mom's care plan - risk for infection HELP!

cutieqq88 · Sep 25, 2009

Can someone take a look at my care plan? Thank you so much!!!

Assessment:

T = 98.5 F Oral

O2=97%

P=64, reg, +3

R = 18, reg, unlabored

bp = 122/86

Pain = 3/10

Objective:

Breast - soft, nipples intact and non-tender

Uterus: Fundus firm, U2 at midline

Perineum - mild edema

1o laceration

Bowel: active bowel sound x 4 quadrants

Voiding - qs, clear, yellow

Lochia - moderate rubra, no clots

Extremities: MAE

Bilateral pedal non-pitting edema

Bilateral upper extremities non-pitting edema

Treatment - Ice pack, topical

Knee high TEDS

RBC: 3.56L

HgB: 10.9L

Hct: 32.4L

WBC: 16.6H

Three nursing diagosis (Priortized)

1. Risk for infection r/t mild perineum edema, high WBC post-delivery s/t 1 degree laceration from NSVD

2. Ineffective breastfeding r/t pt unable to latch infant s/t first time mother

3. Acute pain r/t "3" on pain scale of 1 - 10 d/t breastfeeding causd contraction of the uterine.

Care Plan for Risk for Infection

Long Term Goal: Patient will remain free from symptoms of infection by discharge.

Short Term Goal 1: Pt will state 3 symptoms of infection by the end of the shift.

Short Term Goal 2: Pt will demonstrate appropriate perineal care by the end of the shift.

Nursing Intervention:

1. Nurse will assess perineum for infection every 4 hours

2. Nurse will assess peri pad for amount and color every 4 hours.

3. Nurse will apply epifoam PRN for discomfort

4. Nurse will teach pt to inspect perineum and explain the signs that may indicates infections at beginning of shift.

5. Nurse will provide pt with ice pack PRN for discomfort

ANY COMMENTS???