Nursing Diagnosis for Cesarean Section : Risk for Infection related to tissue trauma / broken skin, decreased hemoglobin, invasive procedures, long membrane rupture, malnutrition.
Goal:
- Demonstrate techniques to reduce risks and / or promote healing.
- Showing the wound free of purulent drainage with early signs of healing.
- Free of infection, no fever, no breath sounds adventius, and the color of urine clear.
Intervention:
1. Encourage, and use careful hand washing techniques, and disposal of reviewers dirt, perineal pads, and contaminated linens appropriately.
Rationale: Helps prevent or limit the spread of infection.
2. Assess the client's nutritional status, consider the weight before pregnancy and prenatal weight gain.
Rationale: Clients whose weight is 20% below normal weight are more susceptible to post-partum infection and require a special diet.
3. Inspection of the exudate abdominal bandage or seepage. Remove the bandage as indicated.
Rationale: A sterile dressing covering the wound in the first 24 hours of cesarean birth helps protect the wound from injury and contamination.
4. Assess the temperature, pulse and white blood cell count.
Rationale: Fever after postoperative day 3, leukocytosis, and tachycardia indicating infection. The increase in body temperature to 38 ° C within the first 24 hours so indicate infection.
5. Assess the location and uterine contractility, consider the involution changes in the air or the presence of extreme tenderness.
Rationale: Slowing involution increase the risk of endometritis. The development of extreme tenderness indicates the possibility of retained placental tissue or infection.
6. Pay attention to the amount and smell of lochia discharge or change in the normal progress of rubra be serous.
Rationale: In normal lochia smells fishy but in endometritis discharge, purulent possible, and foul smelling, and can fail to have indicated normal progress and lochia rubra be serous until alba.
7. Assess the client in splinting the incision for lung exercise.
Rationale: helps prevent stretching the incision, and decrease the possibility of injury dehidens.
8. Collaboration oxytocin or ergot preparations.
Rationale: Maintaining miometrial contractility, thus preventing the spread of bacteria through the wall of the uterus.
9. Get the blood and urine cultures if infection is suspected.
Rationale: Bacteremia is more common on clients who have ruptured membranes for 6 hours or more than the client remains intact amniotic prior cesarean birth.
10. Collaboration of specific antibiotics for the infection were identified.
Rationale: Need to kill the organism.
