NCP 3: Risk for Infection related to surgical wound
Assessment/Cues Diagnosis Background Planning Intervention with Evaluation
Rationale
NOC: Knowledge: NIC: Infection
Subjective: Risk for infection An incision is a cut Infection Protection
related to surgical through the skin that Management
Patient verbalized, wound. is made during
“Mahapdi yung sugat surgery. It is also GOAL: To assess GOAL
ko.” called a surgical After the nursing causative/contributing UNMET
wound. Some interventions, the factors: After the nursing
Patient stated that she incisions are small, patient will be free intervention , the
is allergic to others are long. The from infection to her client was able to:
ointments or to any size of the incision incision site
medications depends on the kind - The patient
administered of surgery you had. was unable to
topically. OBJECTIVES: verbalize
Sometimes, an After implementing understanding
Objective: incision breaks open. the nursing of the causes
This may happen intervention the client and risks for
The surgical incision along the entire cut or will be able to: infection. The
site appears clean just part of it. Your patient also
with no pus or doctor may decide a. Verbalize a.1. Establish rapport didn’t
bleeding. not to close it again understanding with the client. To identify
with sutures of individual ensure a nurse-client prevention
(stitches). causative or trusting relationship interventions
risk factor(s). for risk
a.2. Make health reduction.
teachings especially The patient is
in identification of free from
environmental risk infection.
factors that could
add up on infection. - The patient
To help the client was unable to
modify/change/avoi demonstrate
d some of the techniques
environmental and lifestyle
factors present changes to
which could reduce promote safe
the incidence of environment
infection. and achieve
well-healed
wound free of
discharge,
erythema, and
fever.
b. Identify b.1. Assess for presence
interventions of host-specific factors
to prevent or that affect immunity:
reduce risk of Trauma. The
infection patient
undergone BTL
procedure.
Certain
Medications.
The patient is
allergic to
ointments and
other topical
medication.
Environmental
exposure. This
may be
accidental or
intentional.
Exposure can
occur in
different ways,
such as
Accidental
exposures result
from exposure
to
contaminants
arising from
commonplace
processes (e.g.,
wastewater
recycling),
through animal
contact
(e.g.,
agriculture,
animal food
processing), or
through
contact with
humans (e.g.,
healthcare,
mass, close
contact living,
etc.).
b.2. Observe at-risk
client for: Changes
in skin color and
warmth at insertion
sites of invasive
lines, sutures,
surgical incisions,
and wounds that
could be signs of
developing localized
infection.
Changes in mental
status, skin warmth
and color, heart, and
respiratory rate that
could be signs of
developing systemic
infection.
Changes in color
and/or odor of
secretions (e.g.,
sputum), drainage
(e.g., wound drains
or invasive tubes),
and excretions (e.g.,
urine) that could
indicate onset of
infection.
c.1. Make health
c. Demonstrate teachings especially in
techniques identification of
and lifestyle environmental risk
changes to factors that could add up
promote a on infection.
safe To help the client
environment. modify/change/avoi
d some of the
environmental
factors present
which could reduce
the incidence of
infection.
c.2. Instruct the
client/SO(s) in
techniques to protect the
integrity of the skin, care
for lesions, and prevent
spread of infection.
d.1. Review individual
nutritional needs,
appropriate exercise
d. Achieve program, and need for
timely wound rest.
healing; be
free of
purulent d.2. Encourage patient
drainage or and SO(s) to
erythema; be immediately contact
afebrile. healthcare provider if
signs and symptoms of
infection are noticed.
Medical follow-up
prevent the infection
from getting worse.
