NAME: LABAWIG, AVERY DATE: SEPTEMBER 14, 2019

GROUP: 3D NAME OF CI: MARYLIZA BULATAO

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM

Subjective: The patient has STO: Dx: STO:

undergone LSCS and
“Na-CS po ako has given birth to her Within the shift, the  Maintain aseptic  Prevents entry of (Goal Met)
nung isang araw. first baby. patient will be able to: technique with any bacteria, reducing
Masakit parin pag procedures. Provide risk of nosocomial Within the shift
gumagalaw ako” Post-cesarean wound a) demonstrate ability routine site care, as infections. of effective
infection is an infection to perform hygienic appropriate nursing
Objective: that occurs after a C- measures. interventions,
section, which is also  Note risk factors for the patient
 Pfannenstiel b) demonstrate ability occurrence of infection  To help the patient identified the
incision in the referred to as a to care for the site identify the present
abdominal or in the incision basis of fatigue,
lower segment risk factors that may how she can
cesarean delivery. It is c) identify ways to
of the add up to the control it,
abdomen usually due to a reduce risk of infection infection.
bacterial infection in verbalized
 T: 36.4°C d) verbalize which understanding
 Refusal to the surgical incision  To evaluate if the
symptoms of infection  Observed for localized of the use of
move around site. character, presence
to watch out for sign of infection in the energy
due to pain and condition of the
Common signs include incision present infection conservation
Nursing Diagnosis: fever (38°C-39.4°C), principles and
wound sensitivity,  Monitor vital signs.  Temperature took the
LTO:
RISK FOR INFECTION redness and swelling elevation and prescribed
related to at the site, and lower At the end of tachycardia may medications
insufficient abdominal pain. It is hospitalization, the reflect developing accordingly.
knowledge to avoid important to get patient will: sepsis.
exposure to treated promptly to
a) remain free of
pathogens.
infection, as
prevent complications evidenced by normal Tx: LTO:
from the infection vital signs and absence
of signs and symptoms  Administer antibiotics as (Goal Met)
Some post-cesarean of infection ordered by the
wound infections are physician  Antibiotics will help kill At the end
taken care of prior to b) show capacity to and stop the hospitalization,
a patient being recognize signs and infection and the the patient
discharged from the symptoms growth of bacteria remains free of
hospital. However, which could cause infection, stated
many infections don’t Edx: infection symptoms of
appear until after you infection of
leave the hospital. In  Stress and model proper which to be
fact, many post- handwashing aware of,
 Reduces risk of cross-
cesarean wound technique. demonstrates
contamination/
infections usually appropriate
 Make health teachings bacterial
appear within the first care of incision
especially in colonization.
couple of weeks after site.
identification of
delivery. For this environmental risk  To help the patient
reason, most of these factors that could add modify/change/avoi
infections are up on infection d some of the
diagnosed at follow- environmental
up visits. factors present which
could increase the
SOURCES: incidence of
 Teach patient how to infection.
Wilson, D.R. Post-
change dressings at
Cesarean Wound home and how to  Patient and
Infection. from assess for signs of caregivers need to
http://www.healthline. infection. master these skills to
com/heath/pregnanc make sure that they
can continue
preventing the risk of
y/post-cesarean- infection even if they
wound-infection are already
discharged.
 Teach the patient how
to take antibiotics  Not completing or
properly skipping the required
dose of antibiotics
can encourage
antibiotic resistance.