Berzabal, Jane Arian I.
NCA2-III
Assessment
Subjective:
- incision during
Objective:
 incised skin @ right
lower quadrant
 Incision pain
Nursing Diagnosis
Risk for infection related to
surgical incision at right
lower quadrant of the
abdomen.
Acute Appendicitis
Explanation of the
Problem
The creation of surgical
appendectomy disrupts the
skin integrity of the skin and
its protective function.
Exposure of deep body
tissues to the pathogens in
the environment places the
patient at risk for infection of
the surgical site, a potentially
threatening complication.
Factors related to the
surgical procedure include
the method of preoperative
skin preparation, surgical
attire of the team, method of
sterile draping, duration of
surgery and length of
procedure.
Reference:
Hinkle J.L. Cheever K.H.
(2017) Brunner an Suddath’s
textbook of Medical Surgical
Nursing, Wolters Kluwer,
New York. US.
Planning
Short Term:
Within 8 hours of
nursing intervention, the
patient will be able to
verbalize and understand
the causative/risk factor for
the infection.
Long Term:
After 3 days of nursing
intervention, the patient will
be able to achieve timely
wound healing and be free
of purulent drainage or
erythema.
June 25, 2021
Nursing Interventions Rationale Evaluation
Independent: Short Term:
 Monitor vital signs,  Fever and pain The goal was met, within
onset of fever with indicate inflammatory 8 hours of nursing
chills, and pain. responses, which intervention, the patient was
contribute to able to verbalize and
infection. understand the causative
and risk factor for the
 Note risk factors for  To evaluate infection.
occurrence of presence of infection.
infection.
 Strict compliance to  To establish
hospital control mechanism to Long Term:
sterilization and prevent occurrence
aseptic policies. of infection. The goal was met, after
3 days of nursing
 Instruct good hand  Reduces the risk for intervention, the patient was
washing and aseptic infection or cross able to achieved timely
wound care. contamination of wound healing and free of
bacteria. purulent drainage or
erythema.
 Inspect incision site.  Provides early
Note characteristics detection of infection
of drainage from process, and
wound. presence of
discharges may help
to identify whether
there is an infection.
 Change wound  To reduce existing
dressing as risk factors.
indicated, using
proper technique for
changing/ disposing
of contaminated
materials.
Dependent:

 Administer
antibacterial  To prevent spreading
medication as of bacteria
ordered.

Educative:

 Encourage intake of
fluid and food that is  Promotes healing
rich in Vitamin C. and prevents
dehydration.

Reference:

Herdan, H.T., (2020)

NANDA International
Nursing Diagnosis:
Definitions and
Classifications 2018-2020
11th Edition.