NURSING CARE PLAN 3

1.      Risk for infection related to surgical procedure at abdominal.

Goal: Patient will remain free from symptoms of infection such as redness, warmth, swelling, discharge and increased body temperature.

No.	Nursing Interventions	Rationales
1.	Assess site of wound surgery every day and report signs of infections such as redness, warmth, discharge and increased body temperature.	To observe any changes of wound and further treatment.
2.	Monitor temperature every 4 hours.	Fever is often the first sign of infection.
3.	Assess skin for color, moisture, texture and turgor.	The skin is the body’s first line of defense in protecting the body from infection.
4.	Monitor white blood cell (WBC) count.	An increasing WBC count indicates the body’s efforts to combat pathogens. Normal values are 4000 to 11 00/ mm3.
5.	Maintain or teach asepsis for dressing changes and wound care.	Use of aseptic technique decreases the chances of transmitting or spreading pathogens to the patient.
6.	Encourage fluid intake of 2000 to 3000 ml of water per day.	Fluid intake helps thin secretions and replaces fluid loss during fever.
7.	Encourage intake of protein foods.	Optimal nutritional status supports immune system responsiveness.
8.	Ensure patient’s appropriate hygienic care such as bathing and toileting.	Hygienic care is important to prevent infection.
9.	Limits the visitors during visiting hours.	Restricting visitations by individuals with any type of infection reduces the transmission of pathogens to the patient at risk of infection.
10.	Administer the use of antimicrobial drugs as ordered by doctor.	Antimicrobial is used to toxic to the pathogen or retard the pathogen’s growth.
11.	Teach the patient and family about the symptoms of infection that should be promptly reported to the doctor such as redness, warmth, swelling, tenderness or pain, new onset of drainage and increased body temperature.	Two thirds of wound infections occur after discharge.
12.	Instruct the patient to take the full course of antibiotics even the symptoms improve or disappear.	Not completing the entire course of the prescribed antibiotic regimen can lead to drug resistance in the pathogens and reactivation of symptoms.

Evaluation: Patient remains free of infection as evidenced by normal vital signs and absence of redness, warmth, discharge and increased body temperature from wounds