ACTIVITY # 2
POTENTIAL NURSING DIAGNOSIS PROBLEM
FDAR / NCP
KRISTIAN KARL B. KIW-IS
BSN IV-A
Nursing Explanation Goal Nursing Rationale Evaluation
Diagnosis Of the intervention
and cues problem
Subjective: The state in Short term Assess . Provides Goal fully met
Objective: which an goal: temperature, IV information Short term
Mild bluish individual is After 8 hours site, increased indicating goal:
discoloration at risk to be of effective WBC, increased potential After 8 hours
of lips and invaded by nursing pulse and infection. of effective
tongue, SaO2 an intervention respirations. nursing
83%, Heart opportunisti the patient intervention
rate: 156 bpm c or will not the patient
RR: 48/min, pathogenic experience did not
With IV line agent (virus, any infection Avoid allowing Prevents experience
Post op. fungus, as manifested those with transmission of any infection
bacteria, by absence of infections to infectious agents as manifested
Nursing protozoa, or signs of have contact to infant/child by absence of
Diagnosis: other infection with infant. with signs of
Risk for parasite) such as fever. compromised infection such
infection from defense. as fever.
related to endogenous Long term
Chronic illness or goal: Goal partially
secondary to exogenous After 3 days Provide Protects against met
Tetralogy of sources" of effective adequate rest potential Long term
Fallot urces. nursing and nutritional infection by goal:
intervention needs for age. increasing body After 3 days
the patient resistance and of effective
will be free defenses. nursing
from any intervention
complications the patient
of infection. Wash hands Prevents was free from
before giving transmission of any
care. microorganisms complications
to infant/ child. of infection.
Use sterile Prevents
technique for IV contamination,
maintenance. which causes
infection.
Administer
antibiotics as Describe action
ordered of specific
(specify drug, antibiotic
dose, route, and ordered.
times).
Instruct parents
and SO in Prevents
personal hygiene reduced
and practices defenses or
(rest, nutrition, exposure to
activity, possible
bathroom for contaminants.
elimination,
bathing).
Inform to avoid
contact with
those in family or Infections are
friends that have easily
an infection. transmitted to a
debilitated child.
F Risk for infection related to Chronic illness secondary to Tetralogy of Fallot
D Received lying on bed with an ongoing IVF of 0.9 NACL x KVO at left arm
infusing well,with oxygen via nasal cannula , Mild bluish discoloration of lips and
tongue, SaO2 83%, Heart rate: 156 bpm RR: 48/min, anterior fontanelle normal.
Post op
A Assessed temperature, IV site, increased WBC, increased pulse and
respirations.
Avoided allowing those with infections to have contact with infant.
Provided adequate rest and nutritional needs for age.
Performed hand hygiene before giving care.
Used sterile technique for IV maintenance.
Administered antibiotics as ordered
(specify drug, dose, route, and times).
Instructed parents and SO in personal hygiene and practices (rest, nutrition,
activity, bathroom for elimination, bathing).
Informed to avoid contact with those in family or friends that have an infection.
R The patient did not experience any infection as manifested by absence of signs
of infection such as fever.
FDAR
