South University Student’s Name/Date: ___Virginia Basnight________
Problem Focus Care Plan Patient’s Initials: _____VC
Client’s Priority Basic Health Need: ___Safety_________
1. Nursing Diagnosis
Risk for Infection related to surgical
childbirth
2. Assessment Data Pertinent to above
Nursing Dx
a. Subjective:
Patient just had a cesarean surgery
b. Objective:
-Though there is sterile technique,
there are many people in the room
which increases the changes of
infection.
-This procedure is serious surgery:
There are multiple layers that the
surgeon must go through before
reaching the baby.
-The uterus is cut
-If not cared for appropriately, the
incisions will get infected.
3. Nursing interventions and corresponding rationale
(Number each intervention and its corresponding scientific rationale)
3a. Interventions:
1. Maintain a clean postpartum
environment, including staff
wearing scrubs and clean shoes,
use of individual patient
equipment, not sharing
equipment with other units, and
not accepting transfer patients
with infectious processes.
2. Monitor the patient’s vital signs
q15mins for 2hrs until stable
3. Monitor the incision frequently for
redness, edema, ecchymosis,
drainage, odor, and the
approximation of the edges.
4. Encourage the patient to wash
her hands or use the antimicrobial
hand cleanser (specify) before
and after using the bathroom,
before eating, and before caring
for her baby.
5. Teach the patient the signs of
infection to report to her
caregiver: increased redness and
pain, swelling, drainage, foul
odor, or separation of the edges
of the incision.
6. Reinforce hand washing, incision
care, good nutrition, and signs of
infection to report prior to patient
discharge.
3b. Scientific Rationale:
1. Prevents cross-contamination of
the vulnerable postpartum patient
from other hospitalized patients
and staff member’s clothing.
2. A temperature greater than 101°F
(38.40C) after the first 24 hours
may indicate infection. Severe
infection may result in signs of
septic shock: tachycardia,
tachypnea, and hypotension.
3. Redness and edema are early
signs of an inflammatory process;
bruising may indicate increased
capillary permeability resulting
from inflammation; wound
dehiscence may result from poor
tissue healing related to an
infectious process.
4. Hand washing and approved hand
cleansers help prevent the spread
of microorganisms.
5. Early detection of inflammatory
response facilitates early
diagnosis and treatment for
infection
6. Reinforcement encourages the
patient to incorporate these
activities into her daily routines.
4. Measurable and Realistic Outcomes 3c. Collaborative 3d. Collaborative Rationale
1. Work with Nutritionist: Promote 1. Adequate intake of sufficient
Short Term: optimal nutritional intake for calories, protein, and ascorbic
4a. The patient will not exhibit healing including good sources of acid is required for optimal tissue
signs of infection: temperature will protein and vitamin C. Assist the healing (and breastfeeding, if
patient to identify good sources of indicated). Teaching about
remain less than 101°F (38.40C) after the
first postpartum day. these nutrients in foods she nutritional needs with culturally
enjoys appropriate examples empowers
the patient.
Long Term:
4b. The patient will experience
tissue healing and an uneventful physical
recovery
from her surgical birth.
5. Evaluation of Short and Long Term Outcomes:
Short Term Outcomes (4a)

Outcome met Not met Partially met Client behavior: In recovery, the patients temperature was below 101⁰F.

Long Term Outcomes (4b)

Outcome met Not met Partially met Client behavior: With the short time, there was no way to measure the outcome
of this patient.