NURSING CARE PLAN

ASSESMENT (CUES ) Subjective: Medyo dakkel toy sugat kunsa nakkong; as verbalized by the patient. Objective: Weak and pale in appearance Incision on the abdomen intact abdominal dressing V/s taken as follows: T- 37.4 oC P-102bpm R- 20cpm BP-140/90 mmHg NURSING DIAGNOSIS P= risk for infection ANALYSIS Diet, Lifestyle, UTI, Age, Sex NURSING NURSING RATIONALE OBJECTIVES INTERVENTION/S After 8 hours of Assess signs and Fever may nursing intervention, symptoms of indicate the patient will: infection infection. a. Identify ways especially to reduce risk temperature. for infection with the help of Emphasize the Helps prevent or the nurse. importance of retard spread of b. Demonstrate hand washing infection. techniques to technique and promote proper healing. hygiene..Discuss c. Display wound with client the free of purulent importance of drainage with continuing these initial signs of measures after healing. discharge. d. The patient will maintain Encourage oral Prevents temperature at dehydration; fluids and diet, normal range. maximizes vitamin C, and circulation and iron. urine flow. Vitamin C is needed for collagen formation; iron is needed for Hb EVALUATION Date: December 8, 2009 Time:3::30 PM Level of Attainment: Goal met AEB: a. The patient performed ways or techniques to reduce risk of infection and (proper hand washing proper hygiene) b. Patient demonstrated techniques to promote healing (pt. took oral fluids and diet high in protein, vitamin C, and iron. c. Patients wound is free from

E= r/t broken skin and tissue trauma

Urinary Stasis and Supersaturation

Stone formation (Urinary Bladder)

Urolithiasis

Surgical Procedure

Abdominal incision

Break in the skin

(Open wound)

Microorganisms may grow and accumulate

Infection may occur

Source: The Merck Manual of Medical Information Second Home Edition, 2003 by Merck & Co.

purulent drainage. Maintain aseptic d. Patient is free technique when changing from any signs Regular wound dressing/caring and symptoms of dressing wound. infections as promotes fast Inspect healing and manifested by abdominal drying of absence of fever. dressing for wounds. exudates or V/s taken as oozing. Remove follow dressing, as A sterile dressing T- 36.9C indicated. covering the PR- 80 bpm wound in the first RR- 20 cpm 24 hr following BP- 120/80 cesarean birth mmHg helps protect it from injury or contamination. Oozing may indicate hematoma, loss of suture approximation, or wound dehiscence, requiring further intervention. Removing the dressing allows incision to dry and promotes healing.

synthesis.

Keep area around wound clean and dry. Inspect incision, evaluate healing process, noting

localized redness, edema, Wet area can be pain, exudates, lodge area of or loss of bacteria. approximation of wound edges. These signs indicate wound Emphasized infection. Wound necessity of infections are taking usually clinically antibiotics as apparent 38 ordered. days after the procedure. Premature discontinuation of treatment when client begins to feel well may result in return of infection.