Saint Paul University Philippines

Tuguegarao City, Cagayan 3500

School of Nursing and Allied Health Sciences
College of Nursing
1st Semester, Academic Year 2022-2023

NURSING CARE PLAN

CUES:
Scenario 2 Cues:

Cues:

 35-years old woman

 G2T2P0A0L1
 Spotting was noted during the first trimester.
 In the early part of the second trimester, she didn’t experience any discomfort related to pregnancy except that she felt like her diet was uncontrolled.
 She was fond of eating chocolates, fruit shakes, and ice cream.
 On her 26th week of gestation, she noticed that her urge to void has been more frequent than usual.
 In her 3rd trimester, she was troubled about some discomforts in certain areas of her body and these physiologic changes prompted her to seek medical advice.
 She was then asked by her OB-GYNE to undergo some diagnostic runs, Urinalysis and OGTT.

Urinalysis Result:
Sugar (+)
Protein (++++)
Ketones (-)
Blood (-)
Bilirubin (-)
WBC (0-2)
Bacteria - none
 Laboratory Report Examination: 75 grams oral glucose tolerance test (OGTT)

TEST Result Unit

VALUE

FBS 5.34 mmol/L

2ND hour BS 5.99 mmol/L

Scenario 3 Cues:

 G2T1P1A0L1
 Client underwent diagnostic and physical exams: Ultrasound: cord coil
 Methyldopa 25mg/tab TID
 Fortifer FA 1 cap OD
 Doctor advised to prepare for surgery
 Doctor emphasized the importance of diet
 Immediate operation may be needed if BP is uncontrolled within a week
 First pregnancy: NSD
 Probably 36-37 weeks of pregnancy
 History of Asthma

Scenario 4 Cues:

Subjective: N/A

Objective:
 Mrs. S.C was eventually admitted at De Leon Hospital for the delivery of the baby
 She was told by her Obstetrician that careful operation will be done
 At risk as supported by the results of UTZ
 Preoperative medications
 Thirty five minutes later, she successfully gave birth to a baby girl and both of them were brought to the recovery room
 Careful assessment and close monitoring
 Single live intrauterine pregnancy, cephalic presentation, compatible to 38 weeks 1/7 days AOG
 Placenta is in the anterior and high lying portion with grade 2 maturity
 Cord Coil
 Live baby girl weighing 2.3 kgs, with APGAR score of 5-7

ASSESSMENT/ NURSING BACKGROUND GOAL AND NURSING INTERVENTONS EVALUATION

 CUES DIAGNOSIS KNOWLEDGE OBJECTIVES AND RATIONALE
SUBJECTIVE CUES: Risk for deficient fluid Cesarean birth always NOC: Bleeding Loss NIC: Bleeding Precautions, Fluid Goals partially met
volume related to poses a risk for deficient Severity monitoring
 N/A excessive blood loss fluid volume from After 6 hours of nursing
during surgery surgery due to blood loss GOALS:  Assess the client’s intake interventions, the client
OBJECTIVE CUES: until all blood vessels that After 6 hours of nursing and output and document was able to:
were cut and ligated interventions, the client for at least 24 hours.
 G2T2P0A0L1 during surgery have will be able to:  Have a blood loss
 Uncontrolled thrombosed, sclerosed, Keep an accurate intake and of 1000 ml
blood pressure due and permanently sealed  Remain output record of the client to
to severe close. The risk of heavy normotensive, with ensure an adequate fluid balance  Maintain fluid
preeclampsia bleeding doubles for the fewer than 800 ml has been achieved. A full uterus volume at
 The client was postpartum client because blood loss. can obstruct a full bladder and functional level as
eventually she may not only fetal head; therefore, encourage evidenced by
admitted at De hemorrhage vaginally  Maintain fluid voiding every two (2) hours if normal vital signs,
Leon Hospital for from a noncontracted volume at possible or catheterize if the palpable, good-
the delivery of the uterus but also internally functional level as bladder is distended and the quality pulses,
baby from blood vessels not yet evidenced by client cannot void. normal skin
 She was told by securely closed. normal vital signs, turgor, moist
her Obstetrician palpable, good-  Assess the client’s mucous
that careful quality pulses, respirations, blood membranes, and
operation will be normal skin turgor, pressure, and pulse the right amount
done moist mucous before, during, and after of urine.
 Cesarean Section membranes, and surgery.
the right amount of  Attain a balanced
 Placenta is in the
urine. To detect the earliest signs of 24-hour intake
anterior and high
bleeding, monitor blood and output as
lying portion with
 Attain a balanced pressure, pulse, and respiratory recorded on the
grade 2 maturity
24-hour intake and rate approximately every 15 I/O chart.
 UTZ: Cord Coil
output as recorded minutes for the first hour after
on the I/O chart. surgery, every 30 minutes for the  Have a cognitive
next 2 hours, every hour for the status within the
 Have a cognitive next 4 hours, or as specifically expected range.
 status within the
expected range. prescribed. A minimal but  Remain urine
continued change in vital signs is specific gravity
 Remain urine as ominous a sign of hemorrhage ranging from
specific gravity as is a sudden alteration in these 1.003 and 1.030.
ranging from 1.003 measurements.
and 1.030. After 1 month of nursing
 Assess the client’s interventions, the client
OBJECTIVES: dressing on the incision exhibited:
After 1 month of nursing site and check for
interventions, the client excessive vaginal  Scant bleeding
will exhibit: discharges.
 Weight loss of 5
 Scant to no To document no incisional kg
bleeding bleeding. Observe the perineal
pad for lochia flow and palpate
 Weight loss that is fundal height each time to
not more than 5 to document uterine contraction.
10 lbs. (11 to 22 Blood oozing vaginally or from a
kgs). surgical wound can pool
considerably under the client
before being otherwise visible.

