Nursing Care Plan

Name of the Patient : GC

Medical Diagnosis : Post CS
Nursing Diagnosis : Risk for infection related to post surgical incision
Short-Term Goal : Within the shift, patient will be able to identify ways to reduce risk for infection.
Long-Term Goal : At the end of hospitalization, patient will not manifest any signs and symptoms of infection.

Cues Problem Scientific Reason Nursing Intervention Rationale Evaluation

Subjective:
“Kaninang umaga lang
ako naoperahan”; as
verbalized by the patient.
Objective:
 T-36.3°C
 Weak in
appearance
 Clean and intact
abdominal dressing
Risk for Wounds involving  Assess signs and  Fever may indicate Goal met:
infection injury to soft tissue can symptoms of infection infection.
vary from minor tears to especially temperature. Patient was free from
severe crushing injuries. any signs and
The decision to suture a symptoms of
wound depends on the  Emphasize the  It serves as a first line of infections as
nature of the wound the importance of defense against infection. manifested by absence
time since the injury handwashing technique. of fever.
was sustained the
degree of  Maintain aseptic  Regular wound dressing
contamination. technique when changing promotes fast healing
dressing/caring wound. and drying of wounds.
Reference:
Brunner & Suddarth’s  Keep area around wound  Wet area can be lodge
Textbook of Medical- clean and dry. area of bacteria
Surgical Nursing 11th
edition by Smeltzer,  Emphasized necessity of  Premature
Bare, Hinkle, Cheever taking antibiotics as discontinuation of
ordered. treatment when client
begins to feel well may
result in return of
infection.

Submitted by: Ray Francis C. Bravo

Submitted to: Mrs. Altavano