Submitted by: Jehzielle Kae A.

Sause BSN 1 PARSE

SITUATION: Medical Diagnosis: Acute Appendicitis Treatment/ Surgery: Post Appendectomy
NURSING DIAGNOSIS RATIONALE NURSING INTERVENTION RATIONALE EVALUATION

Infection is caused by Independent GOALS MET

Risk for infection related to multiplication of Skills:
compromised integrity of the pathogenic organisms Practice and instruct proper Reduces risk of spread After 2 next weeks, the
skin due to surgical incision at that may compromise hand washing and aseptic of bacteria thereby client demonstrated
the Right Lower Quadrant. health, especially in wound care. preventing surgical site timely wound healing
cases after surgery. infections. with wound
Subjective cue: approximation with no
verbalised, “Ga sakit akon Schematic Diagram: signs of infection, stable
operation” Monitor vital signs. Note Suggestive of presence vital signs and
onset of fever, chills, of infection, developing laboratory values.
Objective cue: diaphoresis, increase in sepsis, abscess, and
Pain Scale - 8/10, slightly heart rate, changes in peritonitis. K: At the end of the
increased RR - 23 cpm mentation, and reports of shift, the client was able
increasing abdominal pain. to identify when to
GOALS: perform proper hand
Inspect incision and Provides for early hygiene.
dressings. Note detection of developing
The intervention is a 2-week characteristics of drainage infectious processes. At the end of the day,
process. Within the next 2 from wounds. the patient was able to
weeks, the client will exhibit verbalise medication
timely wound healing with no compliance, and has
signs of infection, such as Knowledge: shown cooperation in
free of fever, and the surgical Educate the client with To let the client identify treatment.
site free from erythema, regards to the factors and ways that can reduce
inflammation, or purulent practices that can or prevent the risk of
discharges, and white cell reduce/prevent the risk of infection. (Ex. Area of S: After 1 day, the
count and inflammatory infection. the incision should be patient was able to
markers within normal range. clean at all times). To demonstrate to the
increase awareness nurse of proper
KNOWLEDGE: and understanding of technique of meticulous
By the end of the shift, the infection prevention hand washing with the
client will be able to identify strategies, thus correct steps and length
when to perform good hand decreasing the risk of of the handwashing.
hygiene each time the infection.
opportunity presents itself. After 2 days, the client
(Particularly before meals, REFERENCE: Attitude: Premature was able to
after using the restroom, after Zabaglo, M., & Encourage/emphasis discontinuation of demonstrate to the
contact with contaminants Sharman, T. (2023, compliance to medication treatment when client nurse how to
and before and after wound July). Postoperative begins to feel well may demonstrate wound
care) wound infection. result in return of care using strict aseptic
StatPearls [Internet]. infection. technique.
By the end of the day, the StatPearls Publishing.
client will verbalise https://www.ncbi.nlm.ni A: After 1 week, the
understanding of medication h.gov/books/NBK5605 Encourage coughing and To reduce stasis of client demonstrated
compliance to facilitate wound 33/ deep breathing exercises secretions in the lungs. increased awareness
healing and infection whilst splinting/supporting When stasis occurs, and increased
prevention. the abdomen/post op site microbial infection of compliance to
with a pillow. the respiratory tract strategies to boost their
SKILLS: occurs and may lead to immune system.
Over the next 2 days, the chest infection.
client will master the
technique of meticulous hand Monitor laboratory values To detect early signs of
washing, demonstrating the (white cell count, infection that would
correct steps and the length inflammatory markers) require prompt
of the handwashing treatment or
procedure. Collaborative/Dependent: interventions

Over the next 2 days, the Assess or clarify Adequate nutrition with
client will be able to appropriateness of oral boost in the immune
demonstrate strict aseptic intake after passing gas, system, will promote
technique in wound care, as meanwhile maintain NPO. wound healing and
taught by the nurse. recovery

ATTITUDE: Continue IV fluids Adequate hydration

By the end of 1 week, the promotes wound
client will demonstrate healing.
enhanced immune defences
as evidenced by stable Administer antibiotics as Prophylaxis for wound
laboratory results, and prescribed: infection
verbalise understanding of
individualised strategies to Cefoxitin 1g IVTT q8H x 3
boost their immune system, doses
including medication
compliance. Paracetamol 600mg/IV q 6
hours x 24 hours

Ketorolac 30mg IV q 6
hours x 24 hours

Tramadol 50mg IV q 6
hours PRN of pain