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CA Risk For Infection NCP

1) The client had an episiotomy that was swollen and reddish, putting her at risk for infection due to impaired skin integrity. 2) The nurse established rapport, monitored vital signs and assessed for signs of infection such as fever or chills. 3) Interventions included teaching proper perineal cleaning and providing pain relief to promote healing and prevent infection.

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5K views2 pages

CA Risk For Infection NCP

1) The client had an episiotomy that was swollen and reddish, putting her at risk for infection due to impaired skin integrity. 2) The nurse established rapport, monitored vital signs and assessed for signs of infection such as fever or chills. 3) Interventions included teaching proper perineal cleaning and providing pain relief to promote healing and prevent infection.

Uploaded by

JheanAlphonsineT.Means
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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NCP#3: Risk for infection r/t impaired skin integrity secondary to medial episiotomy.

Assessment: Diagnosis: Objective: Nursing Intervention: Rationale: Evaluation:


Subjective data: Risk for Short term: Communication Short term:
Client verbalized: “naa infection r/t After 3 hours of • Establish rapport. • To gain patient’s trust • Did not manifest
pay mgananggawas impaired nurse-patient Provide reassurance and cooperation. the signs of
ngadugo sa akong skin interactions: and comfort. infection (fever
kinatawo”; “sakit pa e integrity • Not exhibit Safe and Quality and chilling); vital
lihok ang sa akong secondary any signs and Nursing Care: signs within
paadapit” to medial symptoms of • Monitor vital signs normal limits.
episiotomy. infection such especially temperature • A slight elevation in • Listened upon
Objective data: as fever and temperature suggests explanation on the
Method of delivery: chilling. • Note signs/symptoms fever. factor (impaired
NSVD with thick • Identify of fever, pallor and skin integrity) of
meconium staining interventions chills. developing
Episiotomy area is to prevent/ infection.
swollen and reddish in reduce risk of • Perform surgical • To assess if infection is • Was able to
color. infection. handwashing before occurring. verbalize
• Verbalized and after doing understanding of
understanding perineal care on the • To prevent infection to the risk factors.
of individual site of episiotomy. the area and inhibit cross
risk factors. contamination. Long term:
• Do perineal care and • The patient was
Long term: teach the mother on the free from any type
After 2 days of importance of proper of infections.
nursing intervention: perineal cleaning.
• The patient will be • Perineal area should be
free from any type of Health Education cleansed well to prevent
infection. • Explain why the growth of
and how microorganism.
infection is
likely to happen.
• Assist with use
of breathing • To give the client the
techniques idea on the causative
during surgical factors of infection
repair, as formation/process.
appropriate. • Breathing helps direct
• Encourage the attention away from the
use of relaxation discomfort, promotes
techniques such relaxation.
as deep
breathing and
imagery. • May help decrease pain
Collaboration and perception by
Teamwork interrupting the
• Provide optimal conduction of nerve pain
pain relief with impulse.
the physician’s
prescribed
analgesics and
antibiotics. • Each client has a right to
maximum pain relief.
Medications ordered
PRN should be offered
to the patient whenever
the next dose is
available. Antibiotics
help prevent and fight
infection.

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