CUES Objective:

With

surgical incision in the abdomen (-) redness (-) inflamm ation (-) discharge G2p2

NURSING DIAGNOSIS Risk for infection related to inadequate primary defenses of broken skin as manifested by presence of surgical incision

INFERENCE Caesarian operation I Trauma on the skin I

Broken skin I Risk for infection

GOAL & OBJECTIVES Short term: After 2 hours of nursing intervention, patient will understand the risk factors of infection as evidenced by:

INTERVENTION Independent 1. Establish Rapport

RATIONALE

EVALUATION Short term:

To gain trust And cooperation of the patient Hand Washing reduces the risks for infection

2. Teach patient to wash hands often, especially before toileting, before meals and - Verbalizing understanding before and after of administering individual self-care causative/ risk factors of infection 3.Discuss to patients the - Identify following signs of interventions infection, to redness, swelling, prevent or reduce increased pain, or risk for purulent drainage developing on the site and an infection fever

After 2 hours of nursing intervention the patient was able to gain knowledge in infection control as evidenced by her discussion in risk factors for infection. Long term: After 1 week of nursing intervention, the Patient was freefrom signs & symptoms of infection.

To impart to the patient when the wound become infected and when to sought medical care

-Listing down ways on how to promote safe environment Long term: After 1 week of nursing intervention, the patient will maintain a freeinfection state of health as evidenced by: -No drainage or pus present in the surgical site -No localized infection developed -No systemic infections

4.Demonstrate and allow return demonstration of wound care Dependent: - Administer prophylaxis as ordered

To know if the patient really understand the principle of proper wound care

Reduces the risk for infection

arise

Nursing Care Plan

Submitted by: Servanez, Irene Charry Mae M. Submitted to: Maam Hermigildo