ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Risk of infection After 2-3 days of Know history for History of After 2-3 days of
related to nursing preexisting conditions diabetes or nursing
None inadequate intervention, the or risk factors. Note hemorrhage intervention, the
OBJECTIVE: primary defense client will be time of rupture of increase chances client was able to:
secondary to able to: membranes. of infection and
 Dressing dry surgical incision poor wound  Be free
and intact  Be free healing. Risk of from
 V/S taken as from infection
chorioamnionitis
follows: infection  Achieved
T: 35.8 °C increases with the
 Achieve timely
PR: 77 bpm passage of time,
timely wound
RR: 19 cpm placing mother
BP: 100/70 wound healing
and fetus at risk.
mmhg healing without
Presence of
without complicatio
infectious process
complicat ns
may increase
ions.
fetal risk of
contamination

Rupture of
membranes
occurring 24 hr
Assess signs and before the
symptoms of infection surgery may
(e.g., elevated result in
temperature, pulse, chorioamnionitis
WBC; abnormal odor prior to surgical
or color of vaginal
discharge, or fetal intervention and
tachycardia). may impair
wound healing.

Moist from
Inspect dressing and dressing can be
perform woundcare source of infection.

Provide perineal care Decreases risk of

per protocol, ascending
particularly once infection
membranes have
ruptured.

Monitor white blood Rising WBC

count (WB) indicates body's
effort to combat
pathogens

Carry out Decreases risk of

preoperative skin skin
preparation; scrub
according to protocol. contaminants
entering the
operative site,
reducing risk of
preoperative
infection.

Take blood, vaginal,

and placental cultures,
as indicated. Determines
infecting
organism and
degree of
Record Hb and Hct,
involvement.
and estimated blood
loss during surgical
procedure.
Risk of
postdelivery
infection and
poor healing is
increased if Hb
levels are low
and blood loss is
excessive. Note:
Greater blood
loss is associated
with classic
incision than with
 lower uterine
segment incision.

INDEPENDENT:

Give parenteral
broad-spectrum Prophylactic
antibiotic antibiotic may be
preoperatively. requested to
prevent
development of
an infectious
process, or as
treatment for an
identified
infection,
especially if the
patient has had
prolonged rupture
of membranes.
Note: Research
suggests
administration of
antibiotic up to 2
hr before start of
procedure
provides the most
protection from
infection
 CLASSIFICATION MECHANISM OF CONTRAINDICATION SIDE EFFECTS NURSING
ACTION CONSIDERATION

Magnesium Sulfate Circulatory collapse

DOSAGE: Respiratory paralysis

Low core body

temperature
(hypothermia)

Excess fluid in the lungs

(pulmonary edema)

Depressed/poor reflexes

Low blood pressure

(hypotension)

Flushing

Drowsiness

Depressed cardiac
function/heart
disturbances
Increased sweating

Low blood calcium

(hypocalcemia)

Low blood phosphates

(hypophosphatemia)

Low blood potassium

(hyperkalemia)

Visual changes

Breathing difficulties

Confusion

Weakness

Flushing (warmth,
redness, or tingly
feeling)

Feeling like you might

pass out

Anxiety

Cold feeling

Extreme drowsiness

Muscle tightness or
 contraction

Headache

Methyldopa