Risk for Infection as Evidenced by Inadequate Primary Defenses (Right Mediolateral Epsiotomy) Appendix 4

Assessment

Nursing Dx

Rationale

Planning

Intervention

Subjective:

Risk for
Infection as
Evidenced by
Inadequate
Primary
Defenses (Right
Mediolateral
Epsiotomy)

One of the effects of

Surgery to a woman
is an interference with
body defenses. The
skin is a primary line
of defense against
bacterial infection,
when it is incised; the
important line of
defense is lost.
(Adele Piliteri,
Maternal and Child
Health Nursing,
Volume I page 655)

By the end of the

Health Teaching (30m
1hr), client must be
able to:
- Verbalize factors
that may cause
infection to the
wound
- Identify
interventions to
prevent risk of
infection
- Demonstrate
techniques and
lifestyle changes
to promote a safe
environment

To assess causative /
contributing factors

Client
verbalized that
she is worried
that her wound
might get
infected
Objective:
Inadequate
Primary
Defense: has a
broken skin in
the vagina due
to Right
Mediolateral
Episiotomy
Temp: 37.1
PR: 65
RR: 20
BP: 110/80

By clients discharge,
(2 weeks or less),
client must achieve
timely wound healing
without any
complications

Rationale

Note risk factors

for occurrence of
infections

a. Environment:
client must
always be in a
clean and safe
environment

A dirty environment is a
source of infection through
the organic matter in
contained, the environment
must stay clean to avoid
infections (Nightingale
Environmental Theory,
Alligood and Tomey,
Nursing Theory 7th Edition
pg 75)

b. Check the
wound: wound
must always stay
clean no matter
what

A clients first line of defense

is the skin, it serves as a
standard to assess
deviations from the clients
usual wellness (Neuman
Systems Model, Alligood
and Tomey, Nursing Theory
7th Edition pg 312)

Assessment is done to
establish a database about
the clients response to
health concerns o illness
and the ability to manage

Assess and
document skin
condition
together with

Evaluatio
n

Risk for Infection as Evidenced by Inadequate Primary Defenses (Right Mediolateral Epsiotomy) Appendix 4
signs and
symptoms of
sepsis

To reduce/correct
existing risk factors
-

health care needs (Kozier

and Erbs Fundamentals of
Nursing 8th Edition pg. 178)
-

Effective communication is
important among health
care professionals and is
communicated through
documentation of reports,
discussion and records
(Kozier and Erbs
Fundamental of Nursing 8th
Edition page 246)

Hand washing is done to

reduce the risk of
transmission of
microorganism (Kozier and
Erbs Fundamentals of
Nursing 8th Edition pg. 684)

Visitors need o know how to

clean themselves to reduce
the risk of cross
contamination to client
(ozier and Erbs
Fundamentals of Nursing 8th
Edition ph 684)

Cleaning incision and

applying dressing can
promote wound healing by

Give proper
hand washing
techniques

Monitor visitors
to prevent
exposure of the
client

Cleanse incision
daily, apply the
proper solution

Risk for Infection as Evidenced by Inadequate Primary Defenses (Right Mediolateral Epsiotomy) Appendix 4
and change
dressing as
needed

primary intention, to prevent

infection, to assess the
healing process and to
protect the wound from
mechanical trauma (Kozier
and Erbs Fundamentals of
Nursing 8th Edition pg 968)

To promote wellness
-

Review
individual
nutritional
needs,
appropriate
exercise
program and
need for rest
-

a. Food: give food

that the client
can tolerate and
make sure it a
balanced meal

New mothers lose some of

their weight and continue to
shed as they lose their
accumulated fluids and their
blood volume returns to
normal (Zimmerman and
Snow, An Introduction to
Nutrition pg 601)
Health must be restored to
optimum level by giving diet
as tolerated by the patient
by using the Health Living
Pyramid and the food plate
(Kozier and Erbs
Fundamentals of Nursing 8th
Edition pg 1248)

Risk for Infection as Evidenced by Inadequate Primary Defenses (Right Mediolateral Epsiotomy) Appendix 4

Exercise is essential for

maintaining a mental and
physical health (Kozier and
Erbs Fundamentals of
Nursing 8th Edition pg. 1113)

Adults need 7-9 hours of

sleep (Kozier and Erbs
Fundamentals of Nursing 8th
Edition pg 1168)
Sleep is done to cope with
daily stressors, to prevent
fatigue, to conserve energy,
to restore the mind and
body and to enjoy life fully
(Kozier and Erbs
Fundamentals of Nursing 8th
Edition pg 1164)

b. Exercise: do not
do heavy work
or strenuous
activity, walking
is allowed as
exercise
c. Sleep: rest must
be one period in
a day and sleep
for 7-9 hours

Instruct client in
techniques to
protect the
integrity of the
skin

Cleaning incision and

applying dressing can
promote wound healing
Kozier and Erbs
Fundamentals of Nursing 8th
Edition pg 968)

Emphasize
necessity of
taking antibiotics
as directed

Bacterial Infections are

common and require
prompt treatment with
appropriate antibiotics
(James Ritler, et al. A
textbook of Clinical

Risk for Infection as Evidenced by Inadequate Primary Defenses (Right Mediolateral Epsiotomy) Appendix 4
Pharmacology and
Therapeutics 5th Edition pg
400)
-

Promote
checkups /
follow up
checkups

A woman should schedule a

4-6 week check up so she
can be assured involution is
complete