Diagnosis



|Diagnosis |Goal & Goal Criteria |Nursing Actions |Implementation |Evaluation |

|Risk for infection R/T presence |Patient will show no evidence of |Nursing student, from 1200-1700at Riverview | |Over all goal was met |

|of favorable conditions for |infection in 3-5 hours AEB: |Hospital will do the following: | | |

|infections. | | | | |

| | | | |VS within normal limits |

|28 year old female | |Assess VS q4h (R,P,BP,T) | |P--87 |

| |Normal VS |R-increase in respirations and pulse indicate |Assessed vital signs q4h |T--99 |

|Grav. 2, Para 2 | |increased release of epinephrine and | |R-20 |

| |P- 70-90 |norepinephrine as a result of pain associated with| |BP-120/82 |

|4 degree laceration/episiotomy |T- 97-99 |inflammation and infection (Holman, lecture-Fall | | |

| |R- 17-22 |2001) | |laceration/episiotomy site without |

|VBAC 6/19/02 |BP- 120/80-130/85 | | |increased redness, tenderness, edema, |

| | |Assess lab findings regarding Post Partum WBC. | |drainage or foul odor. |

|Baby wt. 7lb 10oz |Episiotomy/laceration site will be |Ra total number of WBC exceeding 9000-30000 | | |

| |without increased redness, tenderness, |indicates an acute infection (Hols 532) |monitored laceration/episiotomy for signs of| |

|Breast and bottle feeding |edema, drainage or foul odor. | |infection such as increased redness, edema, |pt able to urinate with no |

| | |Monitor laceration/episiotomy for signs of |pain and change to purulent, foul smelling |difficulty/discomfort. Stimulation not |

|Light lochia-rubra | |infection such as increased redness, edema, pain, |lochia. |needed. |

| |Pt. Will not experience difficulty or |or a change to prurlent, foul smelling lochia. | | |

|Forceps attempted x2 |increased discomfort related to |R-The body's cellular response to infection is |determined character of urine and whether pt| |

|WBC 12000 |urination. |inflammation-a protective vascular reaction that |experiences frequency, urgency or pain with | |

| | |delivers fluid, blood products and nutrients to |urination. |Pt demonstrated understanding of |

|Vital Signs: |Pt will demonstrate methods she will |interstitial spaces in an area of injury | |preventative hygiene practices / methods by|

| |use to prevent infection. |(Potter-Perry 840) | |return demonstration. |

|T-99 | | | | |

| |WBC will be within normal Post Partum |R-accumulation of fluid and dead tissue cells and | |WBC 12000 |

|BP-122/84 |range |WBC's forms an exudates at the site of | | |

| | |inflammation (potter-perry 840) | | |

|R-20 | | | | |

| | |R-foul odor of lochia suggests endometrial | | |

|HR/P-87 | |infection. (murray 794) | | |

| | | | | |

| | |Determine character of urine and whether pt | | |

|Nipples without abrasion or | |experiences frequency, urgency or pain with | | |

|lacerations | |urination. | | |

| | |R-frequency, urgency or painful urination may | | |

|States pain is a "3" on a 1-10 | |indicate UTI (Murray 794) |assessed nutritional status and established | |

|scale. | | |that 95% of meals have been consumed. | |

| | |Assess nutritional status | | |

|States "everything is fine" | |R-pts with poor nutritional status may be anergic | | |

| | |or unable to muster a cellular immune response to | | |

|States "I'm a little tired" | |pathogens, and are therefore, more succeptible to | | |

| | |infections (Nursing Diagnosis and Intervention |washed hands before and after pt. contact | |

| | |129) | | |

| | | | | |

| | |Wash hands before and after pt contact | | |

| | |R-The most important and most basic technique in | | |

| | |preventing and controlling transmission of | | |

| | |infections is hand-washing. (Potter-Perry 852) |encouraged and explined the kinds of foods | |

| | | |she should eat more of. (poultry, meat, | |

| | |Encourage intake of protein-rich foods such as |fish, legumes, soy products, peanut butter, | |

| | |poultry, meats, fish, legumes, soy products, |and yogurt) and explained the reasoning | |

| | |peanut butter and yogurt. |behind it. | |

| | |R-maintains optimal nutritional status, better | | |

| | |enabling the body's natural defenses to fight |initiated measures to prevent UTI by: | |

| | |invading organisms.(Nursing Diagnosis and | | |

| | |Intervention 130) |*providing and encouraging fluid intake | |

| | | | | |

| | |Initiate measures to reduce the risk of UTI |*monitoring for bladder distention | |

| | |provide and encourage increase in fluid intake | | |

| | |monitor bladder distention to prevent overfilling |*stimulating urination when needed. | |

| | |use methods to promote bladder emptying | | |

| | |(ie-running water in shower or sink and running |Instructed pt in hygiene practices to | |

| | |warm water over perineum) |prevent infection. | |

| | |R- adequate hydration and frequent voiding help | | |

| | |prevent stasis of urine, which increases risk of | | |

| | |UTI (Murray) | | |

| | | | | |

| | |Instruct pt in hygienic practices to prevent | | |

| | |infection: | | |

| | |*Careful handwashing before and after perineal | | |

| | |care. | | |

| | |R-Hand washing is the most important defense | | |

| | |against infection and its spread (Murray 794) | | |

| | | | | |

| | |*Perineal cleansing after elimination | | |

| | |R-Perineal cleansing helps prevent growth of | | |

| | |bacteria (Murray 794) | | |

| | | | | |

| | |*Change peripads frequently | | |

| | |R-Frequent pad changes remove accumulated lochia, | | |

| | |an excellent culture medium for bacteria. (Murray | | |

| | |794) | | |

| | | | | |

| | |*Wipe perineum from front to back | | |

| | |R-wiping from front to back prevents fecal | | |

| | |contamination of the vagina (Murray 794) | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

NURSING CARE PLAN

ANITA CLAPP

Wednesday

June 19, 2002

INSTRUCTOR: P. Hart

-----------------------

Need: Alteration in Safety

REFERENCES:

Gulanik, Klopp, Falanes, Gradishar and Puzas (1998) Nursing Diagnosis and Interventions (4th Edition) St. Louis, MO: Mosby, Inc.

Potter and Perry (2001) Fundamentals of Nursing (5th Edition) St. Louis, MO: Mosby, Inc.

Murray(2002) Foundations of Maternal-Newborn Nursing (3rd Edition) Philadelphia, PA: WB Saunders Company

Shier (1999) Hole's Human Anatomy and Physiology (8th Edition) WCB/McGraw-Hill

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