Nursing Care Plan

Name of the Patient

Medical Diagnosis
Nursing Diagnosis
Short-Term Goal
Long-Term Goal
Cues
Subjective:
Kaninang umaga
lang ako
naoperahan; as
verbalized by the
patient.
Objective:

T-36.3C
Weak in
appearance
Clean and
intact
abdominal
dressing

:
:
:
:

GC
Post CS
Risk for infection related to post surgical incision
Within the shift, patient will be able to identify ways to reduce risk for infection.
: At the end of hospitalization, patient will not manifest any signs and symptoms of infection.
Problem

Scientific Reason

Nursing Intervention

Risk for
infection

Wounds involving
injury to soft tissue
can vary from
minor tears to
severe crushing
injuries. The
decision to suture a
wound depends on
the nature of the
wound the time
since the injury
was sustained the
degree of
contamination.

Reference:
Brunner &
Suddarths
Textbook of
Medical-Surgical
Nursing 11th edition
by Smeltzer, Bare,
Hinkle, Cheever

Assess signs and

symptoms of
infection especially
temperature.

Emphasize the
importance of
handwashing
technique.

Maintain aseptic
technique when
changing
dressing/caring
wound.
Keep area around
wound clean and
dry.

Emphasized
necessity of taking
antibiotics as
ordered.

Rationale

Fever may indicate

infection.

It serves as a first
line of defense
against infection.

Regular wound
dressing promotes
fast healing and
drying of wounds.

Wet area can be

lodge area of
bacteria

Premature
discontinuation of
treatment when
client begins to feel
well may result in
return of infection.

Evaluation
Goal met:
Patient was free
from any signs
and symptoms of
infections as
manifested by
absence of fever.

Submitted by: Ray Francis C. Bravo

Submitted to: Mrs. Altavano

Submitted by: Ray Francis C. Bravo

Submitted to: Mrs. Altavano