ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE Risk for SHORT TERM INDEPENDENT SHORT TERM

infection
2nd day related to After 2 hours - Observe areas - To determine After 2 hours
postpartum alteration in of nursing of impaired skin effectiveness of nursing
skin integrity. interventions, integrity, noting of therapy or interventions,
Post patient will drainage presence of patient was
epissiorraphy verbalize characteristics side effect. able to
understanding and presence of verbalized
of individual inflammation. understanding
causative risk of individual
factors. - Observe - Allows early causative risk
perineum/ identification factors.
incision for and
other signs of treatment; GOAL MET
infection (e.g., promotes
redness, edema, resolution of
LONG TERM ecchymosis and infection. LONG TERM
discharge). Note Note:
After 2-3 extreme uterine Although After 2-3
weeks of tenderness. localized weeks of
nursing infection are nursing
interventions, usually not interventions,
patient will severe, patient was
achieve timely occasional able to
would healing; progression to achieve timely
be free necrotizing would healing;
purulent vasculitis can be free
drainage or be life purulent
erythema. threatening. drainage or
erythema.
- Monitor - Elevations in
temperature, vital signs GOAL MET
pulse rate and accompany
respirations. infection;
Note presence fluctuations or
of chills or changes in
report of symptoms,
malaise. suggest
alterations in
client status.

- Instruct the - Prevents

proper disposal spread of
of contaminated infection.
linens, dressings
and peri-pads.
- Demonstrate - Cleaning
correct perineal removes
cleaning after urinary/fecal
voiding and contaminants.
defecation and Changing pad
frequent removes moist
changing of peri- medium that
pads. favors
bacterial
growth.

- Encourage - Enhance flow

semi-Fowler’s of lochia and
position. uterine/pelvic
drainage.

- Perform - To promote
perineal care. cleanliness to
the perineal
area.

- Provide - First-line
meticulous, defense
clean, or aseptic against
care; maintain nosocomial
good hand- infections.
washing
techniques.

DEPENDENT

- Administer/ - Early
monitor identification
medication of developing
regimen infection
(antimicrobial, permits
topical prompt
antibiotics) as intervention
ordered by the and
physician and prevention of
note the client’s further
response. complications.
COLLABORATIV
E
- Obstetricians
- Refer to are doctors
obstetrician for with
further specialized
assessment and training in
if there are obstetrics
presence of (medical care
complications. before, during
and after
childbirth).