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Risk For Infection

The patient is at risk for infection due to a surgically traumatized area on their perineum from an episiotomy. Vital signs were taken and the patient has a urinary catheter draining yellow urine. The objectives are for the patient to gain knowledge of infection control within 2 hours and show timely wound healing within 3 days. Nursing interventions include establishing rapport, assessing the skin and wound for signs of infection, discussing signs of infection with the patient, and maintaining aseptic technique with wound care.

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3K views3 pages

Risk For Infection

The patient is at risk for infection due to a surgically traumatized area on their perineum from an episiotomy. Vital signs were taken and the patient has a urinary catheter draining yellow urine. The objectives are for the patient to gain knowledge of infection control within 2 hours and show timely wound healing within 3 days. Nursing interventions include establishing rapport, assessing the skin and wound for signs of infection, discussing signs of infection with the patient, and maintaining aseptic technique with wound care.

Uploaded by

camziii
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Risk for Infection

Assessment S> O> -folly catheter draining yellowish in color urine @ 500 cc level - pale palpebral conjunctiva - normal capillary refill time of 2 seconds -good skin turgor. VS taken and recorded as follows: T = 37oC, PR = 94 bpm, RR= 28 cpm, BP= 120/80 mmhg

Nursing Diagnosis A> Risk for infection r/t surgically traumatized tissue at the right mediolateral side of the perinium 2o to episiorrhappy

Scientific explanation 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 & Suddarth s Textbook of Medical-Surgical Nursing 11th edition by Smeltzer, Bare, Hinkle, Cheever .

Objectives Short term: After 2 hours of nursing intervention the patient will gain knowledge in infection control as evidenced by discussing the wound care Long term: After 3 days of NI, pt. will be able to manifest timely wound healing

Nursing Interventions -establish rapport

Rationale - to achieve pt s trust and cooperation - to determine any deviations from normal - to achieve baseline data - to avoid phlebitis and to allow pt obtain proper medication

- assess general condition

- obtain and record vital signs -check for the patency and regulation of IVF

Expected Outcome Short term: After 2 hours of nursing intervention the patient have gained knowledge in infection control as evidenced by discussing the wound care Long term: After 3 days of NI, pt. have been manifested timely wound healing

- Assess skin for severity of skin integrity compromise.

Pt. may manifest: -moaning -vigilance -change in muscle

- The skin is the body s first line of defense against infection. Disruption of the integrity of skin increases the patient s risk of developing an infection or of scarring.

tone -self-focusing, narrowed perceptions

- assess for signs and symptoms of infection such as fever and chills - Discuss to patients the following signs of infection redness, swelling, increased pain, or purulent drainage on the site and fever

-to monitor for the presence of infection

- To impart to the patient when the wound become infected and when to sought medical care

-Maintain aseptic Technique when changing dressing/caring wound. -Keep area around wound clean and dry -Emphasized necessity of taking antibiotics as ordered.

-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.

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