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Risk for Infection
Short term goal:
Possible Etiologies: Surgical incision
$lient %ill not manifest signs of infection as lie lesser redness and inflammation fe% hours postoperatively"
Disease Process: AppendicitisAppendectomy Defining characteristics: Subjective Data: “My operative site is painful and loos stretched! verbatim of client" #bjective Data:
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Temp-37.8°C Pain rating-4/10 WBC-10,000 (+) redness and inammati!n !n t"e !perati#e site
Assessment '" Monitor vital signs every hour (" Monitor operative site appearance
&ong term goal: )" Monitor lab results $lient %ill be totally free of infection occurrence as manifested by dry and intact operative site"
'" +o have baseline data and determine the progress of patient condition (" +o monitor %ound healing and serve as basis for necessary action 3notifying physician if possible4 )" +o monitor occurrence of infection and its progress *" +o monitor hydration
*" Monitor urine output and hydration +reatment '" Administer prescribed antibiotics (" $leanse and dress %ound %ith povidone iodine observing sterile techni,ue )" eep the area clean and dry *" Maintain ./0 patency 1" Assist in early ambulation Educative '" Encourage to do deep
breathing and coughing e2ercises (" .nstruct to increase protein and vitamin $ intae )" .nstruct to avoid touching fresh %ound %ith unsterile articles *" .nstruct to e2ercise regular bo%el movement 1" .nstruct to have regular fiber intae
'" 5elps prevent and fight infection pharmacologically (" Prevents multiplication of pathologic microorganisms in the incision site )" Promotes %ound healing *" +o ascertain good hydration and replenish blood loss 1" 5elps promote blood circulation for faster %ound healing '" Promotes lungs e2pansion and increase blood circulation (" 0or faster tissue repair )" Prevents introduction of infection sources *" Prevents insult of the colonic operative site and occurrence of other 6. problems 1" +o establish good bo%el movement and prevent other 6. problems
$lient did not manifest any sign of development of infection as manifested by rating pain at (7'8 from *7'8 for the first * hours postoperatively Patient did not develop infection as manifested by '7'8 pain rating9 dry and intact incision site9 ;$ of <98889 negative redness and inflammation of the operative site = hours after operation"