DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

NURSING PROGRAM
NURSING CARE PLAN

Name of Patient: Patient Mahani Date of Admission: August 22, 2021   Room: 3002
Age: 29 yr. old Sex: F    Civil Status:
Chief Complaint: Risk for infection related to second-degree perineal laceration.
Religion: ____________________ Attending Physician: Dr. Bonna
 
GOALS/OBJECT NURSING
SCIENTIFIC
PROBLEM  IVES CRITERIA  INTERVENTIO RATIONALE  EVALUATION 
BASIS 
NS 
August 22, At the end of the At the end of
2021, Risk for shift, the patient 1. Assess 1. Fever may the shift, the
 7:35 am infection will be able to:  signs and indicate patient was
related to symptoms of infection. able to: 
second- A. Verbalize infection
Subjective degree understanding especially “Goal Partially
Data: perineal of individual temperature. Met”
laceration. causative or 2. Change in
risk factor(s). 2. Observe and mental status, A. Verbalized
report signs of fever, shaking, understand
B. Identify infection such chills, and ing of
interventions as redness, hypotension individual
to prevent or warmth, are indicator causative
Objective reduce risk of discharge, and of infection. or risk
Data: infection. increased body factor(s).
REFERENC temperature.
Sustained a ES:  C. Demonstrate 3. It serves as B. Identified
second- Doenges, M., techniques, 3. Emphasize first line of interventio
degree Moorhouse lifestyle the importance defense ns to
perineal M. F., Murr A. changes to of handwashin against prevent or
laceration (2013). promote safe g technique. infection. reduce risk
Nurse’s environment. of
Vital signs: Pocket 4. Wear gloves infection.
BP: 90/60 Guide: D. Achieve timely and gowns
mmHg, Diagnoses, wound when caring for 4. Prevents C. Demonstra
PR: 101 Prioritized healing; be open wounds spread of ted
bpm, RR: Interventions, free of or anticipating infection and techniques
17 bpm, T: and purulent direct contact cross , lifestyle
37.6 C° Rationales drainage or with secretions contamination. changes to
(13th ed.) erythema; be or excretions. promote
Philadelphia, 5. Daily
  afebrile. safe
  F.A Davis 5. Cleanse showers can environme
  Company E. Be free from skin gently with help reduce nt.
  any signs and mild soap and the number of
  symptoms of water at least bacteria on D. Achieved
  related to once daily. client’s skin. timely
  infection wound
  6. Provide healing; be
    regular free of
  perineal care. 6. Reduces purulent
  risk of drainage or
  7. Encourage ascending erythema;
  use of peri- urinary tract be afebrile.
  bottle after infection.
  using the E. Free from
bathroom. 7. Cleaning
any signs
the site of
and
8.  Ensure that wound after
symptoms
any equipment using the
of related
used are bathroom will
to infection
properly help to
disinfected or prevent
 
sterilized infections.
before use.
8. This
reduces or
9. Change
eliminates
peripad with
germs.
each void or
defecation or at
least four times
per day. 9. Infectious
agents can
invade when
10. Instruct the skin is
client/SO damage.
(significant
other) in
techniques to
protect the 10.
integrity of Knowledge of
skin, care for ways to
lesions, and reduce or
prevention of eliminate
spread of germs
infection. reduces the
likelihood of
11.
 Demonstrate transmission.
and allow
return
demonstration
of all high-risk 11. Patient
procedures and SO need
that the patient opportunities
and/or SO will to master new
do after skills to
discharge. reduce
susceptibility
to infection.
12. If infection
occurs, teach
the patient to
12. Antibiotics
take anti-
work best
infective as
when a
prescribed. If
constant blood
taking
level is
antibiotics,
maintained
instruct the
when
patient to take
medications
the full course
are taken as
of antibiotics
prescribed.
even if
Not
symptoms
completing the
improve or
prescribed
disappear.
antibiotic
regimen can
lead to drug
resistance in
the pathogen
and
reactivation of
symptoms.