 Assess the client’s fundal

height and abdomen
regularly.

A client who has had spinal or

epidural anesthesia will not
experience pain on uterine
palpation until the anesthesia has
worn off. Therefore, uterine
palpation should not increase her
pain. Palpate gently enough once
the anesthesia has worn off to not
cause increased pain but
thoroughly enough to determine
uterine consistency. Assess the
remainder of the abdomen for
softness. A hard, “guarded”
abdomen is one of the first signs
of peritonitis.

 Assess the location of the

uterus and the degree of
contractility of the uterus.

The degree of uterine

contractility will measure the
status of the blood loss. Uterine
atony allows the blood vessels at
the placenta site to bleed freely
and usually massively because
the muscle fibers that compress
the bleeding vessels are flaccid.
Large venous areas are exposed
after the placenta separates from
the uterine wall and bleeding is
controlled by the contraction of
smooth muscles in the uterus.
The best safeguard against
uterine atony is to palpate the
client’s fundus at frequent
intervals to ensure her uterus
remains contracted. The fundus
should be firm to compress the
bleeding vessels at the placenta
site.
  Assess the client’s uterus
for firmness, assess the
remainder of her abdomen
for softness

A hard, “guarded” abdomen is

one of the first signs of peritonitis
(i.e., peritoneal infection), a
complication that may occur with
any abdominal surgical
procedure.

 Note the shift in behavior

or mental status and
cyanosis of mucous
membranes.

Oxygen deficits are manifested

first by changes in mental status,
later by cyanosis. The
presentation may include altered
cognitive and neuromuscular
function in clients with severe
fluid volume depletion. Altered
mentation can be both a cause
and a consequence of volume
depletion (Asim et al., 2019).

 Remove nail polish if any

and assess the client’s
nails and capillary refill
Removal of nail polish allows the
nurse to visualize the nail beds
for assessing circulatory status.
During the capillary refill test,
pressure is applied on the nail
bed until it turns white. Then, the
pressure is released, and the
amount of time it takes for the
blood to return is measured.

 Place a towel under the

client’s hip.

Placing a towel wedge shifts the

uterus off the inferior vena cava
and increases venous return.
Compression caused by
obstruction of the inferior vena
cava and aorta by the gravid
uterus in a supine position may
cause as much as a 50%
decrease in cardiac output.

 Massage the boggy uterus

using one hand and place
the second hand above the
symphysis pubis.

Ask the client to void first before

performing the massage. With a
gloved hand, place one hand on
the abdomen just above the
symphysis pubis and another
hand around the top of the
fundus to anchor the lower
uterine segment. Do not overly
massage because the excessive
stimulation to contract it will tire
the uterine muscle and worsen
uterine atony. Once the uterus is
firmly contracted, it should be
left alone but still assessed
regularly.

 Encourage the client to

increase fluid intake, as
indicated.

Introduce oral fluid slowly.

Teach the client to continue to
drink large quantities of fluid
after they return home (at least 6
glasses daily) so they have
adequate body fluid to make
breastfeeding successful.

