES

NURSING

RATIONALE

INTERVENTION
S
1. Check on

RATIONALE

EVALUATION

to analyze

After 30

- Presence of

Risk for

A poorly

After 30

dressing on

infection

managed

minutes of

the

the

minutes of

PCNL site.

related to

incision site

Nurse-

dressing

progress

Nurse-

invasive

after an

patient

every 3-4

of wound

patient

procedure

invasive

interaction,

hours if

healing

interaction,

procedure is

the patient

necessary

and

the patient:

at risk for

will:

assess if

microorganis
m growth
and infection.

there is an - was able to

- be able to
understand
proper
wound
manageme
nt
- express
willingness
to
participate

2. Always
apply

impending

understand

infection.
To avoid

proper

septic

clean

growth

technique
when

wound

manageme
nt
- expressed
willingness

managing
the wound
3. Clean the

wound

to
-

to avoid

participate

contamina

in

in

using an

manageme

aseptic

nt

wipe from

tion.

nt

the center
outwards.
Advise not
to use the
same
wipe
twice.
4. Keep the

- dryness or

wound dry

dampness

but not

can lead to

too dry or

infection.

too damp.
5. Advised to
drink
plenty of
fluids

manageme

- overly dried
mucous
membranes
can promote
abrasion and
infection
- to avoid

infection and
6. Administe

avoid drug

r drugs as

resistance.

ordered
and teach
drug

managem

to avoid
contamina

ent.
7. Limit

tion of
wound.

visitors
who have
coughs

and colds

for
optimum

or other

nutrition

diseases
8. Encourage

to boost
immunity.

intake of
protein
and
calorie
rich foods.

to avoid
contamina
tion

9. Advise the
client to
wash
hands

- To initiate

before

awareness

handling
the wound
10. Teach
patient
the signs
and
symptoms
of
infection