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NCP MCMC Post Operative

The patient is a 30-year old single female who underwent a cesarean section and is at risk of infection due to her surgical incision. The nursing diagnosis is risk for infection related to inadequate primary defenses secondary to surgical incision. The short-term goal is for the patient to understand infection signs and report them, and the long-term goal is for timely wound healing without infection within 2-3 days. Nursing interventions include wound monitoring, hand washing education, and encouraging fluid intake to prevent infection.

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Kristiyanong Kabataan
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672 views3 pages

NCP MCMC Post Operative

The patient is a 30-year old single female who underwent a cesarean section and is at risk of infection due to her surgical incision. The nursing diagnosis is risk for infection related to inadequate primary defenses secondary to surgical incision. The short-term goal is for the patient to understand infection signs and report them, and the long-term goal is for timely wound healing without infection within 2-3 days. Nursing interventions include wound monitoring, hand washing education, and encouraging fluid intake to prevent infection.

Uploaded by

Kristiyanong Kabataan
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 DOC, PDF, TXT or read online on Scribd
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ARELLANO UNIVERSITY

NURSING CARE PLAN


LEVEL III

Name of Student: Fernandez, Ma. Leslie Hay’s Date of Assignment: January 6/7,
2010 Ward: OB

Name of Patient: Maribel Icaro Tanio Age: 30 yrs. old Sex: Female Civil status:
Single

Diagnosis/Clinical Impression: post- operative NCP Date of


Admission: January 4 2010

Assessment Nursing Planning Implementation/Inter Evaluation


vention
(Cues) Diagnosis
With Rationale

Subjective: Risk for infection STG: Independent: Patient is expected


related inadequate to be free of
-none primary defenses After 4 hours of - monitor vital sign infection, as
secondary to nursing intervention, evidenced by
patient will be able
Objective: surgical incision
to understand
- inspect dressing and normal vital sign
perform wound care and absent of
causative factors,
- Dressing dry and Inference identifying signs of purulent drainage
intact - monitor white blood from wound,
infection and report
Due to an elective them to health care cell counts incision, and tubes.
- V/S taken as cesarean, patient provider accordingly.
skin were - monitor elevated
follows:
mechanically LTG: temperature, redness
swelling, increased
• T: 37 interrupted. Thus, After 2-3 days of pain or purulent
the wound is at nursing drainage at incisions
• PR: 60 risk of developing intervention,
infection. patient will achieve - wash hands and
• RR: 24 timely wound teach other care giver
healing, be free of to wash hands before
• BP: 110/80 purulent drainage contact with patient
or erythema, be and between
afebrile and be procedures with
free of infection. patient

- encourage fluid
intake of 2000-
3000ml /day (unless
contraindicated)

Dependent:
-Encourage the
patient to take
medication as
prescribed by doctor.

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