 Administer IV fluids with

or without oxytocin, as
indicated.

It is important to infuse IV fluids

during cesarean birth at a
monitored rate. Rapid infusion
can lead to cardiac overload,
while slow infusion can lead to
inadequate circulatory
compensation. Oxytocin may be
added, as prescribed, to the first
one or two liters of IV fluid after
surgery to ensure firm uterine
contraction. Oxytocin aids
myometrium contraction and
reduces blood loss from exposed
endometrial blood vessels. Be
aware that the client is prone to
hemorrhage when the oxytocin is
discontinued. This is the first
time her uterus is asked to
maintain contraction on its own,
so monitor the client’s vital signs
carefully.

 Administer blood and

blood products as
indicated.

A strong recommendation on
blood transfusion in postpartum
hemorrhage is that the client
receives RBCs as soon as
possible in case of massive
hemorrhage. Additionally, the
early treatment of coagulopathy
with fresh frozen plasma (FFP)
and platelets determines
maternal morbidity and
mortality. Fibrinogen plasma
level has been a good predictor
of hemorrhage severity because
it plays a critical role in
maintaining and achieving
hemostasis. Fibrinogen
concentrates offer rapid
restoration of the fibrinogen
concentration with a small-
volume infusion with minimal
preparation time.

 Place the patient on bed

rest with legs elevated

Elevation of the lower extremities

increases venous return,
ensuring greater availability of
blood to the brain and other vital
organs. Bleeding may be
decreased with bed rest.

 Monitor the client’s

hemoglobin and
hematocrit levels.

The initial hemoglobin level does

not accurately reflect blood loss
because compensatory
mechanisms that move fluids
from the interstitial space require
time and are not apparent in the
initial hemoglobin measurement.
However, the initial
measurement is useful to
determine a baseline hemoglobin
level as anemia is very frequent
in parturient.

 Monitor the client’s

platelet count activated
partial thromboplastin
time (APTT), fibrinogen,
and fibrin degradation
products (FDP).

In the presence of DIC,

prothrombin will be low because
it depends on the conversion of
fibrinogen to fibrin, thrombin
time will be elevated because it
measures the time necessary for
the conversion of fibrinogen to
fibrin, and fibrin split products
will be >40 mcg/mL reflecting
the destruction of fibrinogen or
fibrin. Blood needs to be drawn
for prothrombin, thrombin time,
fibrinogen, and fibrin split
products.

 When intestinal
functioning comes to
normal, encourage the
client to subscribe to an
iron-rich diet and to
maintain adequate water
and fluid intake.
 Iron helps regain the blood lost
during delivery whereas water
and fluids like coconut milk,
smoothies, soups, herbal teas can
help ease bowel movements.
These options are not substitutes
of water. The client should still
consume at least t3 liters of
water daily.

 Notify a primary care

provider of any changes
in vital signs that might
indicate hemorrhage.

So prompt action can be taken.

