Cues/Needs Nursing Rationale Goals and Intervention Rationale Evaluation

Diagnosis Objectives
Subjective: Risk for The immune Short term -Provide isolation/monitor -Body substance isolation After 2 hours of
“medyo infection system is the one (BSI) should be used for nursing intervention,
mahina na ko related to protecting the body After 2 hours of visitors as indicated. short term goal is fully
all infectious patients.
kesa dati, Compromised from opportunistic nursing intervention, met as evidenced by:
parang ang immune pathogens and patient will: Wound/linen isolation
dali ko system bacteria. The and - Demonstration
dapuan ng secondary to immune system of a - Demonstrate hand washing may be all of different
sakit hepatitis B cancer patient different that is required for ways to
ngayon.” works by ways to draining prevent
destroying about prevent infection such
infection. wounds. Patients with
Objective: 10,000 mutant as:
cancer cells in the diseases transmitted  monitored
-hepatitis body every day, through air visitors as
patient with all its activity, Long term may also need airborne suggested
the system becomes and droplet precautions. by health
-PR = 57 compromised. After 3 days of provider.
nursing intervention, Reverse
bpm When the immune  Frequent
patient will: isolation/restriction of
system is position
compromised, there visitors may be needed to
changes
is greater risk for - will not protect
acquire  Covering
infection to be the immunosuppressed of mouth
acquired by a infection
patient. by the
person. family
-Reduces risk of cross- whenever
-Wash hands with antibacterial
contamination because they cough.
soap before/after each care
gloves may
activity even if gloves are
have unnoticeable
used.
defects, get torn or
damaged during After 3 days of
use. nursing intervention,
long term goals are
fully met as evidenced
-Encourage/provide frequent -Good pulmonary toilet by:
position changes, deep- may reduce respiratory
breathing/coughing exercises. compromise. - Absence of
infection.
-Encourage patient’s family to -Prevents spread of
cover mouth and nose with infection via airborne
tissue
droplets.