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Assesseme Nursing Inference Planning Nursing Rationale Evaluation

nt Diagnosi Interventions
s

Failed to STG: STG:


progress
O> v/s Risk for >Monitor v/s and >Elevation in After 4 hours of
labor(due to
taken as infection Within 4 hours of record rates may nursing intervention
previous
follow: related nursing intervention signal the pt was able to
cesarean
to tissue the pt will be able infection verbalize ways in
birth,
trauma verbalize ways in preventing
cervical >assess
preventing >to provide
BP:110/80 secondar operative site for infection/contamina
arrest baseline data
y to post infection/contamina tion specifically
mmHg cervical signs of infection
tion specifically for
LTCS proper hand
atrophy) comparison
RR:22 cpm G3P3 proper hand washing, and
washing, and and identify
↓ proper wound care
PR:68 bpm need for
proper wound care as evidenced by:
increase as evidenced by: further
T: 36.5 C
risk for fetal management >stable v/s
>with post distress >maintain stable >change linens
v/s >good skin integrity
op surgical as necessary

incision on >to prevent >no swelling,
>good skin integrity
the lower Increase growth of redness and pain on
part of the risk of fetal >absence of microorganis operative site
abdomen death swelling redness ms on linens occured
and pain on >Instruct pt to and beds
↓ operative site refrain from LTG:
touching/scratchi
>with dry Emergent LTG: After 3 days of good
intact cesarean After 3 days of good ng operative site >for nursing intervention
dressing on delivery nursing immediate the px was able to
the surgical intervention, the
replacement achieve a timely
(the incision patient will be able
site to prevent wound healing that
made on to achieve a timely
wound healing; be skin is free of purulent
the lower
free of purulent breakdown drainage or
part of the drainage or >start 48° post and erythema
abdomen) erythema op daily wound contaminatio
↓ care n of operative
site
Tissue

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