ASSESSMENT/ NURSING BACKGROUND GOAL AND NURSING EVALUATION

CUES DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTONS AND
RATIONALE
SUBJECTIVE CUES: Risk for acute pain The experience of pain during NOC: Pain level NIC: Pain management: Goals partially met
related to surgical childbirth is complex and Acute
N/A trauma subjective. Several factors can GOALS: After 2 hours of nursing
affect the client’s perception of After 2 hours of nursing  Monitor and interventions, the client
OBJECTIVE CUES: labor pain, making each interventions, the client document was able to:
experience unique. Consistently, will: characteristics of
 G2T2P0A0L1 pain during childbirth is ranked pain, noting  Report that the pain
 First pregnancy: high on the pain rating scale  Report pain is verbal reports, is still felt but it has
NSD compared to other painful life minimized or nonverbal cues, been minimized
 The client was experiences (Labor & Maguire, controlled for example,
eventually 2008). Cesarean birth is among moaning, crying,  Appear tensed
 admitted at De surgery procedures that induce  Appear relaxed
Leon Hospital for pain, and surgery threatens the restlessness,  Rest and sleep
the delivery of the body’s integrity. Increased serum  Be able to rest and diaphoresis,
baby catecholamines and cortisol may sleep clutching chest,  Be free of
 She was told by lead to decreased pelvic blood rapid breathing, untoward side
her Obstetrician flow and increased pain during  Be free of and hemodynamic effects if
that careful labor while disrupting normal untoward side response (BP and analgesia/anesthetic
operation will be labor and delivery, prolonged effects if heart rate agents are
done deliveries, emergency cesarean analgesia/anesthetic changes). administered.
 Cesarean Section birth, medical and surgical agents are
interventions, and increased administered. Variation of appearance  Demonstrate an
dissatisfaction with childbirth and behavior of clients in understanding of
experiences (Ahmadi, 2020).  Demonstrate an pain may present a the pain
understanding of challenge in assessment. management
the pain For example, men and discussed by
management women consistently demonstration and
discussed by present differently or an verbalization of
demonstration and individual may present information.
verbalization of differently from one
information. episode to another.
However, most clients OBJECTIVES:
with an acute MI appear After 1 week of nursing
OBJECTIVES: ill, distracted, and interventions, the client
After 1 week of nursing focused on pain. was able to:
interventions, the client Respirations may be
will: increased because of  Report a score
pain and associated of 4/10 using a
 Verbalize a pain anxiety. Release of validated pain
score of less stress-induced scale
than 5 using a catecholamines increases
heart rate and BP.  Report effective
validated pain
control of pain
scale
 Obtain full by discharge
 Report effective
 control of pain  Demonstrate
by discharge description of relief of pain as
pain from client, evidenced by
 Demonstrate
including stable vital signs
relief of pain as
location, intensity and absence of
evidenced by
using a a muscle tension
stable vital signs
validated pain and restlessness.
and absence of
assessment tool,
muscle tension
duration,
and restlessness.
characteristics
(dull or crushing),
and radiation
especially related
to the indication
for cesarean birth.
Assist client to
quantify pain by
comparing it to
other experiences.

Pain is a subjective
experience and must be
described by client.
Provides baseline for
comparison to aid in
determining effectiveness
of therapy, resolution, or
progression of problem.

 Assess the
client’s vital signs

Note for signs of

tachycardia,
hypertension, and
increased respirations.
Changes in these vital
signs often indicate acute
pain and discomfort.

 Review the
client’s chart.
Note for any
concomitant
medications,
idiosyncratic
sensitivity to
analgesics, and
intraoperative
course, including
size and location
of incision, drain
placement, and
anesthetic agents
used.

Approach to
postoperative pain
management is based on
multiple variable factors,
especially medications
used for pain. This would
also help determine what
medication is allowed to
be taken by the patient.

 Encourage the
client to verbalize
feelings about
pain.

Allow the client to

verbalize her perceptions
about pain and
acknowledge the pain
experience. Pain is a
subjective experience and
cannot be felt by others.
Convey acceptance of the
client’s response to pain.

 Review client’s
knowledge of and
expectations
about pain
management and
previous
experiences with
pain and methods
used.

Antenatal childbirth
preparation has a role in
increasing maternal
satisfaction and may
reduce pain scores.
Antenatal education is
also essential when
obtaining consent from
the client; the aim is to
provide good information
to facilitate mothers to
form realistic
expectations about pain
management during
childbirth (Labor &
Maguire, 2008).

 Demonstrate
proper relaxation
techniques—
position for
comfort
(Reposition as
indicated, such as
semi-Fowler’s or
lateral Sims’) as
possible. Use
therapeutic touch,
as appropriate.

These techniques help

shift the focus away from
the currently experienced
pain, anxiety, and tension
and instead focus on
more pleasant
experiences. May relieve
pain and enhance
circulation. Semi-
Fowler’s position
relieves abdominal
muscle tension and
arthritic back muscle
tension, whereas lateral
Sims’ will relieve dorsal
pressures.

 Offer hot or cold

compress to the
affected area.

Applying an ice or cold

pack to the incision site
during the first 24 hours
reduces edema and the
possibility of hematoma
formation. It also reduces
the pain around the
abdomen and incision,
and it promotes healing
and comfort.

 Relieve Muscular
Aches by offering
a backrub
Many women feel so sore
and achy after labor and
birth that they describe
feeling as if they have
“run for miles.” A
backrub is usually
effective in alleviating the
pain. Improves
circulation, reduces
muscle tension and
anxiety associated with
pain. Enhances sense of
well-being.

 Provide regular
oral care,
occasional ice
chips, or sips of
fluids as tolerated.

Reduces discomfort
associated with dry
mucous mem- branes due
to anesthetic agents and
oral restrictions.

