Need: Alteration in Safety

Diagnosis
Risk for infection R/T presence of favorable conditions for infections. 28 year old female Grav. 2, Para 2 4 degree laceration/episi otomy VBAC 6/19/02 Baby wt. 7lb 10oz Breast and bottle feeding Light lochiarubra Forceps attempted x2 WBC 12000 Vital Signs: T-99 BP-122/84 R-20

Goal & Goal Criteria

Patient will show no evidence of infection in 3-5 hours AEB:

Nursing Actions
Nursing student, from 1200-1700at Riverview Hospital will do the following: 1) Assess VS q4h (R,P,BP,T) R-increase in respirations and pulse indicate increased release of epinephrine and norepinephrine as a result of pain associated with inflammation and infection (Holman, lecture-Fall 2001) 2) Assess lab findings regarding Post Partum WBC. Ra total number of WBC exceeding 9000-30000 indicates an acute infection (Hols 532) 3) Monitor laceration/episiotomy for signs of infection such as increased redness, edema, pain, or a change to prurlent, foul smelling lochia. R-The body's cellular response to infection is inflammation-a protective vascular reaction that delivers fluid, blood products and nutrients to interstitial spaces in an area of injury (Potter-Perry 840) R-accumulation of fluid and dead tissue cells and WBC's forms an exudates at the site of inflammation (potter-perry 840)

Implementation

Evaluation
Over all goal was met 1. S within normal limits V

1) Normal VS P- 70-90 T- 97-99 R- 17-22 BP- 120/80-130/85 2) Episiotomy/laceration site will be without increased redness, tenderness, edema, drainage or foul odor. 3) Pt. Will not experience difficulty or increased discomfort related to urination. 4) Pt will demonstrate methods she will use to prevent infection. 5) WBC will be within normal Post Partum range

Assessed vital signs q4h

P--87 T--99 R-20 BP-120/82 2. l aceration/episiotomy site without increased redness, tenderness, edema, drainage or foul odor. 3. t able to urinate with no difficulty/discomfort. Stimulation not needed. p

2.

monitored laceration/episiotomy for signs of infection such as increased redness, edema, pain and change to purulent, foul smelling lochia. determined character of urine and whether pt experiences frequency, urgency or pain with urination.

3.

4. t demonstrated understanding of preventative hygiene practices / methods by return demonstration. 5. BC 12000

HR/P-87 Nipples without abrasion or lacerations States pain is a "3" on a 1-10 scale. States "everything is fine" States "I'm a little tired"

R-foul odor of lochia suggests endometrial infection. (murray 794) 4) Determine character of urine and whether pt experiences frequency, urgency or pain with urination. R-frequency, urgency or painful urination may indicate UTI (Murray 794) 5) Assess nutritional status R-pts with poor nutritional status may be anergic or unable to muster a cellular immune response to pathogens, and are therefore, more succeptible to infections (Nursing Diagnosis and Intervention 129) 6) 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) 7) Encourage intake of proteinrich foods such as poultry, meats, fish, legumes, soy products, peanut butter and yogurt. R-maintains optimal nutritional status, better enabling the body's natural defenses to fight invading organisms.(Nursing Diagnosis and 7. 4. assessed nutritional status and established that 95% of meals have been consumed.

5.

washed hands before and after pt. contact

6.

encouraged and explined the kinds of foods she should eat more of. (poultry, meat, fish, legumes, soy products, peanut butter, and yogurt) and explained the reasoning behind it. initiated measures to prevent UTI by:

*providing and encouraging fluid intake *monitoring for bladder distention

Intervention 130) 8) Initiate measures to reduce the risk of UTI provide and encourage increase in fluid intake monitor bladder distention to prevent overfilling use methods to promote bladder emptying (ie-running water in shower or sink and running warm water over perineum) R- adequate hydration and frequent voiding help prevent stasis of urine, which increases risk of UTI (Murray) 9) 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 *stimulating urination when needed. 8. Instructed pt in hygiene practices to prevent infection.

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)

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

NURSING CARE PLAN ANITA CLAPP

Wednesday June 19, 2002 INSTRUCTOR: P. Hart