Nursing Care Plan

Cues/ Needs
Subjective: - none Objective: - dressing dry and intact -V/S taken as follows: T: 36.8 P: 81 R: 16 BP: 120/70 O2 sat: 97

Nursing Diagnosis
Risk for infection related to inadequate primary defenses secondary to surgical incision

Rationale

Goals/Desired Outcomes
STG: After 4 hours of nursing intervention, patient will be able to understand causative factors, identify signs of infection and report them to health care provider accordingly. LTG: After 2-3 days of nursing intervention, patient will achieve timely wound healing, be free of purulent drainage or erythema, be afebrile and be free of infection.

Interventions

Rationale

Evaluation

Due to an elective cesarean section, patients skin and tissue were mechanically interrupted. Thus, the wound is at risk of developing infection.

Independent: 1.)Monitor vital signs.

-To establish a baseline data. -Moist from drainage can be a source of infection.

2.)Inspect dressing and perform wound care. 3.)Monitor white blood count (WBC).

- Rising WBC indicates bodys efforts to combat pathogens; normal values: 4000 to 11,000 mm3. -These are signs of infection.

Patient is expected to be free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes.

4.)Monitor elevated temperature, redness, swelling, increased pain, or purulent drainage at incisions. 5.)Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient.

-Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another. -Fluids promote diluted urine and frequent emptying of bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or

6.)Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated).

urinary tract infection (UTI). -These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia. -Antibiotics have bactericidal effect that combats pathogens.

7.) Encourage coughing and deep breathing; consider use of incentive spirometer.

Independent: - Administer antibiotics.