 Encourage
adequate rest
periods after
cesarean birth.
The period after cesarean
birth includes recovery
from surgery and
adapting to motherhood.
The client needs to rest
adequately to prevent
fatigue and recover
appropriately before
assuming the new role of
being a mother. Parents
may appreciate early
discharge, as it provides
the family, including
older siblings, an
opportunity to be
together in the home
environment.
Additionally, it provides
adequate social and
moral support for the
woman.

 Discuss with
family ways to
assist the client
and reduce the
pain.

Emotional and
psychological support
provided by the family
can help in recovery and
reduce postpartum pain.

 If indicated,
administer
analgesics,
sedatives,
narcotics, or
preoperative
drugs.

Promotes comfort by
blocking pain impulses.
Potentiates the action of
anesthetic agents. Most
women report pain and
require opioid analgesia
following cesarean birth
—approximately 20% of
women who undergo a
cesarean birth
experience severe acute
postoperative pain.
Individualized or
stratified post-discharge
opioid prescribing
practices have been
shown to reduce
unnecessary opioid
analgesic prescription
and consumption, so they
should be implemented
 routinely.

 Reassess the pain

felt by the client
via pain scale

For outcome and

evaluation.

 Monitor sedation,
respiratory status.
Note effectiveness
and side or
adverse effects of
analgesia (Chou et
al, 2016).

Respirations may
decrease on
administration of opioid,
or synergistic effects with
anesthetic agents may
occur. Note: Migration of
epidural analgesia
toward head may cause
respiratory depression or
excessive sedation.

ASSESSMENT/ NURSING BACKGROUND GOAL AND NURSING EVALUATION

CUES DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTONS AND
RATIONALE
SUBJECTIVE CUES: Risk for infection related If the cesarean birth is performed NOC: Infection Severity; NIC: Infection Control; Goals partially met
 to alteration in skin hours after the membranes rupture, Wound healing Wound Care After 5 hours of nursing
N/A integrity (incision and a woman’s risk for infection will interventions, the client
sutures) be higher than if the membranes GOALS:  Review prenatal, was:
OBJECTIVE CUES: were still intact. Amniotic fluid After 5 hours of nursing intrapartal, and
helps protect the fetus from interventions, the client postpartal record.  Free from
 G2T2P0A0L1 infectious agents due to its will: infection as
 Uncontrolled inherent antibacterial properties. A review of the client’s evidenced by
blood pressure due After the rupture of membranes,  Be free from previous health records normal vital signs
to severe the cervical canal becomes the infection as identifies factors that and no observable
preeclampsia usual pathway for cervical and evidenced by place the client in a high- redness, edema, or
 The client was vaginal flora, causing infections. normal vital signs risk category for the discharge
eventually Additionally, the skin also serves and no observable development/spread of
admitted at De as the primary line of defense redness, edema, postpartal infection  Afebrile
Leon Hospital for against bacterial invasion, so when or discharge
the delivery of the the skin is incised for a surgical  Monitor the  Able to initiate
baby procedure, this important line of  Be afebrile client’s vital signs behaviors to limit
 She was told by defense is lost. (temperature such as the spread of
her Obstetrician below temperature, infection as
that careful 38℃/100.4℉) pulse, and appropriate and
operation will be and free of respiration. Note reduce the risk of
done purulent drainage the presence of complications.
 Cesarean Section or erythema of chills or reports of
the surgical site. anorexia or  Able to have a
malaise. balanced fluid
 The client will intake as
initiate behaviors Elevations in vital signs evidenced by the
to limit the spread accompany infection; clients’ input and
of infection as fluctuations, or changes output record
appropriate and in symptoms, suggest
reduce the risk of alterations in client OBJECTIVES:
complications. status. The fever is most After 2 weeks of nursing
often caused by interventions, the client:
 Be able to have a endometritis, an  Maintained
 balanced fluid inflammation of the inner normal vital signs
intake as lining of the uterus.
evidenced by the Puerperal fever is a  Reported minimal
clients’ input and temperature of 38℃ bowel function
output record (100.4℉) or higher after discomfort
the first 24 hours and for
OBJECTIVES: at least two days during  Achieved timely
After 2 weeks of nursing the first ten days after wound healing
interventions, the client birth. A pulse rate that is with minimal
will: higher than expected and complications like
 Maintain normal an elevated temperature pain and
vital signs often occur when the discomfort
 Regain optimal client has an infection. An
bowel function elevated temperature of
 Achieve timely at least 39℃ (102.2℉)
wound healing or between 38℃
without (100.4℉) and 39℃
complications. (102.2℉) within 30
minutes and one of the
clinical symptoms are
signs of clinical
chorioamnionitis.

