Assessment Diagnosis Rationale Planning Interventions Rationale Evaluation

S: Risk for Wounds involving After 6 housr of  Assess  To obtain Patient was
“kakaopera infection r/t injury to soft nursing interventions, underlying cmparative free
lang sakin presence of tissue the patient will be: condition and baseline data from any
nung friday” surgical can vary from  Able to vital signs .Fever may signs
–as incision s/p minor tears to verbalize the especially indicate and
verbalized by cholecystect severe crushing importance of temperature. infection. symptoms of
the patient omy injuries. The proper  Observe for  To assess infections as
decision to suture postoperative localized sings causative manifested
O: clean and a wound depends care and of infection in contributng by
intact on the nature of wound care. the incision factors. absence of
abdominal thewound the  Able to site site. fever
dressing, time ways to  Emphasize the  It serves as a
weak in since the injury prevent importance first line of
appearance, was sustained the infection and ofhandwashing defense against
increased degree of demonstrate technique. infection.
WBC, T= 36.7 contamination. proper  Maintain  Regular wound
The skin is the first postoperative aseptic dressing
line of defense care. technique promotesfast
against infection.  Be free from when changing healing and
Any break in its any signs and dressing/caring drying of
continuity will symptoms of wound. wounds.
allow infection as  Keep area  Wet area can be
microorganis ms manifested by around wound lodge area of
to enter the body, absence of clean and dry. bacteria
which in turn can fever.  Encourage  It supports
cause infection increase in circulating
and since the fluids volume and
patient has tissue perfusion
undergone and it aids in the
cholecystectomy elimination of
there is a break in microorganisms
the continuity of that may
the skin that can contribute to
cause infections. the occurrence
of infection.
 Promote  Reduces
adequate rest metabolic
periods demands
 Encourage  To decrease risk
early for infection
ambulation since prolong
immobilization
can contribute
to the
accumulation of
secretions and
may lead to
infection
 Emphasized  Premature
necessity of discontinuation
taking of treatment
antibiotics when client
asordered. begins to feel
well may result
in return of
infection
 Administer  Prophylaxis to
prescribed prevent
medications on infection.
time