N3731 Course Packet

Student: Alyssa Grimm

Date of Care: 9/30/2016
Youngstown State University
Department of Nursing
Bachelor of Science in Nursing Program
N3731: Childbearing & Womens Health Nursing

Nursing Care Plan

Nursing Diagnosis: High risk for infection r/t blood loss, invasive procedures in L&D, and unhealed placental site.
Goal: Pt will demonstrate no signs of infection (temp will remain below 100oF; no redness, erythema, edema, discharge at site of
impaired skin integrity; WBC levels within normal range (4,500 10,000)).

Behavioral Objectives Nursing Interventions Documented Rationals

Pt will verbalize understanding of the
importance of proper hand hygiene and
perineal care to help prevent the spread of
infection to self or newborn.
Pt will verbalize understanding on the
signs and symptoms of infection,
including:
- Vital signs (elevated temperature,
increased heart rate, increased
respiration rate, etc)
- Fatigue/lethargy, chills, loss of
appetite, nausea/vomiting, and
abdominal pain.
Nurse will maintain Standard Precautions
and use proper hang hygiene technique
when providing care.
Teach woman to maintain proper hand
hygiene (particularly before handling her
newborn) and to maintain scrupulous
perineal care with frequent change and
careful disposal of perineal pads.
Monitor vital signs.
Monitor level of fatigue and lethargy,
evidence of chills, loss of appetite, nausea
and vomiting, and abdominal pain.
Monitor lochia for foul smell.
Monitor laboratory values (ex: white
blood cell [WBC] count, cultures).
To prevent introduction of or spread of
infection. (pg 810)
To avoid spread of microorganisms.
To detect signs of systemic infection.
To indicate extent of infection and serve
as indicators of status of infection.
To indicate status of infection.
For indicators of type and status of
infection.
- Foul smelling lochia.
- Lab values (elevated WBCs,
positive cultures)
- Pt will express understanding of
the importance of an infection
being treated.
- Pt will feel more in control of her
care because she can assist in her
own care.
Encourage pt to have an adequate fluid To promote healthy recovery & increase
and nutritional intake. pts feelings of control during care.
Administer and monitor broad-spectrum To prevent or treat infection.
antibiotics as ordered.
Administer antipyretics as ordered and To reduce elevated temperature.
necessary.
Encourage relaxing interventions To promote rest & healthy recovery.
(meditation, music, other distraction
techniques).