 Observe for
localized signs of
infection at the
surgical incision
site (redness,
edema,
ecchymosis,
discharge, and
approximation).
Note progress
 toward healing.

Surgical site infection

(SSI) occurs in up to 11%
of women after cesarean
birth and is manifested as
wound infection,
endometritis, or urinary
tract infection. The skin
and subcutaneous tissue
may have purulent
drainage, a positive
culture, complaints of
pain or tenderness, or
evidence of swelling,
redness, or heat.

 Asses for any sign

of subinvolution
of uterus, extreme
uterine tenderness,
and lochia.

The client’s uterus

usually is not well
contracted and is painful
to touch. She may feel
strong afterpains. Lochia
usually is dark brown and
has a foul odor. It may be
increased in amount
because of poor uterine
involution, but if the
infection is accompanied
by high fever, lochia may,
in contrast, be scant or
absent.

 Monitor
oral/parenteral
intake, stressing
the need for at
least 2000 ml fluid
per day.

Note urine output, degree

of hydration, and
presence of nausea,
vomiting, or diarrhea.
Increased intake replaces
losses and enhances
circulating volume,
preventing dehydration,
and reducing fever. Slight
temperature elevations
with no other signs of
infection often occur
during the first 24 hours
because of dehydration.

 Observe reports of
leg or chest pain.
Note pallor,
swelling, or
stiffness of the
 lower extremity.

These signs and

symptoms are suggestive
of septic thrombus
formation. Note: Embolic
sequelae, especially
pulmonary embolism,
may be an initial
indicator of
thrombophlebitis. The
levels of fibrinogen and
other clotting factors
normally increase during
pregnancy. In contrast,
levels of clot-dissolving
factors (plasminogen
activator and
antithrombin III) are
normally decreased,
resulting in a state of
hypercoagulability.

 Keep perineal area

as dry as possible.
Change dressings
as needed.

Large amounts of serous

drainage require that
dressings be changed
frequently to reduce skin
irritation/breakdown and
potential for infection.

 Encourage side-
lying position with
head elevated.
Avoid prolonged
sitting.

Promotes drainage from

wound/drains, reducing
risk of pooling.
Prolonged sitting
increases perineal
pressure, reducing
circulation to wound, and
may delay healing.

 Encourage early
ambulation after
cesarean birth.

Early mobilization is
often part of a surgical
bundle “fast track” or
“enhanced recovery after
surgery” (ERAS). It is
recommended to improve
many short-term
outcomes after surgery,
including a rapid return
of bowel function and
decreased length of
hospital stay, thereby
reducing the risk for
infection.

 Observe client’s
intake, noting
deficient in
nutrition and fluid.

Client may not be able to

ingest (or tolerate)
enough food or fluids in
the early postoperative
period to promote
healing, thereby
increasing risk of
infection.

 Administer
antibiotics, as
indicated.

Antibiotics may be given

prophylactically or to
target specific organisms.

 Irrigate wound as
indicated, using
normal saline
(NS) or specified
antimicrobial
solution, if
 indicated.

May be required (if

surgical wound is open)
to treat to preoperative
infection or
intraoperative
contamination.

 Evaluate
hemoglobin and
hematocrit and
estimated blood
loss during the
surgical
procedure.

The risk of post-delivery

infection and poor
healing increases if
hemoglobin levels are
low and blood loss is
excessive.

 Evaluate the
blood, vaginal,
and placental
cultures, as
indicated.

Premature
discontinuation of
treatment when the client
feels well may yield
reinfection and antibiotic
resistance.

 Instruct client and

family about
techniques to
protect the skin’s
integrity and
prevent the spread
of infection.

Surgical site infections

occur in approximately
10% of clients, >80% of
which develop after
discharge, which
indicates a need for the
client and their family to
be provided with
comprehensive
information on the
normal discharge course,
signs and symptoms of
infection, activity
restrictions, and
instructions on when to
seek medical attention.
Symptoms to watch out
for that may indicate SSI
are fever, pain,
tenderness, purulent
drainage of abscess on
the incision site, and
evidence of swelling,
redness, or heat.