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NURSING CARE PLAN

General Objective: To promote safety through prevention of the spread of infection.


Assessment

Nursing
Diagnosis

Subjective
Cues:
Ga sakit akon
nga tinahi-an.

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

Objective
Cues:
*Dressing dry
and intact.
*Temp 36.50C
(36.5-37.50C)
*CR 83 bpm
(60-100 bpm)
*RR 23 cpm
(12-20 cpm)
*BP 100/60
mmhg
(120/80
mmhg)

Rationale

Specific
Objectives

A Cesarean
section (Csection) is a
surgery to
deliver a
baby. The
baby is taken
out through
an incision at
the mothers
abdomen.
Due to an
elective
cesarean
section,
patients skin
and tissue
were
mechanically
interrupted
thus, the
wound is at
risk of
developing
infection.

Within 18 hours of
rendering care,
the patient will be
able to
understand
causative factors,
identify signs of
infection and
report them to
health care
provider
accordingly.

Nursing
Intervention
Independent
*Establish rapport

*Emphasis and
model proper hand
washing
technique.
*Maintain aseptic
technique in
dressing changes
and invasive
procedures.

Rationale

-To have a good


nurse-client
relationship.
-Prevents
spread of
bacteria and
cross
contamination.
-Reduces risk of
nosocomial
infection.

*Inspect surgical
incisions and
invasive line sites
for erythema and
purulent drainage.

-Early detection
of developing
infection
provides for
prevention of
more serious
complications.

*Encourage
frequent position
changes, deep
breathing and use
of respiratory

-Promotes
mobilization of
secretions,
reducing risk of
pneumonia.

Evaluation

After 2 days of
rendering care,
patient is
expected to be
free of infection,
as evidenced by
normal vital signs
and absent of
purulent drainage
from incisions.
The patient will be
able to
understand
causative factors,
identify signs of
infection and
report them to
health care
provider.

adjuncts.
* Encourage good
perineal care.
*Observe for
reports of
abdominal pain,
especially after
third postoperative
day, elevated
temperature, and
increased white
blood cell (WBC)
count.

-Prevents
ascending
bladder
infections.
-Suggests
possibility of
developing
peritonitis.

Dependent
*Apply topical
antimicrobials or
antibiotics as
prescribed by the
Doctor.

-Prevents
infection in the
wound.

*Administer IV
antibiotics, as
indicated by the
Doctor.

-A prophylactic
antibiotic
regimen is
usually standard
in these clients
to reduce risk of
perioperative
contamination.

*Obtain specimen
of purulent
drainage for
culture and
sensitivity.

-Identifies
infectious
agent; aids in
choice of
appropriate

theraphy.

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