Date Cues Need Nursing Goal of Care Intervention Plan Evaluation

Diagnosis

• Vital Signs:
09/22/ H Risk for Infection At the end of 5 hours of 1. Note risk factors for “GOAL MET”
2010 E related to care, Mrs. B will be free
T= 36.5 occurrence of infection such as
P= 64 A abdominal tissue of infection as skin or tissue wounds and @
@
R= 19 L destruction evidenced by: surgeries or invasive
T secondary to
7 am C= 67 procedures underwent. 09/22/2010
BP= 110/70 H cholecystectomy a. clean and dry ® Causative factors for 12 noon
wound dressing / infection are the following:
P Rationale: opsite;
• Abdominal incision broken skin, suppressed Mrs. B was free of
E Cholecystectomy is
• Opsite b. surrounding area inflammatory response, infection as
a surgical removal
• Cholecystectomy R of the incision site is immunosuppression, tissue evidenced by:
of the gallbladder.
C free of redness, destruction, chronic disease,
• Jackson Pratt An incision is made
E in the upper right swelling and and malnutrition. a. clean and dry
• T-tube P quadrant of the purulent discharge wound
T abdomen. Incision is and; 2. Observe for localized signs dressing /
I made from the c. normal vital of infection at the sutures or opsite;
O upper layer of the signs surgical incisions such as b. surrounding
N skin down to the T= 36.5-37.5 redness, drainage and swelling. area of the
- subcutaneous P & C= 60-100 ® Incisions that have been incision site is
H tissues, to the
R= 16-20 closed with sutures or staples free of
fascia, to the
E BP=90/60-140/90 should be free of redness, redness,
muscles up to the
A peritioneum, to gain swelling, and drainage. These swelling, and
L access to the incisions are usually kept purulent
T gallbladder. covered by a dressing for 24-48 discharge
H Postoperative hours; beyond 48 hours there is and;
wound infection is no need for a dressing if the c. vital signs of:
M an infection in the incision is not draining. T= 36.7
A tissues of the P= 74
N incision and
3. Note for signs and C= 76
A operative area. It
can occur from 1 symptoms of sepsis such as R= 19
G fever, chills, diaphoresis, and BP= 110/70
day to many years
E after an operation altered level of consciousness.
M but commonly ® For the first 48-72 hours to
E occurs between the postoperatively, temperatures
N fifth and tenth days of up to are expected as normal
T after surgery. stress response after major
surgery. Beyond 72 hours,
P temperatures spikes, usually
A occurring in the later afternoon
T or night, are often indications of
T infection.
E Bibliography:
R http://www.mdguidelin 4. Assess all peripheral and
es.com/wound-
N infection-postoperative central IV sites for redness,
swelling, warmth, purulent
drainage, and pain.
® Continual monitoring for
signs of inflammation or
infection is essential.

5. Assess color, clarity, and

odor of urine.
® Cloudy, foul-smelling urine is
an indication of urinary tract
infection, which can occur as
the result of an indwelling
catheter. Other infection might
also occur since the patient has
a foley catheter.

6. Assess stability of tubes

and drains.
® In-and-out motion of
improperly secured tubes and
drains allows access by
pathogens through stab
wounds where tubes and drains
are placed.

7. Wash hands before contact

with the post-operative patient.
® Hand washing remains the
most effective method of
infection control. It the first-line
defense against healthcare-
associated infections (HAI).

8. Use aseptic technique during

 dressing change, wound care,
or handling or manipulation of
tubes and drains.
® Aseptic technique for
dressing changes and wound
care limits the introduction of
pathogens.

9. Ensure that closed drainage

systems (urinary catheter,
surgical tubes and drains) are
not inadvertently interrupted.
® Opening of sterile systems
allows access by pathogens
and puts the patient at risk for
infection.

10. Tape connectors and pin

extension or drainage tubing
securely to the patient’s gown.
Prevent kinking of drain tubing.
® This minimizes tension on
the tubes and connections.
Kinking of tubing prevents
drainage of urine or wound
exudate. Stasis contributes to
the development of infection.

11. Monitor white blood cell count.

® Elevated WBC count is
typically an indication of
infection; however, in older
patients, infection may be
present without an increase in
WBC count because of
normal changes in the
immune system.

12. Obtain culture of any unusual

drainage from wound, incision,
tubes or drains.
 ® This determines which
pathogens are present.

13. Educate the patient and family

on the signs and symptoms of
infection: elevated
temperature, redness, swelling
of the incisional site, and
purulent or foul-smelling
wound drainage.
® Educating the patient and
family assists in early
recognition of adverse signs
and symptoms. It promotes
their sense of control and
minimizes anxiety and fear.