Nursing Care Plan
Date/ Cues Nee Nursing Diagnosis Objectives Nursing Evaluation
Time d of Care Interventions
12/27/202 Subjective: H Risk for Infection r/t post Independent: Goal met:
0 The patient E surgical incision secondary to
verbalized, A Right RMR Short term:
1. Monitor for Short term:
7AM-3PM “2 days ago ako L Rationale: Skin is a natural After 4 signs and After 4 hours
naoperahan” T barrier against infection and hours of symptoms of nursing
10AM H considered as a first line defense nursing of intervention,
Objectives against any foreign organism, intervention, infection. the patient
Vital Signs: M skin impairment may cause a the patient (e.g. identified and
T: 36.8 C A possible entry for the will be able Redness, demonstrate
P: 80 N organism. Even with many to: swelling, d
R: 20 A precautions and protocols to increased interventions
BP: 120/80 G prevent infection in place, any • Identify pain, to prevent or
02 SAT: 98% E surgery that causes a break in and purulent reduce risk
Weakness M the skin can lead to an infection. demonstrate discharge of infection
Pallor E interventions from
W/ dry and N Source: to prevent or incisions)
intact T Surgical Site Infections. (n.d.). reduce risk R: To evaluate Long term:
dressing on Retrieved January 20, 2021, from of infection. if the character, After 3 days
the excised P https://www.hopkinsmedicine.org/ (e.g. presence and of nursing
area A health/conditions-and- Handwashin condition of the intervention
Swelling T diseases/surgical-site-infections. g, Wound present the patient
Hot to touch T care, infection. was free
(incision site) E Dressing from any
Jackson- R Changes) 2. Monitor signs and
Pratt N Vital Signs. symptoms of
drainage- Long term: R: To monitor infection as
30ml After 3 days patient’s status. manifested
of nursing High by (-) fever
intervention, temperature
the patient may indicate
will: infection.
• Achieve
timely
wound 3. Emphasize
healing and the
be free from importance
any signs of
and handwashi
symptoms of ng
infection. technique.
(e.g. Fever, R:
Drainage of Handwashing
pus, serves as a first
Swelling, line of defense
Redness) against
infection.
4. Maintain
strict
asepsis for
dressing
changes/
wound
care.
R: Aseptic
technique
decreases the
chances of
transmitting or
spreading
pathogens to or
between
patients.
Interrupting the
chain of
infection is an
effective way to
prevent the
spread of
infection.
5. Keep area
around
wound
clean and
dry.
R: Wet area
can be lodge
area of
bacteria.
6. Educate
patient and
SO about
appropriat
e methods
for
cleaning,
disinfectin
g, and
sterilizing
items.
R: Knowledge
of ways to
reduce or
eliminate germs
reduces the
likelihood of
transmission.
7. Demonstra
te and
allow
return
demonstra
tion of all
high-risk
procedure
s that the
patient
and/or SO
will do
after
discharge,
such as
dressing
changes/w
ound care.
R: Patient
and SO
need
opportunitie
s to master
new skills
to reduce
risk for
infection..
8. Provide
health
teaching
on
identificati
on of
environme
ntal risk
factors
that could
add up on
the
infection.
R: To help
client
modify/change/
avoid some of
the
environmental
factors present
which could
reduce the
incidence of
infection.
Dependent:
9. Administer
antibiotics
as ordered
by the
physiciana
nd
emphasize
necessity
of taking
antibiotics
as ordered.
R: Antibiotics
will help kill and
stop the
proliferation
and growth of
the bacteria
which could
cause infection.
