Care Plan "Data"

  1. So i am working on a care plan that is is due friday. i have it done except for my data protion. the teacher for this class is requireing that we do these different than we have in the past so it is throwing me off a bit, but her way is much better and realalistic.
    anways my question is what type of data would you put down for a women whom just had a cesarean section and the diagnosis is "risk for infection"

    the sut up for this care plan is.

    Nursing Diaanosis:
    Data:
    Goals:
    Interventions:
    Rational
    Evaluation:

    like i said, i was able to to correctly fill everything else, this data thing is just throwing me off. sorry if it's a dumb question!!

    thanka all:spin:
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    About Loobug

    Joined: May '09; Posts: 3

    1 Comments

  3. by   Daytonite
    well, lets reason this out. what is an infection? taber's cyclopedic medical dictionary says it is the presence and growth of a microorganism that produces tissue damage and that the extent of infection depends on the number and virulence of the organism and the ability of the body to contain and destroy them. it is accompanied by inflammation. if microorganisms are a defining feature, then the next question must be how did the infection get into the postpartum mother and where are they doing their damage? what is the logical answer for that? foundations of maternal-newborn nursing, 4th edition, clinical companion, by sharon smith murray and emily slone mckinney pge 339 states, "any break in the skin or mucous membranes provides a portal or entry for bacterial. the most common sites for wound infections include:
    • cesarean incisions
    • episiotomies
    • perineal lacerations
    clinical signs and symptoms. signs of infection include localized areas of edema, warmth, redness, tenderness, and pain. in addition, the edges of the wound may pull apart, and there may be seropurulent drainage from the wound. if untreated, systemic signs such as fever and malaise may develop." the inflammatory reaction typically begins first with manifestations of 2 or more of the following:
    • temperature > 38 c or < 36 c
    • heart rate > 90 beats/min
    • respiratory rate > 20 breaths/min or paco2 < 32 mm hg
    • wbc count > 12,000 cells/μl or < 4000 cells/μl, or > 10% immature form
    i feel the need to advise you that the nursing diagnosis, risk for infection, is a potential problem which means that infection does not actually exist. the "related to" part of your diagnostic statement is the risk factor, or what would be the cause of a potential infection. in reality, there are no actual symptoms because they do not exist --hopefully they never will. so, your goal for this diagnosis is to prevent the problem (infection) from occurring. the interventions are as follows:

    • strategies to prevent the problem from happening in the first place
    • monitoring for the specific signs and symptoms of this problem (i listed those above)
    • reporting any symptoms that do occur to the doctor or other concerned professional
    nursing diagnosis: risk for infection
    data: see above
    goals: patient will have no signs or symptoms of infection (this will be modified to reflect specific nursing interventions you will develop)
    interventions: strategies to prevent the problem from happening in the first place, monitoring for the specific signs and symptoms of this problem (i listed those above), reporting any symptoms that do occur to the doctor or other concerned professional
    rationale:
    evaluation:

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